Michelle Cornes

Introduction: People with experience of homelessness (PEH) often have multiple inter-related needs and for support rely on various services working together. To improve Out-of-Hospital Care (OOHC), it is crucial to understand their preferences. This study used a Discrete-Choice Experiment (DCE) to identify what matters most to them, ensuring services align with real-life experiences. Methods: A mixed methods approach combined interviews, group discussions, and DCE data. Service users, providers, and planners participated in workshops. Researchers with lived experience of homelessness co-designed a user-friendly questionnaire and supported data collection, fostering trust. Preferences were analysed using logistic regression, with findings presented in clear, interactive dashboards. Results: A total of 112 PEH participated from 10 sites, with 108 valid responses (35% response rate). Participants preferred care delivered at home, delivered by trusted housing workers, with minimal behavioural restrictions. Accommodation type and behavioural rules significantly influenced service uptake. DCE outputs were shared with PEH, who confirmed that the findings accurately reflected their priorities and real-life experiences. In one locality, insights were used to reshape service modelling. Discussion & conclusion: This study highlights the importance of co-designing OOHC services with PEH. Stability, trust, and fewer restrictions encourage service engagement. These insights can guide policymakers and service providers in developing more effective, person-centred care models, ultimately improving access and outcomes for PEH.

This paper explores the economic implications of different support scenarios for individuals who self‐neglect whilst experiencing multiple exclusion homelessness (MEH) or hoarding behaviour (HB). It draws on analysis of six Safeguarding Adults Reviews (SARs) of self‐neglect‐related deaths from across English localities. Focused on the last one or 2 years of an individual’s life, the SARs provide a detailed examination of resource utilisation across various sectors. The study employs economic modelling to compare the costs associated with ‘unmet needs’, the scenario that ended in death, and the potential costs and benefits derived from meeting these needs more effectively. Sensitivity analyses test the robustness of the model, exploring various budgetary adjustments. For MEH cases, the analysis suggests that shifting from uncoordinated use of urgent and emergency services to planned multidisciplinary support for individuals could free up public resources, enabling reinvestment and better outcomes. The study indicates potential cost savings, emphasising the importance of timely and coordinated interventions to improve the well‐being of individuals experiencing MEH. In HB cases, addressing gaps in responses to self‐neglect among older individuals requires increased resource investment mainly for housing and adult social care but also demonstrates a release of resources for health and a significant reduction in costs for criminal justice and fire and rescue services. The study highlights the role of local voluntary sector groups in providing support and guidance. The study evidences the importance of a multidisciplinary approach, early interventions, and ongoing collaboration among diverse professionals to ensure a holistic response to the complex needs of vulnerable populations. It emphasises the need for continuous collection of quality data, to enable service evaluation and facilitate efficient resource allocation for integrated care systems, and ultimately to contribute to better outcomes for individuals experiencing self‐neglect.

Context: Engaging with and involving the public in research has become a widespread consideration in many research fields, including long-term (social) and health care. Perspective: Citizen science (CS) is an umbrella concept that has grown rapidly in many scientific areas and has been noted as increasing in health research. Its root is the need to work at the science-society interface and its place in societal development. This interface is understood to operate in several ways, and the overarching CS goal is to strengthen it through a variety of practices. We seek to encourage a dialogue across long-term care research and CS to the benefit of both sides. Implications: We argue that using CS as an overarching concept for engaging with the public in long-term care research would provide a variety of benefits to that scientific field. These would include opportunities to examine the state of citizen involvement across the field, employing the most appropriate modes of involvement and engagement in specific contexts. It would also open opportunities to develop the methodological imagination by examining examples of CS in other research areas. CS could also benefit from the experience of public involvement in long-term care research, including its extensive consideration of power, payments, and including people with additional support needs. There is a need generally for greater dialogue about being more inclusive and addressing inequalities.

Hospital discharge for people experiencing homelessness is a perennial challenge. The Homeless Reduction Act 2017 (HRA) places new responsibilities on hospitals, but it remains unknown whether this has affected discharge practices. This qualitative study explores stakeholders' views on the challenges around hospital discharge for people experiencing homelessness, in the context of a deprived English city. Semi-structured interviews were conducted with 27 stakeholders. Participants were purposively recruited from local authority, third sector and the National Health Service. Interviews were transcribed and thematic analysis conducted. Analysis generated three main themes. First, a need for better planning and communication with the third sector, particularly around medication, prescriptions and information sharing. Second, the need to improve awareness and 'upskill' hospital staff to work more effectively with people experiencing homelessness, including understanding their needs, the wider support available and HRA requirements. Third, there were calls for (re)investment in a different approach to better support this population, based on outreach and flexibility. The need for improved partnership working and investment was emphasised. Whilst recognising the challenges faced by hospitals, especially within the context of funding cuts, this study highlights the need to recognise the third sector's contribution in supporting people experiencing homelessness in the community. Developing site-specific checklists for practice before discharge (and as early as possible) may help to ensure appropriate measures are in place. Improving legal literacy in the context of what an appropriate discharge is for people experiencing homelessness may help develop staff confidence to challenge the focus on 'quick' discharges.

Background: In 2013, 70% of people who were homeless on admission to hospital were discharged back to the street without having their care and support needs addressed. In response, the UK government provided funding for 52 new specialist homeless hospital discharge schemes. This study employed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines between September 2015 and 2019 to undertake a realist evaluation to establish what worked, for whom, under what circumstances and why. It was hypothesised that delivering outcomes linked to consistently safe, timely care transfers for homeless patients would depend on hospital discharge schemes implementing a series of high-impact changes (resource mechanisms). These changes encompassed multidisciplinary discharge co-ordination (delivered through clinically led homeless teams) and ‘step-down’ intermediate care. These facilitated time-limited care and support and alternative pathways out of hospital for people who could not go straight home. Methods: The realist hypothesis was tested empirically and refined through three work packages. Work package 1 generated seven qualitative case studies, comparing sites with different types of specialist homeless hospital discharge schemes (n = 5) and those with no specialist discharge scheme (standard care) (n = 2). Methods of data collection included interviews with 77 practitioners and stakeholders and 70 people who were homeless on admission to hospital. A ‘data linkage’ process (work package 2) and an economic evaluation (work package 3) were also undertaken. The data linkage process resulted in data being collected on > 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages. Results: There was strong evidence to support our realist hypothesis. Specialist homeless hospital discharge schemes employing multidisciplinary discharge co-ordination and ‘step-down’ intermediate care were more effective and cost-effective than standard care. Specialist care was shown to reduce delayed transfers of care. Accident and emergency visits were also 18% lower among homeless patients discharged at a site with a step-down service than at those without. However, there was an impact on the effectiveness of the schemes when they were underfunded or when there was a shortage of permanent supportive housing and longer-term care and support. In these contexts, it remained (tacitly) accepted practice (across both standard and specialist care sites) to discharge homeless patients to the streets, rather than delay their transfer. We found little evidence that discharge schemes fired a change in reasoning with regard to the cultural distance that positions ‘homeless patients’ as somehow less vulnerable than other groups of patients. We refined our hypothesis to reflect that high-impact changes need to be underpinned by robust adult safeguarding. Strengths and limitations: To our knowledge, this is the largest study of the outcomes of homeless patients discharged from hospital in the UK. Owing to issues with the comparator group, the effectiveness analysis undertaken for the data linkage was limited to comparisons of different types of specialist discharge scheme (rather than specialist vs. standard care). Future work: There is a need to consider approaches that align with those for value or alliance-based commissioning where the evaluative gaze is shifted from discrete interventions to understanding how the system is working as a whole to deliver outcomes for a defined patient population. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 17. See the NIHR Journals Library website for further project information.

Purpose: People experiencing homelessness often have complex needs requiring a range of support. These may include health problems (physical illness, mental health and/or substance misuse) as well as social, financial and housing needs. Addressing these issues requires a high degree of coordination amongst services. It is, thus, an example of a wicked policy issue. The purpose of this paper is to examine the challenge of integrating care in this context using evidence from an evaluation of English hospital discharge services for people experiencing homelessness.Design/methodology/approach: The paper undertakes secondary analysis of qualitative data from a mixed methods evaluation of hospital discharge schemes and uses an established framework for understanding integrated care, the Rainbow Model of Integrated Care (RMIC), to help examine the complexities of integration in this area.Findings: Supporting people experiencing homelessness to have a good discharge from hospital was confirmed as a wicked policy issue. The RMIC provided a strong framework for exploring the concept of integration, demonstrating how intertwined the elements of the framework are and, hence, that solutions need to be holistically organised across the RMIC. Limitations to integration were also highlighted, such as shortages of suitable accommodation and the impacts of policies in aligned areas of the welfare state.Research limitations/implications: The data for this secondary analysis were not specifically focussed on integration which meant the themes in the RMIC could not be explored directly nor in as much depth. However, important issues raised in the data directly related to integration of support, and the RMIC emerged as a helpful organising framework for understanding integration in this wicked policy context.Practical implications: Integration is happening in services directly concerned with the discharge from hospital of people experiencing homelessness. Key challenges to this integration are reported in terms of the RMIC, which would be a helpful framework for planning better integrated care for this area of practice.Social implications: Addressing homelessness not only requires careful planning of integration of services at specific pathway points, such as hospital discharge, but also integration across wider systems. A complex set of challenges are discussed to help with planning the better integration desired, and the RMIC was seen as a helpful framework for thinking about key issues and their interactions.Originality/value: This paper examines an application of integrated care knowledge to a key complex, or wicked policy issue.

Aim: Clinical research nurses work at the fulcrum of clinical trials with clearly defined roles and responsibilities. In England, the National Institute for Health Research (the main funder of health research) has broadened its scope to encompass social care research. The expectation is that clinical research nurses will expand their skill set to support these new studies, many of which will employ qualitative and mixed methods. This discussion paper explores the challenges of facilitating this clinical academic workforce development through a case study of a homeless health and social care research project. This was one of the first studies to engage clinical research nurses in this new and expanded role. Background: Much of what is known about the research nurse workforce has been generated through studies of clinical trials in oncology. The ‘caring ‐ recruiting’ dichotomy has been used as a heuristic device for identifying workforce issues that can impact on study delivery such as how intense pressure to recruit study participants leads to low job satisfaction. Design: This case study reflects on the authors' experiences of employing a clinical research nurse in a social care research project concerned with the discharge of homeless people from hospital. The ‘caring ‐ recruiting’ dichotomy is used to generate new information about the relationship between workforce development and the successful delivery of social care research. Conclusion: The case study illuminates how social care research can generate different pressures and ethical challenges for research nurses. The time and skill it took to recruit study participants identified as ‘hard to reach’ was suggestive of the need to move beyond performance measures that prioritise recruitment metrics. The need for different types of staff supervision and training was also warranted as supporting study participants who were homeless was often distressing, leading to professional boundary issues. Relevance to workforce development: This study highlights that performance management, training and supervisory arrangements must be tailored to the characteristics of each new study coming onto the portfolio to ensure research nurses are fully supported in this new and expanded role.

The impacts on adult social work in England of the Covid-19 pandemic were sudden and are proving long-standing. In England, many social workers moved to home working and virtual contact with colleagues, managers, staff from other agencies and service users. A first national lockdown was followed by a lessening of restrictions, but a second wave started at the end of Summer 2020 and restrictions were re-introduced. This study draws on telephone interviews with a sample of twenty-two social workers working with adults in a wide range of roles and settings in ten local authorities and two National Health Service Hospital Trusts, interviewed August–October 2020. Following transcription, interview data were analysed thematically. Findings are reported under three emerging themes: using professional judgement, new and emerging case work and embedding change. These are compared with findings from studies of practice in children’s services and of surveys of social workers during the Covid-19 pandemic. Implications for practice, service users and research are explored.