Tackling homelessness and exclusion-understanding complex lives

1. Tackling homelessness and exclusion-understanding complex lives Helen Keats, National rough sleeping advisor, DCLG

2. Tackling homelessness and exclusion-understanding complex lives • My presentation will cover three areas- • The main findings of the JRF report on four projects examining the interaction between homelessness and other support needs • Key recommendations from the report • What they mean for front line agencies

3. Tackling homelessness and exclusion-understanding complex lives • The report looked at 4 research programmes commissioned as part of the Multiple Exclusion Homelessness (MEH) Research Programme, which ran form Feb 2009 to Sept 2011. • Fitzpatrick et al., Heriot-Watt University • Cornes et al., King’s College London • Dwyer et al., University of Salford and Nottingham Trent University • Brown et al., University of Salford and University of Lincoln

4. The main findings • Nearly half of services users reported experiences of institutional care, substance misuse and street activities such as begging as well as homelessness. • Using hostels or making homelessness applications commonly happened after contact with non-housing agencies such as mental health services, the criminal justice system and social services. • Traumatic childhood experiences and later self harm and suicide attempts in adulthood were a commonly reported factor. • Housing and hostel staff often take the primary responsibility for supporting people with multiple and complex needs, often without support.

5. The main findings • These tell us three important things. • Some clients using non-housing services will go on to rough sleep and staff in these services need to be able to recognise those at risk, and know where and how to make appropriate referrals. • The impact of early childhood trauma must be explicitly acknowledged by both housing and non-housing service providers and included in the assessment process. • Housing and hostel/floating support/day centre staff should be trained and supported to work with clients with multiple and complex needs.

6. The main findings • The report describes four broad phases into multiple exclusion homelessness • Substance misuse- early use including solvents, glue or gas and often linked with leaving home or care and developing a problematic relationship with alcohol. • Transition to street lifestyle- depression and anxiety, sofa surfing, survival shop lifting, survival sex work, being the victim of violent crime, spending time in prison. Also being made redundant. • Confirmed street lifestyle- rough sleeping, begging, IV drug use, hospital admission for mental health issue. Also becoming bankrupt or divorced. • “Official” homelessness- making homelessness applications, moving into hostels or other TA. Also being evicted/repossessed or the death of a partner.

7. Recommendations for policy and practice • Prevention • Increased recognition of the childhood experiences that lead to MEH. • Understanding the critical intervention points for prevention, especially mental health and drug treatments.

8. Recommendations for policy and practice • When prevention has not worked. • Recognise a forgotten group-the majority of the MEH cohort were men over 30 with substance/alcohol use and anxiety/depression for whom there is little specialist provision. • Address acute mental distress. • Ensure better access to coordinated support through community care assessment and access to adult social care. • Provide coordinated support to move on

9. Recommendations for policy and practice • When prevention has not worked. • Help professionals to learn from each other, providing a route to integrated care and personalised support and a shared understanding of the Community Care and Fair Access to Care Services processes. • Recognise and develop the coordinating role of support workers which is truly cross sector. • Improve positive social networks and relationships.

10. Opportunities for the sector -the Ministerial Working Group on homelessness • Aim • “The aim of the Ministerial Working Group is to prevent and reduce homelessness, and improve the lives of those people who do become homeless. By bringing the relevant Government departments together to share information, resolve issues and avoid unintended policy consequences, we will be able to help enable communities to tackle the multi-faceted issues that contribute to homelessness. “ • Its first report was published in July 2011 and is available on • http://www.communities.gov.uk/housing/homelessness/homelessnessworkinggroup/

11. Membership of the MWG • Grant Shapps MP (Con) - Department for Communities and Local Government (housing and homelessness) (Chair) • Andrew Robathan MP (Con) - Ministry of Defence (welfare of veterans)   • John Hayes MP (Con) - Department for Business, Innovation and Skills (adult skills) • Paul Burstow MP (LD) - Department of Health (health and care services) • Lord David Freud (Con) - Department for Work and Pensions (housing benefit) • Crispin Blunt MP (Con) - Ministry of Justice (criminal justice) • Baroness Browning MP (Con) - Home Office (crime prevention) • Tim Loughton MP (Con) - Department for Education (children and youth services)

12. Commitments of the MWG • Commitment 1: Helping People Off the Streets • Commitment 2: Helping People to Access Healthcare • Commitment 3: Helping People into Work • Commitment 4: Reducing Bureaucratic Burdens • Commitment 5: Increasing Local Control over Investment in Services • Commitment 6: Devolving Responsibility for Tackling Homelessness • Commitments 2 and 3 are highly relevant to the people in the MEH studies.

13. Opportunities for the sector-the Health and Social Care Bill • The Health and Social Care Bill currently before Parliament contains 2 important proposals that will have an impact on the homelessness sector. • Health and Wellbeing boards (HWBBs) will be established in each Local Authority to bring together local government and NHS commissioners (along with other local stakeholders) to enable the co-ordinated planning and delivery of the full range of local health and social care services. • In addition to their current housing and social care responsibilities, it is also proposed that local authorities take on commissioning responsibility for alcohol and substance misuse treatment as part of the transfer of public health responsibilities to boroughs.

14. Opportunities for the sector-the health and Social Care Bill • HWBBs are required to drive improvement of health outcomes at local level, and to enable local democratic accountability for health improvement. • The sector, assisted by organisations such as Homeless Link, should ensure that HWBB include an explicit, shared local ambition to meet the needs of MEH homelessness people, especially those of the “forgotten” group.

15. Opportunities for the sector-developing psychologically aware services • Research carried out by Dr Nick Maguire at Southampton University on behalf of the Department of Communities and Local Government (DCLG) 2009/10 identified that up to 60% of adults living in hostels in England have diagnosable personality disorder compared with about 10% in the general population. • There are particular issues to consider around 16-17 year-olds who may have had traumatic and abusive childhoods. On top of the problems of adolescence which affect young people generally, they may also exhibit behavioural problems such as conduct disorder, often associated with antisocial behaviour which can lead to homelessness.

16. Opportunities for the sector-developing psychologically aware services • The behaviour observed in people with personality disorder can be described as a way of coping with the traumatic experience of difficult childhoods. It is better described as ‘complex trauma’, in other words, as a reaction to an ongoing and sustained traumatic experience. • People with complex trauma who have experienced homelessness may behave in a range of ways that suggest underlying difficulties with relationships, or with managing their own emotions.

17. Opportunities for the sector-developing psychologically aware services • Some people may for example: • • self-harm or have an uncontrolled drug and/or alcohol problem • • appear impulsive and not consider the consequences of their actions • • appear withdrawn or socially isolated and reluctant to engage with help which is offered • • exhibit anti-social or aggressive behaviour • • lack any structure or regular daily routine • • not have been in work or education for significant periods of time • • have come to the attention of the criminal justice system due to offending.

18. Opportunities for the sector-developing psychologically aware services • The research led to the publication of non statutory guidance: “Meeting the psychological and emotional needs of homeless people” July 2010 and development of the concept of Psychologically Informed Environments. • www.nmhdu.org.uk/complextrauma • The concept of a PIE was originally developed by Robin Johnson and Rex Haigh, as part of the Royal College of Psychiatrists’ Enabling Environments initiative.

19. Opportunities for the sector-developing psychologically aware services • Those services that have developed a psychologically aware approach will recognise that clients with challenging behaviour have particular support needs, often arising from earlier trauma and abuse. • As part of this approach, they will be working within a therapeutic framework, enabling them to develop clear and consistent responses to clients who may be chaotic and distressed and who have learned not to trust.

20. Opportunities for the sector-developing psychologically aware services • People who are homeless or insecurely housed are among those most in need of psychologically informed help, but are also among those least able to access mainstream clinical psychology services. • Psychologically aware housing services cannot be a replacement for clinical services. Health commissioners ( and the HWBBs) must be involved in the development of PIEs to ensure that people with complex trauma have referral routes into appropriately designed clinical services, including those for people with dual diagnosis.

21. Opportunities for the sector-developing psychologically aware services • Psychologically aware services are vital to deal with the high incidence of acute mental distress in those with a history of troubles childhoods, many of whom fall within the MEH cohort. • Psychologically aware services help staff to work more effectively with clients with challenging behaviour and can help reduce burn out and high staff turnover. • A draft operational paper to help providers and commissioners develop or remodel services in order to address identified emotional and psychological issues amongst rough sleepers and young homeless people is out for consultation now.

22. Conclusions • The challenges of developing effective services for MEH people when public spending is being cut cannot be denied, but progress is being made. • The Hostel Capital Improvement Programme, now the Homelessness Change Programme has had a positive impact on service design and provision. • .The Ministerial Working Group on Homelessness will publish a second, broader homelessness strategy in spring 2012. This will consider how to tackle the complex underlying causes of homelessness, prevent homelessness at an earlier stage and deliver integrated services that support an individual’s recovery.

23. Conclusions • There is a growing body of evidence on the cost effectiveness of developing services for people who have complex support needs. This includes evidence from the Multiple Disadvantage Local Inclusion Laboratory Areas and from the Making Every Adult Matter ( MEAM) pilots. • Both these initiatives focus on finding better ways of coordinating services to deliver for the whole person and will offer a platform for innovation at a time of change.

24. Conclusions • There is a very high degree of connection between homelessness and other complex social issues. • Some people, especially those with very complex and multiple needs, do not fit neatly into existing service compartments. • We need to focus on outcomes for the whole person rather than designing services and responses around client groups.

25. Contact details • More information on the projects described in the report on complex lives can be found at • www.homeless.org.uk/esrc-programme • I can be contacted at helen.keats@communities.gsi.gov.uk