Exploring the role of ‘choice’ in
achieving increased wellbeing for
clients of Housing First: A Case Study
Chris Parker
Northumbria University
Structure
• The rise of consumerism and the concept of
‘choice’ in welfare provision
• The benefits and ‘antagonisms’ of ‘choice’ in
welfare provision
• Choice and control in single homeless
literature
• ‘Antagonisms’ of choice and Housing First
• This study
Consumerism and ‘choice’ in UK
welfare provision
The rise of consumerism in Welfare Provision
• Winter of Discontent
• Campaigns from Disabled
service user groups for ‘full
citizenship’ and greater
independence
• Shift in global dynamics of
capitalist restructuring in
globalising, post-Fordist or
neo-liberal forms
• Election of the Thatcher
Government in 1979
How consumerism became ‘choice’
‘Choice puts the levers in the
hands of the parents and
patients so that they as
citizens and consumers can be
a driving force for
improvement in their public
services’
(Tony Blair, Guardian, June 2004 c. Greve
2011).
Who choosing what (and why)?
• Choice of provider, of professional, of service, of
appointment time and of access channel. (Le Grand
2005)
• Having choice over services empowers individuals
and motivates them to take control of their lives
• Enhancing perception of choice enables greater
subjective wellbeing
• Services are made more fair and responsive
What’s the problem with ‘choice’
- Clarke, Newman et al. (2008) summarise the wide
literature critiquing choice in public service into 3
main ‘antagonisms’:
Equity
Public
provision
Power relations
‘Responsibilisation’, conditionality and
Multiple Exclusion Homelessness
• Traditional services have been widely critiqued for
their ‘responsibilisation’ agenda (Whiteford, 2010)
• Those who don’t meet conditions can be excluded
from support and often end up rough sleeping
• They are termed as living chaotic lifestyles and can
be seen as ‘responsible’ for maintaining
homelessness
Housing First
• Shifted from a model to principles to a
philosophy as more implementations have
spread
• The principles which are retained are:
- Immediate, ‘private’ housing
- Harm reduction approach
- Separation of housing and treatment (‘right to
refuse’)
- Commitment to open ended but intensive support
- A ‘client led’ approach emphasising choice and
control for the client
Housing First
• Focused primarily on individuals who other
services haven’t worked for – MEH/ ‘stock’
rough sleeper population
• Spread to a wide range of contexts largely due
to the rigorous evaluation framework which
surrounds the original.
‘Success’ in Housing First
• Housing retention is a success in itself
• North American studies have shown decreases
in psychiatric outcomes, substance misuse and
improved quality of life
• Long term outcomes elsewhere less
established
‘Antagonisms’ of choice and
Housing First
Equity
• Housing First generally
works with MEH individuals
so there are less chances of
inequity occurring
• Key differences in
characteristics may allow
some to interact with
choice more positively
than others
• Housing First widens the
offer to encompass those
who traditional services
don’t work for
• Those homeless
individuals who may be
more ‘housing ready’
aren’t given this option
Public Service Provision
• Housing provides
ontological security and
greater subjective wellbeing
• ‘Selling’ MEH individuals to
landlords is difficult and
affordable stock is likely to
be in low income areas.
• A lack of conditions enables
engagement and saves
public money on emergency
support
• Welfare reform measures
may retain conditionality
on clients
• The ACT support model
enables a wide range of
support and specialists to
inform choices
• Service provision in the UK
is less joined up and
funding usually restricts
services to single
caseworkers
Power relations
• Conditions of entering
Housing First are less
imposing (no specific
conditions)
• Conditions may not be so
favourable (tenancy
conditions, isolation)
• The ‘right to refuse’
shifts power to client
• Clients need to be informed
and motivated to exercise
the ‘right to refuse’
• Client’s have a ‘safety
net’ for bad choices in
terms of tenancy
liaison and support.
• UK commissioning
arrangements conflict with
‘client led’ and ‘open ended’
support
Summary
• Housing First offers more choice than traditional
‘treatment first ‘ services
• The extent and importance of choice has not been
examined
• Less evidence to suggest that control and autonomy
are achievable under Housing First philosophy
• Long term outcomes of greater sense of wellbeing
and citizenship may be limited
Exploring the role of consumer
choice in achieving increased
wellbeing for clients of Housing
First: A Case Study
Objectives
• To establish and measure service outcome priorities for
commissioners, providers and clients, and explore any
differences in these outcome priorities.
• To identify and measure the level of choice and
autonomy achieved by clients and explore the role of
these in meeting outcomes related to wellbeing and
social integration
• To establish the social, political and economic factors
which influence how clients of Housing First in Newcastle
achieve outcomes and interact with choice
Overview
- The study will focus on a Housing First service in
Newcastle – upon – Tyne.
- Longitudinal study with mixed method interviews
over 3 stages (0, 6, 12 months)
- Participants include all individuals entering the HF
service from the ‘stock’ group of rough sleepers
between Feb 2015 – May 2015
Measures of ‘success’
• Council’s indicators will be transferred into validated
scales and measures
• Client’s own priorities identified in pilot and
translated into valid and reliable measures
• Choice will be measured using ‘perceived choice’
question and Pearlin and Schooler Mastery Scale
• Qualitative elements will allow greater depth on the
service, sense of choice and control and outcomes
Interview stage 1 (0 – 3
months in service)
Stage 2 (6 – 9 months in
service)
- Explores client’s past
experiences of
homelessness
- Measures outcomes
through service outcome
indicators and client’s
priorities
- Measures outcomes
according to service
outcome indicators
- Explores and measures
choice in early stages of
service
- Defines client’s personal
priorities for success
Stage 3 (12 – 15 months in
service
- Measures outcomes
through council
indicators and client’s
priorities
- Explores and measures
choice in this stage of
service
- Explores and measures
choice in this stage of
service
- Observation of the
‘communication of
choice’
- Explore priorities for the
future and how these
match with former
priorities and service
outcome indicators