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The purpose of this paper is to explore integration and complexity through the evaluation of a case study service which supports multiply excluded homeless people.

A mixed methods theory based evaluation. Data gathering included semi-structured interviews with external stakeholders, analysis of referral and outcome data, focus groups with frontline staff members and managers, and interviews with people living in the service.

The service was highly rated by its stakeholders due to its ability to meet the immediate needs of many individuals and to facilitate access and engagement with community and specialist resources. However, not every individual responded to the support that was an offer, and a number were unable to access the service due to the nature of their needs or a lack of capacity in the service. Whilst the service was able to engage community and specialist services this often appeared to be within the parameters set by these services rather than flexibly around the needs of the individual.

The research is based in one case study service and findings may not be transferable to different local contexts and providers. However, the findings are consistent with previous studies.

It is possible for commissioners to intervene in the complexities that multiply excluded homeless people experiences through the introduction of a new service. However, this is unlikely to address all of the gaps and fragmentation that people in these circumstances face. It is therefore important that partners are sensitive to such limitations and have a shared willingness to respond to continuing gaps and shortfalls.

Despite specific national policies people continue to experience multiple exclusion homelessness which suggest that more still needs to be done to prevent people from this extremely disadvantaged social circumstance. Whilst specialist services can provide excellent support the response is still fragmented for some people meaning that work to better integrate their responses must continue.

The paper contributes to the evidence base of support models for multiple excluded homeless people and the factors that can enable a housing support service to respond to such needs. It also provides comment on the relevance of the concept of complex adaptive systems to the study of integration.

This paper aims to throw light on the value of accommodation and support services and the likely consequences of their withdrawal.

Research was completed by a team of researchers from Nottingham Trent and Salford Universities under the Multiple Exclusion Homelessness programme funded by CLG, the Economic and Social Research Council and the Joseph Rowntree Foundation.

Agencies whose priorities are influenced by other agendas arising from statutory limitations or government targets have conflicting priorities that sustain multiple exclusion homelessness in a number of key circumstances.

Findings from this research will enable policy‐makers and practitioners to take better account of service user perspectives, experiences and priorities.

The shift in policy discourse towards individualism is affecting service provision and access, which has become increasingly conditioned on individual agency and the “deservingness” of the recipient. Gendered and intersectional experiences of homelessness and excluded populations less likely to be living on the streets remain overlooked and unaddressed. This study thus aims to uncover what drives “invisibility” in services for women experiencing multiple disadvantage and the gendered constraints the women are facing when exiting and navigating multiple disadvantage.

The paper draws on in-depth interviews with women who face severe and multiple disadvantage and their support staff. Data is also gathered through survey data and observations with a wide range of frontline service providers, as well as support notes and numerical progress data recorded by one of the service providers.

Contradicting the common assumption that people act as rational actors in their interaction with services, the author found that women’s decisions to (dis)engage may be blinded by forces of multiple disadvantage and mistrust. These are often developed as a result of systemic and gendered constraints that limit women’s capabilities and exercise of choice. Barriers in service access often amplified the personal barriers they were facing and reinforced women’s decisions to not engage with services.

The author hopes that this paper sheds light on the particular set of barriers women with multiple disadvantage face, which will be vital to reach women who face severe disadvantage and provide more effective policies, care and support.

This study gives voice to a particular hidden population: women with multiple disadvantage. It contributes to existing frameworks on agency and choice by understanding gendered barriers behind service engagement and how services themselves may be contributing to women’s invisibility.

There is much current policy and practitioner enthusiasm for using social enterprise to tackle the problems faced by homeless people. However, there is no evidence base to support (or negate) this policy focus. The purpose of this paper is to identify the different ways in which social enterprise responds to the needs of homeless people, and some of the challenges faced by social enterprises in the homelessness field.

Desk‐based research of the grey literature identified different models of social enterprise in the homelessness field. A review of the two sets of literature on homelessness and social enterprise was conducted to identify the implications of these models for homeless people.

Six models of social enterprise in the homelessness field are identified. Social enterprise involves balancing social and economic objectives. As third sector organisations become more business focused, there is a risk that those homeless people with the most complex or acute needs are abandoned as they are not profitable to work with.

This paper is the first to bring together two sets of literature in order to identify how social enterprise responds to homelessness. The paper is of use to policy makers aiming to develop targeted approaches to tackling homelessness. It is also of use to organisations in the homelessness field looking to develop social enterprise models.

Without the voices of those impacted by homelessness, there is a risk that important understandings essential to the development of effective solutions to homelessness will remain obscured. The purpose of this paper is to provide an overview of the evidence base and insights into recommendations for development and implementation of policies and practices to promote meaningful involvement of people experiencing homelessness as part of a community response to homelessness in a mid‐size Canadian city.

A scoping literature review was conducted, focusing on homelessness and social exclusion/inclusion.

Based on this review, the authors provide insights into the processes of social exclusion and inclusion as a beginning place for developing strategies for meaningful engagement in community responses to homelessness. Roots of social exclusion, towards social inclusion and creating social inclusion were three themes which emerged as central to developing inclusionary policy. First, the roots of social exclusion associated with homelessness are located in unequal power relations, highlighting contextual factors that produce exclusion with implications for health and well‐being. Second, towards social inclusion, reflects theoretical perspectives and principles that have been used to inform inclusionary practices. Third, creating inclusion highlights some strategies that can support inclusion for people experiencing homelessness and foster development of inclusionary policy.

There is little evidence of effective practices that promote social inclusion or attention to specific strategies that engage diverse homeless populations that account for gender, ethnicity and other important differences. A key next step is the development of guidelines for social inclusion at the organizational and municipal levels of decision making with those impacted by homelessness.

Homeless people experience extreme health inequalities and high rates of morbidity and mortality (Aldridge et al., 2017). Use of primary care services are low, while emergency healthcare use is high (Mathie, 2012; Homeless Link, 2014). Duration of admission has been estimated to be three times longer for homeless patients who often experience poor hospital discharge arrangements (Mathie, 2012; Homeless Link, 2014). This reflects ongoing and unaddressed care and housing needs (Blackburn et al., 2017). The paper aims to discuss these issues.

This paper reveals how GPs employed in secondary care, as part of Pathway teams, support improved health and housing outcomes and safe transfer of care into community services. It draws on published literature on role of GPs in working with excluded groups, personal experience of working as a GP in secondary care, structured interviews with Pathway GPs and routine data collected by the team to highlight key outcomes.

The expertise of GPs is highlighted and includes holistic assessment, management of multimorbidity or “tri-morbidity” – the combination of addictions problems, mental illness and physical health (Homeless Link, 2014; Stringfellow et al., 2015) and research and teaching.

The role of the GP in the care of patients with complex needs is more visible in primary care. This paper demonstrates some of the ways in which in-reach GPs play an important role in the care of multiply excluded groups attending and admitted to secondary care settings.

The purpose of this paper is to consider evidence for the effectiveness of the psychologically informed environments (PIEs) approach to working with homeless people in the five years since the national guidance was published.

The author reviewed the intended outcomes of the original guidance and then looked at a range of data from evaluations of current PIE services in UK and Ireland.

The findings were that the PIE approach is effective in meeting the outcomes suggested by the original guidance; in reducing social exclusion and improving the mental health of homeless people; and in improving staff morale and interactions.

This is a practice-based evidence. There needs to be more practice-based evidence gathered, and it would be useful if there were some standardised measures, as long as these did not limit the richness of the data which suggests that PIEs have a wide, not narrow, impact.

The implications are that homelessness services should use the PIE approach, and that they should be supported by clinically trained psychotherapists or psychologists; and that wider mental health services should look at the PIE approach in terms of working effectively with socially excluded people with complex needs/mental health problems.

PIEs are an effective way of working with socially excluded people with mental health problems/complex needs, enabling the reduction of social exclusion among this very excluded client group.

This is the first review of evidence, much of it so far unpublished, for the effectiveness of PIEs, despite the fact that this approach has been increasingly adopted by both providers and commissioners in the homelessness sector.

This paper seeks to discuss the association between homelessness and poor health, both physical and mental. A pilot project run by St Mungo's suggests that adding clinical mental health interventions, notably psychotherapy, makes existing social care interventions several times more effective, enables deeper recovery, and frees people to move on across all the domains of their lives.

St Mungo's was awarded a grant by the Cabinet Office as one of the national pilots working with “adults facing chronic exclusion” (jointly funded by the Department of Work & Pensions, Ministry of Justice, Department of Health, Department of Communities, and Department of Families and Children – because these clients impact on the remits of all these departments). The aim of the project was essentially simple: to test the hypothesis that, if chronically excluded adults were excluded because of their psychological disorders, then could a psychotherapeutic intervention reduce their exclusion?

Recently, 274 people have attended for therapy; 30 per cent of these are women, 70 per cent men, with 68 per cent white and 32 per cent black. In total, 30 per cent did not come to the initial assessment session, and there are many reasons for this, for example, people abandoning or being evicted from their accommodation, death, imprisonment and resettlement. Some were also referred without proper consultation, so that when they were contacted it turned out they did not want psychotherapy or, in a few cases were already accessing it elsewhere. Of those who did attend assessment, 80 per cent went on to attend four or more sessions; most clients attended either two to four sessions, or more than 12. Attendance overall was 76 per cent, and non‐attendances were noted on 11 per cent of occasions.

Many homeless people become caught in the “revolving door” of hostels, prison, hospitals and the streets, often for many years. This paper argues that this form of homelessness affects people because of their mental health, and that social solutions alone are not sufficient, which is why the door continues to revolve. Offering appropriate clinical interventions alongside existing social ones could begin to transform this situation.

The purpose of this paper is to present a case study describing the progress that is being made in one city in England to increase access to Care Act 2014 assessments and personal budgets among people with experiences of homelessness and multiple exclusion.

A case study employing a “study group” to describe and reflect on local development work.

The authors focus on the “systems change” activity that was undertaken by one voluntary sector partnership project to address issues of referral and access to adult social care. This included the development of a “Multiple Needs Toolkit” designed to support voluntary sector workers to communicate more effectively with adult social care around the application of the new Care Act 2014 eligibility thresholds. The authors discuss the role of “persistent advocacy” in increasing access to assessments and also the limitations of this as regard the potential for poorer joint working.

Throughout, the authors draw on the “ambiguity-conflict” model of policy implementation to assess if the learning from this single case study might be applied elsewhere.

This study aims to examine the emotional and cognitive responses of frontline homelessness service support staff to the highly insecure attachment styles (AS) exhibited by people experiencing multiple exclusion homelessness (MEH), that is, a combination of homelessness and other forms of deep social exclusion.

Focus groups were conducted with frontline staff (N = 19) in four homelessness support services in Scotland. Hypothetical case vignettes depicting four insecure AS (enmeshed, fearful, withdrawn and angry-dismissive) were used to facilitate discussions. Data is analysed thematically.

Service users with AS characterised by high anxiety (enmeshed or fearful) often evoked feelings of compassion in staff. Their openness to accepting help led to more effective interactions between staff and service users. However, the high ambivalence and at times overdependence associated with these AS placed staff at risk of study-related stress and exhaustion. Avoidant service users (withdrawn or angry-dismissive) evoked feelings of frustration in staff. Their high need for self-reliance and defensive attitudes were experienced as hostile and dismissing. This often led to job dissatisfaction and acted as a barrier to staff engagement, leaving this group more likely to “fall through the net” of support.

Existing literature describes challenges that support staff encounter when attempting to engage with people experiencing MEH, but provides little insight into the causes or consequences of “difficult” interactions. This study suggests that an attachment-informed approach to care can promote more constructive engagement between staff and service users in the homelessness sector.