Q: What’s the evidence? — The role of research in the homeless sector’

05.02.2021: Reflecting on this week as the Lead for Psychologically Informed Environments (PIE) at the national youth homeless charity Centrepoint, the highlight has definitely been being able to access the COVID-19 Oxford AstraZeneca vaccine as a ‘keyworker’ via our partnership with Camden Local Authority. Apart from feeling a bit hot later in the evening, with a bit of a headache and sore arm (all easily solved with a paracetamol), I am also pleased to report that I had not significant side effects or impact of the vaccine afterwards. Centrepoint have been campaigning for all our ‘frontline’ key-worker staff to have access to the vaccination as a priority group along with other health and social care staff (e.g. https://twitter.com/centrepointuk/status/1347578307781550090). Consequently, it is brilliant news that some of our statutory local authority partners have recognised that our staff working in our supported accommodation services are at increased risk from COVID-19, and have responded with access to the vaccine. Personally, I hope that it is one step closer towards enabling me to return to face-to-face PIE delivery as soon as possible.

It was also particularly apt that I attended my vaccination appointment at the Francis Crick Institute in London (c.f. https://www.crick.ac.uk/), an academic centre of scientific /genetic research. As I waited in the queue, I spoke to some of their scientists who were volunteering at the vaccination centre, and it was fascinating to hear about the evidence and scientific process that had occurred over the past 12 months to get us to the position of having an evidence based viable vaccine for distribution amongst the population. For more details of the process of developing the vaccine see this highly informative BBC Panorama link here: https://www.bbc.co.uk/iplayer/episode/m000qdzd/panorama-the-race-for-a-vaccine.

It made me reflect again on the importance of ‘evidence’ and value of scientific research, or an expert ‘voice’, which can sometimes get drowned out in the sea of information circulating on the internet and/or social media about COVID-19. How do we therefore discern what we should be paying attention to in the world of information overload? How do we ensure that science and ‘evidence based practice’ can cut through all of the information and data we are exposed to, so we can utilise appropriately what is reliable and valid in order to inform our decision making? Of course, this doesn’t mean we ignore the individual level of analysis, as all our approaches should be individualised to ensure the best possible outcomes, but starting at the point of scientific research and fact, rather than anecdotal opinion, is important if we are to be truly psychologically informed or PIE in our approach. What we do, how we do it, when we do it and where we do it, should be guided by the ‘evidence’ as far as possible.

In the key PIE paper prepared by Keats et al (2012) (c.f. https://eprints.soton.ac.uk/340022/1/Good%2520practice%2520guide%2520-%2520%2520Psychologically%2520informed%2520services%2520for%2520homeless%2520people%2520.pdf), it is noted that ‘Evaluation of outcomes is crucial in the development of psychologically informed services. Evaluations are crucial because they are a cornerstone of reflective practice, which in turn is a cornerstone of psychologically informed environments. If you do not know what impact what you do or say is having, how can you know whether it is positive and how can you improve it? There is not a great mystique about evaluation: it is the opportunity to know which things you do or say are effective, in what situations and with whom’ (p26). Of course as noted by Halpern (2020), this is not always the easiest thing in practice, even if we strive for this aim. There are often methodological barriers to answering the question of ‘what works’, especially in the homeless sector. Even when we might have some idea of this, organisations and policy makers still also want to know what the relative cost-effectiveness of options might be and it can be a challenge to change practice or embed new approaches in services. In addition, we need to look not just at the evidence of what interventions might work in addressing the consequences of homelessness but also what evidence is there for the underlying causes of homelessness, which also need to be addressed in order to #endyouthhomelessness in the future.

Therefore, the concept of gathering evidence, analysing the data and applying the knowledge gained from this process can be a challenge. We need to be open to new approaches, try to test them out, be prepared to modify them if necessary and then commit the resources to upscale the successful approaches more widely (Homeless Link, 2020). As Teixeira (2020) argues, the time has come for a ‘what works’ movement in homelessness, using evidence to help those at risk of, or experiencing homelessness. This also means ‘acting promptly on the best available knowledge, while being aware of the limited of what we know’ in order that we can, as per the COVID-19 vaccine, ‘reject the dangerous half-truths that can pass for wisdom’. Evidence can also help us to ‘move from a crises driven approach … to a more strategic and targeted methodology’ (Teixeira, 2020).

When reviewing the evidence of what works in homelessness, it is interesting that there are few studies from the UK, with the vast majority of the published research coming from the United States, which may not be applicable here due to system differences. Moreover, whilst the PIE approach has demonstrated some effectiveness in improving outcomes for homeless individuals in the UK (e.g. Maguire, 2006; Cockersell, 2011; Stronge & Williamson, 2014; Phipps et al, 2017), and the ‘Housing First’ approach is one of the few interventions to have evidence supporting it, neither have enough studies to provide reliable cost-effectiveness and longer term outcome data yet. Vital will be the collection of larger data sets, and improvements in the way that data is collected and analysed, both within organisations such as Centrepoint, but also nationally within the Government Statistical Service (Homeless Link, 2020) in order to inform both local decision making and national policy. As rightly noted by Teixeira (2020); ‘if we want to gain momentum for evidence based approaches with a view to ending homelessness for good, we need to start routinely testing the effectiveness of interventions while taking a bird’s eye view of the issue’.

So what does this look like in the real world? Teixeria (2020) goes on to argue that some key principles would be useful to follow, not just in a PIE but in any of our work in the homeless sector. Firstly, we need to understand the problem in order to work out how best to solve it. In other words we need to prioritise asking the right questions and collect the right data in order to answer them. This means prioritising and advocating for collecting the data we need, by building the appropriate technology systems to collect it and supporting those we are asking to collect it (e.g. ensuring that staff know what they need to record and why this is important). Being selective in what data we are collecting with a focus on the question we are asking, can be helpful rather than just collecting data for the sake of it, which tends to result in poorer data quality. Ensuring that we collect data on how well an intervention is reaching a particular population, whether it is improving their outcomes, and whether it is being implemented correctly are all key questions that help promote ongoing improvement. We also need to ensure that we attend to evidence or data at different levels otherwise improvements in practice will have difficulty ‘scaling up’ if they do not consider the wider system and context. Finally, we need to have an appetite for research or an ‘experimental mind-set’ in order to embrace new approaches to create change. This might mean that we fail at first, but this failure can create further learning and improvements in the longer term.

One example of using data and evidence in homelessness is the research on the impact of the COVID-19 pandemic, such as the recent Centrepoint report (with policy recommendations) on youth homelessness (c.f. https://centrepoint.org.uk/media/4293/locked-out-report.pdf). There is now sadly, plenty of evidence of the increasing number of young people being adversely effected by the impacts of recent events, such as a rise in the number of young people facing homelessness (e.g. https://www.bbc.co.uk/news/av/uk-55399979) or rough sleeping (e.g. https://twitter.com/centrepointuk/status/1355793691902836736), as well as the increased risk of households being made homeless during lockdown (e.g.

https://twitter.com/CP_Policy/status/1355097360129515525). There is also evidence that young people have been placed at increased risk of homelessness in the future, due to unaffordable rents (e.g. https://www.eyh.org.uk/en/news/living-anywhere-in-england-is-unnaforadble-for-young-people-on-minimum-wage/), and being hardest hit by disruptions to education or increased unemployment following lockdown (e.g. https://www.bbc.co.uk/news/business-54146833 or https://www.theguardian.com/business/2020/oct/26/covid-job-losses-hitting-young-people-hardest-in-uk-study-finds). Consequently, and unsurprisingly, we are seeing a significantly increased number of calls to our Centrepoint National Helpline (0808 800 0661) and there is increasing evidence of an impact on the mental health of young people (e.g. https://youngminds.org.uk/about-us/reports/coronavirus-impact-on-young-people-with-mental-health-needs/).

Whilst all of this evidence can make somewhat depressing reading at the moment, it is important that it is collected, published and highlighted in order that organisations such as Centrepoint amongst others can argue for significant social policy changes post COVID -19 (e.g. https://www.homeless.org.uk/sites/default/files/Policy%20Briefing%20-%20Youth%20COVID-19%20final-2.pdf or https://www.bma.org.uk/media/3582/bma-submission-impact-of-covid-on-homelessness-and-prs.pdf). It is much harder to ‘ignore’ evidence and data, and any desire or momentum for social change needs this information in order to lobby effectively and/or take action. We owe it to the next generation to ensure that we continue to use research and evidence to guide our decision making, and ensure that the longer-term impact of the current pandemic on young people is minimised. As noted by The Health Foundation (2020), the data shows that not all young people have been impacted equally, some groups (e.g. those in the North of England or those from minority ethnic groups) are more at risk of many negative outcomes including future homelessness. Therefore, we need to use this data / evidence to identify those at risk as well as co-produce and evaluate any interventions to address these (c.f. https://www.health.org.uk/publications/long-reads/generation-covid-19).

On a more positive note to end this blog, I have been telling my children throughout the past year that ‘science will save us’. The vaccine that I was honoured to be eligible to receive this week is just one example of the scientific research having a positive impact on the course of this pandemic. However, within a PIE and within wider society, we should be using research and evidence much more broadly to improve outcomes for young people and ensure that whatever the ‘new normal’ looks like after COVID-19, it is guided by facts and evidence, rather than mistrust and misinformation…