Hospital, health inclusion, hostels, homelessness, dental hygiene and hope

The Health Inclusion Pathway, Plymouth (HIPP) is a multi-disciplinary team that works between the community and University Hospital Plymouth.

The service was commissioned on the back of the PL1 report which looked at health inequalities and access to services for people experiencing homelessness and other issues in Plymouth. People experiencing multiple deprivation struggled to access care, and services were under strain. The team is a co-delivered venture, with Livewell Southwest, Peninsula Dental Social Enterprise, University Hospitals Plymouth, Plymouth Alliance and the surgeries at St Levan Road and Adelaide St. We are supported by Pathway UK.

The team is made up of our Clinical Lead, who is a GP, another GP (providing 2 sessions a week), a psychologist, a mental health nurse, a social worker, an occupational therapist, a physical health nurse, a health care assistant and a health inclusion support worker. We also have a peer researcher with us part-time. We have a route to refer people for specialist dental provision to support long term rehabilitation.

Our work is with people who are experiencing homelessness or people who have physical and mental health needs, substance use issues, criminal justice involvement and who have struggled to engage with services previously.

We provide a service with three main aims:

• Admission Avoidance, where we support people in the community, with work in the homeless hostels and drop-ins, to prevent “avoidable admissions” to hospital. We offer physical health clinics and mental health clinics in these areas.

• In-patient Support, where we support people who have been admitted to UHP. We in-reach into the wards, supporting the client and the ward to team to ensure the optimum length of stay. (Historically the majority of this client group self-discharge before completion of treatment). We have at least one member of our team based in UHP every weekday morning.

• Supporting Safe Discharge, where we support a clients discharge from UHP, into the community, when they are medically fit for discharge. The aim is for adequate accommodation and access to health provision, including registration with a local GP.

Access to appropriate urgent health and social care input is important, but meaningful recovery is impossible without links to longer term recovery services. Our unique level of integration across health, social care and the third sector and commissioned access to oral health and dental services means people can be supported to build independent and meaningful lives.

The understanding and system leadership inherent to our service helps us to identify gaps and to continue to innovate and advocate for the right services to meet patient needs.