Step-Down Homeless Medical Care Pathway

Mildmay Mission Hospital is London's primary facility for homeless COVID-19 patients that do not require intensive care

This is a great opportunity for Mildmay Hospital to once again practically demonstrate how it is working with the NHS and our charity partners such as Pathway to improve the lives of Londoners”

- Geoff Coleman, Chief Executive


To discuss or make a referral please contact our Admissions and Information Officer by telephone on 0207 613 6347,

or by email:

*Step down care is a term used primarily in the UK for supportive and rehabilitative healthcare given to a patient recuperating from an illness or intervention, who is regaining the ability to function independently.

People who are homeless:

attend A&E 6 times as often,

are admitted to hospital 4 times as often,

stay 3 times as long,

than the general population.

Data courtesy of Pathway

NHS hospitals across the capital are able to treat the acute illnesses and injuries of patients who are homeless, but do not have the resources to give them time to recuperate before safely discharging them back into the community.

With homelessness in London and other major cities across the UK increasing, there is urgent need for the highly focused, specialist care of the sort Mildmay provides. The number of rough-sleepers in London has more than doubled in the last 10 years. 8,855 People were seen sleeping rough in London in 2018/2019.These record levels of homelessness in London are putting NHS hospitals under increased pressure.

To address this, Mildmay has introduced the Step Down Homeless Medical Care Pathway to help ease the burden on NHS hospitals and provide the care that these patients need.

Those experiencing homelessness are among the most vulnerable and isolated people in our society, with the worst health outcomes

Mildmay is the first specialist unit aiming to provide pioneering step down care* for the homeless population of London and the surrounding regions

In 2020, Mildmay Hospital began a ground-breaking pilot service employing the expertise of our doctors, nurses and therapists to ease the burden on NHS hospitals by providing rehabilitative healthcare for people who are homeless or rough-sleeping and recuperating from illness or injury.

This frees up NHS beds and provide respite for this  vulnerable cohort, with a far better chance of a safe and full recovery.

Once discharged from Mildmay, the aim is that people will be supported by specialist homelessness charities such as Pathway.

Pathway teams can provide patients with:

  • Complex care planning and discharge liaison
  • Links to community services
  • Housing and benefits advice
  • Help to recover important documents such as birth certificates, passports etc
  • Support and collaboration with other clinicians e.g. advice on drug interactions
  • Referral for addictions support
  • Help with GP registration
  • Fresh clothes, shoes and other basics (for example where these have been destroyed because of infection/infestation)
  • Help to reconnect with loved ones

Despite being at risk of closure and our ongoing #SaveMildmay Campaign, we  continue to care for sick and vulnerable people as we have been doing for over 150 years.

1 in every 200 people in Britain is homeless and sleeping on the streets or stuck in temporary accommodation, including hostels and B&Bs.

A worsening situation

A 2018 analysis from Shelter recorded 320,000 people as homeless

In the last year alone, the overall number of people who are homeless increased by 13,000.

Many people who are homeless or rough-sleeping have complex combinations of physical illness, mental illness and substance misuse problems, and histories of trauma and abuse. They are some of the most vulnerable people in society. Traditional systems of health and care often struggle to meet their needs.


London has a significant and rising homeless population with highly complex health and care needs.

It has the highest levels of homelessness, with almost 170,000 people, or 1 in 52, without a place to call home.

Rough sleeping is at the extreme end of homelessness. The Greater London Authority’s Combined Homelessness and Information Network (CHAIN) system - managed by the charity St. Mungo’s - separately monitors the numbers of people who sleep rough in London.

From 2017 to 2018 around 7,484 people were seen sleeping rough in London by outreach workers over the course of that year. The CHAIN data reports that rough sleeping has almost doubled in the capital since 2010 (up 88%).

Westminster has a larger rough-sleeping population than all Greater Manchester

In 2018, London had the highest rate of deaths of those who are homeless in all of the English regions

An estimated 800 homeless people died in the 18 months prior to March 2019 and the data shows that there is an increasing trend in the number of people sleeping rough in London.

The charity Homeless Link conducted a national survey in 2010 looking at homeless health:

73% of homeless people reported physical health problems

41% of homeless people reported a long-term physical health problem (compared to just 28% of the general population)

80% of respondents reported some form of mental health issue, 45% had been diagnosed with a mental health issue (25%)

39% said they take drugs or are recovering from a drug problem, while 27% have or are recovering from an alcohol problem (5%)

35% had been to A&E and 26% had been admitted to hospital over the past six months.

All these issues are exacerbated in winter

Healthcare challenges of people who are homeless

People who are homeless experience some of the worst health problems in society


times more likely to have tuberculosis


times more likely to have Hepatitis C


times more likely to have epilepsy


times more likely to have heart disease


times more likely to have a stroke


times more likely to have asthma

The longer a person experiences homelessness, particularly from young adulthood, the more likely their health and wellbeing will be at risk

Co-morbidity (two or more diseases or disorders occurring in the same person) among the longer-term homeless population is common.

Data courtesy of Pathway

Why we developed the Homeless Pathway

Most charitable work around rough sleeping and homelessness centres on social welfare, so a step-down service from acute hospital care for respite, recovery and palliative care is much-needed.

In 2012, it was reported that 70% of homeless patients were being discharged from hospital back onto the street, without housing or underlying health problems being addressed.

This is further damaging their health and increasing costs to the NHS through ‘revolving door’ admissions.

The number of people who are homeless being treated in hospitals is not accurately known, nor is the number ‘discharged to the street’

However, the homeless healthcare charity, Pathway, found that a total of 2,851 homeless patients were admitted in one year.

High-intensity care and end of life care is required from a much younger age with many needing a safeguarding approach.

There is a clear inequality in provision, with the frailty-age in this group similar to those in their 80’s, but little, if any, service provision similar to the six weeks of funded intermediate care an older person would receive, if they couldn’t be discharged home.

This is where Mildmay comes in

We have the capacity to provide dedicated inpatient and outpatient care, addressing a huge unmet need for specialised medical care following a referral by other physicians.

There is currently no other provision in London like Mildmay

No step-down facilities exist for patients who are homeless with extremely complex and high health needs and traditional intermediate care units feel unable to cope with the triple whammy of mental, physical illness and substance misuse.

There are only a small number of step-down services, such as Gloria House (6 beds) and Olallo House (2-4 beds), which take patients where the health needs are lower, and there are a small number of floating support services in Westminster and Lambeth.

Mildmay has developed partnerships with a number of homelessness charities, such as Pathway, already doing incredible work across London, and we are working together with them to make a truly game-changing difference to the lives of people who are homeless in London.

Mildmay is rated as ‘outstanding’ by the Care Quality Commission (CQC), providing a ‘gold standard’ level of personalised, multidisciplinary care for people with extremely complex needs.

Our specialist services give us the capability to take on the most challenging and complex homeless patients safely, including those requiring end-of-life support.

Mildmay has the potential to become a world-class centre of excellence in homeless health care and a training hub for other step-down services in London

Tackling homelessness early could save the government between




for every person helped.

2015 research by Crisis drawing on large studies on homelessness across Britain 

Mildmay is a charity providing specialist services to the NHS, not an NHS or private hospital.

We don't make a profit and all donations are invested in our services and facilities

We have established relationships with homeless healthcare providers and experts for clinical sponsorship, governance, training and mentorship:

Healthy London Partnership

Greater London Authority

NHS Trusts and Commissioning Groups and other statutory bodies

Local Authority housing and adult social care agencies in Tower Hamlets, Hackney, Newham, Westminster, etc

Sector charities such as Pathway


Our aims are simply that:

  1. No rough sleepers die on the street
  2. No one is discharged from a hospital to the street
  3. There is equal and fair access to healthcare for those who are homeless.

A 2010 government study of the use of healthcare by single homeless people reported that they are 3.2 times more likely than the general population to be an inpatient admission, at an average cost that is 1.5 times higher.

This implies a gross cost of £76.2 million per year, rising to £85.6 million when outpatient usage and accident and emergency attendances are added estimates equivalent to annual costs ranging from £24,000 to £30,000 (gross) per person.

This pilot is in line with the London Vision and with a view to providing these services for the most complex cases London-wide.


80% of funding for patients who are homeless is covered by NHS Contract funding. We need your help to raise the remaining 20%

Help us secure the future of our UK hospital in developing this new pathway, so awe can ensure equal and fair access to healthcare for those who are homeless

Mildmay employs a Housing Officer and Drug and Alcohol Worker for the Homeless Pathway to improve the quality of care for homeless hospital patients and to assist them with moving forwards.

They work to improve the quality of care for homeless hospital patients through specialist advocacy, support, and quality discharge interventions.

Watch this video :

Homeless pathway image by Jonathan Rados

Registered Charity no: 292058

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