Joined-up care in action

Author: Tom Hardie, Improvement Fellow at the Health Foundation
Joined-up care in action
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Every week across the country, homeless people are discharged from hospital back to the streets or an unstable housing situation. For many, hospital readmission is likely and death a real possibility, particularly in winter. Data from the Office for National Statistics (ONS) shows that in 2017, 597 homeless people died in England and Wales, a 24% increase since 2013. It’s a shocking example of how gaps in service provision make it harder to support people with complex health and social problems, and underlines the urgent need for holistic and integrated care.

This challenge is the focus of the ‘Pathways from Homelessness’ conference, at which Professor Stephen Powis, National Medical Director of NHS England, sets out the NHS’s plans to improve health care for homeless people in England. The event considers varied approaches, including the work of Pathway, a London-based charity that has developed a model of enhanced care coordination for homeless people who are admitted to hospital, which is being scaled up with support from the Health Foundation. Despite the challenges of bringing together services to support people with such complex needs, Pathway’s work shows that it can be done. In the process, it highlights some key ingredients for successful integration that can inform service transformation elsewhere.

Putting the right care in place

I saw this approach in action when I visited the Pathway team at the Royal Sussex County Hospital in Brighton. Led by Chris, a local GP, the team brings together a community nurse from Sussex Community NHS Foundation Trust, a key worker from the homelessness charity St Mungo’s, and an advocacy and discharge coordinator from Justlife, a health engagement charity. They aim to bridge the gap between hospital and community services by providing a dedicated service in the hospital and outreach to day centres, hostels and other community services.

When a homeless person arrives at the hospital, they are assessed by the Pathway team. This team then works with the homeless person to devise a treatment plan and register them with Arch Health CIC, a primary care service dedicated to addressing the health needs of homeless and vulnerably housed people in Brighton. The Pathway team work with the homeless person to start applications for housing and other benefit support. The team also work with hospital staff to ensure that homeless patients aren’t discharged until this care package is in place.

From the Pathway team’s small office, among posters advertising their services and the sleeping bags and jackets they hand out to people sleeping rough, I heard how the advocacy and discharge coordinator accompanies clients to the council’s housing department to help them through the final stage of the application process and ensure they get the housing support they need.

A shared commitment to work together

This is joined-up care in action. Through engagement, education, and leveraging the relationships built at the Royal Sussex and in the community, the Pathway team has convinced acute, community and social care services, as well as local charities, to become partners in the initiative. 

The team runs a fortnightly cross-sector review meeting with these partners to discuss the most complex cases, and each person contributes to deciding on the most appropriate action – from the community nurse and mental health advisor to the shelter manager.

The service also benefits from the support of the public, local politicians and Brighton and Hove CCG. The CCG funds Arch to run the Pathway team and provide city-wide leadership for the provision of integrated care for homeless people. It embodies a visible, shared commitment to work together. And it’s through this collaboration that Arch has been able to achieve an 8.9% reduction in A&E attendances and a 14.9% reduction in unplanned admissions among their registered patients since 2015/16.

Looking to the future

So far, the Pathway model has been adopted in 11 hospitals in locations with large homeless populations, and the charity is exploring the potential to scale it further through the Health Foundation’s Exploring Social Franchising programme.

Pathway’s experience of delivering integrated and holistic care shows that – when the right partners come together around a problem, develop a shared vision, agree to work together in a new way, and are given the resources and space to do so – success is possible.

As the English NHS moves towards creating integrated care systems, as envisioned in The NHS Long Term Plan, the lessons and insights from projects like Pathway’s are invaluable. Making better use of this and similar approaches to delivering more integrated and holistic services will be vital to improve the care and support that homeless people so badly need.

This article was first published by the Health Foundation.