What is multiple exclusion homelessness?
People have experienced MEH if they have been homeless, including experience of temporary/unsuitable accommodation as well as sleeping rough, and have also experienced one or more of the following domains of deep social exclusion: institutional care (prison, local authority care, mental health units); substance misuse (drug, alcohol, solvent/gas misuse); or participation in street culture activities (begging, street drinking, “survival” shoplifting or sex work).
Key words: Homelessness ❙ Exclusion
Author: Theresa McDonagh, published by the Joseph Rowntree Foundation
Aim: An examination of services for people with complex needs to suggest what might be done to ensure more comprehensive ways of working that are better able to tackle homelessness and meet people’s needs and aspirations for recovery and well-being.
Methodology: Multiple methods including a survey to explore the overlap between homelessness, drug and alcohol dependencies, institutional experiences and street culture activities.
Conclusion: Since the advent of the Supporting People programme and the introduction of a wide range of specialist housing-related support services, social workers play a much reduced role in direct work with homeless adults. However, this research identifies a need for social workers to re-engage with this area of practice.
The report rounds up the evidence from four separate research projects that were commissioned as part of the Multiple Exclusion Homelessness (MEH) Research Programme. The overall aims of the programme were to provide a statistically robust account of the overlap between homelessness and other issues associated with deep social exclusion, for example drug and alcohol dependency, and to explore how services work together to address multiple needs that cut across health, housing, social care and criminal justice.
Working in 13 sites across England, including rural and urban areas, the studies used a range of qualitative and quantitative methods to capture the views of people with experience of homelessness, commissioners, service providers and front-line workers. Life history and reflective interviews were undertaken with people who had first-hand experience of homelessness and one of the studies used longitudinal “tracking” to explore how services supported people over a six-month period.
The centrepiece of the research was a questionnaire of people using a wide range of homelessness and other low-threshold services such as drug and alcohol services and services for ex-offenders and street sex workers. This found that of the 1,286 people surveyed, 98% had experienced homelessness, 70% had experienced substance misuse, 67% had been involved with street culture activities such as begging or sex work and 62% had been in care or in prison. The degree of overlap between these experiences was very high, with 47% reporting all four experiences.
This was followed by more in-depth interviews with 452 service users whose questionnaire responses indicated that they had experienced MEH. These interviews drew attention to the very high prevalence of mental health problems. Almost four out of five (79%) of those interviewed had a period in their life when they were very anxious and depressed, 38% had attempted suicide and 28% had been admitted to hospital with a mental health problem.
The most complex needs were experienced by men aged between 20 and 49, and especially those in their mid-thirties. Some of the factors associated with less complex MEH experiences were being female and being younger (under 20) or older (over 50). Being an adult migrant to the UK was another factor but this was not true of migrants from central and eastern Europe.
A key finding to emerge from the life history interviews was how the roots of many people’s experience of MEH in adulthood lay with very troubled childhoods. The quantitative study underlined this with 78% of service users reporting a range of trauma, distress or exclusion as a child.
When it came to supporting people with experience of MEH, the researchers found very little evidence of integrated assessment and support planning. The longitudinal tracking study found “homeless people” were routinely excluded from community care assessment.
Across all sectors, including social work or care management services, there was poor understanding of how Fair Access to Care Eligibility Criteria might be applied in the context of MEH. Very often the perception was that homelessness was a housing issue and that “homeless people” should be referred to Supporting People provision such as hostels. Front-line practitioners rarely acknowledged how the interplay between different needs and issues could conspire in ways to pose a critical risk to independence and well-being. Some “homeless people” might therefore have been eligible for social care services and care management from a social worker, as well as housing-related support services.
For people using services (or those falling through the net), the limitations of current “joint working” were exposed where needs were identified which were perceived to go beyond the scope and remit of existing provision. This caused considerable tensions between different agencies and professionals as each tried to avoid taking on responsibility for the most vulnerable and “chaotic”.
According to one social worker, who viewed her role in homelessness as essentially preventive: “We get to the point of being frustrated with the whole concept of prevention because we signpost [homeless people] to an agency that’s appropriate for them. When we follow them up to see what the outcome was to feedback to the Care Quality Commission, we find that the agency thinks it has done a grand job because they have signposted them on to somebody elseEventually, they get sign-posted back to us and the circle will start again or the person who we thought was very vulnerable just disappears.”
For the individuals concerned, such disputes can lead to a “revolving door” in which they might be offered a service (reluctantly) with some seemingly impossible goals attached such as remaining abstinent after a life time of alcohol misuse. This increases the likelihood of eviction or abandonment and further periods of homelessness, imprisonment and/or hospitalisation.
The researchers conclude that rigid interventionist approaches that dictate the speed of engagement are not appropriate for people with complex needs. They point to the potential of more personalised approaches, which draw on traditional social work skills such as counselling and building one-to-one relationships. To what extent there will scope for such participatory and empowering approaches in the current economic climate is debatable, especially because social worker caseloads are already stretched and the Fair Access to Care Eligibility Criteria are rising.
However, the report alerts us to a range of collaborative ideas that might be introduced to bridge the gap between best practice and what is possible. For example, as part of the research practitioners in one area piloted a programme of interprofessional group supervision for housing support workers. This allowed social workers and other professionals to share their skills and expertise in a cost-effective and time-efficient way and to hopefully make a difference to people experiencing MEH, albeit in an indirect way.
● Social workers have a key role in delivering more personalised and integrated services to people who are experiencing multiple exclusion homelessness (MEH).
● Social workers’ scope for practice may include supporting wider processes for interprofessional education and training.
● Social workers in housing and homelessness organisations have much to offer in terms of making links with social care.
● Managers working on current initiatives in integration should bear housing in mind, as well as NHS and social care.
● Care leaver services should be alerted to new evidence of the risks of MEH among young people leaving care.
Department of Health, Prioritising need in the context of Putting People First: a whole system approach to eligibility for social care – guidance on eligibility criteria for adult social care, England, 2010
About the authors: Michelle Cornes is a research fellow and Jill Manthorpe is director of the Social Care Workforce Research Unit at King’s College London
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