What we do
A Pathway team
Stopping the cycle
Life on the streets is difficult. A daily search for food and shelter, a struggle for existence. Unsurprisingly many people experiencing homelessness become ill.
Because of the severity of their illnesses, people experiencing homelessness:
- attend A&E six times as often as people with a home,
- are admitted to hospital four times as often,
- stay three times as long1.
Many homeless patients are not identified as such until the point of discharge. Some will fear the stigma of disclosing homelessness and give a past address to conceal their situation. Others will give the address of a friend, or a made up address or a hostel or night shelter address.
Homelessness and resulting adult social care issues can contribute to delayed discharge. Pathway is aware of some hospitals discharging homeless patients to the street in order to avoid breaching NHS targets. This practice is contrary to the new legal ‘duty to refer’ which the Homelessness Reduction Act 2017 places on hospitals and other public authorities2, and also often fails to comply with safeguarding adults principles in the Care Act 20143.
Patients discharged to the street, without access to water, nourishment or rest, are highly likely to deteriorate. Most will be readmitted to hospital again, rapidly caught in a costly downward cycle of deteriorating ill health.
The team GP helped him to register with a local surgery and referred him to a drug and alcohol service for support with his drinking.
Kenneth was admitted to a central London hospital after collapsing in the street. Doctors diagnosed a gastric ulcer. Five days after emergency surgery, the doctor declared him medically fit for discharge. It was only then Kenneth explained he had nowhere to go.
He'd been sleeping on a friend's sofa since the breakdown of his marriage. As his alcohol use worsened they had asked him to leave. The doctor referred Kenneth to the Pathway homelessness team. Their GP knew that Kenneth could not get the rest the consultant advised on the street, and that his drinking was likely to worsen there. He arranged for Kenneth to be discharged into Pathway respite care for a few days, a quiet hostel with support from the team.
The team GP helped him to register with a local surgery and referred him to a drug and alcohol service for support with his drinking. Pathway's Care Navigator helped Kenneth to fill in forms to claim benefits until he could return to work. When he was well enough, she accompanied him to an appointment at the housing department, who offered him temporary accommodation. Pathway supplied him with a home starter kit of crockery, a duvet and pillow and helped him settle in. Kenneth's road to recovery is likely to be long, but he is making steps in the right direction.
Offering a new Pathway
The Pathway partnership programme offers a new way to help people who are homeless. It trains NHS staff to help patients access the accommodation, care and support they need to recover and get life onto a better pathway after their stay in hospital.
Pathway teams are led by specialist GP’s who bring their experience caring for homeless people in the community, as well as expertise in methadone prescribing, personality disorder, and chronic disease management.
Nursing staff manage the team caseload and bring vital clinical experience in homelessness, addictions and/or mental health.
Housing specialists bring their expertise to the service and help build links with voluntary sector services in the community. Some Pathway teams also include Care Navigators who have personal experience of homelessness, and larger teams also include occupational therapists, social workers and mental health practitioners.
Teams work with patients to create bespoke care plans for their support, including referrals to addiction services, ongoing treatment for health issues such as hepatitis C and tuberculosis, and community services offering social care. Coordinating input from housing departments, mental health and addictions services, social services, community and charity sector partners, Pathway teams provide empathetic, patient-centred, recovery-focused care.
Based in the hospital, Pathway teams:
- Provide expert advice and clinical advocacy around homeless and inclusion health issues (such as substance misuse and substitute prescribing) for inpatients, improving care and treatment outcomes
- ensure patients with complex needs are able to engage with health and other services through holistic inpatient support and care, thereby reducing rates of early self-discharge
- help homeless patients find somewhere safe and appropriate to stay on discharge, taking into account their needs around health, care and general support
- support patients with financial issues, welfare entitlement and to access specialist legal help where possible
- help to replace lost ID documents
- ensure patients are registered with a GP for ongoing care
- refer and signpost to specialist community services to help with a variety of social, mental and physical health, and addictions issues
- reconnect patients to family and social support networks on discharge
Pathway teams do this by coordinating and hosting regular multidisciplinary team meetings, attended by key professionals within the hospital and also external community services. They also carry out ward rounds as a team to review the care of all homeless patients within the hospital.
Pathway’s experience has shown that multidisciplinary teams are most effective in addressing the multiple health issues homeless people face. National evaluations have shown that integrating housing and clinical staff into the team led to ‘better outcomes and more positive working practice’ and recommends this as one of the key ‘components of effective models for future replication4.
An audit of the UCLH Pathway team published in 20175 showed a:
Pathway teams have been shown to be cost-effective
In today’s NHS, the drive for financial savings seems to compete for priority with improving patient care. Pathway promotes medically evidenced models of care with compassion at their heart. However, a randomised controlled trial showed that a Pathway team is cost effective, and improves people’s health and housing status, confirming that a little bit of help puts life on a better Pathway6.
Pathway hospital teams:
Enable NHS Trusts to meet their legal ‘duty to refer’ requirements of the Homelessness Reduction Act 2018. Emergency departments, urgent treatment centres and hospitals providing urgent care are now subject to this duty, in order to prevent homelessness2.
Does your hospital need a Pathway team?
- an identified, responsible member of staff
- a referral protocol to the local authority, ensuring that all staff are aware of their duty under the Homlessness Reduction Act
- an information pack with signposting to local hostels, food banks, housing department details
- a small supply of spare, warm, clean clothing
- a dedicated housing worker
- a named link hospital coordinator to maintain the referral protocol and support the housing worker in obtaining necessary medical assessments (with the patient’s consent)
- strong relationships with the local council housing department, hostels and charities training and education of all hospital staff by the housing officer and named hospital coordinator
- a full Pathway team including GP, Nursing staff and Care Navigators
- a coordinator if the service spans multiple sites
- any specialist staff identified in the needs assessment
This tiered model has been endorsed by the Royal College of Physicians as setting the best practice standard for hospitals in the NHS14
Annual cost of basic core Pathway Team
| Item | Cost |
|---|---|
| Specialist GP – 4 sessions per week | £62,400 |
| Band 7 Nurse – full time | £47,950 |
| Housing Worker / Care Navigator - full time | £28,050 |
| Total staff costs | £138,400 |
| Non staff costs – Pathway Partnership fee, IT, reflective practice, travel, patient consumables and office supplies | £34,750 |
| Estimated total cost | £173,150 |
“You were the only ones that felt my life was worth saving. I am now back with the family I have not seen for 10 years"
Find out more...
Below you can find more information on homelessness, how Pathway helps, and how you can get involved
Footnotes
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Department of Health (2010). Inclusion health: improving primary care for socially excluded people.
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Homeless Link (2015). Evaluation of the homeless hospital discharge fund. London: Homeless Link.
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Wyatt L. Positive outcomes for homeless patients in UCLH Pathway programme; British Journal of Healthcare Management 2017 Vol 23 No 8: p367-371
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Hewett, N., Buchman, P., Musariri, J., Sargeant, C. et al. (2016). Randomised controlled trial of GP-led in-hospital management of homeless people (‘Pathway’). Clinical Medicine, 16(3), 223-229.
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Dorney-Smith S et al. Integrating health care for homeless people: the experience of the KHP Pathway Homeless Team. Br J Healthc Manag 2016;22(4):225-34.
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Zana Khan, Sophie Koehne, Philip Haine, Samantha Dorney-Smith, (2019) "Improving outcomes for homeless inpatients in mental health", Housing, Care and Support, Vol. 22 Issue: 1, pp.77-90.
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Hewett N et al. A general practitioner and nurse led approach to improving hospital care for homeless people. Br J Healthc Manag 2016;22(4):225-34.
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MPath. A review of the first 6 months of the pilot service. July to December 2013.
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Dorney-Smith S et al. Integrating health care for homeless people: the experience of the KHP Pathway Homeless Team. Br J Healthc Manag 2016;22(4):225-34.
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Bristol Service Evaluation of Homeless Support Team (HST) Pilot in Bristol Royal Infirmary. Internal evaluation, presented at Faculty for Homeless and Inclusion Health Conference March 2019 Link: video at bottom of page
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Gazey A, Wood L, Cumming C, Chapple N, and Vallesi S (2019). Royal Perth Hospital Homelessness Team. A report on the first two and a half years of operation. School of Population and Global Health: University of Western Australia, Perth, Western Australia.
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Homeless and Inclusion Health Standards for Commissioners and Service Providers