The document sets out the health challenges experienced by marginalised groups such as people who are homeless, people who well sex, people from gypsy and traveller communities, and vulnerable migrants. It calls for the incorporation of values such as compassion and continuity of care to support integrated collaborative systems that improve patient outcomes.
The document has been endorsed by 14 medical Royal Colleges and health bodies, including the RCP, RCGP and RCPsych.
This unprecedented level of support demonstrates positive action towards the commitment made by the Academy of Medical Royal Colleges (A0MRC). In 2017 the AoMRC made a joint statement with The Faculty for Homeless and Inclusion Health pledging that medical Royal Colleges would support patients to improve their health, not only through medical treatment, but by providing advocacy, inter-professional working and engagement with public health.
Professor Dame Jane Dacre, past President of the Royal College of Physicians, said:
“Addressing the social determinants of health is an essential component of effective health care. New ‘duties to refer’ imposed by the Homelessness Reduction Act 2017 present a real opportunity for secondary care to contribute to integrated care, these standards explain clearly how to do this well.”
The launched, attended by 70 delegates included presentations and discussion from Professor Dame Jane Dacre, Dr Nigel Hewett OBE, Jon Sparkes CEO of Crisis, and Mo Elmi, an ‘Expert by Experience’ who uses his experiences of homelessness and health issues to train medical professionals.
Pathway were recently awarded a 15-month leadership grant from the Burdett Trust for Nursing to identify, network and support all nurses working across the UK in the emerging discipline of homeless hospital discharge.
Homeless hospital discharge nurses work in partnership with patients experiencing homelessness to achieve timely, holistic and compassionate assessment, treatment and discharge plans that improve health and housing outcomes.
Most of these nurses work in hospitals, although in many cases this is an in-reach intervention from community-based services. Some nurses work in Pathway teams, but many others do not. A small number of nurses that work to achieve better discharges for people experiencing homelessness are entirely based in the community.
The first clear reference to homeless hospital discharge practice was in 2003. A Department of Health document ‘Discharge from hospital: pathway, process and practice’ stated that all acute hospitals should have formal admission and discharge policies to ensure that homeless people are identified on admission, and that the discharge of homeless people should be notified to relevant primary health care and homelessness services.
Fast forward to 2019, and there are now around 25-30 specialist nurses in the UK directly involved in homeless hospital discharge (nearly all of whom have been involved in this project), and the NHS Long Term plan cited homeless hospital discharge teams (in this case a Pathway model team) as an example of good practice to reduce health inequalities.
Additionally, since October 2018, the Homelessness Reduction Act (2017) has now conveyed a ‘duty to refer’ on Accident and Emergency departments and inpatient settings for patients identified as experiencing homelessness, or being at risk of homelessness within the next 56 days. This requires patients to be referred to a Local Authority for support (with their consent). The hope is to focus acute hospitals on their responsibilities for safe discharge in this group. It may also result in the recruitment of more nurses into specialist roles.
Our Burdett funded project has revealed that homeless hospital discharge nurses need to be experts in clinical advocacy, patient empowerment, motivational interviewing, and health and housing rights. In addition, they need a broad clinical background in physical health, mental health and addictions and a good understanding of public health, and the concept of ‘making every contact count’, as well as an ability to gradually chip away to deliver systemic culture change. Having said that, to a large extent best practice has been developed locally by expert practitioners ‘doing the job’, and the evidence base is still limited.
Through shadowing and observation, interviews, and group workshops, the project has attempted to define the homeless hospital discharge nurse role clearly, including providing a breakdown of the knowledge, skills and experience required for the role with specimen job descriptions. An early vision for best practice has been defined, and local innovations have been highlighted. Continuing professional development needs have been analysed, and voluntary standards for practice are being developed.
Finally, and perhaps most importantly the project has helped the nurses to develop a shared vision of quality, and has defined this in terms of the value of a safe, effective and compassionate discharge, rather than by cost reduction per se (although the need to deliver efficiency has been taken into account).
The short report can be found here. The full report and resources developed on the project will be published and shared soon.
The Royal London Pathway team, who support homeless people in Tower Hamlets to live healthier, better lives, has today been awarded a top accolade in the prestigious NHS Parliamentary Awards.
Led by GP Dr Peter Buchman, the Pathway team has beaten the rest of the country to pick up the acclaimed Excellence in Urgent and Emergency Care Award.
Working at The Royal London Hospital and East London NHS Foundation Trust, the team were rewarded for their tireless work improving care for vulnerable homeless people.
The NHS Parliamentary Awards sees the NHS and MPs join forces to honour some of the biggest achievements in health and social care from across the country.
Dr Peter Buchman said:
“We are absolutely delighted to win this national award. People who are homeless often have complex needs, so they can require support from multiple agencies. We work in partnership with health, social care, legal and housing professionals to really help patients get onto a better pathway in life. Thank you for recognising the work of our small dedicated team.”
Jim Fitzpatrick MP, who represents Poplar and Limehouse, nominated the team. He said:
“I am absolutely delighted that the Pathway Homeless Team are the national winners in the NHS Parliamentary Awards. This is well-deserved and a great example of joint working between ELFT, Barts Health and the Clinical Commissioning Group to truly support homeless people who are among the most vulnerable in Tower Hamlets. Congratulations to everyone involved.”
The Pathway Team are based at The Royal London Hospital and has the ultimate aim of ensuring homeless people cared for by the hospital do not get discharged back to the street, but instead are found other options for housing, healthcare and ongoing support in the community. When an individual admitted to hospital is ready to leave, the team will work to arrange a smooth discharge to a safe place.
The team also encourage rough sleepers and people in temporary housing to register with a doctor at Health E1 Homeless Medical Centre in Brick Lane in Aldgate.
Simon Stevens, NHS England chief executive, said:
“It has once again been a privilege to celebrate with some of the extraordinarily dedicated and selfless health and care heroes who make the NHS what it is today – the much-loved institution that our patients say is what makes them most proud to be British.
“From those who have devoted their lives to helping people and supporting some of our most vulnerable, to delivering pioneering lifesaving treatments, the NHS Parliamentary awards are rightly honouring those who continue to make a huge contribution to our country, through our NHS Long Term Plan.”
The NHS parliamentary awards ceremony saw twelve winners honoured on Wednesday 10th July at the Palace of Westminster’s Terrace Pavilion, hosted by Dr Sara Kayat, NHS GP & TV Doctor.
Have you lived through homelessness, addiction, violence or abuse, sold sex or been involved in the criminal justice system?Or perhaps you are from a marginalised group, such as the gypsy and traveller community, or faced struggles after coming to the UK as a migrant or refugee.Most importantly, would you like the chance to take a free 6-week course at University College London (UCL)?
The health consequences of exclusion and practical responses
Social theories of exclusion
Women and inclusion health
Quantitative and qualitative research methods
Structural and legal factors
Service development and evaluation
The course is open to medical professionals, social care practitioners, hostel and housing workers, researchers and commissioners, but UCL is offering two free places for ‘Experts by Experience’ (EbEs) – people like you, who have lived through social exclusion and have extra insights that have come from real life, not just books and study.
You don’t need to have previous qualifications, and you don’t have to tell other students on the course about your experiences if you don’t want to, but you will need to write a short statement explaining:
why you should be given the ‘Experts by Experience’ rate
why you want to study the course, and
how it will further your career.
Please let us know if would like to apply, but cannot cover travel, food and stationery costs, and we’ll do our best to help.
Stan took the course as part of his role leading EbE inclusion for Pathway. He said:
“My education wasn’t the best, I left school with no formal qualifications. Taking part in the course was both challenging and rewarding. I was able to study as an equal for most part, but I got additional in good study practice and how to focus.The teachers ranged from acclaimed academics to people with lived experience of homelessness and exclusion. I’d recommend this course to anyone. If I can pass from a standing start then imagine what you can achieve.”
Bean took the course in 2018. He’d never studied at university level before. He passed and successfully applied for a new job as an outreach worker with an infectious diseases unit. He said:
“Doing this course had a direct impact on the type of work I do. It gave me the confidence to apply for a new job, which is a step up in my, admittedly late, career path. I would recommend it to everybody no matter what their job or interests.”
“Getting access to a dentist when you’re homeless can be hard. Tooth pain is pushing homeless people to desperate measures, like trying to pull out their own teeth. Nobody should suffer this way. Today will help dentists across the Midlands to develop skills to help the people who need it most”
Homeless health charity Pathway ran a pilot project, restoring smiles to homeless people. Stan Burridge was homeless for many years, he developed, managed and participated in the scheme, which he described as ‘life changing’.
“The biggest difference for me has been food. I had to cut it into small pieces that I could swallow whole, it’s embarrassing, and not being able to chew impacts on the taste. Now I have a full set of dentures. Having false teeth isn’t perfect, but as least I can enjoy eating, and I can chew most things.”
Stan will be presenting at the conference, presenting his work on supporting homeless people who are frightened of dentists. The day also includes sessions on helping people who have been sexually abused, and chance to meet former British Dental Association Chair, Janet Clarke MBE to discuss starting new services.
‘Homeless and Inclusion Oral Health’ takes place on 23 November 2018.
Researchers have launched an online toolkit to help hostel staff identify and support homeless people who are facing death.
www.homelesspalliativecare.com will give hostel staff caring for terminally ill homeless patients high quality information and advice with guides, tools and activities to help plan care and provide support.
The free resource was created by a partnership between Pathway, Marie Curie Palliative Care Research department (UCL), St Mungo’s and Coordinate My Care.
The group’s previous report, published in Palliative Medicine, revealed that hostel staff often care for homeless people with terminal conditions and complex needs, despite not having palliative care training. They face huge emotional and physical burdens with minimal support and limited resources.
In response, the team developed a two-day training course for hostel staff, recently published in Nurse Education Today. The course was tested with staff at London homeless hostels, and improved their confidence and knowledge.
However, the team’s work has shown that training sessions aren’t enough, the next stage of the project will explore new models of training and support.
Dr Briony Hudson, Marie Curie Palliative Care Research Department at UCL, said:
“The deaths of homeless people are often perceived as sudden, untimely and undignified. This can be very traumatic for everyone involved, especially hostel staff, as they are often left to support people who are very unwell, even when they have high care needs, due to a lack of suitable alternative places to live.”
“One of the reasons homeless people are dying without support is that they are not recognised as having a terminal illness. Throughout this toolkit we suggest that concern about a client’s deteriorating health should act as a trigger for action, rather than waiting for a palliative or terminal diagnosis. We hope this resource will be helpful in supporting homeless people.”
Alex Bax, Chief Executive, Pathway, said:
“Pathway is delighted to have hosted this hugely important work, helping to improve care for seriously ill homeless people facing the end of life. We hope this new toolkit will help the many services that work with homeless people to at least improve the quality of care and support provided to people who have had faced a traumatic and often foreshortened life. At the very least a civilised society should seek to provide dignity in end of life for people who have had so little before.”
Professor Bee Wee, Consultant in palliative medicine at Oxford University, commented:
“I’m absolutely delighted to welcome this online resource, which supports staff working to support people who are homeless who are entering the last stages of their lives. It is a truly valuable contribution to our collective efforts to improve palliative and end of life care for all.”
The research was funded by The Oak Foundation and hosted by Pathway, with support from Marie Curie, St Mungo’s and Coordinate My Care. The online toolkit was funded by a grant from UCL Innovation and Enterprise.
Simon Jones, Director of Policy and Public Affairs at Marie Curie, said: “Dying in familiar surroundings, in comfort, with dignity and with those we love and who love us is what we want for our own deaths and those close to us. Sadly, very rarely is this something that someone who is homeless will experience. There is no reason why a homeless person should not have compassionate care at the end of their lives and a dignified death – this resource brings us one step closer to making this happen.”
Howard Sinclair, St Mungo’s Chief Executive, said: “It’s now a decade since St Mungo’s began the first palliative care service in the homelessness sector, working alongside Marie Curie. We recognised a need to support clients to make informed choices about their care, as well as supporting staff and other clients affected by someone close to them approaching the end of their life.
“This new toolkit brings together essential expertise from across the homelessness and health sectors, ensuring people approaching the end of their life will be treated with the dignity and respect they are due. I hope this resource is in itself a legacy to those who have died, and to what we have learnt from them about loss, bereavement and improving our care for the future.”
Notes to Editor
About the research
The objective of the research was to pilot and evaluate the impact of a two-day training course for hostel staff around supporting homeless people with palliative care needs.
21 frontline staff from two London homeless hostels took part in the training – pre and post training data was collected.
The training was found to be useful for improving knowledge, confidence, openness and work-related stress. However, one-off training isn’t enough.
In response, the team developed an online toolkit to share resources and information which can be accessed at homelesspallaitivecare.com
Next steps of the project include building communities of support for frontline homelessness and health staff – exploring ways to embed training into routine practice for staff by developing links between local palliative care, primary care and homelessness services to better support staff consistently and promote multi-disciplinary working.
Pathway works to improve healthcare for homeless people. The charity has helped the NHS to create 11 homelessness teams in hospitals across England, supporting over 3000 patients every year. Pathway also develops models to facilitate improvements in patient care, carries out research in new and developing areas, provides training for healthcare professionals and supports specialist commissioning. Pathway also hosts The Faculty for Homeless and Inclusion Health, a network of over 900 health and social care professionals providing support for homeless people, vulnerable migrants, gypsy and traveller communities and people in the sex industry.
About St Mungo’s
St Mungo’s provides a bed and support to more than 2,600 people each night who are either homeless or at risk of homelessness. As a charity and housing association, we work to prevent homelessness, through more than 250 projects including emergency services, supported housing, specialist physical and mental health services and advice, skills and work services. We believe everyone should have a place to call home and be able to fulfil their hopes and ambitions.
About Marie Curie
Marie Curie is the UK’s leading charity for people with any terminal illness. The charity helps people living with a terminal illness and their families make the most of the time they have together by delivering expert hands-on care, emotional support, research and guidance.
Marie Curie employs more than 2,700 nurses, doctors and other healthcare professionals, and with its nine hospices around the UK, is the largest provider of hospice beds outside the NHS.
The Marie Curie Palliative Care Research Department at UCL is an internationally recognised centre of research with a team of over 20 full-time researchers. The department receives core funding from Marie Curie and also undertakes research funded by the National Institute for Health Research (NIHR), the Alzheimer’s Society and other research funders. The department has particular research strengths in the areas of palliative care for people with dementia, prognostication in advanced cancer and the management of cancer-related fatigue.
Pathway has introduced the first dedicated digital health-screening template to help health services supporting homeless people.
Following two years of development with EMIS Health, the template is now available free of charge to organisations using the EMIS Web clinical system. It was supported by 11 specialist homeless healthcare services for use by 200 staff.
Developers aim to roll the template out across the UK, and hopes it will ultimately relieve pressure on hard-pressed hospital departments.
The template enables doctors and health workers to create and maintain a detailed picture of a homeless person’s health, capturing vital information including clinical history, mental health and addiction issues, as well as details on housing and financial status. The template utilises national clinical coding and is ‘SNOMED CT ready’.
In the past hospitals were using different codes and record systems, resulting in inconsistent record-keeping, that meant some homeless people were not receiving the best treatment.
“Homeless people are five times more likely to attend A&E and four times more likely to be admitted to hospital than the housed population. The template will enable doctors to see patients’ health priorities, provide more effective treatment and help relieve pressure on the NHS by reducing bed days and treatment costs”
She says it will also enable the NHS to accurately track and analyse illness and infection rates amongst the homeless population: “The template will make it much easier to commission large-scale health services, treating patients who are homeless more effectively, economically and on a much larger scale. It has the potential to be a real game changer.”
Mo became homeless after being seriously injured in an accident. A year on, he is safely housed and helped Pathway with developing the template. He said:
“Comorbidities hurt patients and cost the NHS a great deal of money, so it’s important that we capture and use data in ways that really help people. Having my health record follow me would have made diagnosis and treatment quicker, and it probably would have saved the NHS money too.”
Dr Shaun O’Hanlon, Chief Medical Officer at EMIS Group said:
“We have a long-standing relationship with Pathway and were pleased to offer our expertise free of charge to help create this vital template. With homeless people statistically 10 times more likely to die early than the rest of the population, there is a real need for this vulnerable group to receive specialist help, and this template will assist clinicians in driving up standards of care.”
A collaboration of dentists, dental organisations and homelessness charities (including Pathway, Groundswell, Streets Kitchen, Den-Tech and Dentaid) have published a response to an article in the Guardian in which people experiencing homelessness were described by Mick Armstrong, who chairs the British Dental Association as “no hopers” in the context of the current NHS contract.
The letter is a reassurance to both the public and people experiencing homelessness that despite frustrations about the current dental contract there is hope and that good work is taking place across the country through a range of innovative initiatives to provide accessible care for vulnerable people.
In a recent article published in the Guardian, the head of the British Dental Association referred to people experiencing homelessness as “no hopers” in the context of current dental commissioning. We—a coalition of members of the dental profession, dental charities and homelessness outreach organisations—strongly reject the message that this article is sending to vulnerable individuals and the wider public.
The chaotic and dangerous nature of homelessness can make it difficult for individuals to be at a certain place at a certain time. This is not a failing to be condemned, but a challenge to be met: it is our professional responsibility to make services more easily accessible to the growing number of vulnerable people in our society.
Commissioning models need to be sufficiently flexible to embrace innovative approaches to providing high quality care to those most at need. Good examples include Community Dental Services who provide dental care for homeless people at multiple locations across the country.Based in Plymouth, Peninsula Dental School offers free dental care at four locations, and supports dental students to provide outreach advice at local homeless shelters. Den-Tech provides same-day denture services for people experiencing homelessness. In Manchester, Revive Dental Care offers drop-in dental clinics for vulnerable people. Dentaid holds free monthly clinics in Southampton and their ‘mobile dental unit’ visits night shelters and soup kitchens around the country.
Instead, we should marry lessons learned in these contexts to resources available within the NHS, and push for greater inclusion at all levels: policy, commissioning, education, training, service design, and inter-professional collaboration.
Until then, we will continue to share experience and resources, establish new partnerships, and innovate in delivering services to members of our society whose requirements are not easily met by existing structures. We believe strongly that there is hope.
Janine Doughty, University College London / Pathway Homeless Healthcare Charity / Crisis at Christmas Dental Service Deputy Service Organiser
Jon Glackin, Streets Kitchen
Matt Downie, Director of Policy and Social Affairs, Crisis
Professor Andrew Hayward, University College London / Pathway Homeless Healthcare Charity
Professor Ruth Freeman, University of Dundee
Vanessa Muirhead, Clinical Senior Lecturer, Barts and the Royal London School of Medicine and Dentistry
Jack Monroe, Author
Martin Burrows, Groundswell
Al Story, UCLH Find and Treat Service Lead
Natalie Bradley, Community Dental Service
Ben Atkins, Revive Dental Care
Janine Brooks, Director of the Dental Coaching Academy
Stan Burridge, Pathway Experts by Experience Lead
Fiona Ellwood, Patron of Society for British Dental Nurses
Nicholas Ransford, Clinical Director of Birmingham Community Dental Service
Jill Harding, Dentaid
Laura Daly, DCT2 in dental public health
Professor Christophe Bedos , McGill University, Montreal
Frances O’Leary, DCT3 Paediatric dentistry
Pippasha Khan, Dental student, Kings College London
Andreas Johnson, Chair of Den-Tech Denture Charity
Professor Blanaid Daly, Professor in Special Care Dentistry, Trinity College Dublin
Renato Venturelli Garay, Research Assistant UCL
Sara Harford, Clinical Fellow
Nadia Khalique, Dental Hygienist / therapist
Holly Bretel, StR in Special Care Dentistry
Mehdi Yazdi, Principal dentist Crown Bank Dental practice
Jo Dick, Registrar in Special Care Dentistry
Deborah Manger, Deputy Medical Director & Specialist in Special Care Dentistry for NHFT
Zana Khan, GP in homeless and inclusion health
David Conway, Professor of Dental Public Health, University of Glasgow
Caoimhin MacGiolla Phadraig, Special Care Dentist, Dublin Dental University Hospital
Esther Stephenson, Dental Core Trainee in Oral and Maxillofacial Surgery
Neil Martin, Specialist in Special Care Dentistry/DCT East Anglia Training Programme Advisor
Samina Nayani, StR Special Care Dentistry, Kings College Hospital
Alexander Holden, University of Sydney
Nahush Shah, Senior Registrar in Orthodontics / Service Lead for Crisis at Christmas
Dorothea Hackman, Euston Foodbank
David Croser, General Dental Practitioner
Rob Whitton, Peninsula Dental School
Martha Paisi, Peninsula Dental School
Serena Luchenski, NIHR/HEE Clinical Research Fellow and Honorary Public Health Consultant
Mili Doshi, Consultant in Special Care Dentistry
Laura Gartshore, Senior Lecturer and Honorary Consultant in Paediatric Dentistry
Maryam Ahmadyar, Community Dental Officer
Councillor Ruth Rosenau, Stoke
Matthew Turtle, Museum of Homelessness
Art Hindocha, Senior Registrar in Orthodontics
Jessica Turtle, Chair of Trustees, Simon Community
Gabriel Galia, Wellcome Clinical Research Career Development Fellow
Daniel Stone, Labour Councillor for Stroud Green, Haringey
Jackie Bird, Director of Joanna Project
Andrea Rodriguez, Senior Research Fellow – Homelessness (Advocacy and Policy) Smile4life Programme
Norma Smart, Specialist in Special Care Dentistry
Sam Joseph, Street Vet co-founder
Jade Statt, Street Vet co-founder
Melissa Scott, Service Lead, Homeless Health Service, Bournemouth
Rachel Cullen, Simon Community
Bhavik Patel, Integrated Clinical Fellow, Northamptonshire Healthcare NHS Foundation Trust
Brooke Zaidman, SpR in Special Care Denistry
Jenny Lawson and others, Nag’s Head Solidarity Centre Womens Group
Garima Arora, Research Assistant, University of Dundee
Paul Jackman, Still Human Outreach
Nikki Kenyon, Manchester: Life On The Streets
Louise McTernan, Outreach worker Manchester
Derek Richards, President British Association for the Study of Community Dentistry
It’s a lucky day for three homeless health services, who have been shortlisted for prestigious Nursing Times Awards.
Pathway homeless hospital teams at Bristol Royal Infirmary and Bevan Healthcare CiC in Bradford will be going head to head in the HRH Prince of Wales Nursing category, whilst Pathway’s Nursing Fellow is up for the Technology and Data in Nursing award.
People experiencing homelessness often have serious physical and mental health problems and are more likely to face difficult and sometimes life-threatening illnesses such as tuberculosis, Hepatitis, epilepsy, heart disease, stroke and asthma.
Pathway helps hospitals to set up teams to support homeless patients during their admission, and make sure they have somewhere safe to sleep when they are discharged, help with financial and legal issues, links to day centres and support services and clean clothes and toiletries.
Dr Nigel Hewett, Medical Director of Pathway said:
“Nurses play a key role in homelessness teams and change the lives of patients who are homeless with their compassionate care and clinical excellence. We’re incredibly proud of the teams who have been shortlisted and look forward to some friendly rivalry on the night.”
The team braved one of the hottest days of the year and took to the streets of east London, finishing the challenge and raising a whopping £765 to help seriously ill homeless people.
Pictured here with Pathway CEO Alex Bax (who met them at the finish line!), the team has raised enough to provide 50 homeless hospital patients with ‘dignity in care’ kits, including toiletries and pyjamas for their hospital admission, travel tickets to a safe bed once a Pathway team has arranged one, and a duvet and pillows to help them set up in a new home.
Stan was homeless for 20 years, and now helps formerly homeless people to be part of Pathway’s work. Stan said:
“Being ill, alone and in hospital was one of the scariest experiences I faced when I was homeless. Knowing that someone cares really helps. This donation will make such a difference to so many people. Well done, and a huge thank-you to all of the runners and donors who took part and made this an amazing event.
Ruth Carnall, Chair at Carnall Farrar said:
“We are very proud of all our runners for completing the gruelling race and absolutely delighted that the money raised by their efforts will be going to such an important and worthy cause.”