Agency and choice in multiple exclusion homelessness

Carolin Hess is a PhD student at the NIHR Policy Research Unit in Health and Social Care Workforce, King’s College London. (583 words)

Carolin HessAs part of the NIHR Policy Research Unit in Health and Social Care Workforce Homelessness Series, Research Fellow at the Unit, Jess Harris, and Stan Burridge (public contributor) recently presented ‘lived experience’ perspectives from the emerging findings of an NIHR School for Social Care Research funded national study of homelessness, self-neglect, and safeguarding. The event, held on 25 April, was attended by over 180 people.

In light of a recent report that revealed that 1313 people died while homeless (including people sleeping rough, in emergency or other insecure settings) in the UK during 2022, an 85% increase on the number recorded in 2019, the research could not be more timely.

Bringing together the voices of multi-disciplinary practitioners and people with lived experience, the study findings highlight the complexities of safeguarding but also offer suggestions on how to strengthen safeguarding responses and more effectively support people who face multiple exclusion homelessness (MEH).

While safeguarding referrals may require urgent multi-disciplinary scrutiny and action, the study findings highlight gaps in assessments which often lead to “no action” from services in the support of people experiencing MEH. Safeguarding engagement may not proceed because of services’ perception of an individual’s “choices” or “unwise decisions”. However, these are often shaped by negative past experiences, trauma, mental health crises and service mistrust.

The webinar offered an opportunity for participants to hear the study findings, discuss their experiences of safeguarding, and to share and develop ideas for improvements. In the subsequent discussion on “how to manage a better balance in the application of the principles of empowerment, proportionality, prevention and protection in the Care Act 2014”, the difficulties of looking beyond ‘choice’ and ‘agency’ in safeguarding referrals became apparent.

Supporting the findings of an earlier report, discussants – practitioners and people with lived experience – described their frustrations with the process, and structural and resource constraints they face when trying to address safeguarding risks for this population. They described how, if a person was deemed to have the ability to make choices themselves, often no action was taken to support the person with their unmet needs. One discussant with lived experience, for example, described how her MARAC (Multi-Agency Risk Assessment Conference) risk assessment report was dismissed because she was able to collect medication by herself, despite having been ‘scored’ as a highest risk domestic abuse case. Other discussants corroborated her experiences and described how referrals were often rejected without any further investigations of how trauma, addiction, or mental ill health were impeding the individual’s capacity to make a “wise choice”.

A short follow-up School for Social Care Research (SSCR) funded project is building on these findings led by Stephen Martineau, looking beyond the “default assumption of capacity” and examining Mental Capacity Act approaches to multiple exclusion homelessness.

In my own PhD project, funded by the NIHR SSCR, I aim to further investigate the mechanisms behind agency and choices among multiply excluded women. I want to explore how societal, professional and personal processes influence their agency and capabilities to change their homelessness and social exclusion trajectories.

Both projects are opportunities to further engage with the questions raised at the webinar, gaining a better understanding of why a person may refuse, or feel unable, to engage with support, and how services can “look beyond choice”, finding the right balance in daily practice, to protect and prevent when someone appears to be severely self-neglecting without dismissing a person’s agency. Further research is needed to look at training and trauma-informed approaches to strengthen safeguarding responses, as a failure to act can have severe, even deadly consequences.

Carolin Hess is a PhD student at the NIHR Policy Research Unit in Health and Social Care Workforce, King’s College London.

The slides from the Homelessness Series event are available on the event page.