A chance to change

One in every five people at Plymouth’s Derriford Hospital emergency department is experiencing addiction or homelessness.

In many parts of the country a fragmented health and care system under extreme pressure sends these patients back to exactly the same life circumstances which led them to hospital – the inverse care law in full swing, the cycle continues.

In Plymouth the building of a new emergency department has helped provide better facilities, and more space, but even much-needed capital investment will ultimately be outstripped by demand without intervention where the reality of people’s lives leave them needing care. 

For the pathway team in Plymouth, a hospital attendance or admission is much more than just a statistic to add to the pile of need – it is an opportunity. This isn’t just a single episode of care, as the NHS is so set up to provide. It can be the beginning of a better story. Here, a team of specialists including a GP, an occupational therapist, a psychologist, a mental health nurse and a physical health nurse wrap care and services around patients attending hospital who are homeless or struggling with addiction.

‘We see this intervention as hopefully a step on the course to recovery – we learn the background, understand what the future needs to be and put that episode of care into context,’ says Ben Jameson, Plymouth GP and clinical lead for the local health inclusion pathway (pictured above).

It isn’t easy. There are never as many staff and resources as staff would like. It can be difficult to build relationships and trust with people who have so often been let down by society but the team gives staff a chance to forge those bonds. Dr Jameson says patients grow to know staff and often begin to listen to them and believe in them. 

For Dr Jameson, sending patients back to their trauma – unsuitable living conditions, addiction and isolation – is what motivated him to take on this role. ‘It was such a lack of curiosity,’ he says. ‘Discharging people with no plan, without checking their phone number or if they even have a phone.’

Dr Jameson recalls one case. It was a patient who had a dislocated shoulder, which could not be reduced in the emergency department. She was sent back to a tent with an abusive partner and told to come back to the crowded ED and wait for hours. When it wasn’t possible to treat her, the process began again. 

The pathway team, Dr Jameson says, is not just a solution to the problems facing a particularly vulnerable cohort of patients who are rarely advocated for, but also a means by which to help a struggling system and provide a standard of care which would benefit so many patients.

He says: ‘Although we’re focusing on the most vulnerable, if we get this right, we change people’s thinking, so they are thinking about the whole system and it’s right for everybody. We mess up care for the frail, older people, and other people who are excluded.’

Dr Jameson adds: ‘It’s a moral argument but a practical one, too. This is a practical solution to overcrowding, poor flow in hospitals, all those kinds of things. The morals can be what gets us out of bed in the morning but the practicalities are what are going to save the NHS. People should be biting their arms off to learn from pathway and to implement these teams in every hospital across the country.’

The Pathway charity, which supports the development and running of these teams at hospitals and in communities around the UK, has published a report which reveals the effectiveness of its model amid striking statistics showing homelessness rising to record levels.

The expert MDT (multidisciplinary hospital teams), which are part of the programme, have now supported 4,778 desperately sick homeless patients during 2024/25 who had been unable to get the right help before. Their figures show that their trauma-informed care reduced returns to rough sleeping by 62 per cent and sofa surfing by 33 per cent. These interventions, it says, save the NHS more than £9m a year and free up 13,000 bed days for other patients by reducing readmissions. 

The charity is calling for its specialist homelessness teams, which advocate for patients and join local services and support organisations together, to be ‘part of the solution for hospitals under intense pressure and for the Government’s ambition to tackle homelessness’.

Alex Bax, Pathway CEO, says: ‘Sadly, the context in which our teams are working is becoming more challenging. Short-term funding arrangements for these teams are the norm; the threat of closure or service reductions ever present. But we are ambitious to achieve more. We estimate that if every hospital in the country that would benefit from a pathway team had one, some 21,000 more people would be helped each year, helping end homelessness at scale, and saving the NHS over £37m a year.

‘We look to the Government to ensure that the forthcoming cross-Government homelessness strategy drives the cross-government system change needed to tackle homelessness through cost-saving action in the NHS.’

Retired GP and Pathway clinical director Chris Sargeant – formerly an executive director at Arch Healthcare in Brighton which cares for homeless and vulnerably housed people – says he is ‘enormously proud’ of the work.

Dr Sargeant adds: ‘The excellent outcomes they are achieving for vulnerable people and for hard pressed hospital trusts are not only due to their hard work and compassion but also a direct result of their specialist training and skills. These results would not have been achievable without the trauma-informed training, detailed knowledge and excellent local relationships the teams have built.’

Homelessness has a devastating effect on health. Major barriers to accessing healthcare in the community result in preventable diseases going untreated, shocking rates of clinically assessed frailty – 400 per cent higher than for people with homes – and, tragically, people dying on average 30 years younger than the general population. People experiencing homelessness attend EDs six times as often as people with homes and are admitted to hospital four times as often.

Danielle Williams, GP and clinical lead for the homelessness inclusion pathway team at St George’s Hospital in London, says the work her team do is ‘incredibly rewarding’.

‘What we hear from a lot of our patients is so often just that they want to “be normal” and live a “normal” life. They have told us that our team helps them feel seen and heard as a human being. Just being there and having the time to listen and build a relationship with that patient is vital to building trust which has so often been lost as they have moved through different systems. 

‘These systems can be so difficult to navigate even as a full MDT never mind if you are alone dealing with homelessness. Being able to help support someone to literally change the trajectory of their life is incredibly rewarding.

‘All our patients are in crisis when they are referred to our team but, with the right interventions during their admission, they have been able to be discharged into safe, secure housing, engage to improve their health, beat addiction, return to work and reunite with family.’

In recent weeks, the team at St George’s have received messages from patients saying the team restored ‘faith in humanity’ and that they ‘went above and beyond the call of duty’. 

During the last financial year 750 people were helped to find housing and wider support – ensuring they arrived from the streets but were not returned there.

Mark – whose name has been changed – was one of those 750 people. After arriving unwell at a London ED, the hospital’s pathway team discovered he had suffered a brain injury many years ago. He had been unable to cope living alone and was evicted from his home and left to live on the streets. The team were able to wrap local services around Mark, find specialist ‘step-down’ accommodation while support was organised and then helped to move into long-term supported accommodation. Mark is no longer destitute or homeless.

BMA policy supports integrated models of healthcare for homeless people, including the pathway teams. It says doctors’ representatives are ‘seriously concerned by the increased number of homeless people living and sleeping outdoors across the UK and recognises the deleterious effects of homelessness on physical and mental health’.

It also urges medical schools to ensure the healthcare needs of homeless patients are included in curriculums, that NHS bodies should provide NHS clinical staff with local guidelines including admission and discharge procedures for patients from this population and ‘for UK governments to commit additional resources to support the primary medical care of these vulnerable people’.

Dr Sargeant admits to being an 'eternal optimist' who always believes genuine change can still be achieved despite things being 'as bad as they have ever been' when it comes to homelessness in 2025.

In December 2025, the Government published its much-anticipated national plan to 'end homelessness', which includes commitments to develop interventions to stop people being discharged from hospitals and prisons into homelessness.

If the Government is to look anywhere for a model to do exactly that, pathway is best-practice ready to be rolled out in hospitals across the country. Given the moral and economic arguments seem indisputable maybe – just maybe – Dr Sargeant's optimism might be rewarded.