Written evidence submitted by Miss Katie Wood, Ms Sabrina Davis and Mr Kaddison Poskitt (TH0012)

 

Rationale for study

Portsmouth has a large provision of services for rough sleepers including a rough sleeping pathway.  Local authorities only have a duty to provide temporary accommodation to a homeless person if they have reason to believe that a person may be in "priority need" according to legislation.   Those in priority need include households containing children, pregnant women and those who would be more vulnerable when homeless than a typical person (e.g. as result of physical or mental health problem)[1].  This means that many people who are homeless are owed no statutory accommodation duty. 

In Portsmouth some provision of shelter or accommodation have been provided for people who sleep rough since 2018.  There were significant changes during the Covid-19 Pandemic during the national "Everyone in".  This government directive gave Portsmouth the opportunity to expand its provision for rough sleepers and develop the current rough sleeping accommodation and support pathway, which consists of 105 bed spaces over three sites.  One site for people deemed with lower support needs, one for people with medium support needs and one for higher support needs.  This pathway is funded until the end of March 2025.

Portsmouth homeless drug and alcohol team is funded by the Office for Health improvement and Disparity through the rough sleeping drug and alcohol treatment grant (RSDATG).  The Team supports rough sleepers and people at risk of rough sleeping.   The team includes recovery workers, peer mentors, a social worker, psychologist and assistant psychologist and they provide wrap around trauma informed support 7 days a week.  The team meet and engage people experiencing homelessness at hostels, homeless days services and the street.  One of the main objectives of the grant is to increase access for this cohort to drug and alcohol treatment and to also reduce overall number of rough sleepers.  

Portsmouth has been in receipt of the grant since 2021.  Despite this resource and best efforts of the team and the well-established rough sleeping pathway, the number of rough sleepers in Portsmouth have been slowly increasingly.   

With the government's ambitious target to end rough sleeping, this Realist Evaluation aims to understand why, whom and when people who are experiencing homelessness in Portsmouth, decline an offer of accommodation so continue to sleep rough.

Objectives 

 

Why realist

Realist Synthesis methodology has been increasingly used in Public Health settings as it seeks to understand the complexities of how, why and for whom programmes work. Often what is evaluated in relation to projects is what can be measured empirically but this does not address the context in which the program operates or how it works.  For example rough sleeper numbers in Portsmouth are counted and used as a measure but this does not tell us anything about how the system functions or what works, and for whom under what circumstances.

Realist evaluation is a methodology that aims to understand what works, for whom, under what circumstances and how [2]The realist approach achieves this through an iterative process, refining “programme theories” which hypothesise that outcomes are a consequence of interactions between context and mechanisms[3].

 

Literature search:

To inform the first iteration of the evaluations Initial program theories (IPTs), a thorough literature search was undertaken with the support of Public Health librarian. Searches were conducted across electronic databases PROQUEST, EBSCO and OVID which were selected due to their relevance. Sources were limited to peer reviewed journal articles that were produced post 2010, in countries with similar socioeconomic circumstances to that of the UK.

Design:

Initial Program Theories:

In conjunction with the evidence base, IPTs were also informed by “professional hunches”. This experience was considered specifically through the lens of interaction between contextual factors and mechanisms resulting in commonly seen outcomes. The researchers began with 19 IPTs that attempted to explain the outcomes of the serviceThese can be separated into 5 key themes.

Theme 1: Substance use

Rationale: In the Portsmouth homeless community, substance use is near ubiquitous. Engaging in and funding substance use places considerable pressure on maintaining accommodation from a financial and interpersonal perspective.

Theme 2: Disadvantage and trauma

Rationale: Many of the cohort that are homelessness in Portsmouth come from disadvantaged backgrounds and/or have experienced complex trauma. The hostel environments could conceivably present triggers to service users, resulting in negative outcomes.

Theme 3: Rough sleeping is sometimes less undesirable than undesirable accommodation.

Rationale: Some rough sleepers have previously reported that the challenges presented by rough sleeping are preferable to the challenges presented by being accommodated in the housing pathway.

Theme 4: Unmet need.

Rationale: The current limitations in accommodation that Portsmouth City Council are able to offer can sometimes result in unmet client's needs. In response clients may decline offers of accommodation.

Theme 5: The Offer

Rationale: Variance in how the offer of accommodation is made and received could foreseeably impact whether or not an offer of accommodation is accepted.

The researcher top three IPTs (best guess at what was happening) were:

  1. If a rough sleeper perceives housing projects to be unsafe then the offer of accommodation may elicit feelings of fear resulting in the offer being declined.
  2. If a rough sleeper is using drugs or alcohol then they may prioritise spending on using their substance and so refuse an offer of accommodation
  3. If a rough sleeper has previous experience of the RS pathway and they were evicted or abandoned their accommodation, they may be unwilling to navigate this again, and refuse offers of accommodation.

 

Stakeholder event:

According to realist methodology, establishing IPTs should be an iterative rather than linear process, with multiple attempts made to refine hypotheses before and during testing them out.  To broaden the perspective, from which the initial IPTs were drawn from, researchers organised a stakeholder event that canvassed the opinions of 15 professionals from across the housing pathway. Many of the original IPTs were confirmed as shared professional hunches and 2 new theories were added that were not originally considered including an IPT about people refusing offers of accommodation to avoid detection by the authorities, as being accommodated made people more visible.

Interviews:

To test the 22 IPTs, the research team conducted interviews with the below inclusion criteria:

Inclusion 

 

Exclusion 

Twenty interviews were completed in total to test programmed theories, this included 5 current rough sleepers. 2 previous rough sleepers and 13 staff/stakeholders.

Analysis: 

Transcripts from interviews were loaded into Nvivo 11 for analysis.

Findings:

Who is declining an offer of accommodation  

A typical rough sleeper we spoke to or heard about, shared the below experiences,

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“I have a lot of anxiety or dwell over a lot of things that happened               the past…I was taken into care at 15

 

When::

An offer of accommodation is more likely to be declined in the summer months when the conditions outside are more favourable, this IPT was spoken about in 10 interview 19 times.

[I] first got into a tent, and it was alright, in the summer months… normally the               weather is not cold enough and I can survive without the hotels. P15

It was also highlighted that not only are people more likely to decline during the summer months, but they may also jeopardise their current accommodation as the consequences of being street homeless aren’t as severe.  This was also supported by the quantitative data that Portsmouth City Council routinely collect which shows seasonal trends.

If offers of accommodation are made by a trusted person, someone with an established relationship, such as a peer support worker, then the person maybe more likely to accept the offer as deem it suitable.  This was closely linked to the environment in which the offer is made, whether the person felt they were involved in the plan; had any control or choice over their offer, the persons relationship to authority, and how the offer was communicated.  A trusted person was mentioned in 15 interviews over 30 times.

If they’ve been told by someone they have a relationship with and have built that trust…. it is going to take some of that fear away, Isn’t it.  P16

 

If the council had of made this offer I would have thought that it was a trap I would think that it was a conspiracy. P11

Substance use was a common theme, and the interviews highlighted that if a rough sleeper has entrenched chaotic drug or alcohol use then housing may not be a priority, as their priority is to spend any income on using their substance of choice and so they refuse an offer of accommodation.    This was mentioned in 14 interviews over 30 times.  Often people prioritising their income on substance use over accommodation was not due to choice but to manage withdrawals and the associated ill feelings of being unwell and uncomfortable.

They want to spend their money on drugs they don't like the fact they have to spend money on bills. That's the main reason that I was out there. P11

You have a habit, then this comes first. P 20

They prioritize that need to feel well on that day, it also means that if they can pay for their gear, then they don't have to go out and shoplift.  So, It gives them a break from that. P1

 

Why:

This focused on people's previous experience or perception of Portsmouth's rough sleeping pathway. The team had hoped to speak to more rough sleepers however due to the inclusion criteria, we spoke to far fewer than anticipated this was because people generally don't decline offers of accommodation but do accept; there are a small minority that are accommodated, but then the placement fails; either the person might abandon the accommodation or are evicted.

Portsmouth rough sleeping pathway is generally larger style hostels, there is only a small provision of dry accommodation an 8-bed unit within the substance misuse pathwayPeople's experience or perception related to the safety of these larger hostels including exploitation, other residents, the environment itself, so the hostel being noisy, chaotic and shared communal living.

No way, I did not feel safe sleeping in those places even if you do have a lock on your door you will wake up to people coming in your room. P11

It is quite chaotic in the big hostels…we have a lot of complex clients, it's very noisy it is very loud.  Knocking on each doors at 2 o clock in the morning …things being stolen by other residents there’s [the] potential of abuse from other residents over drugs, over money, P16

There are triggers in hostels that represent something from certain clients' pasts and I've always felt for specific clients, all we have to offer is a building that ….is triggering. What this person really needs is a wide-open space…... We can't offer that, we don’t have that to offer. We have tiny spaces and little boxes.  It doesn't make sense. p13

Fear of relapse or people's substance use exacerbating was a big factor for people declining offers of accommodation, where there was known active substance use within larger hostels. This was mentioned 36 times in 15 interviews

I turned the [hostel] down as at the time I was coming off the drugs and it was the wrong place for me, and I didn't want to be around that type of person coming off the drugs. P20

 

I think if you have to go into a hostel for one year to prepare for a flat then it is the wrong place for me because everybody else is getting out of their head so it is easier to get out of your head. – p11

 

He came here he wasn't using any substances, he come in and I think he lasted around month… and then he was evicted through violence but not long after he came, he started using substances and then the behaviour escalated – P 17

 

 

The direction of the rough sleeping pathway and inconsistency from the different accommodation providers was also seen as a barrier, where if the move on accommodation was seemed as less desirable as the current placement, so for example moving to hostel with a shared kitchen or bathroom or moving to a property with a higher service charge; this could lead to offers being declined.  Interviews highlighted that some people would accept accommodation to end their period of street homelessness, but may have no intention to pay service charges, so fall into arrears, with little consequence to being evicted, they go back around the pathway again.

 

You start at the [name of hostel] which is high support, and your positive move on from having a room with your own suite, a kitchenette, your positive move on is to share a flat with six, eight other people and shared with the bathroom and the kitchen.  That's what gets people back up, because how is that in their eyes a positive move on when you're trying to get them ready for their own accommodation? – P1

 

Considering the typical rough sleeper that we spoke to i.e. background of trauma, mental health, lack of self-worth and if the offer is made in the summer, not by a trusted person or the person is in active substance use, and people's perception or previous experience of the rough sleeping pathway; this sometimes led to people preferring to rough sleep, as the alternative that was on offer was deemed less desirable, a feeling that this is a good as it gets.

I've been in tent for so long, the normal problems of being outside is, you're really cold, you can always get bedding and places to go, you’ve then got to find a shower , so you find a shower, you’ve  then got to get something to eat…. it could be worse, what you could give me could be worse than what I've got at the moment , that is the problem, being homeless for me it is not that difficult. P15

Top Programme theories:

Revisiting the IPTS and considering the findings from interviews the most evidenced IPTs included:

Recommendations:

Following the conclusion of interviews and to remain respectful of the iterative process of realist methodology, another stakeholder event was held where the findings were presented, and stakeholders were asked about recommendations and further considerations. The following was drawn from the interviews and the event.

  1. Commissioning flexible post/s to move with seasonal demands
  2. Review access/provision of homeless day service considering seasonal demands
  3. Outreach housing assessments  - Review of who and where assessments take place
    1. Ask the person experiencing Homelessness how to communicate with them, who is that best professional
    2. Offer Itself - given by that trusted professional

 

  1. Continue to fund a separate homeless outreach service - assertive outreach for rough sleepers and those at imminent risk to engage into Substance misuse treatment.

 

  1. Further exploration oh enhanced harm reduction approach - Safer place for substance use in our hostels.

 

 

  1. Review of current pathway (Range of accommodation for different needs, smaller units, tailored support, more dry accommodation, access pathway at different points).

 

  1. Manage perception of active drug use - meet staff, visit venue, person centred support plan/recovery plans. 

 

  1. Development of housing/pathway peers - meet and greet, support with above plans = as many people do successfully go through the pathway.

 

 

Limitations:

People experiencing homelessness are a difficult group to recruit and retain in research, this coupled with the inclusion criteria that a rough sleeper needed to have declined an offer, meant fewer rough sleepers were spoken to than anticipated, meaning a likely insufficient number to reach data saturation 13 were members of staff, possibly leading to an overrepresentation of professional views in the data set.  This raises questions over the external vitality of the research.   Some IPTs weren’t evidence from interviews for example IPTs referencing physical health and neurodiversity, however this is a likely reflection of the limited sample size.

There were also IPTs that were disproven and highlighted areas of good practice happening in Portsmouth, for example people declining offers if they want to stay as a couple or if they have a pet, this was highlighted in the literature however Portsmouth are accommodating and will try to place a couple and a pet if appropriate.

November 2024

 

 

 

 

 

 

 

 

 

 


[1]  What is priority need? - Shelter England

 

[2] Pawson, R. and Tilley, N., 1997. An introduction to scientific realist evaluation. Evaluation for the 21st century: A handbook, 1997, pp.405-18.

[3] Realist synthesis: illustrating the method for implementation research | Implementation Science