Transforming the lives of people experiencing homelessness in Westminster and across North West London through integrated team working

25 April 2022

Homelessness is an issue that Westminster, like many other towns and cities in the UK, has been confronting for decades. A destination of choice for a transitory population of tourists, casual workers, students and evacuees, Westminster also has a high proportion of rough sleepers and people needing temporary hostel accommodation.  There’s also the ‘hidden’ homeless - the term ‘sofa surfing’ doesn’t accurately convey the grim reality of having to sleep on a family or friend’s sofa because there’s nowhere else to go.

The brutal combination of cold nights, intense hunger, isolation and uncertainty, as well as the ever present threat of violence takes a toll on this vulnerable cohort’s mental and physical health. They are at a much higher risk of TB and other chronic and debilitating respiratory and cardiovascular health conditions, as well as serious mental health difficulties and disorders. It’s hardly surprising that drug and alcohol dependency are common coping mechanisms and that life expectancy rates are so low (43 for men, 45 for women).

Westminster already has a network of specialist services who are skilled at treating this population with complex needs. However the pressures of the pandemic galvanised our system efforts to ensure this vulnerable cohort were protected. The initial focus on Westminster is because this borough has historically experienced the highest levels of homelessness across all of North West London.

Pre-pandemic, there was no clear pathway for supporting any individual who found themselves homeless. However the first phase of the pandemic required an emergency public health response. The ‘Everyone In’ campaign resulted in a number of homeless hostel hubs being set up in hotels throughout North West London to ensure homeless individuals were successfully housed and cared for. Health teams working with partners were on hand to ensure their wellbeing was prioritised, with medical checks and vaccinations being an integral part of the process. This integrated care in practice approach proved extremely effective.

We know there are high stakes for an individual’s wellbeing post hospital discharge – sending them back on the streets not only increases the known risks to their health and safety, but increases the likelihood of costly repeat A&E attendance, known as High Intensity Use (HIU).  This aligns with recently published NICE guidelines on supporting people who find themselves homeless – they emphasise the effectiveness of an integrated care approach post A&E discharge.

Our own Homeless Health pilot scheme, which started in November 2021,  is a trauma-informed Pathways project that builds on the partnership work established during the pandemic by ensuring that no homeless person with a connection to the local area is discharged from hospital back onto the streets.

Our out of hospital blended care team is funded by the Department of Health & Social Care and consists of nurses, a GP, local authority hosted housing link workers, as well as specialist charities.  The team regularly meets to ensure they ‘work as one’ to provide the ‘wrap around’ support that is essential to supporting this vulnerable cohort. This collective effort between acute trusts, community providers (e.g. CLCH), VCS (voluntary and community sector), primary care (hosting GPs) and the local authorities who are hosting housing workers is proving successful and it’s hoped to replicate this model in the outer North West London boroughs, with the additional support of a team social worker.

The process starts while the homeless person is still in hospital. Following ‘duty to refer’ principles, the health team liaises with the council to see if they have a local connection to the borough. If so, they liaise with the housing team to make a housing assessment - this may include permanent or step down housing accommodation.

The homeless person also receives person-centred post-discharge community support, whether it be wound care from the team’s skilled community nurses, or a substance misuse referral to a specialist charity.

Groundswell is one of these specialist charities and they provide support workers to accompany the individual to all their discharge meetings and medical appointments. The seemingly straightforward process is paying dividends - it’s this winning combination of befriending and support that’s proving so vital in helping to prevent HIU.

One homeless individual who benefited from this approach, once a key worker himself, was so bolstered by the kindness and support shown to him by the team that he’s gone from feeling ‘lost’ and helpless, to having the strength to ‘fight for his life’.

A more complex case involves an individual in his forties with palliative care needs that involved alcohol-induced epilepsy, decompensated liver disease and a brain injury. Frequent attendance at A&E and several admissions meant his case was reflected in the HIU statistics. Now assigned in safe, temporary accommodation, the community nurses and his key worker work closely together to ensure his medication plan is on track, he attends his medical appointments and he receives specialist support from palliative and alcohol support services. He’s has also been referred to the dentist for tooth pain (drinking had provided a form of pain relief). This wrap around care and support means that he’s only been back in hospital once, for a booked outpatient appointment. 

The success of this work in Phase One is reflected by the figures. During an initial two month period, the inner North West London team has supported 102 patients, many high intensity users (HIU) with complex needs and tri-morbidities. Additional early outcomes include 19% of patients supported to register with a GP and 59% of cases under the care of a community-based care health care professional. Over 2022/23 the team has plans to support an additional 1,000+ people with experience of homelessness in hospitals. The teams are also driving broader change in local hospitals by upskilling staff with the confidence and knowledge to signpost to the Inclusion Health teams, therefore improving the access of this vulnerable cohort and their health outcomes. 

Although there are clearly significant fiscal savings, the most vital element of this work has to be the transformational effect on the lives of real people. A stable and settled life outcome is the project’s key goal and a clear indicator of success.

There are now plans for the project to be expanded and delivered to all eight inner and outer boroughs across North West London ICS, subject to additional funding. In the second phase this will help to address the surge in homelessness experienced by the population in Ealing, who often end up at Northwick Park hospital.

The commonality in both phases seems to be that integrated team working is the glue that’s proving to be highly effective at not just improving, but saving, lives.


NICE Guidelines: Overview | Integrated health and social care for people experiencing homelessness | Guidance | NICE

This short film shows the challenges faced by some people in accessing primary care:

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