Editorial

Citation

Whiteford, M. (2017), "Editorial", Housing, Care and Support, Vol. 20 No. 1, pp. 1-7. https://doi.org/10.1108/HCS-04-2017-0008

New beginnings

Welcome to the first edition of Housing Care and Support in 2017. This edition contains a relatively small, but thoroughly thought provoking collection of papers. The first of the three papers examines the issue of housing options for people with memory problems and those who care, or have cared for, people with dementia. This is a particularly timely empirically informed contribution given the startling human and financial costs of dementia in the UK. To put this into perspective, dementia costs the health and social care sector more than cancer, stroke and heart disease combined[1]. In purely economic terms the overall cost of dementia in the UK is estimated to stand at £26 billion (Alzheimer’s Society, 2014). By 2040, predicted costs are expected to treble (Parkin and Baker, 2016). Understandably, then, the economics of dementia present significant challenges to public health and social care and systems. Housing and housing-related support constitutes a significant part of this financial envelope. There is a human cost too. A diagnosis of dementia can be devastating for patients, families and caregivers, with negative physical and psychosocial effects. Providing or facilitating access to appropriate forms of housing support can thus be seen as a vital component in delivering dignity in care for people with dementia.

Set against this background, Poyner et al.’s (2017) paper is concerned with exploring the viability of extra care for couples living people with dementia. Extra care is broadly defined here in terms of access to purpose built apartments or houses for people over the age of 65. What further distinguishes extra care from sheltered housing or retirement housing is the 24 hour presence of on-site care staff alongside supplementary care packages (Housing LIN, 2015, p. 4). To date, as Poyner et al. carefully explain, extra care has largely been the preserve of a healthier cohort of older people. But as the number of people affected by dementia is set to double every 20 years, there is an urgent incentive on the part of policymakers, welfare providers and families affected by dementia to consider extra care as a housing option[2].

Drawing on qualitative interviews, Poyner et al.’s account is particularly attentive to the way in which the coupling of dementia and housing transitions can variously give rise to feelings of loss, guilt and stress. In keeping with this sensitivity to the psychological and emotional aspects of dementia, housing is framed and understood as both an existential and material resource. The paper is, ultimately, a very humane example of a form of academic inquiry and engagement that sensitively pilots a very difficult course, and in doing so, successfully manages to dignify the views, experiences and aspiration of people with dementia and their carers.

The second and third papers in this short compendium contribute to an issue that, in many respects, is au courant in housing-related support circles: namely, the development of psychologically informed environments (see e.g. Haigh et al., 2012). Put simply, psychologically informed environments (designed in the UK) and trauma informed care (a US innovation) are principally concerned with the psychologically well-being of service user, volunteers and staffs alike (Homeless Link, 2017). In broader terms, psychologically informed practice consists of five key features: relationships, staff support and training, the physical environment and social spaces, a psychological framework, and evidence generating practice (for a detailed overview see MEAM, 2015).

Coral Westaway et al. (2017) take up this theme by exploring the potential role of psychologically informed environments in enabling people with complex and multiple needs to find sustainable housing solutions. Drawing on interviews with ten men who have moved at least three times through supported housing services, Westaway et al. identify four major themes that have the potential to impact negatively or positively on routes out of recurrent homelessness: looking forward and the role of help; relationships to help; identity and stigma; and trauma and separateness, intimacy and connection. Viewed through this prism, Westaway et al. describe how some of the men who took part in the qualitative interviews articulated a reluctance to move-on based on the belief that to do so would represent some form of rupture from the safety and stability afforded by supported accommodation.

Westaway et al. are keen to impress on the reader the centrality of what they refer to as the “relational nature of hope” in shaping and structuring therapeutic relationships vis-à-vis support staff and service users. Under these conditions, the role played by frontline support staff in maintaining hope, even when it appears remarkably fragile or seemingly desiccated, is of critical importance in terms of being able to effectively support people to attain better housing outcomes. This can be achieved, Westaway et al. suggest, through the cultivation of “small, manageable service user led steps forward, celebrating each of these achieved and reviewing and revising when steps go unmet rather than lose hope”.

There is of course a parallel process at work here, though. It is, for example, captured in the observation that the psychological well-being of staff providing [support] to people affected by multiple exclusion homelessness (Cornes et al., 2014) requires specialist training and on-going support. This leads Westaway et al. to contend that there is a need on the part of psychologically informed services to more adequately support frontline staff through supervision, reflective practice and complex case discussion. This concern with an active process of reflective practice – understood here as a prerequisite to the development of positive and empowering relationships – is a message taken up and advanced by Phipps et al. (2017) in their contribution to this edition.

Catriona Phipps et al. plough a similar furrow to Westaway et al. in the sense that they are also interested in elucidating the dynamics of psychologically informed environments. Where they depart from their peers, though, is in their explicit engagement with attachment theory and its guiding concern with personal development (Bowlby, 1969). In its clinical formulation, attachment theory directs therapists to pay special attention to the importance of childhood relationships with “at least one primary caregiver”. The ability to form a physical and emotional attachment with another person is seen to provide the necessary scaffolding from which to become self-reliant, develop self-worth and better coping strategies. The inability to do so is understood to result in an insecure attachment style (Ainsworth and Bell, 1970). Transposed to the field of housing and homelessness, therapists and/or frontline staff are encouraged to build therapeutic relationships with service users. This service user attachment to a therapist and/or frontline member of staff serves, in turn, to provide the service user with a secure basis for exploration.

Phipps et al. draw on semi-structured interviews with staff, residents and psychotherapists from two housing projects in London to both reinforce and problematise much of the received wisdom running through the psychologically informed environments and enabling environments literature (Royal College of Psychiatrists, 2013; Breedvelt, 2016). Phipps et al. find evidence to support the importance of positive keyworker relationships and the development of a corresponding sense of trust. Again, and perhaps not unsurprisingly, the role of reflective practice is given particular prominence in their discussion. Its utility is seen to reside in its ability to allow keyworkers to step back from the demands of everyday practice and reflexively work towards gaining a more informed awareness of the behaviour, needs and aspirations of service users. Of particular interest is the research finding that to express or project negative feelings towards service users’ is viewed as incongruent with staff perceptions of keyworking as the embodiment of a helping relationship. It is also shown how this sense of criticality leads to some of the research participants putting forward the argument that the language of psychologically informed environments is little more than a shibboleth for general good practice. This is an important observation insofar as it not only openly calls into question the perceived singularity of psychologically informed environments, but also throws up the related question of how keyworkers understand their work and the institutions in which they work, and their place with it.

There are a number of common threads woven into each of the three papers in this quarterly edition of Housing, Care and Support. The first of these threads relates to the way in which housing and housing-related support is an emotionally laden resource and activity. In this regard, Poyner et al. show how housing as a concept is intimately tied up with the complex relationship between home and identity as they relate to well-being in later life. In a similar sense, Westaway et al. and Phipps et al. reveal how psychologically informed practice is, in essence, about creating a context in which housing and homelessness support workers are able to constructively and creatively engage with complex – and often challenging – “emotions, personalities and past experiences” (Homeless Link, 2015, p. 2) in such a way that it engenders emotional resilience and positive behavioural change.

The second thread relates more directly to the notion of housing transitions. If the concept of housing pathways (Johnsen and Teixeira, 2010) suggests a linear process than Poyner et al.’s research, particularly its focus on moving out of the family home and into extra care accommodation, suggests in its own enlightened way a more nuanced form of housing movement or transition. The authors show how people with dementia and their carers do not simply reject outright the idea of moving into extra care at some future point in their lifespan. Rather, what Poyner et al.’s research participants speak about is having no great desire to move to extra care in the early stages of their “dementia journey”. In fact, people articulated a clear sense of wanting to maintain their independence and preserve an intimate relationship in familiar surroundings. This notion of housing as a transition point is also evident in Westaway’s et al. and Phipps et al.’s respective contributions, although this sense of change is perhaps closer to the more traditional idea of progressing through a “continuum of care” (see Busch-Geertsema, 2012 for a useful overview). Notwithstanding this caveat, each of these two papers poses a similar question about the extent to which psychologically informed approaches can effectively promote recovery as well as contribute to settled and sustainable housing outcomes.

The third, and final, thread running across the three papers relates to the issue of funding, specifically the funding of community-based care in respect of dementia and continuity of care in terms of psychologically informed environments. So, for example, Poyner et al. describe how the absence of welfare support services for people with dementia and their families means living in the community becomes particularly difficult. A divided health and social care system compounds (and reinforces) this situation. Phipps et al. and Westaway et al. also touch on the precariousness of the voluntary homelessness sector in an age of austerity. It is indeed the case that homelessness organisations are caught in the pincer movement of cuts to funding on one hand, and an expectation that in a period of rising statutory homelessness they will be able to respond to increasing demands on their services from people experiencing severe and multiple disadvantage on the other. On this theme, Phipps et al. make the telling point that despite guidance stating that services should not need to invest large sums of money on establishing psychologically informed environments, the reality is somewhat more complicated: the fact is that services do need sufficient time, resources and structures to establish and then embed new ways of thinking and working. This is a clear message that bears repeating.

Taken together, then, the three aforementioned papers raise a number of important and interesting points about the role of housing and housing-related support in a period of significant demographic, social and economic change. Helpfully each paper makes a number of suggestions in respect to possible research avenues and agendas deserving of further exploration. There is indubitably a need for critically engaged scholars and ethically informed practitioners to forcibly prise open this space and fill the extant gap with new empirical and theoretical insights. It is therefore to be hoped that future contributors to the journal will take up these batons and thus work towards extending and elaborating our understanding of these much discussed, but in some ways under-appreciated dimensions of housing, care and support.

This is happily my inaugural edition as editor of this esteemed journal. In the past as a contributing author and avid reader, I often felt that Housing, Care and Support occupied a distinctive space in the relatively small – some might argue rather niche publishing world – of housing-related journals. This distinctiveness is perhaps most clearly apparent in the way that contributors’ reject the view that housing is simply an economic driver or impersonal commodity. Rather, and I think this is a crucial point, the journal’s explicit focus on the triumvirate of housing, care and support gives rise to a particular orientation towards the complexity of housing. It is one that foregrounds a sensitivity, and indeed sensibility, to the intersections of housing, health and social care as it relates to older, disabled and homeless people (among others). This standpoint, grounded in the journal’s multi-disciplinary outlook, is inarguably one of its strengths, and one which will I am very keen to ensure continues to define it going forward.

What also sets the journal apart from many of its housing-related counterparts is an avowed concern with straddling the so-called academic practitioner divide. Housing, Care and Support has an enviable record of publishing submissions from housing, health and social care practitioners across the broad gamut of paper types (i.e. research paper, viewpoint, technical paper, conceptual paper, case study, literature review and general review). This is based on the recognition that academically inspired accounts of housing and housing-related issues should, as a matter of necessity, be informed by a close engagement with particular or more general practice, commissioning and policy developments. In a similar sense, practice-informed papers also need to demonstrate a firm engagement with the wider academic literature and policy making world. This suggests a symbiotic relationship between theory and practice. It also means that academically inclined and practice-based papers are engaged in a critical and creative dialogue. There should, then, be a feedback loop that serves to ensure that each paper is accessible to the many and varied constituencies that together make up the readership of Housing, Care and Support.

This maiden editorial should not, however, be interpreted as a piece of hagiography. For all the journal’s obvious strengths, there is no getting away from the fact that the journal has a relatively patchy record when it comes to promoting and privileging the perspectives of “experts by experience” in its pages. Research funding bodies (e.g. NIHR, ESRC) and statutory and voluntary sector organisations increasingly require the involvement of members of the public in research. This requirement is based on the view that involving service users or patients helps to ensure research quality and relevance. INVOLVE, the national advisory group devoted to supporting active public involvement in NHS, public health and social care research in the UK, argues thus:

Public involvement is an intrinsic part of citizenship, public accountability and transparency. In addition public involvement in research can lead to empowering people who use health and social care services, providing a route to influencing change and improvement in issues which concern people most[3].

These impulses are to be welcomed. There is, moreover, a clear responsibility on the part of this journal to encourage submissions rooted in the philosophy and practicalities of co-production, peer and participatory research. Embracing such an agenda will enable Housing, Care and Support to make a more credible argument that it is an inclusive and comprehensive forum for housing-related discussion and debate.

It should be self-evident to regular readers of this journal that it is a publication that actively seeks to be internationalist in its focus and coverage. The bulk of the journal’s readership, as measured by site visits and electronic downloads, is to be found in the Anglophone world (i.e. Australia, Canada, UK and the USA). The fact that English has become the language of choice for international scholars is indisputable (Curry and Lillis, 2007). There is, nevertheless, a strong(er) argument to be made that Housing, Care and Support should do more to encourage aspiring authors from some of those other countries (e.g. China, India, Indonesia and Malaysia) that routinely feature in the top ten countries by downloads on a month-to-month or year-to-year basis. This is not simply about ensuring that the journal better reflects its existing customer base. Rather, it is based on the impulse – and conviction – that submissions from these and other under-represented countries can contribute to new forms of learning and cross fertilisation in terms of practice development. As we move forward under my stewardship the journal will continue to actively promote international dialogue and understanding on issues of housing, care and support.

Closer to home – and apologies here for invoking the rather parochial vantage point of the UK – one does need not look too far or too wide to see multiple political crises unfolding. Brexit, that most inelegant of portmanteaus, has been positioned as the signal marker for a series of interrelated political earthquakes (e.g. Scottish constitutional crisis) and social fissures (e.g. NHS funding crisis) threatening to engulf the very fabric of life. Housing and housing-related issues appear to occupy a rather distinct and rather uncomfortably position on top of these shifting and volatile tectonic plates. The UK is, for example, currently beset by a housing crisis that is as fractured along generational lines as it is on class lines. It is one where baby boomers have been pitted against millennials (Charted Institute of Housing, 2017; Willetts, 2011). And while it is incontestable that younger people have been disproportionately affected by rising rents, coupled with the local housing allowance freeze, reliance on casual employment and involvement with the gig economy, this generational divide is in fact a reflection of an ideological preference for a small state based on the principles of self-sufficiency and self-control. Elsewhere chronic cuts to social care funding have hit the elderly and most vulnerable particularly hard. There is also a workforce crisis as significant – and potentially as intractable – as the funding crisis (Hudson, 2017). The UK has witnessed a shocking increase in on-street homelessness. Since 2010, rough sleeping statistics have shown a year-on-year rise in England. Figures show that an estimated 4,134 people were forced to sleep on the streets in 2016, up 16 per cent on the previous year (Homeless Link, 2016). These three crises have deep and tangled structural roots. They also speak clearly to the damaging effects of the on-going experiment in austerity politics.

There is no doubt that the above state of affairs can induce a disorientating sense of despair. Importantly, though, this is only a snapshot and should not therefore be viewed as full or complete picture of the status of housing, care and support in the UK. As a counterpoint to some of the above developments, we can also spy the beginnings of new, more progressive ways of designing and delivering care and support for people with complex and multiple needs. Of which housing may be only the most visible and/or acute need. Chief among these, certainly from a housing-related perspective, is the increasing interest given to Housing First among policy makers and service commissioners. Strictly speaking, we are witnessing the internationalisation of Housing First models (see e.g., Tsemberis, 2010; Pleace, 2016). Indeed, it is a guiding philosophy in the homelessness strategies of Canada, Finland, France and the USA. Its imputed ability to reduce homelessness and increase housing retention has emboldened the right-wing think-tank, the Centre for Social Justice, to call on the British government to invest £110 m to secure homes in the private rented sector to support people affected by long-term and recurrent homelessness together with co-occurring support needs (e.g. reoffending, problematic substance use and mental ill-health).

Housing First is now a ubiquitous concept in housing policy and practice. The basic premise of Housing First is to provide service users with access to long-term accommodation along with comprehensive and flexible support services. A distinctive feature of Housing First is the fact that it makes no conditions in terms of compliance with treatment, symptom improvement or abstinence. This understanding has led the housing scholar Beth Watts (2017) to conceptualise Housing First in terms of a personalised, non-institutional and re-integrative response to homelessness. Thus understood, it amounts to a rejection of “treatment first” and conditional forms of welfare provision.

There is a strong evidence base supporting the effectiveness and cost-effectiveness of Housing First approaches. The existing research literature suggests that Housing First is associated with positive outcomes in the following domains: mental health, physical health, substance misuse, reductions in acute health service use, housing retention and social integration. There is almost a settled assumption within housing circles that Housing First is the most effective and ethical way of proving settles accommodation and wraparound care for some of society’s most excluded people. There is, though, a lack of detailed evidence emanating from Britain and Europe about the role of choice on the one side, and the role of the private rented sector in Housing First on the other. There is also a similar lack of longitudinal data about the efficacy of Housing First models.

Notwithstanding Finland’s revolutionary approach to rough sleeping, Britain can rightly be considered an international outlier in the development of homelessness legislation (Hollander, 2016; Whiteford and Simpson, 2016). There is another area of housing, care and support, where Britain is an international trailblazer, namely in the healthcare of homeless people (for an important precis see Hewett and Halligan, 2012). The Faculty of Homeless and Inclusion Health and the Pathway approach have been instrumental in promoting person-centred and collaborative healthcare for people affected by homelessness and by the triple impact of physical and mental ill health and substance abuse[4]. It based on the understanding that homelessness is a marker of complex health needs and social exclusion. Crucially, though, it is also an approach that understands housing vulnerability and tri-morbidity require a holistic response, which spans health, housing and social care. There are, I would contend, important lessons and insights here that are perfectly transferable to other areas of housing, care and support.

And on a final note, I hope that the three papers in this edition and some of the issues raised in the course of this editorial go some way to prompting critical reflection and a collegiate exchange of ideas in future editions of Housing, Care and Support.

Notes

1. See Alzheimer’s Research UK’s online Dementia statistic hub, available at www.dementiastatistics.org/statistics-about-dementia (accessed 3 April 2017).

2. It is estimated that the number of people with dementia and Alzheimer’s will almost double every 20 years worldwide, to 65.7 million in 2030 and 115.4 million in 2050.

3. See INVOLCE, Briefing note three: why involve members of the public in research, available at www.invo.org.uk/posttyperesource/why-should-members-of-the-public-be-involved-in-research/ (accessed 5 April 2017).

4. See www.pathway.org.uk for a detailed overview.