We must end the revolving door between homelessness and hospitals

People facing homelessness have five times the level of heart disease as the mainstream population and 10 times the level of chronic obstructive pulmonary disease. They are a third less likely to be registered with a GP. At the extreme end, this situation results in 1,474 deaths a year.

At Pathway, the homelessness and inclusion health charity, we believe it doesn’t have to be this way. We know from our work providing expert support to specialist hospital homelessness teams that evidence-based care, rooted in compassion and kindness, is not only more just and humane, but also more cost effective. The National Institute for Health and Care Excellence’s (NICE) 2022 homelessness guideline offers an array of efficient and effective good practice for policymakers and commissioners to choose from.

We believe that the most urgent place to start is by driving up the quality of hospital care for people facing homelessness and bringing an end to the inhumane and inefficient practice of discharging people from hospital to the street.

“The most urgent place to start is by driving up the quality of hospital care for people facing homelessness and bringing an end to the inhumane and inefficient practice of discharging people from hospital to the street”

A recent Freedom of Information request revealed that more than 4,200 people a year were discharged from hospital to homelessness. Anyone who has been in hospital knows that all you want afterwards is somewhere safe and warm to recover, and policy and funding for people with homes support this ambition. It seems unbelievable, then, that this basic comfort is denied to so many people in 21st century England, but the results are evident in homelessness services throughout the country.

People show up in day centres in hospital gowns. People try to manage wound care and new medication regimes on the street or in squalid temporary accommodation. People are recovering from cancer or stroke treatment while trying to find somewhere to sleep for the night.

All of this is not only miserable, but places further pressure on the NHS. People discharged into homelessness have two-and-a-half times the rate of emergency readmission of those who have homes.

There is a cost-effective solution. We are calling for the scaling up of hospital-based Pathway teams, and of specialist intermediate care for people who are homeless leaving hospital.

This form of step-down care, which has the backing of NICE, provides safe, short-term accommodation and support to someone recovering from a hospital admission, while helping them to access services such as GPs and find long-term accommodation. This supports their healing and recovery, and helps to free up much-needed hospital beds by preventing avoidable readmissions.

A recent evaluation of intermediate care for people facing homelessness in one county in England found a 56% reduction in A&E visits and a 67% reduction in emergency admissions. Pathway recently commissioned independent cost-benefit analysis of a proposed programme to roll out intermediate care nationally that shows every £1 invested returns £1.20 in financial savings and generates £4.30 in societal value.

The programme is estimated to deliver financial savings of approximately £5,200 per patient, including savings of £790 directly through the end of street discharge, and £4,400 through the reduction of delayed discharges.

“The number of street discharges means there is a major shortfall in provision, and, like all specialist healthcare services for people facing homelessness, funding for it often operates on a short-term basis, leading to endless piloting and short-term initiatives at the expense of long-term, sustainable change”

Multi-disciplinary homelessness teams, such as those of Pathway, also end homelessness and make better use of NHS resources. The number of bed days used by patients facing homelessness can fall by as much as 30% after a hospital trust introduces a Pathway team.

These services do exist in pockets of excellence. The award-winning Health and Homeless Bed Intervention service in Leeds, Gloria House in Hackney, and intermediate care services in Oxford and Brighton, and the network of eight Pathway teams, all show what is possible when local leadership and will combine to do things differently.

But these pockets are just that. The number of street discharges means there is a major shortfall in provision, and, like all specialist healthcare services for people facing homelessness, funding for it often operates on a short-term basis, leading to endless piloting and short-term initiatives at the expense of long-term, sustainable change.

The government has a major opportunity to end the revolving door between hospitals and homelessness through the Spending Review, a cross-government homelessness strategy and the NHS 10-Year Health Plan. Our cost-effective plan to scale up intermediate care and specialist hospital teams would end the harm and misery of street discharge, while saving the NHS money.

It would also achieve health secretary Wes Streeting’s prized shift from hospital to the community, and deliver the Ministry of Housing, Communities and Local Government’s ambition to reform the system and provide effective joined-up support. 

Getting homelessness spending right would benefit thousands of people a year, and make better use of precious public resources. It’s time to stop the madness.

Dee O’Connell, director of policy and programmes, Pathway