Research and analysis

​Rough sleeping and complex needs process evaluation: Key findings

Published 11 December 2025

Applies to England

Acknowledgements

This evaluation was undertaken by a team from the Centre for Regional Economic and Social Research (CRESR) at Sheffield Hallam University on behalf MHCLG.  The Evaluation Team would like to thank Professor Sarah Johnsen (Heriot-Watt University) and Dr Peter Mackie (Cardiff University) for acting as special advisers to the project.  We would also like to thank members of the evaluation’s Steering Group for their helpful comments and suggestions.  Our research managers at MHCLG, particularly Jenny Jackman and Lucy Spurling, have been very supportive and we are extremely grateful to them.  And to CRESR’s Emma Bimpson, Gail Hallewell, Melissa McGregor, Emma Smith and Sarah Ward – thanks for your support along the way.

We are very grateful to all the staff from the 12 case study areas who were very accommodating and gave up their time to speak with us.  And finally, we would like to extend our special thanks to the beneficiaries who agreed to speak with us about their experiences.

Dr Stephen Green, on behalf of the Evaluation Team

Foreword

The Ministry of Housing Communities and Local Government is committed to following an evidence-informed approach to reducing homelessness and rough sleeping. The Rough Sleeping and Complex Needs Process Evaluation is a further step to understanding how services can best support people who sleep rough.

This report builds on the evidence on how interventions work or services are experienced. It has been published alongside a number of other reports focused on rough sleeping including the Rough Sleeping Initiative process research, the Housing First Regional Pilots process research, qualitative research exploring access and use of support services by people with experience of rough sleeping, and the initial findings of a large-scale survey using the Rough Sleeping Questionnaire. In addition, the department has published reports addressing wider homelessness: a review of the Homelessness Reduction Act and a report on the costs of Temporary Accommodation.

This report focuses on services, funded as part of the Homelessness Prevention Programme, which provided support for people with experience of rough sleeping with complex needs, such as co-occurring mental health and substance misuse needs.    

The report would not have been possible without support from a number of people who invested considerable time and energy.  We are grateful to Steve Green and Sarah Pearson and the wider team at Centre for Regional Economic and Social Research at Sheffield Hallam University for delivering this research.

We are grateful for the advice of all those who fed into the design of the questionnaire, including Rob Edgar at Groundswell, and Nick Maguire of Southampton University.

I would also like to thank Jenny Jackman and Lucy Spurling, as well as the wider Homelessness and Troubled Families Analytical Team in MHCLG.

And, most importantly, we would like to thank all the service users and all the local authorities and service providers who gave their time to participate in this research, without whom the research would not have been possible.

Stephen Aldridge

Chief Economist & Director For Analysis and Data

Ministry of Housing Communities and Local Government

1. Introduction

1.1 Background

In December 2016 the government committed £51m to the homelessness prevention programme across England. This included targeted support for people sleeping rough and those at risk of rough sleeping across several funding streams.  This evaluation was concerned with two of these streams:

• £20 million for Rough Sleeping Grants (RSGs) to provide targeted support for people at imminent risk of sleeping rough or those who are new to the streets.
• £11m to support locally commissioned Social Impact Bonds (SIBs) to help those sleeping rough with the most complex needs.

In addition, £20 million was released for Homelessness Prevention Trailblazers to pilot new initiatives to tackle homelessness in local authority areas.

1.2 The rough sleeping and complex needs process evaluation

The Rough Sleeping and Complex Needs Process Evaluation was funded by MHCLG and carried out by the Centre for Regional Economic and Social Research (CRESR) at Sheffield Hallam University.  The evaluation examined how two funding initiatives – Rough Sleeping Grant (RSG) and Rough Sleeping Social Impact Bond (SIB) – provided support for people who had slept rough and had complex needs^{[footnote 1]} (co-occurring mental health and substance misuse needs). The evaluation focuses only on projects supporting this particular cohort (referred to as ‘projects in scope’), rather than on all projects funded by the RSG and Rough Sleeping SIB.

The aim of the process evaluation was to provide evidence on different approaches taken to working with people who are sleeping rough who have co-occurring mental health and substance misuse needs, and to identify the lessons learned in designing, setting up and delivering these across the RSG and Rough Sleeping SIB funding programmes.

This includes specific objectives:

• To understand what the different projects working with this service user group are delivering, considering the needs of the service users, any multi-agency partnerships and any constraints in the local context.
• To understand the influence of the funding mechanism on design, set up and delivery.
• To identify the process factors that stakeholders identify as working well across the design, set up and delivery of the interventions, where the challenges lie, and how these have been or may be addressed.
• Where services are near to the end of their funding period, explore any plans for sustaining the intervention in original or redesigned form and the reasons behind this.

These objectives were met through research focused on 12 projects.  Six were Rough Sleeping SIBs, and six were initiatives funded by the Rough Sleeping Grant.  Table 1.1 provides an overview of the 12 case studies.

Table 1.1: Case Studies

Area	Project	Fund	Funding Total (£)	Launch Date
A	Rough sleeping outreach	RSG	263,700	April 2017
B	Rough sleeping outreach	RSG	390,736	July 2017
C	Rough sleeping outreach	RSG	166,209	September 2017
D	Housing first style initiative	RSG	393,000	September 2017
E	Housing first style initiative	RSG	211,629	January 2018
F	Housing first style initiative	RSG	376,652	March 2017
G	Rough Sleeping SIB	SIB	1,000,000	January 2018
H	Rough Sleeping SIB	SIB	1,251,000	November 2017
I	Rough Sleeping SIB	SIB	1,261,980	November 2017
J	Rough Sleeping SIB	SIB	3,000,000[footnote 2]	November 2017
K	Rough Sleeping SIB	SIB	1,449,020	September 2017
L	Rough Sleeping SIB	SIB	1,540,000	January 2018

Qualitative and quantitative data collection was carried out.  Interviews were undertaken with a range of stakeholders, including local authority commissioners, delivery teams, partner services and service users who had used the projects in scope and had experienced rough sleeping and complex needs.  A questionnaire survey of service users was analysed, project outcome logs were analysed, and an assessment of the costs and resourcing of the projects was made.

This report summarises the key findings of the Rough Sleeping and Complex Needs Process Evaluation. The evaluation has produced the following reports:

• Report 1: Key Findings from the Evaluation (this report)
• Report 2: Understanding Service User Experiences and Progress
• Report 3: Learning from Six Rough Sleeping Grant Case Studies
• Report 4: Learning from Six Rough Sleeping Social Impact Bond Case Studies

Also, three short briefing notes, aimed at practitioners and commissioners, are available on the following subjects: Workforce Development, Access to Services, and Meeting Accommodation Needs.

2. What are the needs of people who are sleeping rough?

This chapter focuses on the characteristics and needs of people using the projects in scope – those who have slept rough and had complex needs including addiction and poor mental health.  Evidence from the service user questionnaire, outcome logs and depth interviews with staff and service users has:

1. provided insights into people’s needs and,
2. demonstrated that local projects have invested time into gaining a better understanding of needs and shaping services accordingly.

Those supported by the case study projects were either sleeping rough or at risk of sleeping rough and had co-occurring mental health and substance misuse needs.  The majority of service users who completed the service user questionnaire^{[footnote 3]} were male (78%), white (84%), and around half (47%) were under 40 years of age.

Service users had experienced insecure housing, both immediately prior to their engagement with the projects and often for many years before that. One fifth of service users had not had access to secure accommodation for over ten years and it was common for individuals to have been in and out of different forms of housing and to have experienced different forms of homelessness.

The large majority of service users self-reported that they had at least one of: a mental health issue (85%); addiction issue with drugs (66%) or alcohol (47%); or long-standing physical illness or disability (54%). Levels of co-morbidity were high. Levels of mental well-being were much lower than the national average and there was frequent engagement with mainstream services, including GPs, A&E and ambulance services. Many reported that they had first experienced health and well-being needs in young adulthood: the average ages for first experiencing issues relating to drug and alcohol addiction were 18 years and 20 years respectively.

Service users had also often experienced other negative life events.  Almost three quarters (71%) had spent time in prison, almost a half (43%) had been in the care system, and around two fifths (38%) had experienced permanent exclusion from school.

Interviews with project staff revealed that the needs of service users were very complex, and often more complex than providers had originally anticipated.  Interviews with service users revealed a general pattern of needs consistent with the findings from the questionnaire: long and repeated episodes of homelessness and rough sleeping; underlying mental health issues and low self-esteem; drug and alcohol dependencies; histories of criminality; estrangement from family; experience of trauma in early life; and financial issues.  One Rough Sleeping SIB project worker gave an account that was reflective of common issues across the cohort:

This particular person has got […] they’re quite an exhausting client to work with in that they have a lot of demands on workers, they have personality disorder and complex attachment patterns from children trauma, quite significant physical violence in their past, but that accumulates into a desire to have their needs met in a very specific way and a very timely way […] I guess their needs around keeping to appointments, managing their anxiety, trying to contain them when they go over the edge, and the SIB have been really responsive to that, being able to manage that in a trauma-informed way. This chap is also experiencing ongoing financial abuse from other people in the street community and hostel communities so it’s about managing their relationships and social needs, keeping himself safe. (SIB worker)

There was evidence too of deep entrenchment for many people, who had long-standing lived experiences of rough sleeping and a history of accessing services without gaining positive and lasting outcomes.  The SIB teams talked about the more entrenched members of the cohort and how particular needs presented particular challenges for supporting individuals and ensuring they had the most appropriate services in place. This included service users:

• with drug or alcohol dependencies who faced barriers accessing treatment for their mental health issues (and vice versa)
• who lacked formal identification so had problems opening a bank account and accessing benefits and a space in a hostel, and
• who had lived in extremely poor conditions for a long period of time and had several physical and mental health (including trust) issues as a result.

Jack^{[footnote 4]} talked about his experience:

You weren’t allowed to smoke in the room and they found some ash on the skirting board so I got kicked out of there so they put me into X and it was about 7 o’clock at night, I had this bag, I’m on a lot of medication, take about 15 tablets a day, went into the room and chucked everything on the bed, there were a few loose tablets in here so I literally just walked in the room for the first time ever, put down my bag, went to McDonald’s, came back and there was an eviction notice cos of these tablets. So I’ve gone to my chemist, got a print out of what the medication is, what it looks like, where I get it from, what I need it for and a copy of my prescription to say that it was my medication but they still didn’t care, they just kicked me out so cos of that I just lost confidence in them and stopped working with them and I just lived in a doorway for about eight months.

3. How have the case study projects sought to meet needs?

As Chapter 2 demonstrates, the needs of people who benefited from RSG and SIB initiatives were complex, varied and extensive.  To better support people, projects responded by tailoring their services accordingly.  Many projects took person-centred approaches, provided all-round services, negotiated access to key services (such as mental health and addiction treatments) and supported people to remain engaged with those services.

Three RSG case study projects provided forms of outreach services. Key findings were:

Support for people who were sleeping rough in the case study areas came from a broad range of agencies and there was a need for this to be coordinated.  Hubs were considered to be a good model for effective coordination of support and service provision.

Intensive outreach was vital to ensure that service users were better able to access key support including housing, health and drug and alcohol services.

Interviewees reported that other key agencies and services were not always responsive to the needs of people who are sleeping rough. Outreach teams therefore needed to be able to balance partnership working with other agencies alongside holding those agencies to account and advocating for their service users when necessary.

Outreach was reported to work most effectively where it did not replace other specialist services but provided extra support and navigation towards appropriate help for individuals.  Evidence suggested that some over-stretched services tended to pull back their support for an individual once an outreach worker became involved.

Specialist services, such as the specialist health-led outreach teams, have an important role in expanding provision to support people with complex needs.  Mental health and substance misuse services were reported to be more effective where they were specifically tailored to mitigate the difficulties that people who are sleeping rough can encounter under their ‘regular’ service offer – for example, providing services on the street, rather than relying on appointments at clinics.

Access to housing provision for service users is a key challenge for outreach teams.  Case study projects were more effective where there were distinctive pathways into housing for people who are sleeping rough. This required multi-organisational agreements and changes to allocation systems that provided people who are sleeping rough with timely access to suitable housing.

Outreach services provided continuity and ongoing support to sustain improvements to an individual’s housing, health and wellbeing.  However, in the case study areas there were concerns around the future viability of services beyond the RSG funding period.

Three RSG projects provided forms of housing first style services.  Key findings were:

• These projects could be a catalyst for change in the way that housing allocation systems operated in the case study areas by giving priority need to individuals who sleep rough and supporting them to gain stable accommodation.
• The ability to have choice of location was particularly important for service users, especially for those looking to move away from traumatic and dangerous past experiences.
• Giving service users a genuine choice required the ready availability of different types of suitable housing across a relevant geographical area. This was a challenge in all the case study areas but those that had been best able to address it had timely access to both social and private rented sector housing.
• Long-term support was required to sustain tenancies.  Models where a key worker or coordinator engaged with service users were reported to work well, if access and availability from more specialist service providers was also available.
• The housing first style schemes in this evaluation created, as was intended, a small number of accommodation places.  As such, Housing First should be considered as an additional initiative to relieve rough sleeping, rather than as a substitute for other means of securing suitable accommodation.
• There were concerns around long-term viability and sustainability beyond the RSG funding period.  Stakeholders reported that this was particularly concerning given that long-term support for tenants was a fundamental aspect of the Housing First model.

Analysis of evidence from the six Rough Sleeping SIBs provided a range of key findings relating to meeting the needs of their service user cohorts.  On delivery:

• The freedom and flexibility given to SIB workers (by commissioners and providers) to take a needs-based approach made an important difference.  SIB workers found this empowering, service users recognised a ‘step change’, other services benefited from the additional support being provided, and the evidence suggested that this way of working was having positive outcomes for service users.
• The time that SIB workers had to get to know their service users was another key driver for success.  It is, therefore, important to consider caseloads that can facilitate this and have consideration of the wellbeing of staff.
• The Rough Sleeping SIB teams adopted a position of unconditionality and ‘stickability’ with their service users; trying again when things did not go to plan and not giving up.  This was made possible by having freedom, flexibility and time.
• The inclusion of specialist roles adjoined to Rough Sleeping SIB teams was very beneficial.  It provided quicker action for service users and provided a better interface with key services, such as Mental Health.  Commissioners and providers may consider building in such support in their business plans.  The use of other rough sleeping-related funding streams for this purpose was used effectively by some in the programme.
• Taking a needs-based approach was critical for those people whose needs were the highest in the cohort.  SIB workers were required to give a higher proportion of their time to those whose needs were higher, but this group were also reported to be less likely to meet as many ‘rate card’ outcomes, and so returns via payment by results (PbR) were likely to be lower.  Principled working practices, therefore, mitigate against strategies that prioritise maximising payment by results.
• SIB workers could be defined in a number of ways – key workers, coordinators, advocates, navigators and befrienders.  These are difficult roles to perform concurrently and stakeholders should consider what they want from their workforce.  It should be acknowledged that when SIB workers struggled to gain access to other services, they went beyond navigating and coordinating and provided direct support that others may have performed.  Such replacement of other services, rather than enhancement, was beneficial, but would not outlast the intervention.

The analysis of the Rough Sleeping SIBs also provided strong evidence of the requirements to work effectively within the broader service environment:

• Rough Sleeping SIB teams were felt to be most effective where they can integrate into the local service community and play a role that supports a clear strategic and common focus.  A broad range of stakeholders are required to achieve this; teams cannot achieve it alone.
• Housing outcomes for service users are improved because SIB workers can advocate and engage with the housing system to source accommodation.  The involvement of a SIB worker reassures landlords and lowers the risk of tenancy (or licence) failure.
• Rough Sleeping SIB teams would benefit from enhanced access to accommodation.  Where it is possible to make some dedicated provision for SIB workers to access, or a distinctive pathway, this will be beneficial.
• Stakeholders should regularly assess whether the local supply of supported accommodation is adequate.
• Rough Sleeping SIB teams provided better access to, and sustainment in, mental health and substance misuse services.  However, the evidence suggested that local provision (especially for mental health) was often overstretched.  Stakeholders should consider that SIB teams will stimulate more demand for these services – demand that was previously ‘hidden’.

Overall, therefore, RSG projects and Rough Sleeping SIBs demonstrated that effective approaches rely on focusing on the needs of their service users, informed by an understanding of the service barriers that people faced, and working in a non-judgemental manner.  Moreover, stakeholders felt that mainstream services would benefit from embracing such approaches to a greater degree.  While some services were adopting bespoke responses to those who were sleeping rough and having co-occurring health and addiction needs, they faced challenges associated with finite resources and high demand.  These challenges often meant that supporting people with very high needs was extremely difficult.

These projects played a key role in helping individuals to navigate support systems and enhance their access to critical services and suitable housing.  The close relationship between worker and service user – and the ‘stickability’ of that relationship – appears to be a critical and vital element of the service framework.  There was very clear evidence that project workers provided ‘scaffolding’ for service users, helping them to remain with services by advocacy and brokering, and by such things as helping with welfare benefits, getting ID, bank accounts etc.  The role should be regarded as a necessary component, particularly if mainstream services cannot overcome the barriers that exist for people with lived experience of rough sleeping.

4. What has been achieved?

This chapter outlines what RSG projects and Rough Sleeping SIBs have achieved.  While this evaluation was fundamentally a process evaluation, the qualitative and quantitative evidence demonstrated a number of important outcomes.^{[footnote 5]}

Data on outcomes and progression provided evidence of change for a sample of service users between a baseline position (close to the point of initial engagement with the projects) and six, nine, or 12-month intervals.^{[footnote 6]}

On housing outcomes: Over these time periods, there were statistically significant reductions in rough sleeping and gains in access to homeless or temporary accommodation.  At six months the proportion of service users in homeless or temporary accommodation increased from 28% to 49%.  At nine months the proportion of SIB service users in homeless or temporary accommodation increased from 42% to 67%.

On health outcomes: The analysis identified three statistically significant decreases in service usage over time.  Firstly, the proportion of service users who had attended a hospital appointment for a physical health problem decreased from 39% to 23%.  Secondly, the proportion of service users using A&E decreased from 38% to 18%.  Thirdly, the proportion using ambulance services decreased from 35% to 18%.  There were no statistically significant improvements in the mental health and wellbeing of service users.  Despite high levels of self-reported mental health needs at the baseline stage, access to mental health services remained low. 

On addiction outcomes: Analysis identified one positive statistically significant difference between the first and follow-up questionnaires in terms of reductions in substance usage - the proportion of service users who had used cocaine at least monthly in the last three months decreased from 61% to 39%.  In addition, between baseline and nine months, the proportion of SIB service users receiving treatment for substance misuse increased from 17% to 36% and this increase was identified as statistically significant.

The qualitative data, gathered from interviews with stakeholders and service users, corroborated quantitative findings regarding improvements in housing and health outcomes, and also provided evidence that the various projects had made a positive difference to the wellbeing and stability of service users.

Projects had made progress by helping service users to access suitable housing.  However, this was challenging in some areas. A key limiting factor was the lack of clear housing pathways from temporary to more stable housing.  Also, many workers struggled to find supported accommodation that met the needs of their service users.  For many, with an extended history of sleeping rough and health and addiction issues, supported accommodation was required, as an independent tenancy was unsustainable.  Workers also reported the variance in the ‘support’ provided by supported accommodation.  In some areas for example, hostels were believed to be understaffed and could not provide the level of support required by those whose needs were high.

In addition, the overall needs of service users were felt to be better managed when people were successfully engaged with a project, by virtue of access to and sustainment with support services.  However, the evaluation was unable to assess whether these changes could be effectively sustained in the long term.

The relatively short-term life of projects – 12 to 18 months for RSG and three years for Rough Sleeping SIB – meant that ongoing support could not be guaranteed.  Project workers invested substantial time, energy and effort into helping service users to sustain their engagement with services and sustain tenancies.  It was reported that this work rarely followed a straightforward script.  Rather, it involved ups and downs, disengagement and reengagement, multiple different housing placements and relapses.  This required flexible and sustained support, and it was evident that mainstream services were not always equipped to provide this.

For the Rough Sleeping SIB cohort, progress towards recovery was often characterised as ‘small steps’.  It often took time, and many small steps, for people with complex needs to experience substantial change in their lives. In other cases, there had been a more transformative effect, and all the SIB workers identified examples of individuals whose lives had been turned around by the support they had received.

The SIB enabled service users to reconnect with services, but also provided the opportunity for people to connect with services in ways that had not been previously possible.  SIB workers’ improved understanding of their service users’ needs was a driver to improving the treatment or support offered, and this was recognised by the service users:

Other services promise you the world and they give you nowt, these at least if they promise to take you somewhere they’ll be there, or they’ll ring me up and say ‘I’ve rang up and got the appointment another day cos I cannot come’ they’ll at least change it and tell you why they cannot come, where other services just promise you.  (James)

I’ve had experiences with other agencies and they just basically give up on us. Now the SIB team have always found us somewhere.  (Liam)

In relation to employment and education outcomes, SIB workers felt that most service users were some distance from the labour market and that these outcomes (if they were to be achieved) were some way down the line; and for some, probably further than the end date of the Rough Sleeping SIB programme.

5. Costs and resourcing

This evaluation assessed the costs and resourcing of the projects, to: quantify the average ‘unit’ cost of providing each project to a beneficiary (known as the cost efficiency); explore how these are affected by factors such as the project type and funding mechanism used; and inform the future funding of interventions to support people with multiple, complex needs who are sleeping rough.

The 12 case study areas participating in the evaluation were asked to complete a ‘Project Costs Tool’ which built up a detailed and robust evidence base on the costs and staffing of the projects. The information gathered covered actual financial (excluding VAT)^{[footnote 7]} and staffing information for each of the last two full financial years: 1 April 2017 to 30 March 2019.

The average cost per beneficiary into long-term accommodation after 12 months was calculated to be £15,065.  This was lower than the benchmarks which these figures were set against,^{[footnote 8]} although delivery costs need to be put into context of the outcomes achieved.  Accepting limitations in these comparisons (for example regarding the nature of the beneficiary population, the outcomes considered and potentially the quality of outcomes achieved) it appears that overall the projects have provided good value for money.

The average cost per beneficiary, composition of expenditure, level of staffing and composition of staffing all varied by the nature of the intervention and the funding mechanism applied in the projects. On average, the RSG housing-led projects (housing first style initiatives) had the highest average cost per beneficiary and level of staffing per month per 100 beneficiaries. This is to be expected given they delivered an intensive intervention to relatively few beneficiaries. On average non-operational costs comprised a greater proportion of the SIB project expenditure compared to the RSG case study projects. This relates to the increased monitoring and management costs required to oversee the SIB.

The evidence suggested that the projects were staffed with people at appropriate grades for the respective task or activity.

A more detailed analysis is provided in the Evaluation’s Report 2.

6. Factors that influence success

The evaluation revealed a range of enabling factors that were required to effectively help those with lived experience of rough sleeping.

6.1 Engaging with service users

Effective engagement with service users was a key enabler for success, and doing it well required a range of skills.  Skills and strategies reported to support effective engagement included the following aspects:

• Being knowledgeable and having good interpersonal skills; using methods of communication that are tailored to the individual.
• Being able to challenge a service user effectively (without the service user taking offence and without withdrawing support).  This involved being assertive, honest and persistent, rather than punitive.  At the same time, staff emphasised the need to be sensitive particularly around identifying needs and planning support.
• Being able to challenge agencies on a service user’s behalf.  This was described as a delicate balancing act of maintaining good relationships with partners but also holding them accountable. Workers also needed to be conscious that people’s previous experiences of contact with services and agencies may not have been positive.
• Positioning themselves as workers, and a service, that offered something new and different to the service user, helping to break down the negative perceptions fostered by their previous encounters with support services.

There was ample evidence from interviews with service users that they responded positively to these approaches, with many of those interviewed comparing favourably their experiences of positive engagement with the projects to those of previous experiences of involvement with services. 

6.2 Workforce development

Across all the projects in scope for this evaluation, the issue of workforce development was very apparent and some key learning was identified for developing a workforce to effectively engage with, support and inspire people towards achieving positive outcomes.

Stakeholders reported that working with people with complex needs who are sleeping rough requires a range of skills.  Projects were best able to meet the needs of this group where staff could be empathetic and patient with their service users and could maintain a positive relationship without sanctioning.  This was eloquently summarised by one SIB manager as ‘stickability’ – the idea of never giving up on a service user and maintaining an unconditional offer of support.

Staff were drawn from a range of professional backgrounds which built teams with mixed skills relevant to the complexity of the needs of their beneficiaries.  Some stakeholders had identified scope for recruiting staff with ‘lived experience’ of homelessness, but this required investment in training, development, well-resourced supervision and management structures.  In addition, it was noted in one case study area that employees who had lived experience had found it particularly difficult to sustain long-term engagement with people with complex needs and had sought to move to other roles in the homelessness sector.

It was not always easy for the projects to recruit staff with the requisite skills, and there was evidence of high levels of staff turnover in the case study projects. The issues highlighted included: short-term contracts associated with time-limited funding; and challenges to staff wellbeing and satisfaction associated with long-term and intensive engagement with people with complex needs.  While projects had successfully recruited teams, in some cases it had taken longer than anticipated which had knock-on effects for implementation timescales.  Recruitment was driven by the need to acquire staff with the relevant competencies and attitudes rather than a specified set of skills developed in particular professional frameworks or contexts.

Stakeholders in the RSG projects identified a dearth of relevant training and development opportunities geared specifically towards working with people who are sleeping rough and have complex needs.  Conversely, Rough Sleeping SIB workers reported that they had access to training and skills development, including health and safety, risk management, benefits, housing and domestic abuse.  However, staff across the two programmes reported their most effective upskilling was ‘on-the-job’ working; including shadowing other workers.

The evidence from interviews with project staff demonstrated a huge sense of personal commitment to supporting people with complex needs who are currently or have experienced sleeping rough. Nevertheless, interviews with some staff raised concerns for their long-term wellbeing due to working in very challenging circumstances.  This may well impact on future sustainability and turnover in these roles. There was a clear sense across all the projects that those in key worker and support roles (however defined) were often working very long hours and were subject to high levels of stress. In two Rough Sleeping SIB areas, staff had access to regular clinical supervision.  This benefited their wellbeing and helped them develop their practice.

Many projects experienced problems with capacity due to staff absence and turnover.  For small, and relatively short-term, projects these problems were amplified.  Some of this resulted from illness and was thus unexpected. In other cases, staff on fixed term contracts (as a result of time-limited funding) had moved to permanent roles elsewhere. In all cases, however, there were significant impacts on small teams, and project leaders reported that they were dealing with high levels of temporary cover and unfilled posts.

The lack of a defined role for frontline workers (especially those working in the SIBs) created challenges for training and skills development.  The ‘catch all’ nature of the role made it difficult to define an affordable, yet comprehensive training programme.  Staff teams had developed robust mechanisms to cope with the demands of the job, including; regular supervision with a line manager; space to meet and talk through issues with colleagues; clinical supervision (for some); and co-working or swapping difficult cases (though it was acknowledged by some workers that this could potentially erode the trust established with someone). Working with service users often meant: being available at unsociable hours; working across multiple agendas; juggling relationships with many services; working with service users who, by virtue of their complex needs, could be difficult, untruthful and abusive; and often dealing with disappointment when progress was slow.  This had consequences for both the recruitment and retention of staff.  It appeared that the sector had yet to develop clearly defined and common professional standards and competencies associated with working with people with complex needs who are sleeping rough.

6.3 Multi-agency working

The ability to engender effective multi-agency working practices and protocols was another key enabling factor.  The projects in scope aimed to support their service users in a range of ways, and this included making links with other services to improve the coherency and quality of the services offered to individuals.  The evaluation identified a range of key enablers, benefits and challenges to multi-agency working.

For the RSG projects, overall multi-agency and partnership working in the six RSG case sites was working well and seen to have a positive impact on service user experiences and outcomes.  Good quality relationships, based on trust, were reported by stakeholders to be vital and were supported by relevant skills, shared ethos and approach and commitments to sharing data and information.   Multi-agency working was reported to have improved referral and treatment pathways but in some case study areas there were challenges associated with service overlaps where multiple organisations were delivering similar forms of support.  The factors which appeared to have made multi-agency working more effective included: strong governance arrangements; data sharing which supports improved service user journeys; a willingness to challenge organisational silos; and having staff with the skills to deliver high quality support and develop relationships based on trust with service users and other service providers.

For RSG projects where there had been frequent changes in personnel, this had impacted on relationships between service providers. Maintaining consistency in approach was reported by stakeholders to be an important strategy in sustaining the engagement of service users even when there was staff turnover; but this was not easy and the relatively short-term life of the RSG projects was found to stymie efforts to create lasting partnerships and changes to service provision.

The Rough Sleeping SIBs were modelled to provide direct support to individuals and ‘open doors’ to a broad range of other health and social services.  They provided robust evidence of the importance of developing multi-agency working practices.  SIB teams had created and fostered partnerships with services including housing, health and welfare.  Doing so accounted for a significant proportion of time in the initial period.  It was recognised also that partnership building was an ongoing process, re-defining and refining those arrangements.

Project teams had to establish themselves in the local service community, develop an understanding of their position in that community and gain some trust.  However, there was evidence that some projects were poorly equipped to do this as they lacked the resources (time) and the authority to do so.  Some Rough Sleeping SIBs benefited from the involvement of LA commissioners and senior leaders to promote the SIB and ensure that other services were responsive.

Partner organisations held a broad recognition of the SIB’s aims and objectives, but did not always understand the SIB model well, particularly the need to provide an evidence base of outcomes on which to claim payment by results (PbR) payments.  SIBs did report though that this had improved as partnerships matured.

Despite good progress with partnerships, there were still some limitations to gaining access to services where capacity was limited and working with services that were not responsive to the needs of this service user cohort.  SIB workers, for example, were invariably adept at utilising local informal voluntary services to help their service users with food, clothing, furniture and social activities.  However, workers also reported that this informal sector could be counterproductive to the SIBs broad aims by supporting people’s existence on the street – for example, by providing tents, sleeping bags and places to sleep out.

The Rough Sleeping SIB teams played a critical role in bending formal and informal services towards the needs of their service users, while providing additional support at the same time.  This is a central aim.  However, evidence suggests that there were some partner services requiring transformation to better support people who may be sleeping rough and have co-occurring needs.

The following sections explain the findings to emerge in relation to key service areas.

Housing

Finding suitable housing was a key challenge in all Rough Sleeping SIBs.  Teams frequently reported a lack of supported housing options for their cohort, alongside affordability and availability issues for more permanent accommodation.  None of the Rough Sleeping SIBs had ring-fenced accommodation access that they could offer to their service users.  Instead they had to seek and negotiate access to housing via traditional routes.

For people with co-occurring complex needs, decent housing was regarded by Rough Sleeping SIB teams as a prerequisite for sustaining treatment and recovery of health and substance misuse.  SIB teams regularly used hostel accommodation.  It was reported that this varied in quality (of physical and support aspects).  In some areas, hostel provision was reported to be poor alongside a lack of other affordable housing options.  However, some hostels were reported to be supportive places for some SIB service users with more stability in their lives.

For SIB service users with very complex needs in early stages of their recovery, there was a paucity of suitable supported accommodation.  Workers often provided extra support in partnership with the accommodation’s ‘support offer’. The involvement of a dedicated worker in someone’s life could help to foster better access to housing providers by giving the reassurance that support was on hand and that the service user was being assisted toward recovery in a holistic way – dealing with other needs like mental health and drug addiction.

Temporary accommodation was often precarious for service users.  People were excluded from temporary accommodation for issues such as drug use and antisocial behaviour, which they were often ‘powerless’ to avoid.  Workers had been successful at preventing tenancy (or licence) failure and promoting greater sustainment. 

Local connection rules were a barrier to finding suitable accommodation for some service users.  Workers reported that the rules made helping their service users with homelessness applications difficult, required a ‘case’ to be made, and submit evidence of local connection that was often difficult to obtain.  Responsibilities were reported to be passed between local authorities when individual service users could not demonstrate a local connection to the area where they were rough sleeping or living in temporary accommodation.

Housing First was discussed by Rough Sleeping SIB staff and others as a rapid rehousing model that could be well-suited to the needs of those who had slept rough and experienced co-occurring needs.  There was some evidence though, that these schemes were still relatively small-scale, and did not offer an especially high level of support to tenants.  Also, some Housing First schemes were reluctant to accept people who were already receiving help via the SIB.

Mental health services

Gaining access to mental health assessments and treatments represented a key challenge for projects.  One RSG-funded project provided direct enhanced clinical treatment to people with lived experience of rough sleeping, and the availability of mental health services was regularly discussed by Rough Sleeping SIB workers.

The degree of mental health difficulties amongst the cohort was high, and SIB workers reported that service users’ mental health needs were higher than had originally been anticipated.  Workers also reported that a service user’s needs only fully presented over a period of time and would not have been apparent during a 15 to 30 minute assessment or encounter.  Therefore, it was argued, SIB workers were able to gain a better understanding of needs and could use this knowledge to better engage with mental health workers (provided that access to services could be achieved).

In several areas, people with co-occurring mental health and substance misuse needs were being ‘bounced’ between two services; the conundrum being that mental health services would prefer that a person’s drug usage is dealt with prior to treatment, and vice versa for drug treatment services.  Added to this, mental health services were reported to be significantly stretched in certain areas and could be inflexible to the situations of service users.  Strict appointment times and a lack of mental health outreach services were a barrier for the cohort.

Where local services were offering outreach and in-reach services, this had a comparative advantage, providing better access to assessments and treatments.  In the case of the Rough Sleeping SIBs, workers operated in tandem with professionals offering these services to ensure that people could better engage.  For example, project workers were better able to locate people, they had a broad understanding of what their service users were doing day-to-day and had insights into the things that service users had found difficult in the past.  In several areas, SIB teams had formed partnerships with voluntary sector mental health services that had previously not supported people with lived experience of rough sleeping.  Workers offered their support, skills and experience to open up these services to the SIB cohort.

Drug and alcohol services

There were key barriers for the cohort when accessing drug and alcohol treatments.  Keeping appointments was challenging for those with co-occurring needs and a particular feature of drug and alcohol services was the number of appointments and the length of time they took.  Beyond forgetfulness or chaotic situations that might cause someone to miss an appointment, long appointments took away time from earning enough money (usually from begging) to purchase drugs to satisfy a habit.  For those with prior experience of the particular service, there was scepticism that a prescription for methadone, for example, would be available quickly or be of an adequate strength.

Compared to mental health services, stakeholders reported that it was easier to access drug and alcohol services in some form.  However, they were often very busy and not always responsive and flexible to the needs of those sleeping rough. Therefore, positive outcomes had previously been limited for their service users.  Workers had a role to play in ensuring that their service users could gain better access to drug and alcohol services.  All teams had formed partnerships with services and there were indications that workers were able to ‘open doors’ and better sustain their service users’ involvement with treatment.  Workers did this by building positive relationships with services and providing assurances that their support could secure better engagement with treatments.

Work and volunteering

Access to work and volunteering was a key focus for the Rough Sleeping SIBs, but not for the RSG-funded projects in scope.  There were some positive instances of SIB service users finding work and volunteering opportunities or starting training.  However, teams reported that service users required much support and resolution of their health and addiction issues before concentrating on finding employment and training.  Gains in this area were, therefore, expected to come later in the SIBs three-year delivery period.

At the time of fieldwork, SIB teams were mostly concentrating their resources and efforts towards housing and health needs.  It was reported that services to support people into employment, volunteering and training were relatively scarce.  Where they did exist, they were not really set up to respond to the needs of the SIB cohort. 

6.4 Funding and sustainability

The RSG was viewed by stakeholders as time-limited funding for activities that, by their nature, required long-term resourcing. For housing first style initiatives, the RSG was too short a period to adequately embed the principles locally.  It also risked leaving new tenants without the intensive and ongoing support required to sustain both their tenancies and their recovery.  Similarly, for outreach services, key stakeholders were grateful for the opportunity to learn how to relieve rough sleeping for those with complex needs but, in general, longer-term funding mechanisms were not available and stakeholders reported that funding sources to continue initiatives were very limited.  They reflected that local authorities often now rely on grant funding for homelessness initiatives, and that available local authority budgets are mostly restricted to crisis services, with little opportunity to directly fund preventative initiatives.

In only one of the RSG case study areas, the service funded through the RSG had been mainstreamed into the core housing support offer of the local authority. This had required commitment from both the commissioners and the housing officers to prioritise funding for the service.  In the remaining case study areas, there were a range of approaches to sustainability which included funding of reduced or partial services, or the incorporation of aspects of services into other existing or proposed initiatives.

The Rough Sleeping SIBs benefited from a longer delivery period – three years for the most part.  While there were concerns about the ability to sustain services past that period, the delivery model was premised on providing support to an identified cohort of individuals over a three-year period.  This process evaluation could not effectively assess whether three years was a sufficient amount of time to transform people’s lives in a sustained way.

7. Conclusions

The data provide a rich insight into the needs and experiences of people with complex needs who are experiencing rough sleeping. The needs and experiences of people who experience rough sleeping should not be seen as separate to those of other groups who experience homelessness. Many of the people being supported by the case study projects had been in and out of many different forms of accommodation and had experienced periods in temporary accommodation, rough sleeping and sofa surfing. Early access to suitable permanent accommodation needs to be a priority for this group.

The Rough Sleeping SIB teams were felt to be most effective where they can integrate into the local service community and play a role that supports a clear strategic and common focus.  A broad range of stakeholders are required to achieve this; teams cannot achieve it alone.

The high levels of complex health and wellbeing needs amongst this group require specific service approaches. The projects were working towards improved access to drug and alcohol treatment services and quantitative analysis indicated a rise in SIB service users accessing substance treatment services.  For mental health and wellbeing outcomes, no significant improvements were found, and lack of timely access to mental health services remains a major challenge in meeting the needs of those who are experiencing multiple vulnerabilities.

There were no significant changes in the education or employment status of service users and service providers prioritised their attention on other outcomes such as access to health and support services. There may be scope for these outcomes to improve in the longer-term for the SIB projects.

There is evidence from this data to conclude that the projects delivered cost-effective interventions. Common features of the delivery models and implementation of the RSG and SIB case study projects included person-centred and tailored support, focusing on targeted outreach, improved and sustained access to services (including housing), reductions in service duplication and improved cross-referrals through collaboration. The analysis presented here suggests that these are effective approaches, but that their success depends on capacity within mainstream services to accommodate the needs of people with complex needs.

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1. The term ‘complex needs’ was used throughout the evaluation and in this report to refer to people who were sleeping rough and also experiencing one or more other needs which included mental and physical ill-health, substance addiction and offending behaviour. In many cases these needs are severe and long-standing. ↩

2. This includes a contribution of £1m from the host authority. ↩

3. The methodology for the service user questionnaire is described in the Evaluation’s Report 2: Understanding Service User Needs and Progress. ↩

4. All names in the reports have been changed. ↩

5. Note that the Rough Sleeping SIBs worked towards outcomes defined in the payment by results rate card, whereas RSG projects had varied and less clearly defined outcomes. ↩

6. The methodology for the quantitative analysis is described in Report 3: Understanding Service User Needs and Progress. ↩

7. As per Treasury Green Book Guidance. ↩

8. Ministry for Housing Communities and Local Government (2018) Rough Sleeping Strategy. Crisis (2018) Everybody in: How to end Homelessness in Great Britain. ↩