The hospital taking direct action on treating homeless people

Homeless people admitted to A&E are often twice as sick as the general public and cost eight times as much to treat. Has one hospital found the solution?

After 12 hospital admissions in the past four years alone, Gary Spall – a heroin addict for the past two decades – can sum up his life with devastating conciseness. “Hostel, drugs, hospital. Streets, drinking, hospital. Prison, street, hospital,” he recites in a soft, level voice. “I always ended up in hospital. The doctors and nurses did their best, but people like me aren’t easy to fix. You can patch us up medically but the real problems are all the other things wrong in our lives. Take me, how can you easily help someone with drug and mental health issues, who’s chaotic, defensive and runs away or relapses when things get difficult?”

As Spall admits – and hospital staff privately acknowledge – long-term homeless people are not easy to help. It is an open secret in A&E departments and inpatient wards that there is often a lack of compassion among staff for people like Spall. With complex physical and mental health problems, exacerbated by drug or alcohol misuse, they are often considered as having brought their problems on themselves.

“We do make it difficult to help us,” admits Spall. “We go back on the drugs. We go awol. We don’t like explaining ourselves or asking for help. If pushed, we flip out. Doctors and nurses don’t know how to deal with us, so they fix us medically then chuck us back out on the streets. It’s understandable, but it means it’s only a matter of time before we end up back at A&E, at death’s door. I must have cost the health service a fortune over the years.” He pauses and pulls his baseball cap down further over his eyes. “It’s embarrassing how much I must have cost them.”

The financial demands that patients such as Spall place on the NHS are, indeed, substantial: rough sleepers and those in hostel accommodation attend A&E six times as often as those with a home. They are admitted four times as often, and stay twice as long – not, research shows, because they have nowhere to move on to but because they are twice as sick. The result? Hospital care that costs eight times that of the housed population.

As difficult as they are to help, the economic justification for targeting this most hard-to-reach of groups can be boiled down to two simple facts: there are around 40,500 homeless people in England, and altogether they generate secondary care costs of £85m a year.

Finally, a new project has grasped the nettle. It’s Thursday, and in a small room at University College hospital (UCH), London, a group including social workers, mental health teams, drug and alcohol workers, discharge liaison teams and housing specialists are painstakingly tailoring personal, multi-agency care packages for each homeless patient in the hospital.

Using information gleaned during specialist ward rounds – led by a GP, nurse team and peer mentor, all of whom have expertise in homelessness – the group carefully untangles each patient’s complex web of needs, identifying their inpatient requirements and drawing up a structured plan of discharge and long-term follow-up and support to help them return to, and remain in, the community.

This is the London Pathway for Homeless Patients, a service for homeless patients at UCH, funded by University College London hospitals NHS foundation trust charity, NHS Camden and NHS Westminster. It is the brainchild of professor Aidan Halligan, director of education, UCH; Nigel Hewett, a GP who specialises in homelessness and substance misuse; and specialist nurse Trudy Boyce. The project is the first to offer homeless and rough sleeping patients a fully integrated, “whole person” package of long-term care.

“The problem with the social care system as it stands, is that it is adversarial,” says Hewett. “The onus is on the individual to demonstrate they have the right to support. With shrinking budgets, there’s an increasing trend in housing departments and social service departments – both of which work to different definitions of entitlement – engaging in ‘gaming’: looking for ways in which individuals don’t meet with their criteria.”

While there are many good primary care services for homeless people, they struggle to connect effectively with the hospital sector. Once a homeless person is admitted to hospital, Hewett acknowledges the quality of care is variable: homeless patients are repeatedly readmitted and discharged without proper planning or discharge themselves, with little – if any – coordination with other agencies.

One of the most innovative components of the London Pathway structure is the creation of a “care navigator” role. Formerly homeless themselves, they guide homeless patients through what can often be a scary and alien experience, and play a key role in the follow-up care, post-discharge.

“With a care navigator on the ward round no one can say, ‘You don’t know what it’s like,'” says Boyce. “There is an immediate rapport and a recognition that the team is there to help them get what they need from the hospital stay. The care navigator [who works for a six-month attachment] gets experience of the workplace, work experience for their CV, as well as training and support. The team benefits by being kept grounded, and by effectively having a service user representative with us all the time to check that we don’t tend to run the service for our convenience, rather than for the patient.”

Don Glass (not his real name), 55, has lost count of the times he has delivered himself to A&E, desperate for help. Brought to the hospital last week by a carer from a detox unit, Glass has a long-standing and deep leg ulcer – an infection that doctors fear could spread to the bones of his leg.

“I’ve been homeless, on and off, since I was 14,” Glass says. “I hit rock bottom a few years ago but even though I kept asking for help from hospitals and A&E departments, I was just passed around. I had no sense of self-worth. I didn’t feel able to complain. I didn’t feel I deserved to be treated better. I’d more or less decided life wasn’t worth living any more.”

A chance self-referral to the A&E department at UCH put him in contact with the London Pathway team. “They took control of everything,” he says. “For the first time, I was being treated with humanity and being listened to. I heard one of the specialist nurses spend all day on the phone getting my benefits and accommodation sorted. All day! When I saw how much she cared, I decided to give life another go. It’s still early days but I want to stay in the hostel and off drugs this time. It’s the first time anyone’s really cared about me, and it’s made me care just a little bit more about myself.”

In this age of spending cuts, however, personal stories count for little. Instead, new schemes such as the £100,000-a-year London Pathway must be able to make strong economic arguments to justify their existence. And according to the first in-house evaluation of its work, published today, the project is making a difference.

The audit found the London Pathway saves UCH at least £300,000 every year: vital reserves for increasingly hollow hospital coffers. The savings were generated by an average reduction in the time each homeless person stayed in hospital by 3.2 days. Stays longer than 30 days were also reduced from 14% to 3%. And 10 times as many patients left the hospital with multiagency care plans in place. Computerised databases were created to give A&E staff access to the care plans of homeless people with a history of repeated emergency admissions. It also increased the number of homeless inpatients being discharged with the official documents and other information required by local authorities to provide help with housing, GPs and community methadone treatment plans.

The project is getting noticed. It has just received a £400,000 grant from the Health Foundation charity to develop the model and adapt it for acute trusts across London and the UK. This follows winning the top prize last autumn at the Andy Ludlow Homelessness Awards – which promote innovation and good practice in tackling homelessness in London – when it beat five other shortlisted groups to £25,000.

The review findings have catalysed interest from government departments and other hospitals, including Royal London hospital and Brighton and Sussex university hospital trust. And Steve Field, chair of the government’s new health inclusion board to tackle chronic health problems among vulnerable people, recently visited to discuss what lessons could be learned.

But the team is not resting on its laurels: as well as working to replicate the scheme across London and beyond, it is seeking funding to build a 32-bed “sanctuary”: a collaborative venture between health, housing support and social care to provide intermediate care for around 16 weeks in the community for those well enough to leave hospital but not likely to cope in hostels or on the streets. The unit will also provide support for homeless former patients who are deteriorating but might yet be prevented from getting bad enough to necessitate another hospital admission.

For Spall, the project’s success is measured against a rawer backdrop. “I wouldn’t have lasted much longer on the streets,” he says. “But now I don’t want to die. I want to give something back to society. I want to get better so that I can become one of the scheme’s peer mentors.” He grins: “The thought of filling my days by helping others? Yeah, that makes me feel good.”