Written evidence submitted by Dr Patrick Murphy [EXA 053]

Hi, I am Patrick Murphy. I am making a submission in my capacity as a clinical psychologist in the NHS, where I have worked in the adult mental health sector and in specialist neurological services for almost 10 years. This has provided me with extensive experience on how the quality of housing can impact the quality of life, level of functioning and mental health of people with neurological conditions and long-term mental health problems.

My aim in this brief submission is to provide further information that is related to the following points from the terms of reference:

• What is the quality of exempt housing provision?
• How should exempt accommodation be provided and what should the service cost?
• How should the regulatory oversight of exempt accommodation be organised?

What is the cost of exempt accommodation?

The goal of exempt accommodation is to provide housing for often-vulnerable individuals with housing needs (e.g. prison leavers, rough sleepers, refugees and migrants, and those experiencing substance abuse issues) but who do not meet the threshold for supported specialised housing1. The provision requires unspecific (and un-monitored) “additional support” to be provided in order for additional funds above the housing benefit cap to be claimed directly by the landlord. Many individuals are housed in small units within converted houses, thus allowing allowing the provider to receive a reasonably large sum of money from the taxpayer for providing this accommodation; an estimated annual bill of £200 million for the provision of exempt accommodation for Birmingham area alone has been given2.

The scheme has been criticised in terms of the lack of value that it provides given that the “more than minimal support” it calls for is not properly monitored3. However, it seems safe to assume that the actual cost of this accommodation is likely far greater than the direct and unmonitored payments made for the provision. This is because the users of exempt accommodation are by definition far more likely than average to have complex care needs. If the housing offer and support they receive is inadequate, there will be a vicious cycle of further costs to the individual, to social services, mental health and substance abuse services and to the police services.

By way of evidence for these claims; a well-cited review of the scientific literature noted that nearly every study of housing and mental health has found that multi-occupancy houses are associated with adverse outcomes for mental health4. Most relevant to the provision of exempt accomodation, the review in particular noted that:

“Poor housing quality reduces behavioral options, diminishes mastery, and contributes to a general sense of helplessness”

and

“Size and quality of space can restrict flexibility, disallowing multiple uses of space, particularly important when amount of space is limited. Difficulties in regulating social interaction, inability to control and regulate access to space, and lack of jurisdiction over the immediate public environment might all contribute to feelings of low self-efficacy”

Beyond this, other well-designed studies have found that the provision of adequate and secure housing has as beneficial an effect on recovery from substance abuse as established treatment programs5. Even memory and other cognitive functions have been seen to improve when individuals with substance abuse problems were moved to a more supportive type of accommodation rather than living alone in small flats6

To bring this all together, I would suggest that when we ask “what should the service cost?”, we need to ask what are the wider costs to tenants, the government, local authorities, social services, the NHS and the police force in terms of the issues that poor quality exempt accommodation creates. Thus, one should consider whether the accommodation being provided is triggering issues such as a relapse in substance abuse, deterioration or lack of recovery in terms of mental health, an increase in the likelihood of anti-social or recidivist behaviour, etc.

With all of this in mind, to maximise the benefit for tenants and the systematic impact that the additional funds provided for exempt accommodation can have, I would suggest that any regulation scheme should involve the following:

• Linking additional funding over and above the housing benefits cap to the provision of specific aspects of a housing service that are of advantage to tenants. These could include for example (a) providing a level of living space that is a defined amount above minimum building regulations requirements, (b) having access to an outdoor space, (c) having living spaces that are above minimum building regulations in terms of managing noise from other units within the property (d) having access to suitably trained and available keyworkers to deal with safety and other issues occurring at the property.
• If the additional money provided is indeed to provide support to vulnerable tenants, it seems absurd to assume that the property owner alone should decide how this money is best spent. Providers that I am aware of are in the main property developers and ex-estate agents, with no obvious expertise in managing the needs of vulnerable individuals. It seems sensible to me that the extra money that is made available for vulnerable tenants should be linked with their health and social care needs. Thus, health and social care services that are involved with tenants, along with the tenants themselves, should have some say in how this additional money is spent.
• I would also suggest that proof of appropriate screening is required to ensure that that an appropriate mix of individuals are being housed within a single property. E.g., minimising the grouping of individuals with a history of substance abuse, not housing women with a history of domestic or sexual violence alongside men with a history of violent offending.
  

References

1. https://www.insidehousing.co.uk/insight/insight/the-story-explained-what-is-exempt-accommodation-73541

2. https://www.birminghammail.co.uk/news/midlands-news/broken-people-landlords-raking-millions-19424464

3. https://www.insidehousing.co.uk/insight/insight/the-story-explained-what-is-exempt-accommodation-73541

4. Evans GW, Wells NM, Moch A. Housing and mental health: a review of the evidence and a methodological and conceptual critique. J Soc Issues. 2003;59:475–500.

5. Hurlburt MS, Hough RL, Wood PA: Effects of substance abuse on housing stability of homeless mentally ill persons in supported housing. Psychiatric Services . 1996;47:731–736.

6. Caplan B, Schutt RK, Turner WM, et al. Change in neurocognition by housing type and substance abuse among formerly homeless seriously mentally ill persons. Schizophrenia Research. 2006;83(1):77–86.

January 2022