When assessing a patient from a socially excluded group, it is important to remember that this may be an opportunity to build trust and to intervene and link the patient to appropriate services. The patient may not be registered with a GP, may not be receiving follow up for chronic conditions and may not be taking prescribed medication. They may have complex medical and/or mental health problems and are seeking help so these patients are deserving of your time. Even those who are frequent attenders are repeatedly visiting the ED because they have unmet needs despite many encounters with healthcare professionals (19).

Since many of these patients have a complex combination of poor physical health, mental health problems and alcohol and/or drug dependence, it is often difficult to distil an ED attendance into a single presenting complaint and the patient may not be able to articulate their needs. While the presenting complaint may initially seem like a simple limb injury, for example, there may be psychosocial factors contributing to the presentation which may need to be explored and there may be other ongoing health problems requiring treatment. Check in with them in terms of their overall health, participation in screening programs etc. Standard follow-up and treatment plans may not be suitable e.g. advice regarding weight-bearing, diet and/or ability to engage with medication or follow-up appointments may not be achievable.

When taking the history, ask about previous medical history and medications. Bear in mind that they may not be taking prescribed medicine for several reasons (chaotic lifestyle, financial difficulties, poor understanding etc.) but they may be taking medications which have not been prescribed for them. This will only become evident if the history-taking is done in a non-judgemental manner.