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Policy Research Programme - Understanding the Missing Links: Integrated Health and Social Care for People Experiencing Homelessness

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Published: 30 August 2022

Version: 2.0 October 2022

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Timetable and Budget

Dates updated 03 October 2022

Deadline for Stage 1 Applications 14 February 2023, 1 PM
Notification of outcome of Stage 1 Application April 2023
Deadline for Stage 2 application 06 June 2023, 1 PM
Notification of outcome of Stage 2 Application October/November 2023
Project Start End 2023/Early 2024
Project Duration 36 months
Budget Up to £700,000 (see note below)

Description

Deadline/Limit

Introduction

1. The National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP) invites applications for a single research project to ‘Understanding the Missing Links: Integrated Health and Social Care for People Experiencing Homelessness’.

2. In March 2022, NICE published its guideline ‘Integrated health and social care for people experiencing homelessness’ (NG214) which includes recommendations on ways to improve access to, and engagement with, health and social care services for people experiencing homelessness [1]. This research aims to complement the recommendations made in this guidance to help reduce variation in practice (and understand the causes of, and barriers to, overcoming variation) and improve integrated working.

3. NICE identified evidence gaps and made specific recommendations for research [1]. This bid looks to progress these recommendations. There is high potential for such research to be impactful due to the dearth of evidence that is currently available.

4. The research questions to be answered are:

  • How do structural and systems factors help or hinder commissioning and delivery of wraparound health and social care that is integrated with housing, for people experiencing homelessness; and how does this affect outcomes?
  • What is the effectiveness and cost-effectiveness of longer health and social care contacts compared with usual care for people experiencing homelessness?

Background

5. In this research 'people experiencing homelessness' means people aged 16 and over who [2]:

  • are sleeping rough
  • are temporary residents of hostel, B&B, nightly-paid, privately managed accommodation and other types of temporary accommodation
  • use day centres that provide support for people experiencing homelessness
  • are obliged to stay temporarily with other people
  • are squatting
  • are newly homeless
  • have a history of homelessness (as defined above), and are at high risk of becoming homeless again because of ongoing severe and multiple health and social care needs.

6. People experiencing homelessness often face multiple overlapping risk factors for poor health, such as severe and multiple disadvantage, poverty, violence, and complex trauma, as well as stigma and discrimination [3]. These individuals are not consistently accounted for in data, face barriers in access to healthcare, underuse some services, such as primary and preventative care and use more acute hospital services and emergency care than the general population. When admitted to a hospital, the length of hospital stay is usually much longer due to health problems having been untreated for so long; individuals often present with severe and complex multiple unmet health needs [2].

7. This leads to people experiencing homelessness facing some of the poorest health outcomes and lowest life expectancy in our society. The average age of death for the population of people experiencing homelessness is around 30 years lower than for the general population, according to the Office for National Statistics' Deaths of homeless people in England and Wales: 2019 registrations [4].

8. The costs of homelessness to society are significant. The report by Pleace and Culhane (2016), published by Crisis, estimated the total public sector costs of a person experiencing homelessness to be as much as £38,736 per year in England (based on 2019/20 prices) [5] - in comparison, in the same year, the average public expenditure spend per head for the population of England was £8,816 [6]. The estimate included the following costs:

  • NHS (£4,298)
  • Mental health services (£2,099)
  • Drug and alcohol services (£1,320)
  • Criminal justice sector (£11,991)
  • Homelessness services (£14,808).

9. The report estimated that preventing homelessness for 1 year would reduce the public expenditure by approximately £10,000 per person for whom homelessness is prevented, on average. In addition, if the 11,850 households that were assessed as rough sleeping in England were prevented from experiencing 1 year of homelessness, annual public spending would fall by as much as £115.8 million. If other forms of homelessness were included, these cost savings would be substantially higher [5].

10. The Government committed to ending rough sleeping by 2024, and the Department for Levelling Up, Housing and Communities (DLUHC) recently announced they will deliver an ambitious cross-government Rough Sleeping Strategy in due course. This will have a significant health and care component, with integration of services being at the heart of driving progress.

11. Initiatives such as ‘Everyone In’ saw local authorities, health services, and the voluntary/charity sector work together during COVID-19 to support and protect the homeless population. An evaluation of Everyone In’s impact on physical and mental health outcomes, including substance misuse, has recently been commissioned and is due to report in December 2023 [7]. We intend for this new research to build on the learning from the Everyone In initiative.

12. We know there is considerable variation in current availability and provision of health and social care support associated with housing. In March 2022, NICE published its guideline ‘Integrated health and social care for people experiencing homelessness’ which includes recommendations on ways to improve access to, and engagement with, health and social care services for people experiencing homelessness [1]. This research aims to complement the recommendations made in this guidance to help reduce variation in practice, understanding the causes of it and the barriers to overcome and improve integrated working. The research questions come directly from the NICE guideline’s recommendations for research.

Research priorities

13. This research will support our understanding of how the NICE recommendations can be best implemented. This includes how national policy, funding and delivery can be designed and operationalised to support local areas to deliver in line with the recommendations. This will also support wider government priorities of health disparities reduction and ‘levelling-up’ as well as the manifesto commitments. The research will help identify where cost efficiencies can be identified on current expenditure (such as the £2bn committed on rough sleeping over the Spending Review period) and any future funding streams, supporting value for money to the taxpayer.

14. Knowledge of which structural or system factors help or hinder wraparound health and social care will enable the national government to make changes and improvements to the system to ensure it enables integrated care. Based on their experience, the NICE guideline committee discussed that integrated working among commissioners across different sectors is essential to bring all the knowledge and services together to ensure that there is a strategy and funding for coordinated and holistic support for people experiencing homelessness.[3] These system-level changes can be very high impact with low or no cost. Where there are recommendations from the research that come at a cost, the timing of the interim research findings will enable the development of bids for Spending Review 2025, joining up with NHSE, other policy teams and other government departments where possible. These research questions will have a direct impact on service provision by identifying best practice.

15. The first question is: How do structural and systems factors help or hinder commissioning and delivery of wraparound health and social care that is integrated with housing, for people experiencing homelessness; and how does this affect outcomes? This should cover the ‘system’ across health, social care and housing, and how we integrate these to improve health and care outcomes. This should uncover factors helping or hindering commissioning and delivery of services and to what extent those services support health outcomes. We envisage a qualitative (case-study based) review of existing wraparound models of care focused on the barriers and facilitators to the commissioning and delivery of wraparound health and social care integrated with housing. Wraparound health and social support is defined as: ‘a multidisciplinary team-based collaborative approach to support the person experiencing homelessness holistically, taking into consideration their individual needs, including physical and mental health needs, drug and alcohol treatment needs, care and social needs, and practical needs, in addition to their housing needs.’ The researcher should aim to answer such questions as:

High priority:

16. How can we better integrate the ‘system’ across health, social care and housing to improve health and care outcomes?

17. Do these services support improved health outcomes when integrated and if so, to what extent?

18. How are multidisciplinary teams working to meet the specific needs of people and the barriers they face?

19. What is the impact of structural factors, such as the way strategies, commissioning and delivery is separated between national government, local authorities, ICSs and third-sector providers?

20. Making use of different case studies, how do different approaches to commissioning wraparound health and social support compare with each other?

21. What is the experience of those with lived experience of homelessness of wraparound services and what does that tell us about the effectiveness of different models of health and social care?

22. What is the impact of the methods and models outlined in the NICE guideline, including investigating potential barriers such as frequent recommissioning of short-term services, and successes of pan-city models of care in urban areas?

23. How do findings support greater efficiency both from a commissioning and delivery perspective?

24. Which structural and systems factors are modifiable, and how so?

Medium priority:

25. Are the services analysed cost-effective and do they offer value for money?

26. What may the unintended consequences be, if any, of working to ameliorate structural and systems factors?

27. Which structural and systems factors are modifiable, and how so?

28. What can we learn about structural and system factors from international comparisons?

Low priority:

29. What impact do workforce constraints have on commissioning and delivery of integrated wraparound health and social care for people experiencing homelessness?

30. The second question is: What is the effectiveness and cost-effectiveness of longer health and social care contacts compared with usual care for people experiencing homelessness?

31. ‘Longer health and social care contacts’ is an umbrella term for people spending ?more time with any health and social care services. This includes reducing caseloads on staff and thus increasing time spent with clients such as increased frequency in appointments and duration. We know that longer contacts are often driven by the provision of specialist services rather than mainstream provision. We want to understand whether longer contacts are more effective and cost-effective than more standard practice of large caseloads and short appointments, and under which circumstances this could be most beneficial. Additionally, we want to understand how much of any difference in outcomes is attributable to differences in the various types of care received (e.g. pharmacological or psychosocial interventions), versus how much is attributable to length of contacts alone.

32. This will require understanding the complexity and level of health and social care needs that are experienced by people experiencing homelessness. The researcher should seek to disentangle and explain the relationship between contact times, types of care and outcomes in terms of effectiveness and cost-effectiveness.

33. This question focuses on making an assessment under which circumstances longer health and social care contacts should be utilised. As this is driven by complexity of needs, significant data is required to answer this question. This should include comprehensive assessments of health, social care and housing needs, successes of the trust building, referrals and integration with other services. We envisage an evaluation that covers both qualitative methods and a full economic evaluation that builds on the work carried out by the NICE committee. Longer contact times imply an increased average time and/or frequency of contacts. The researcher should aim to answer such questions as:

High priority:

34. What improvement to health outcomes would be needed to justify such an increase?

35. Is such an increase realistic, given the sorts of things people might be doing with that time?

36. What should professionals and service users be doing with that increased time?

37. What impact does reducing caseloads on practitioners have on longer contact times?

38. What are the costs and benefits of that increased contact time?

39. What are the improvements to health outcomes of longer contacts, both regarding the length and content of longer contacts? Focus on investigating what specifically is being done that yields benefits.

40. What is the impact to health outcomes (e.g., in terms of cost per QALY) and what is the impact of the extreme inequalities involved on said health outcomes?

41. What is the cost-effectiveness of longer contacts and what are the preventative benefits in terms of reducing Severe and Multiple Disadvantage (SMD)?

Medium priority:

42. What may the unintended consequences be, if any, of longer contact times?

43. With cost-effectiveness, the perspective taken should primarily focus on Health and Social Care systems cost-effectiveness. Care should be taken to capture the preventative benefits both in terms of helping individuals to escape pre-existing Severe and Multiple Disadvantage (SMD) and of preventing individuals from falling into SMD in the first place. This may be difficult to capture as any benefits will be hypothetical – once an individual ends their SMD ‘career’ or does not start one (when one would otherwise have been started) it is expected that their health outcomes are improved relative to what would have been the case otherwise, which is never realised. Moreover, it should be taken into account that many of the gains may be in other sectors, such as employment and the justice sector - significant non-health benefits that may be achieved. In addition to this, the researcher should aim to answer three sub-questions:

44. What can we learn about the relative effectiveness and cost-effectiveness of longer health and social care contacts from international comparisons?

45. What are the impacts of implementing longer health and social care contacts, relative to usual care, across the different groups outlined in the NICE guidelines Equality impact assessment? This includes protected and other characteristics, including age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex, sexual orientation, socio-economic factors, refugees and asylum seekers, migrant workers, looked-after children, prisoners and young offenders, families, veterans, sex workers, people experiencing dependency on alcohol, people experiencing enduring mental health issues, and people with hidden speech, language and communication needs.

46. What is the specific impact of specialist care as opposed to general care? Specialist care generally translates to longer contacts, which presents opportunities to investigate those specialist services that can take a longer time, and to find out what happens in that longer time.

47. To answer the two research questions, we propose first an assessment of health, social care and housing needs, and then a full economic evaluation of any benefits of longer contacts.

48. We expect some supplementary questions to arise through exploring these questions that can be explored too, such as what the impact of specialist services is (specialist care generally translates to longer contact times) and including international comparisons.

49. For both questions, special consideration should be given to people in Inclusion Health groups where they intersect with people experiencing homelessness, including vulnerable migrants, sex workers, and Gypsy, Roma and Traveller groups.

New Guidance on Health Inequalities data collection within NIHR PRP Research:

50. Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data, if appropriate for the research. Our goal is to collect information on health inequalities in research and data relating to the main outcome(s) of the proposed research. Please clearly identify in this section whether or not your application has a health inequalities component or relevance to health inequalities and detail the core set of health inequalities breakdowns that will be reported; if none please explain why. We understand that research projects have different methodologies and focus on different populations, so please explain what data will be collected and reported for the methodology you plan to use. If a health inequalities component is not included, please explain why this does not fit within your proposed research. This should only be a few sentences.

51. For quantitative research we would ideally like researchers to provide one-way breakdowns of their main outcome(s) by the following equity-relevant variables: age, sex, gender, disability, region, 5 ONS Ethnic groups, and the 5 IMD quintile groups. If more detailed cross tabulations are appropriate, please include these. This table should be submitted to NIHR PRP at the end of the project. Due to data limitations, judgement calls may be necessary about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgement calls yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies. More details and an example table can be found in Appendix A.

For qualitative research projects, this can be purely descriptive statistics giving the number of observations against the various variables.

Further details about this new request can be found in Appendix A.

We will also be holding a Health Inequalities in NIHR PRP Research Q&A Event on 19 September 2022, more details in APPENDIX B. 

Areas out of scope for this programme of work

52. This research looks at health and social care integrated with housing in England and as such other parts of the UK are out of scope.

Expertise required

53. Strong experience in using mixed methods, including managing data collection across services and sites.

54. A track record in complex service evaluations across settings (including healthcare settings or health inclusion), especially in the context of multiple disadvantage and homelessness.

55. An ability to communicate well and work in engaging and participatory ways with local sites and healthcare professionals.

56. Can evidence how previous work has impacted policy and service development, and what role they played in enabling impact.

57. The researcher should be skilled in understanding experiences, perspectives and everyday practices to give in-depth insight into a particular context, group or culture. Such experience may include such methods as observations, fieldwork, informal conversations, interviews, document analysis, surveys, filming and photography.

58. Have experience in economic evaluations with an understanding of the efficiency and the costs/benefits of implementing different models of health and social care. Experience should cover both cost-effectiveness and cost-benefit analysis.

59. Ability to co-design research with relevant stakeholders including those with lived experience of homelessness.

60. Familiarity with QALYs and cost per QALY, including specialist use of QALYs in exceptional circumstances (for example, in the context of extremely disadvantaged groups), would be desirable.

61. Subject expertise of homelessness is essential including an in-depth knowledge of the complex needs and barriers faced by people experiencing homelessness. An understanding that many people experiencing homelessness encounter or perceive stigma, discrimination and lack of understanding from health and social care practitioners. Researchers will need to be aware of the impact that traumatic experiences can have on a person's life and how it can manifest in their behaviour.

Outputs

62. Applicants are asked to consider the timing and nature of deliverables in their proposals. Policymakers will need research evidence to meet key policy decisions and timescales, so resources need to be flexible to meet these needs. A meeting to discuss policy needs with DHSC officials will be convened as a matter of priority following contracting.

63. An interim report should be produced reporting interim findings of the case studies and development of reports. This interim report should include most of the substance of the research in terms of answering the research questions and providing recommendations for policy. This should be produced in time to inform the next Spending Review, likely to begin in autumn 2024.

64. A final report to be published at the end of the project focussing on the economic evaluation carried out based on the project’s findings, but also including findings from other elements of the evaluation.

65. Ongoing dissemination of findings from throughout the life cycle of the project. A strategic dissemination plan following the final report would be desirable.

Budget and duration

66. Applications will be assessed on value for money, we would not expect them to cost more than £700K.

67. Costings can include up to 100% full economic costing (FEC) but should exclude output VAT. Applicants are advised that value for money is one of the key criteria that peer reviewers and commissioning panel members will assess applications against.

68. It is envisioned that this research will take around 3 years.

69. Timescales are driven by the manifesto commitment to end rough sleeping by 2024 and the bidding process for funding at Spending Review (SR25). Evidence from this research will be used to support bids at SR25 that make the case for health interventions for those experiencing homelessness, and for the cost-effectiveness of any such measures. This evidence would be used to support and target interventions and inform our approach to the delivery of the Rough Sleeping Strategy and wider work on health disparities reduction. As such we would like research to begin as soon as possible following a phased approach to enable sufficient evidence for a timely interim report delivered in time to inform the Rough Sleeping Strategy with final findings following.

70. An interim report should be produced by the end of the second year, reporting interim findings of the case studies and development of reports. This interim report should include most of the substance of the research.

Management arrangements

71. A research advisory group including, but not limited to, representatives of DHSC, NHS England, other stakeholders such as the Local Government Association (LGA), and the successful applicants for the research should be established. The advisory group will provide guidance, meeting regularly over the lifetime of the research. The successful applicants should be prepared to review research objectives with the advisory group, and to share emerging findings on an ongoing basis. The successful applicant will be expected to:

  1. Provide regular feedback on progress
  2. Produce timely reports to the advisory group
  3. Produce a final report for sign off

72. The successful applicant will be expected to work with nominated officials in DHSC, its partners and the NIHR. Key documents including, for example, research protocols, research instruments, reports and publications must be provided to DHSC in draft form allowing sufficient time for review.

References and key documents

  1. National Institute for Health and Care Excellence (2022). Integrated health and social care for people experiencing homelessness. Recommendations for research. NICE guideline [NG214]. [Accessed August 2022]
  2. National Institute for Health and Care Excellence (2022). Integrated health and social care for people experiencing homelessness. Context. NICE guideline [NG214]. [Accessed August 2022]
  3. National Institute for Health and Care Excellence (2022). Integrated health and social care for people experiencing homelessness. Rationale and Impact. NICE guideline [NG214]. [Accessed August 2022]
  4. Office for National Statistics (2020). Deaths of homeless people in England and Wales: 2019 registrations. [Accessed August 2022]
  5. Pleace, N. & Culhane, D.P. (2016) Better than Cure? Testing the case for Enhancing Prevention of Single Homelessness in England.[Accessed August 2022]
  6. HM Treasury (2016). Country and Regional Analysis November 2016. [Accessed August 2022]
  7. National Institute for Health Research. Lessons from the ‘Everyone In’ programme to help people who were homeless during COVID-19. [Accessed August 2022]

Appendix A: Further Detail on the New Guidance on Health Inequalities data collection within NIHR PRP Research

Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data related to health inequalities, if appropriate for the research. Collecting specific information about health inequalities in research submitted to the programme will allow for categorisation of health inequalities research, curation of data to aid future health inequalities research and enable policymakers to better understand the implications of health inequalities within their policy areas. This is a new request from the NIHR PRP and we will be continuing to monitor queries and adapt the process as needed. If you have any feedback on this new request, please contact us at prp@nihr.ac.uk.

Our goal is to facilitate more widespread and consistent reporting of health inequality breakdown data relating to the primary outcomes of NIHR funded research. We would ideally like researchers to focus on the following equity-relevant variables: age, sex, gender, disability, region*, 5 ONS Ethnic groups**, and the 5 IMD quintile groups. These variables are considered an ideal, but we understand that these are subject to change depending on the sample population and specific research question.

For qualitative research projects, this can be purely baseline characteristics of the participants, for example, the number of participants in each ethnic group.

For quantitative research projects, if there are multiple outcomes/effects with your stakeholders, select a small number of main outcomes as appropriate to report equity breakdowns. We will not be prescriptive about the number of the outcomes, as it will depend on the number of study design types and the nature of the project aims. We are asking for one way cross tabulations of each primary outcome by these equity-relevant variables, if appropriate for your research, together with the number of observations in each cell. If more detailed cross tabulations are appropriate for your proposed research, please include these as well. This request applies to both primary data collection studies and secondary analysis of routine data, and to causal inference studies as well as descriptive studies; however, if this is not possible due to data limitations then please explain. Due to sample size and other data limitations there may be difficult scientific and/or data security*** judgement calls to make about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgments yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies. We also ask that researchers report breakdowns for the unadjusted as well as adjusted outcomes/effects, as appropriate.

We understand that research projects may employ different methodologies, and focus on different populations. Please explain how the variables and data collection methods chosen are appropriate to the methodologies used.

We ask that you please clearly identify in the research plan section of the application whether your application has a health inequalities component or not and detail the core set of health inequality breakdown data that will be collected, if applicable. Submission of the data collection will be a condition of the final report for all research with relevant methodologies regardless of whether the research has a health inequalities component that will need to be submitted to NIHR PRP when the grant has finished. This should only take a few sentences within the research plan section.

* Table below uses the nine regions in England, further regions can be used if using the UK as the study population. Please report region breakdown for large samples in nationally representative descriptive studies. There is no need to report this for small sample studies, for sub-national studies, or for quasi-experimental studies where it would require time-consuming re-estimation.

** White, Mixed/ Multiple ethnic groups, Asian/ Asian British, Black/ African/ Caribbean/ Black British, Other ethnic group. If the sample size is small then it is fine to report only some of the requested equity breakdowns and to merge some of the sub-groups as appropriate.

*** For guidance on how to handle data security concerns in reporting of sensitive data please see ONS guidance.

Example data table for submission at the end of the funded research project

(N.B. If there is more than one main outcome then you will require more tables and if you adjust your outcome then you will need two tables for the adjusted outcome and unadjusted outcome. For other methodologies, variable vs number of observations may be more appropriate to record participant data). This table is for an example only. It does not contain sub variables and does not illustrate any preference for certain variables, as these will be dependent on the proposed research.

VariableOutcome (an appropriate average for this subgroup, usually the mean)Number of observationsAdditional information about variation if appropriate, e.g. range, standard deviation
Age  -
Sex  -
Gender  -
Disability
Ethnic Group
IMD Group
Region -

Appendix B: Health Inequalities in NIHR PRP Research Q&A Event

This event will take place on Monday, 19 September 2022 from 2:00 - 3:00pm. There will be a discussion from the NIHR PRP, the Department of Health and Social Care and other panellists followed by the opportunity for a Q&A session to help applicants navigate this new request. Please register for the event using the google registration form for the event. Any questions that are not answered during the session will be anonymously answered and published in a FAQ document on the health inequalities webpage.