1. Exploring the role of ‘choice’ in achieving increased wellbeing for clients of Housing First: A Case Study Chris Parker Northumbria University

2. 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

3. Consumerism and ‘choice’ in UK welfare provision

4. 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

5. 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).

6. 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

7. 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 Power relations Public provision

8. ‘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

9. 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

10. 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.

11. ‘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

12. ‘Antagonisms’ of choice and Housing First

13. Equity Housing First generally works with MEH individuals so there are less chances of inequity occurring Housing First widens the offer to encompass those who traditional services don’t work for Key differences in characteristics may allow some to interact with choice more positively than others Those homeless individuals who may be more ‘housing ready’ aren’t given this option

14. Public Service Provision Housing provides ontological security and greater subjective wellbeing A lack of conditions enables engagement and saves public money on emergency support The ACT support model enables a wide range of support and specialists to inform choices ‘Selling’ MEH individuals to landlords is difficult and affordable stock is likely to be in low income areas. Welfare reform measures may retain conditionality on clients Service provision in the UK is less joined up and funding usually restricts services to single caseworkers

15. Power relations Conditions of entering Housing First are less imposing (no specific conditions) The ‘right to refuse’ shifts power to client Client’s have a ‘safety net’ for bad choices in terms of tenancy liaison and support. Conditions may not be so favourable (tenancy conditions, isolation) Clients need to be informed and motivated to exercise the ‘right to refuse’ UK commissioning arrangements conflict with ‘client led’ and ‘open ended’ support

16. 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

17. Exploring the role of consumer choice in achieving increased wellbeing for clients of Housing First: A Case Study

18. 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

19. 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

20. 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

21. Interview stage 1 (0 – 3 months in service) -Explores client’s past experiences of homelessness -Measures outcomes according to service outcome indicators -Explores and measures choice in early stages of service -Defines client’s personal priorities for success Stage 2 (6 – 9 months in service) -Measures outcomes through service outcome indicators and client’s priorities -Explores and measures choice in this stage of service -Observation of the ‘communication of choice’ 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 -Explore priorities for the future and how these match with former priorities and service outcome indicators