Pathway was involved in the inception and commissioning of these teams through needs assessments and developing business cases, and in some cases training, implementation and guidance. Although Pathway are not currently commissioned to provide the ongoing package of direct support, data gathering and reporting that our Partnership Teams receive, these teams form part of the same network that we support through ongoing training and in specific areas via ad hoc funding.

The Pathway team at UCLH began work in October 2009. This was the first Pathway team, set up following a detailed needs assessment. Initial funding came from short-term CCG grants, followed by Health Foundation funding. Pathway funded a care navigator supervisor, one full time care navigator and two apprentice care navigators. Care navigators are people with lived experience of homelessness who provide individual care and support for homeless patients. In 2017 the team supported over 500 admissions each year. 

King’s Health Partners (KHP) is an academic health sciences centre which brings together three NHS Foundation Trusts with King’s College London University. 

The KHP Pathway team was planned and set up following a needs assessment funded by Guy’s and St Thomas’ Charity and carried out by Pathway in 2012. The service was launched in January 2014 with core funding from Lambeth and Southwark CCGs and benefiting from housing workers funded by the DH Hospital Discharge Fund. For the first year the team covered Guy’s and St Thomas’ and King’s College hospitals, and has now been fully commissioned by the local CCGs including the housing workers. From February 2015 the service was extended to the Lambeth and Southwark sites of South London and Maudsley (SLAM) Mental Health Trust, funded by money provided by Guy’s and St Thomas’ SLAM Charities for a three year pilot. The project is later planned to extend across the whole of SLAM. 

The clinical team consists of two GPs providing 11 sessions, two general nurses, one social worker, an occupational therapist, two mental health practitioners, 4.5 housing workers seconded from St Mungo’s Broadway, the Passage and St Giles Trust, and Peer Advocate support provided by Groundswell. In 2014 the team received 1,603 referrals from 1,414 patients. 54.5% of patients were no fixed abode on referral, and 69.7% of these improved their housing status on referral. Analysis from the first 6 months showed a 24% reduction in bed days. There have been a number of significant successes in terms of complex case resolution. 

The Royal London Pathway Team was launched in December 2011 as the first site of the two-centre randomised controlled trial of the Pathway approach, funded by the National Institute for Health Research. The trial ended in June 2013 and the service continued with short term funding from Barts Health and Pathway. 

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 rough sleeper outreach (Thames Reach). The team deals with around 900 admissions of homeless patients a year.

The Salford Primary Care Together (SPCT) Inclusion Service was launched in July 2021. The team consists of an Advanced Nurse Practitioner, GP and Case Worker, enhanced with the support of a Dual Diagnosis Practitioner and Housing Officer via the OOH care model project pathway.

The service benefits from the fact that it is embedded in the SPCT Inclusion GP Practice which is an enhanced offer of primary care, to support people experiencing homelessness and other vulnerable groups such as sex workers and the travelling community.

Bevan Healthcare CIC is a social enterprise providing primary health care for the most vulnerable groups in society, including homeless people, asylum seekers and refugees in Bradford. 

In November 2013 Pathway established the Bradford Bevan Pathway Team with two years funding from the DH Innovation, Excellence and Strategic Development Fund. The team consists of a full time nurse, a senior support worker and 3 GP sessions. Separate funding from the DH Hospital Discharge Fund has provided 14 step down beds in the Bradford Respite and Intermediate Care and Support Service (BRICSS), which has been an invaluable addition to the service. 

The Pathway Team at The Royal Sussex County Hospital, Brighton and Hove (part of University Hospitals Sussex NHS Foundation Trust) was the second site of the two-centre randomised controlled trial of the Pathway approach in 2012. Since then, funding has been taken over by the Sussex ICS. The team work as a collaborative in-reach team from ARCH Healthcare, Sussex Community Foundation Trust (SCFT) and Justlife.  

The service consists of 2 GP sessions and 14 nurse half-day sessions weekly,  a full time Team Co-ordinator, full time rough sleeper in A+E worker, and 1 half-day session of a weekend support worker. The service has provided the stimulus for other successful services locally including the expansion of the Justlife health engagement service, support workers who provide advocacy for homeless patients and  those placed in temporary accommodation in Brighton and Hove.  

The team works closely with the stepdown service run by YMCA Downslink at the St. Patrick’s and New Steine Mews supported accommodations, who between them, have six beds for people discharged from hospital needing extra recovery time but with no available accommodation. They have also developed close links with ARCH Healthcare Primary Care service and the Sussex Community NHS Foundation Trust Homeless Health Inclusion team, and a fortnightly Multi-Agency Homeless Health Meeting is held to discuss people who have recently been in hospital and community patients who are at risk of admission. 

The team see 400-450 patients per year, the vast majority of whom are discharged to accommodation.  

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. 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, where she could see there was a need for homeless people to get timely help with all their needs after they presented in hospital. 

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 (Manchester Pathway) 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 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 accessed below.