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Step-down Homeless Medical Care Pathway 

People who are homeless:

  • attend A&E 6 times as often,

  • are admitted to hospital 4 times as often

  • stay 3 times as long

...as the general population.

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Image credit: Jonathan Rados

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 provides 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.

*Stepdown 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.

A worsening situation

Nearly half (46%) of all people sleeping rough on a single night in autumn 2023 are in London and the South East, which is similar to previous years.

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.

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


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

It has the highest levels of homelessness, with almost 165,220 people, 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 separately monitors the number of people who sleep rough in London.

In 2022/23 around 10,053 people were seen sleeping rough in London by outreach workers over the course of that year. 

For more information about the clinical aspects of this Pathway, visit our UK Hospital website.

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.

This is where Mildmay comes in, as we have the capacity to provide dedicated inpatient care, addressing a huge unmet need for specialised medical services and rehabilitation following a referral by other physicians. 

For more information about the clinical aspects of this Pathway, visit our UK Hospital website.

There is currently no other provision in London like Mildmay

No other 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, and physical illness and substance misuse.

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

Mildmay has developed partnerships with several homeless charities, such as Pathway, which is already doing excellent work across London. We are working with them to make a truly game-changing difference in the lives of London's homeless people.

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

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, equivalent to annual costs ranging from £24,000 to £30,000 (gross) per person.

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


Tackling homelessness early could save the government between




for every person helped.

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

Goals and outcomes

Mildmay's aims are 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.

Our purpose is two-fold

1. To deliver better care and health outcomes for homeless patients

2. To make more efficient use of all available health resources by freeing up NHS acute beds and providing medical respite/rehabilitation for this vulnerable cohort, improving the likelihood of a safe and full recovery.

Our funding

Nearly 90% of funding for patients who are homeless is covered by NHS contracts and we depend on your help to secure the remaining 10% or more.

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.

Help us secure the future of our UK hospital in developing the Homeless Pathway, so we can ensure equal and fair access to healthcare for those who are homeless.


The London Borough of 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.

Image credit: Young Shih on Unsplash

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Healthcare challenges of people who are homeless

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


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

Data courtesy of Pathway

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Introducing our new REBUILD Pathway

Post-detox inpatient rehabilitation care for patients who are homeless or rough-sleeping
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