By Dr Gemma Ashwell 

The thing I find the most difficult in my role as a GP is the monthly deaths audit meeting. The practice I work in is in the centre of a city in northern England and the average age of death of patients registered with us is only 43 years old.

Our practice is a specialist Inclusion Health service. The young age of death of patients registered with us is typical of severely socially excluded groups in the UK; research has shown mortality rates that are 8 times higher than the general population for men and 12 times higher for women.1 It is both a source of hope and frustration that many of these premature deaths are from preventable and treatable conditions.2 

We recently discussed the case of Mr B. He had experienced homelessness intermittently over the past 5 years and had been both sleeping rough and staying on various friends’ sofa prior to his admission to hospital with a severe exacerbation of chronic lung disease. He spent two days in hospital before being discharged back to a friend’s sofa. He died 48 hours later, aged 45, before the practice had even received his discharge letter.

The circumstances surrounding the death of Mr B are not unusual. A Freedom of Information Request to hospital trusts in England in 2024 showed that at least 4,200 people were discharged from hospital into homelessness in the preceding year.3 At the annual international homeless and international health symposium in March, Dr Elspeth Carruthers presented research that analysed coroners reports to identify factors contributing to preventable deaths of people experiencing homelessness in the UK.4 The cause that came up the most frequently was inadequate discharge arrangements from institutions, including: a lack of consideration for safe and suitable accommodation; failure to notify appropriate agencies or individuals about discharge arrangements; and a failure to follow discharge policies and statutory duties.

We are currently standing at a crossroads; at the end of 2025 the UK Government recognised the vital role played by the NHS in addressing homelessness and made a commitment to end the unacceptable practice of discharging people from hospital to the streets. Thanks to the work of Pathway, multiple research teams and all those involved in the creation of NICE Guidance 214, we know the steps needed:

  • We know that step-down intermediate care services can provide the safe, short-term accommodation and support needed for someone experiencing homelessness to recover after a hospital admission.5  
  • We know that specialist, multi-disciplinary hospital homeless teams integrating clinical and housing expertise can improve continuity of care post discharge and address issues such as early ‘self-discharge.’6  
  • We know that we need to remove the many barriers to accessing health care felt by people experiencing homelessness.7 
  • We know that more needs to be done to challenge the stigma still faced by people experiencing homelessness when accessing health services.8 
  • We know that involving people with lived experience of homelessness in co-designing services can improve the quality of health and social care.6 

At the annual symposium in March, we were able to share a very different story to that of Mr B.9 Miss K was in hospital for a leg amputation. A thorough assessment by the admitting clinician had identified that Miss K was experiencing homelessness. She was then referred to the Pathway Homeless Healthcare Team. The lead nurse and housing support worker from the team were able to be involved early in planning Miss K’s discharge. When a bed became available at BRICSS (Bradford Respite and Intermediate Care Support Services) she was discharged with a package of care ready. BRICSS is a partnership between Bevan Healthcare and Horton Housing Association. It has 13 self-contained, furnished rooms, homely communal spaces and is staffed 24 hours a day. The service provides essential short-term support for people experiencing homelessness who have healthcare needs, but who do not currently need inpatient hospital care. People can be referred as a ‘step-down’ from the hospital or as a ‘step-up’ from the community. Residents benefit from regular input from a range of visiting services, including occupational therapy, health psychology, nursing, drug and alcohol recovery services, care services, adult social care, and a weekly GP ward round which I have had the privilege of contributing to over the past 10 years. The service offers a vital opportunity for residents to stabilise their health while working towards personal goals such as securing independent accommodation. Reflecting on her stay at BRICSS, Miss K shared with us:

“If it wasn’t for BRICSS, then I wouldn’t be where I am now. I have a bungalow, I have savings, I’m completely off drugs, I love feeding the birds, gardening and nature. I have started to be fully committed to physiotherapy and working on using a prosthetic leg. I haven’t lived a normal life for years and now I am on that journey.” 

The annual homeless and inclusion health symposium this year provided an opportunity to celebrate Pathway’s successful influence on the Government’s National Plan to End Homelessness and specifically their commitment to ending discharge to the street and promoting the use of Better Care funding for homeless intermediate care. Stories like those of Miss K can illustrate the personal benefits of these plans, but the scale of the benefits are also demonstrated through research. A recent evaluation on hospital discharge for patients who are homeless showed that step-down intermediate services like BRICSS are associated with a significant reduction in subsequent hospital use.5 A 2024 cost-benefit analysis found that investment into a national programme of homeless intermediate care services would result in a financial benefit of £1.20 and societal benefit of £4.30 for every £1 spent.10 There are clear benefits to scaling up intermediate care services alongside specialist hospital in reach teams, but commitments alone are not enough. Whether we see many more deaths like Mr B’s, or whether we take a better path supporting journeys to recovery like Miss K’s, will depend on action, adequate resources and political will. 

References

1. Aldridge RW, Story A, Hwang SW, Nordentoft M, Luchenski SA, Hartwell G, et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet. 2018;391(10117):241-50. doi:10.1016/S0140-6736(17)31869-X. 

2. Aldridge RW, Menezes D, Lewer D, Cornes M, Evans H, Blackburn RM, et al. Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England. Wellcome Open Res. 2019;4:49. doi:10.12688/wellcomeopenres.15151.1. 

3. Bancroft H. Clutching morphine and sheltering in a bus stop: the NHS patients sent from hospital to the street. The Independent [Internet]. 2024 Mar 17 [cited 2026 May 22]. Available from: https://www.independent.co.uk/news/uk/home-news/homeless-nhs-hospital-discharge-beds-rough-sleeping-b2507850.html 

4. Carruthers E. Preventable deaths of people experiencing homelessness: analysis of Prevention of Future Deaths reports. [conference presentation]. Pathways from Homelessness 2026: Shift to Inclusion, 15th Annual International Homelessness and Inclusion Health Conference; 2026 Mar 18-19; London, UK. 

5. Cornes M, Aldridge RW, Biswell E, Byng R, Clark M, Foster G, et al. Improving care transfers for homeless patients after hospital discharge: a realist evaluation. Health Soc Care Deliv Res. 2021;9(17). doi:10.3310/hsdr09170. 

6. National Institute for Health and Care Excellence. Integrated health and social care for people experiencing homelessness. NICE guideline NG214 [Internet]. London: NICE; 2022 Mar 16 [cited 2026 May 22]. Available from: https://www.nice.org.uk/guidance/ng214 

7. Armstrong M, Shulman C, Hudson B, Stone P, Hewett N. Barriers and facilitators to accessing health and social care services for people living in homeless hostels: a qualitative study of the experiences of hostel staff and residents in UK hostels. BMJ Open. 2021;11(10):e053185. doi:10.1136/bmjopen-2021-053185. 

8. Reilly J, Ho I, Williamson A. A systematic review of the effect of stigma on the health of people experiencing homelessness. Health Soc Care Community. 2022;30(6):2128-41. doi:10.1111/hsc.13884. 

9. Ashwell G, Nicholson H. Breaking Barriers, Building Care: Lessons from Ovre Ten Years of Homeless Intermediate Care in Bradford. [conference presentation]. Pathways from Homelessness 2026: Shift to Inclusion, 15th Annual International Homelessness and Inclusion Health Conference; 2026 Mar 18-19; London, UK. 

10. Alma Economics. Intermediate care for people experiencing homelessness: cost-benefit analysis [Internet]. London: Pathway; 2024 Oct [cited 2026 May 22]. Available from: https://www.pathway.org.uk/app/uploads/2024/11/Pathway-Intermediate-care-for-people-experiencing-homelessness-A-cost-benefit-analysis.pdf