Practice Quality Improvement Report

A general practitioner and nurse led approach to improving hospital care for homeless people

BMJ 2012; 345 doi: (Published 28 September 2012) Cite this as: BMJ 2012;345:e5999
  1. Nigel Hewett, clinical lead, Pathway Homelessness Team, University College London Hospitals NHS Foundation Trust1,
  2. Aidan Halligan, director of education, University College London Hospitals NHS Foundation Trust2, director of safety, Brighton and Sussex University Hospitals3,
  3. Trudy Boyce, homeless health practitioner1
  1. 1Discharge Lounge, University College Hospital, London NW1 2BU, UK
  2. 2Education Centre, University College Hospital, London NW1 2PG
  3. 3Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
  1. Correspondence to: N Hewett nigelhewett{at}
  • Accepted 1 July 2012
  • Problem Long term homelessness is characterised by “tri-morbidity” (the combination of mental ill health, physical ill health, and drug or alcohol misuse). This results in frequent and prolonged unscheduled admissions to hospital with annual costs that are eight times the local average.

  • Design Qualitative study. A needs assessment was conducted over three months to inform the design of a specialist support service.

  • Setting Inner city teaching hospital in the United Kingdom.

  • Key measures for improvement To improve the quality of care for homeless patients while monitoring the impact on duration of hospital stay.

  • Analysis and interpretation Homeless patients often felt that they were being treated differently, and the networks and understanding necessary for care coordination were not in place. The complexity associated with tri-morbidity is compounded by complicated legal rights of access to housing and social care and the need for a person to prove repeatedly that they have an association with a local area in order to receive help.

  • Strategies for change Development of a specialist support service in the hospital (general practitioner (GP) and nurse led); rapid establishment of rapport by demonstrating a clear understanding of the problems facing the homeless patients; weekly multiagency meetings to coordinate care, with GP advocacy in complex cases.

  • Effects of the change Homeless patients felt more cared for, and hospital and community staff, through better support, provided better integrated care. The strategy resulted in a total reduction of 1000 bed days (30% reduction) in the first full year of service delivery and commensurate cost savings.

  • Lessons learnt A partnership between a GP and a hospital nurse can improve the qualitative and quantitative value for homeless patients in secondary care.

In 2005 the governing board of trustees of University College Hospital in central London, UK, began to seek a new approach for the …

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