LTP Priority: Inclusion health groups – homeless people and rough sleepers
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: Pathway (GP-led in-hospital management of homeless patients)
Major driver of health inequalities in your area of work
- People who are homeless experience ‘extreme health inequities’ and have standardised mortality ratios which are many times higher than the general population- homeless women have rates 12 times, and homeless men 8 times, those of the most deprived housed populations. They experience massively increased rates of health problems particularly: infections such as 90% for hepatitis C, 65% for hepatitis B, 51% for latent tuberculosis infection
- mental health problems e.g. 4% for schizophrenia
- cardiovascular conditions e.g. 13% for coronary heart disease
- respiratory conditions e.g. 26% for asthma.
People who are homeless, when compared to the housed population:
- attend A&E 6 times as often
- are admitted to hospital 4 times as often
- and stay 3 times as long when they are admitted
Multiple studies show a far higher prevalence of many conditions, in particular mental illnesses, self harm, alcohol and drug dependence, and chronic physical health problems (see National Center for Biotechnology Information and The Lancet).
The DHSC’s own estimate is that these health inequalities and the subsequent increased use of health services cost at least £85 million per year.
Currently only 10 UK sites have Pathway teams and the response to this group in other sites is highly variable, with some having no provision for the management and discharge of homeless patients at all.
Deprivation. Inclusion group: People who are homeless or rough sleepers.
Pathway (GP-led in-hospital management of homeless patients).
The Pathway model of GP-led hospital management homeless patients has been shown in a peer-reviewed published clinical trial to provide cost-effective improvement in patient outcomes, quality of life and housing status on discharge from hospital. Subsequent studies have also shown cost savings that vary depending on locality and study method.
The Pathway approach involves a multidisciplinary team, including part-time GP with experience in homeless health, full time nurse, and housing/engagement worker, identifying, supporting and planning discharge of patients who are homeless by interventions such as early application for housing on discharge, GP registration, benefits, plus connection with community support, mental health and substance misuse services when needed.
Ten UK teams currently exist, and Pathway has worked over the last two years to design and create a social franchise package of materials to guide, train and monitor new services from the initial stages of development, to recruitment and go live, through to creating an established team.
Pathway teams hold regular multi-disciplinary planning meetings involving community and hospital services improving joint working and co-operation and instigate a change in culture regarding the treatment people who are homeless, improving collaborative working across Primary, Secondary and Community care services, and large reductions in the number of people discharged to sleep on the street.
Health inequalities are reduced by improving the experience of hospital admission and treatment completion, planning ongoing community service follow up and support, registration with GP in the community, improved housing status, linking with alcohol and drug dependence services, mental health services, and in some cases help with returning to family or friends in other areas for increased social support.
The first Pathway team was launched in 2009 with rigorous evaluation built into each subsequent pilot, so that all current Pathway teams are now recurrently funded. The positive outcomes from these evaluations culminated in the Pathway approach being cited as best practice in a case study in the 2019 NHS long term plan, (p42).
The evaluations and outcome studies were all published. The citation list at the end of this section presents these studies chronologically, with the key findings. The wealth of published data supports three key benefits of providing a Pathway team.
- Pathway improves outcomes for homeless patients. Better health 90 days after discharge3, less rough sleeping3 and improved housing outcomes on discharge4,5,6 Pathway improves capacity in a busy hospital by reducing the average duration of admissions for homeless patients1,2,5,6,7, and by reducing subsequent A&E attendance2,5,8, and the number and duration of subsequent unplanned admissions expressed as total bed days1,2,5,7,8.
- Pathway is cost effective. This has been calculated using Quality Adjusted Life Years3, and also by comparing the costs of the team to the reduction in secondary care activity for involved patients7,9.
- Hewett N et al. A general practitioner and nurse led approach to improving hospital care for homeless people. BMJ 2012; 345:e5999. An observational study of the first Pathway pilot, this compared outcomes for homeless patients identified from hospital records (No fixed abode, hostel address or registration with homeless practice) for two years before the service began and two years after implementation. A 30% reduction in bed days was observed, with positive feedback from patients and colleagues.
- A review of the first 6 months of the pilot service. July to December 2013. Reporting outcomes for 100 homeless A&E frequent attenders showed a 47% reduction in A&E attendances, 48% reduction in admissions and 39% reduction in bed days
- Hewett N et al. Randomised controlled trial of GP-led in-hospital management of homeless people (‘Pathway’). Clin Med 2016;16(3):223-9. A two centre NIHR funded randomised controlled trial, at Royal London and Brighton and Sussex University Hospital. Quality of life scores (EQ-5D-5L) improved significantly in the intervention arm and quality-of-life cost per quality-adjusted life-year was £26,000. Street homelessness was reduced, the proportion of people sleeping on the streets after discharge was 14.6% in the standard care arm and 3.8% in the enhanced care arm.
- Evaluation of the Homeless Hospital Discharge Fund. Homeless Link. 2015. This study evaluated 52 projects set up with a one-off government grant. The table on p37 summarises the outcomes. Projects were of 3 broad types, housing link worker in the hospital, accommodation with link worker, housing and clinical staff working together in the hospital (Pathway). The Pathway approach demonstrated best outcomes with 93% discharged into suitable accommodation, 89% receiving health support on discharge, 92% receiving housing support on discharge and 23% readmitted within 30 days.
- Dorney-Smith S et al. Integrating health care for homeless people: the experience of the KHP Pathway Homeless Team. Br J Healthc Manag 2016;22(4):225-34. Using a comparison group of patients identified as homeless on hospital records before and after introduction of Pathway showed a 9% reduction in A&E attendances, and an 11% reduction in bed days at Guy’s and St Thomas’ and 56% of patients with improved housing status on discharge.
- Zana Khan, Sophie Koehne, Philip Haine, Samantha Dorney-Smith, (2019) “Improving outcomes for homeless inpatients in mental health“, Housing, Care and Support, Vol. 22 Issue: 1, pp.77-90. This study of Pathway in an acute mental health setting (South London and Maudsley Trust) showed 74% of patients had improved housing status on discharge. Comparison with a control group in the hospital has also shown reduced bed days (in press).
- Bristol Service Evaluation of Homeless Support Team (HST) Pilot in Bristol Royal Infirmary. Internal evaluation presented at Faculty for Homeless and Inclusion Health Conference March 2019. This evaluation compared outcomes for a control group of homeless patients identified from hospital records during the needs assessment, with the outcomes for patients seen by the Pathway team during the first 12 months. Results showed a 74.5% reduction in average duration of stay (11 to 2.8 days), 35.7% reduction in self-discharge, 62% reduction in re-admission within 28 days (132 to 50). Estimates of savings in secondary care costs were £921,300. Taking into account the costs associated with the team this equates to an overall saving of £766,300 annually.
- Wyatt L. Positive outcomes for homeless patients in UCLH Pathway programme; British Journal of Healthcare Management 2017 Vol 23 No 8: p367-371 This audit examined secondary care activity for homeless patients in the 90 days before and after contact with the Pathway team at UCLH. This showed a 37.6% reduction in A&E attendances, 66% reduction in hospital admissions and a 78.1% reduction in bed days.
- Gazey A, Wood L, Cumming C, Chapple N, and Vallesi S (2019). Royal Perth Hospital Homelessness Team. A report on the first two and a half years of operation. Schol of Population and Global Health: University of Western Australia, Perth, Western Australia. This evaluation demonstrates that the Pathway method is beneficial in other health care systems. Comparing secondary care activity for a year before and after contact with the Pathway team showed $7,302 cost savings per person, or $4.6 million in aggregate.