The Royal London
From September 2014 the service has been funded by Tower Hamlets CCG and provided by Health E1-Homeless Medical Centre, a specialist primary health care service for homeless people, managed by East London NHS Foundation Trust. Funding beyond March 2015 is subject to the commissioning cycle. The service currently has funding for 4 GP sessions, 2 full time nurses and a part time administrator. Barts Health currently fund a social worker post seconded into the team and the London Borough of Tower Hamlets Housing Department commission a “Routes to Roots” service from Providence Row (based at the Dellow Day Centre) comprised of 2 housing workers who can support the team with rough sleepers and insecurely housed people without a local connection to Tower Hamlets.
For homeless patients with a local connection to Tower Hamlets the team is supported by Tower Hamlets Floating Support (Look Ahead) and THSORT rough sleeper outreach (Thames Reach). The team deals with around 900 admissions of homeless patients a year. The results of the randomised controlled trial are yet to be published, but are expected to show an improvement in health outcomes for homeless patients receiving Pathway care.
Brighton and Sussex University Hospital
Kings Health Partners
The Urban Village Medical Practice offers a comprehensive primary care service for 8,500 patients in the inner City, including 700 homeless patients.
They set up the mpath service in June 2013 with funding from Central CCG to improve patient experience and health outcomes for homeless people by working across primary and secondary health care boundaries. The service works with homeless people admitted to Manchester Royal Infirmary (MRI) and who frequently attended A&E. The service consists of one (whole time equivalent) GP, a nurse, a service manager, two case managers, and a housing worker.
During the first six months of Better Care funding the service worked with 216 of the 272 (79%) homeless people admitted to the MRI, achieving 43% fewer A&E attendances (down from 1089 to 618); 39% fewer non-elective admissions (down from 409 to 249); a 66% reduction in bed days (down from 3647 to 1211); and 39% fewer repeat admissions within 28 days (down from 409 to 248).
In 2016 the service audited the needs of homeless patients in the area, producing a comprehensive analysis with a series of recommendations for future services. The audit can be downloaded here.
The Team was launched in September 2013 and includes a clinical lead, a lead nurse and care navigators as well as GPs from the York Street practice who oversee sessions and hospital visits. The Team provides individual support to vulnerable homeless adults, offering medical and psycho-social support and timely, open discussions to help patients make their own decisions.
Delivering a citywide service, the Team visits patients in Leeds’ hospitals and at St George’s Crypt, a homeless charity supporting people living on the streets into accommodation. They support and help facilitate good discharge planning and ongoing care.
As part of its work, the Team also provides a Gypsy and Traveller outreach nursing service and visit Gypsy and Traveller sites and roadside encampments. With this, they provide support and facilitation to services that often struggle to engage with people who may not have a permanent address, and help those who may be transient to engage with health services.
The Bristol Homelessness Engagement Team is made up of staff from the NHS, Bristol City Council and St Mungo’s. The team work at the British Royal Infirmary, run by University Hospitals Bristol Trust. Lead practitioner Lucy Harrison has been leading the team since it started operating in January 2017. Council social care practitioners assess homeless ‘clients’ to see what they need and how they can be helped when they are ready to leave hospital. And St Mungo’s outreach workers then look to find suitable accommodation. This team was spearheaded by Dr Kate Rush, Associate Medical Director at the BNSSG CCG, which oversees the NHS in the Bristol area. Dr Rush formerly worked as a GP in inner city Bristol, mainly in substance misuse, and could see there was a need for homeless people to get timely help with all their needs after they presented in hospital.
The Hull Pathway team launched in October 2019. It is made up of one full time nurse, two GPs covering two GP sessions per week, and two full time Health Support workers. The service benefits from the fact that the staff were already known to the patients and other professionals in the Hull homeless sector from prior work association.
The Hull Pathway team also has two other health support workers who currently work in the Covid Protect facility and in the community.
The size of this team is an extension of the original contract. Hull CCG extended the Pathway team hours to cover extra community support, with a contract variation to extend the remit of the team. Hull CCG have been keen to develop a Brighton (Pathway plus) model where support is extended out into the community.
Pathway and Salford Primary Care Together Inclusion GP Service launched a new Pathway model intervention service into Salford Royal NHS Foundation Trust in July 2021.
Working alongside local homelessness charity Salford Loaves and Fishes, the team will provide a vital service to vulnerable and homeless patients in Salford.
Read a team case study here.
A new Pathway team at St George’s Hospital in south west London launched in November 2021.
Advisory support in the community works alongside GPs and other clinicians in the hospital Emergency Department to help put a stop to the cycle of hospital readmission of vulnerable patients. The new team will help to resolve housing and care issues as well as treating injuries.
The team is made up of a GP, a specialist nurse, a care navigator and two housing advisors.
North West London
A new Pathway team went live at the beginning of December 2021 in North West London.
The new inclusion health team is collaboration with Imperial NHS Trust, Chelsea and Westminster Hospital, St Mungo’s, Westminster Council, Central London Community Healthcare, Great Chapel Street Medical Centre, North East London CCG and North West London CCG.
This team has been fully co-designed, funded and developed in complete partnership and has GP, nurse, housing, and social work input.
The Croydon Pathway team launched in early December 2021.
The specialist inclusion health team, includes nurses, mental health professionals, GPs and supporting teams from Croydon Council, working together with those at risk of homelessness to find somewhere safe to live and to support ongoing health needs. Care navigators are also part of the team, and will be able to support patients by providing clean clothes and essential items and offer signposting to additional advice services.
The Homerton Inclusion Health Team launched in January 2022.
The team has been brought together in partnership with Homerton University Hospital, the City and Hackney Centre for Mental Health, NEL CCG, ELFT, Hackney Council and the Peabody Trust.
The team is made up of a GP, nurse, occupational therapist, social worker, peer link workers and a housing worker. The team work with specialist community support services and access step down accommodation.
The Homerton Inclusion Health team support and advocate for homeless patients, improve patient care, enable safe discharge and follow-up in the community. They also help to train hospital staff to identify homelessness, and host regular multi-disciplinary team meetings to ensure the ongoing progression of complex cases.
Referrals to the service are accepted from within the hospital, GPs, supported housing providers, local authorities or from people experiencing homelessness themselves.