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Inner North West London

This Pathway team went live at the beginning of December 2021 in North West London. 

The Inner Northwest London team at Imperial College Healthcare NHS Trust went live at the beginning of December 2021 based at St Mary’s Hospital, Paddington.

The team currenty comprises a Team Lead (social worker), two Band 7 Nurses and two Housing Coordinators and will be completed this year by a third Housing Coordinator and a part-time GP. Community nurses are also being recruited to follow up patients after discharge when required.  

The team provides homeless health cover to three hospital sites (St Mary’s, Charing Cross and Hammersmith) and has a wide group of statutory and voluntary sector stakeholders across five boroughs who contribute to weekly multdisciplinary team meetings. 

It is a busy team with almost 100 referrals over the final quarter of 2023, of which two thirds were inpatients and over a third were verified rough sleepers.  They provide a remote advice and signposting service for most A&E referrals and more substantial face-to-face support to inpatients or high intensity users of A&E. 

They work with health (Dr Hickey Surgery, Great Chapel Street, Community Nurses), housing and social services (Hammersmith & Fulham, Westminster, Brent, Kensington & Chelsea), and the wider homelessness sector (St Mungos, Marylebone project, West London Women’s Service, the Passage, Crisis, CSTM) to ensure that hospital inpatients get the best possible health impact from admission and are linked into appropriate housing and health services on discharge.

Claire’s referral to the Inclusion Health Team was pivotal –they prevented her hostel from closing her bed space due to non-attendance and the team were able to support her in registering with a GP and accessing drug services in her area. 

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Read Claire’s story