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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.

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 Hypothetical case vignettes depicting four insecure AS (enmeshed, fearful, withdrawn and angry-dismissive) were used to facilitate discussions.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 Avoidant service users (withdrawn or angry-dismissive) evoked feelings of frustration in staff.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.

This article seeks to summarise the recent publication, Turning the Tide: A Vision Paper for multiple needs and exclusions by Revolving Doors and Making Every Adult Matter. It addresses the significant financial and social costs of society's failure to support the 60,000 adults facing multiple needs and exclusions in England today and how this damage can be prevented.

In total, six qualitative evidence seminars and a series of individual meetings were held, with 60 stakeholders consulted. The paper draws on the expertise of member agencies, partners, and the members of Revolving Doors' service user forum who have direct experience of multiple needs and exclusions.

People facing multiple needs and exclusions experience several problems simultaneusly, have ineffective contact with services and, as a result, live chaotic lives. They are a small group but impose disproportionate costs on themselves, families, communities and the public purse. The paper sets out the vision that in every local area people facing multiple needs are supported by effective coordinated services. It argues that to achieve this, a new approach is needed from national government. Five building blocks to achieving the vision are examined in detail.

Drawing on a wide evidence base, the paper shows how politicians, local leaders, and commissioners can act to make coordinated services for people facing multiple needs and exclusions the norm. It is of relevance to service managers/providers who can act now to tackle multiple needs by building partnerships, taking proposals to commissioners, and supporting elected members to develop new approaches.

The purpose of this paper is to discuss “system transformation” in the context of different workforces and organisations seeking to support people experiencing multiple exclusion homelessness (MEH). From a relational and integrated care perspective it aims to identify barriers to achieving more effective ways of working in the prevailing context of “managerial domination”. Communities of practice (COPs) are evaluated to identify their potential to overcome some of these barriers.

The paper presents a theoretical and conceptual discussion of a project in which a number of COPs were established and evaluated to ascertain their value in developing more relational ways of working in the context of MEH. Case studies of COPs operating in the context of MEH are explored and discussed.

It is concluded that COPs have the potential to deliver small-scale changes (“little miracles”) which are characteristically more subversive than transformative. Nevertheless, the authors still see these small gains as significant when compared to the inertia that is often found in local systems of care where more traditional management techniques (such as “payment by results”) prevail. The authors also draw attention to the scope for much improved service quality which flows from moving beyond the “tick box” and into the realms of what it really takes to tackle homelessness and multiple exclusion. In other words, although often requiring considerable amounts of “craft and graft” to deliver seemingly very small amounts of change, these “little miracles” may actually be more conducive in the long run to delivering the kind of tangible “real” change that is often aspired to by both workers and service users and their carers.

The COPs project was limited in terms of time and scale and, hence, further research would be needed to, for example, ascertain their longer-term potential.

There is merit in the theoretical perspectives discussed and, from these, of understanding how best to establish and operate COPs as a vehicle for achieving better outcomes through integrated or collaborative working.

There is much scope for better integrated or more collaborative working in the context of MEH and this paper draws attention to how COPs could be one means of achieving better outcomes for people experiencing MEH.

This is the first paper to set out the theoretical analysis of COPs as a means of achieving better integrated or collaborative working.

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 paper aims to remove the self-evidence of the concept of severe and multiple disadvantage (SMD) by drawing upon a historical as well as a critical perspective to show its contingency.

This paper will introduce the concept of SMD by examining how it has come to be understood in the way that it has. This paper does so by exploring key texts which have informed the development of the concept as well as its conceptual near neighbours such as “multiple needs”. This paper traces some advancements of the concept within practice and further research with a focus on the Fulfilling Lives programme and the Lankelly Chase Foundation. Finally, the author reflects critically upon the concept and the manner in which the concept has become operationalised.

This analysis demonstrates how a particular definition of SMD has come to dominate over the past few years because of the research and practice of key organisations. On the one hand, this has further marginalised alternative definitions and ways of working, but on the other hand these stakeholders have been able to influence the way in which UK policy has taken up the concept within its governmental priorities.

To date, research has taken the term SMD for granted which limits the ability to critique its definitions and applications. This is an important and timely contribution because concepts are all-too-often taken for granted and at a pivotal moment when SMD has become nationalised through policy, critique is a political, potentially transformative, act.

The critical potential of hospital discharge policies and practices to ameliorate the health and social care needs of homeless people has become the focus of considerable interest in England. Central to this rise in policy formation and practice development is an acute understanding of the multiple exclusions homeless people face in navigating public health and social care systems. In ways small and large this nascent landscape is serving to redefine and reshape hospital arrangements for homeless people, and opening-up new ways to deliver care across clinical, social and therapeutic boundaries. The purpose of this paper is to seek to add empirical vigour and theoretical rigour to this unfolding policy and practice terrain.

This paper draws on findings from a case study concerned with exploring and explaining how statutory and voluntary sector organisations use specialist hospital discharge policies and practices to coordinate pathways of care for homeless people.

This paper illustrates how people affected by homelessness and ill-health are routinely denied access to statutory housing support, social work assessments and district nursing provision through acts of institutional gatekeeping and professional abrogation.

This paper makes an important contribution to understandings of the connections between hospital discharge arrangements for homeless people and statutory housing, social work and district nursing provision.

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.

People experiencing homelessness are being identified as a potentially vulnerable group in relation to gambling-related harm. The purpose of this paper is to explore the links between gambling-related harm and homelessness.

A scoping review of the English-language literature was conducted in 2016-2017 using a wide range of international sources. Qualitative content analysis was employed to code and identify key themes within the literature.

Five themes were identified: emerging knowledge about why people experiencing homelessness may participate in gambling; emerging knowledge about the prevalence of gambling within the homeless population; the likelihood that gambling-related harm is under-reported within the homeless population; emerging knowledge about the extent that people experiencing homelessness access gambling support services; and limited awareness about the potential impact of gambling participation among people experiencing homelessness.

The paper reviews research concerning the links between gambling, gambling-related harm and homelessness, which may be relevant to those working with people experiencing homelessness.

The purpose of this paper is to update the core data set of self-neglect safeguarding adult reviews (SARs) and accompanying thematic analysis and explore the degree to which SARs draw upon available research and learning from other completed reviews.

Further published reviews are added to the core data set, mainly drawn from the websites of Safeguarding Adults Boards (SABs). Thematic analysis is updated using the four domains used previously. The four domains and the thematic analysis are rounded in the evidence-based model of good practice, reported in this journal previously. Multiple exclusion homelessness and alcohol misuse are prominent in this sample of reviews.

Familiar findings emerge from the thematic analysis and reinforce the evidence-base of good practice with individuals who self-neglect and for policies and procedures with which to support those practitioners working with such cases. Multiple exclusion homelessness emerges as a subset within this sample, demonstrating that SABs are engaging in reviews of people who die on the streets or in temporary accommodation.

The national database of reviews commissioned by SABs remains incomplete and does not contain many of the SARs reported in this evolving data set. The Care Act 2014 does not require publication of reports but only a summary of findings and recommendations in SAB annual reports. NHS Digital annual data sets do not enable identification of reviews by types of abuse and neglect. It is possible, therefore, that this data set is also incomplete. Drawing together the findings from the reviews nonetheless builds on what is known about the components of effective practice, and effective policy and organisational arrangements for practice.

Answering the question “why” remains a significant challenge for safeguarding adult reviews. The findings confirm the relevance of the evidence-base for effective practice but SARs are limited in their analysis of what enables and what obstructs the components of best practice. Greater explicit use of research and other published SARs might assist with answering the “why” question, drawing attention where appropriate to policies being pursued by the central government that undermine any initiative to end rough sleeping.

This paper extends the thematic analysis of available reviews that focus on work with adults who self-neglect, further reinforcing the evidence-base for practice. The evidence-base also supports practice with individuals who experience multiple exclusion homelessness. Policymakers and practitioners have an approach to follow in this complex, challenging and demanding area of practice.