The London Pathway project has gained accolades and awards for their work on re-designing healthcare for homeless people. Alex Bax shows that by integrating services that had become too siloed or had lost their sense of compassion, Pathway has improved the health and wellbeing of some of the most vulnerable and excluded members of our society.
Health service reforms over (at least) the last two decades have tended to focus on managerial, structural, process or system change, always trying to get more from NHS resources and nearly always with improved patient care as a stated objective. The London Pathway has been developed by a team led by Professor Aidan Halligan, Director of Education at UCLH (and now also chairman of the new Pathway charity) to respond to specific failings he found in the treatment homeless people received in hospital.
Shocked by the death of a homeless man in the street outside one of the UK’s pre-eminent hospitals, Aidan investigated what had happened. The man (we’ll call him John for this blog) was in his mid 40s, a homeless alcoholic who had previously had a good career. Various life shocks had left him alcoholic and on the streets. John also had three teenage daughters, as does Aidan. Post mortem tests showed that John had died from a brain haemorrhage that could have occurred at any time, but as Aidan found out more about the John’s experience in the hospital he became convinced something needed to change.
John had landed in the A&E department numerous times in the year before his death, and had been admitted to the hospital more and more frequently. Investigating the care he had received, Aidan found that hospital staff had dealt with his acute conditions, patched him up and sent him back out to the streets. While some staff tried to treat him with compassion and dignity, others had little time for him, and some wondered why the hospital bothered with people like him at all. He was seen as a challenging, smelly alcoholic about whom nobody seemed to care. Aidan found no medical negligence, but was dismayed to realise that his excellent hospital failed to really care for homeless people.
At the same time Aidan’s experience across the NHS had taught him that the vast majority of people working in the NHS start out because that want to care for people. He wondered whether the endless cycles of reform and the huge pressure for measurable ‘results’ have made it harder and harder for NHS staff to put compassion at the heart of their practice. Pathway’s nurses say they know it when they see it in colleagues, and our homeless patients certainly know it when someone treats them badly, but how do you manage for and imbue compassion in a complex health system?
Compassion is something we would all hope to underpin any care we might receive if we ended up in hospital, but it doesn’t feature much in NHS corporate documents or the new Health and Social Care Bill. Is it something about British reticence that we feel uncomfortable talking about empathy and emotions? Yet in healthcare treating patients with dignity, humanity and compassion must be central. Legislation alone cannot make people feel in a certain way and all truly compassionate medical staff seem to be driven by the strength of their capacity for empathy and their beliefs in the basic humanity of their patients.
The many, many public inquiries over the years into failings of care in the NHS and other services have shown how easy it is for negligent or abusive care to become tolerated and then commonplace. How do you manage for compassionate care and create a system where staff can grow their capacity for empathy and become intolerant of bad practice?
The Pathway team at UCH is led by a specialist homelessness GP. He leads four ward rounds a week, going from bed to bed visiting every homeless patient in the hospital. Two nurses and a Pathway Care Navigator work alongside the doctor, befriending the patients, taking time to find out what has happened to them, and planning with the patients what will happen when they leave hospital. The Pathway team tries to care for the whole person while in hospital as a counterbalance to the increasing specialisation of so much medical practice.
The GP’s presence gently reminds others doctors involved in a homeless patient’s care that the patient is not alone in the hospital. Pathway nurses provide support not just to the patients, but act as a point of support and advice for ward staff. The team’s presence in the hospital has begun to change attitudes – shifting prevalent perceptions of homeless patients as troublesome and possibly frightening, ward staff now feel supported and better able to cope. Busy junior doctors know they have an experienced colleague ready to discuss with them the complexities of an unplanned alcohol detox, levels of opiate tolerance or how best to work with patients with personality disorders.
More recently, the addition of Care Navigators to the team has further extended our impact. Pathway Care Navigators are paid members of the Pathway team and people with substantial personal experience of street homelessness. Josie, our first Care Navigator, has a remarkable personal story of survival and recovery from the street. She works as part of the team in the hospital, building trust with patients (who often expect to be treated badly), and for the most challenging patients, following up with them post discharge, helping them keep their appointments with detox teams, with social workers, benefits staff, hostel key workers, street outreach teams, mental health services and many others.
Josie’s presence in the hospital also challenges pre-existing attitudes towards homeless people. Walking away from a patient’s bedside recently a doctor again wondered why we bothered ‘wasting time on people like that’. Josie was able calmly to tell her story and the doctor in question has asked if he can work with the Pathway team more closely in future.
Homeless patients remain challenging – our research shows that homeless people are not usually admitted until they are two to three times sicker than the average patient. Many homeless people bring huge physical and long-term psychological damage with them to hospital. In this sense they can be seen as the casualties of the growing inequality of British society. The Pathway service doesn’t work miracles. We simply remain committed to our patients and if they keep coming back, so do we.
Pathway is an effort to put compassion back at the heart of healthcare, focussed on some of the most excluded individuals in our society who present complex sets of healthcare needs alongside challenging personal behaviours. Our intention is to show how the most complex and needy can be treated with true care, dignity and respect, and how putting these qualities at the centre of their treatment actually improves their health and wider wellbeing. By showing that compassion works we hope to help bring it back as a part of the bedrock of the NHS, encouraging the many young people who enter medical careers with passion and commitment to maintain their sense of vocation.
We formed the Pathway charity initially to share our simple model for improved hospital care for homeless people, but also to develop other components of a more integrated health service response to the most excluded. Two further hospitals (in London and in Brighton) will be launching Pathway services this autumn, and we hope that most inner London hospitals will have signed up to the service within the next three years. For managers, our monitoring data so far suggests that we can reduce homeless patient bed days by up to one third, but far more importantly, we also seem to deliver better outcomes for patients.
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