Homelessness in the UK has been an ongoing problem and has increased year by year for the past 5 years. By the end of 2021, it was recorded that 227,000 households across Britain were experiencing homelessness (Crisis.org.uk).
Although hostels are a place designed to provide support for those without a home to recover from their status of homelessness, residents may require extra support due to complex needs, including mental health and/or addiction related issues. We know that chronic homelessness increases the risk of ill-health and premature death (Hewett & Halligan, 2010), with the average life expectancy for those experiencing homelessness being reported as 43 for women and 45 for men (Crisis.org.uk). A study looking at homelessness and suicide found that those that were homeless that died by suicide were more likely to have experienced substance misuse problems compared to those in stable accommodation (Culatto et al, 2021, Cummins, 2021). Getting appropriate and timely support is crucial for those experiencing homelessness.
There is a lack of research that investigates the experiences of accessing required health care from both hostel staff and residents. This qualitative study (Armstong et al, 2021) used baseline data from another project to understand some of the barriers and facilitators in accessing health and social care services for those living in homeless hostels, and the problems experienced both by the staff and residents.
The study used secondary baseline interview data that was collected during an initial intervention study of palliative care in-reach in hostels, to look at the experiences of access to health and social care services for hostel residents and staff.
Eighteen managers of hostels and support staff and fifteen residents experiencing homelessness took part in baseline interviews from six hostels in London and Kent between April 2019 and October 2019. The hostels provided support for people with medium to high support needs and varied in size (23-60 beds).
Hostel residents were approached by the staff and asked if they wanted to take part in an interview. All interviews were carried out using a semi-structured interview schedule, the design of which was contributed to by experts by experience of homelessness. Interviewers were either a health practitioner or research fellow.
Hostel residents were asked about their experiences of being homeless, their health and health needs and the support they have accessed from services outside of the hostel and from hostel staff.
Hostel staff were asked about the health needs of their residents, the support that both staff or their residents have received from health and social care services, as well as the impact of a lack of support.
The authors used thematic analysis (following a Braun and Clarke framework, 2006) to find themes in the semi-structured interviews and this was conducted in collaboration with individuals with lived experience of being homeless.
The authors highlight three main themes, each with further subthemes:
1. Internal and external service barriers to health and social care access
- Hostel staff reported a misunderstanding of what their role was and what they were able to provide the residents from external services such as social care providers
- Hostel staff reported difficulty in accessing support for residents from external services for various reasons including lack of response and poor communication
- Hostel staff reported feeling marginalised, stigmatised, and mistrusted by external services. Hostel residents also report feeling stigmatised
- Hostel staff felt under pressure to move residents on. Hostel residents also feared moving on before they felt ready
- Hostel residents reported frustration in not having continuity of care and having to retell their situation many times, as well as correct out of date information.
- Hostel staff felt the mental capacity of residents was incorrectly assumed by external services, leading to a lack of support being provided.
2. Impact of lack of health and social care support on hostel staff
- Hostel staff reported going above and beyond their role to support residents, often in the absence of adequate training. Due to this, hostel staff reported experiencing burnout
- Hostel residents reported receiving helpful support from hostel staff, especially where other services hadn’t provided this.
3. Potential facilitators to health and social care access
- Hostel staff reported wanting support from external agencies that understood this population
- Hostel staff reported GP in-reach to be useful and said that providing this consistent support reduced barriers to access of necessary care, as well as helping to build trusting relationships
- Hostel residents felt regular in-reach would improve engagement with other services
- Hostel staff reported lacking appropriate training to support residents.
This study highlights many complex and wide-ranging problems hostel staff and residents endure in relation to accessing health and social care support across six hostels in the UK.
The authors concluded:
Significant barriers were faced, which increase the inequity experienced by some of the most marginalised and unwell people in society and contribute to staff burnout. Hostels urgently need additional support from health and social care providers, including in-reach to deliver care to people in an environment in which they feel comfortable.
Strengths and limitations
A strength to this study is the use of public and patient involvement throughout all stages. The interview guide was informed by those with a history of being homeless, ensuring the interview was appropriate and sensitive. During analysis stages, line by line coding was done by two separate researchers, providing a more credible assessment of the interviews.
However, there are some limitations. Firstly, the residents were asked to take part in interviews by the hostel staff. Hostel residents may have been carefully approached and selected on the basis that they were likely to report the positive relationships and events relating to hostel life and staff. Hostel residents may have also refrained from mentioning particularly negative experiences due to fear of how this may impact their relationships with staff and other services.
A further limitation is that the type of hostels included varied, and hostels with higher levels of support were not included in the study. Hostels with mental health services, in-reach primary care and services relating to addiction may provide better support and more positive experiences, in comparison to what has been found in the present study, and so these findings cannot be generalised to all hostels.
Implications for practice
It is clear that people experiencing difficulties, including homelessness, mental health problems and/or addiction do not have easy access to consistent person-centred care and support. There is a disconnection between some UK hostels and the access to required care, and a misconception about what hostel staff roles involve.
The varying issues highlighted seemingly feed into one another. It is evident that there is a need for hostel residents with complex needs to have easier access to the right care from external services such as GPs or secondary mental health care teams, yet there are numerous barriers to this. Further, there is a pressure to move residents onwards to less supported accommodation or out of a hostel due to the lack of space and the recovery nature driven practice of hostels, despite residents not being in a position to leave.
Structural change is required. A triage service for hostel residents may be beneficial in providing support when and where needed, in order to help individuals move out of hostels when they are ready to. In addition, in-reach services should be a requirement for all hostels.
Further, to facilitate better communication between hostel staff, residents, and external services (NHS and social services), a new role could be developed that acts as a bridge between the barriers discussed and aids in reducing the stigma experiences, as well as reducing the burnout experienced by overworked hostel staff.
As highlighted in the interviews, further training should be provided for all hostel staff, so they are able to support hostel residents with complex needs confidently and aptly.
Further research into other higher-level support hostels should be conducted to assess and compare the issues found in the current study, and whether there are solutions that can be adopted from other UK hostels.
Statement of interests
Armstrong, M., Shulman, C., Hudson, B., Stone, P., & Hewett, N. (2021). Barriers and facilitators to accessing health and social care services for people living in homeless hostels: a qualitative study of the experiences of hostel staff and residents in UK hostels. BMJ Open, 11(10), e053185.
About Homeless| Crisis UK, Retrieved at: //www.crisis.org.uk/ending-homelessness/about-homelessness/About Homelessness | Crisis UK
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101.
Culatto, P., Bojanić, L., Appleby, L., & Turnbull, P. (2021). Suicide by homeless patients in England and Wales: national clinical survey. BJPsych open, 7(2).
Cummins, I. (2021). Are homeless people more likely to die by suicide? The Mental Elf, August 2021.
Hewett, N., & Halligan, A. (2010). Homelessness is a healthcare issue. Journal of the Royal Society of Medicine, 103(8), 306-307.