Mental health and homelessness

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I haven't written a post for a while. I wanted everyone to read the post I wrote in November about my niece Annie's suicide. Writing new posts drops older ones down the list, and I didn't want her memorial post to disappear off the radar until after her funeral. Annie's funeral was last Tuesday, 18th December, the day after her 29th birthday. Now, it is time to write again.

But not yet to move on from the issues that Annie's death highlights. This post is about the link between mental ill health and homelessness. Particularly, "street" homelessness, or in common parlance, "sleeping rough".

Homelessness and rough sleeping have risen hugely in recent years. Government statistics show that between 2010-15, estimates of the number of those sleeping rough rose by 102%. This is partly due to changes in methodology to correct suspected under-reporting of the problem. But the Government admits that there is a real and considerable increase in the numbers sleeping rough. Its own figures show that in Autumn 2017, 4,751 people slept rough on a typical night, an increase of 15% since the previous year.

The homeless charity St. Mungo's identifies four causes for the increase in homelessness and rough sleeping:

• Increasing housing costs and welfare reform leading to homelessness 
• A shortage of supported housing 
• Homelessness services overloaded
• More people from Central and Eastern Europe sleeping rough. 

The last of these could reduce as the Government clamps down on EU migration after Brexit. But the other three are a direct consequence of government policies particularly since 2010. Unless these policies change, they can only get worse.

The image many people have of a typical rough sleeper is a middle-aged white man with alcohol problems. But this is no longer the case. A 2018 report by the University of York highlights the changing composition of rough sleeping populations:

A broad trend reported since the 1990s has been for increasing numbers of women to appear in the rough sleeping population, within a wider pattern of change that has seen the population shift from older, white, often alcohol-dependent and mobile men, towards a younger population with more complex needs. There have been major changes in health, social care, social housing and welfare systems, as well as in the UK housing and labour markets, along with significant cultural changes, and these data are within a longstanding pattern of increases in female youth homelessness.

Today's rough sleepers are more likely to be young, more likely to be female (though men still make up by far the largest proportion), more likely to be from ethnic minority backgrounds, and more likely to have mental health problems. St. Mungo's says that around half of those living on the streets have mental health needs. Among women, the proportion is higher - as much as 60% in London.

Annie was one of them. In 2015, her landlord had raised her rent from £400 to £700 per month. She could not afford to pay it, so he gave her notice to quit. This is not an unusual experience for young people in London: St. Mungo's reports that the end of a private sector tenancy is the commonest reason for someone becoming homeless. But for Annie, who already had a long history of unstable mental health, it was disastrous. It triggered an acute depressive episode which resulted in her being hospitalised.

Although the NHS could treat Annie's symptoms, it could not solve her problem. When she left hospital, she became homeless. She spent some time sofa-surfing, but eventually ended up on the streets.

While she was homeless, Annie suffered repeated physical, sexual and emotional abuse. This seems to be a near-universal experience of homeless women, especially those sleeping rough. The University of York's study graphically describes the abuse suffered by women in its focus groups:

Most had been subjected to horrific violations; this included being spat, urinated and vomited on. Many had been robbed, threatened, experienced physical violence and been continually harassed for sex by male members of the public...Verbal abuse and being treated with contempt were common experiences; there was also a frequent assumption that being on the street meant they were involved in sex work.

Unsurprisingly, Annie's mental state worsened considerably and she was again hospitalised. This time, when she left hospital, she was given temporary secure accommodation in a hostel. Her troubles did not end there, though: homeless hostels are not always safe places for women. Annie was sexually assaulted while living in a hostel then physically attacked when she reported the abuse.

But how did Annie, a young woman with a long history of mental illness, come to be homeless? Local authorities have a duty to house those who are vulnerable due to mental illness. When she lost her private sector tenancy, Annie suffered an acute mental health crisis that led to her being hospitalised. Why didn't Southwark Council provide her with accommodation on her discharge from hospital?

Sadly, there are many examples of the NHS discharging mental health patients from hospital into inappropriate accommodation and without appropriate care or follow-up. Annie was far from alone. And being under the care of the Community Medical Health Team after discharge was not enough to make her a priority case. When she asked the council to house her, the council decided that she was not vulnerable enough to justify housing. In hindsight, this was a catastrophically bad decision.

The council decided that the fact that she had left her accommodation voluntarily when the landlord's notice expired, instead of waiting for bailiffs to evict her, meant that she was "intentionally homeless". This was perverse, since remaining would have meant building up rent arrears, potentially making it much harder for her to find alternative accommodation. However, it had the useful effect of diminishing the council's legal responsibility towards Annie. All they now had to do was decide whether she was sufficiently vulnerable to justify emergency accommodation despite being "intentionally homeless". As we shall see, their sole purpose in conducting an assessment of Annie appears to have been to evade their legal responsibility towards her.

The letter in which Southwark Council advised Annie of their decision outlines the reasons (these are selected excerpts):

We are satisfied that even though you suffer from severe depression and emotionally unstable borderline personality disorder the conditions are not such as to impede your normal function, nor impair your ability to fend for yourself if street homeless. You do not take any medication at present for these conditions. For this reason, we are satisfied that you would be able to cope if street homeless and that you would continue to be able to engage with relevant services... 

If you were faced with street homelessness we are not satisfied that you would be more at risk than another ordinary street homeless person... 

After considering all these facts, we are not satisfied that you are vulnerable as a result of suffering from severe depression and emotionally unstable borderline personality disorder. We are satisfied that you will be no less able to fend for yourself if street homeless or that you would experience difficulties with finding and keeping accommodation." 

I was struck by the poor grammar and construction of this letter, and its repetitive nature. It was almost as if the author were cutting and pasting paragraphs from a standard document. The terms "street homeless" and "fend for yourself" were repeatedly used. Yet this was supposed to be the result of an individual assessment of Annie's housing needs. Something didn't quite add up. So I did a bit of investigation.

The rationale for the council's decision was derived from case law: Regina vs Camden LBC ex parte Pereira, 1998 (referred to as "Pereira" in the council's letter). I looked it up. The case rested on the interpretation of section 59(1)(c) of the Housing Act 1985, which assigns priority need for housing to:

...a person who is vulnerable as a result of old age, mental illness or handicap or physical disability or other special reason, or with whom such a person resides or might reasonably be expected to reside

In particular, the problem is what is meant by the term "vulnerable". Lord Justice Hobhouse concluded:

The Council must consider whether Mr Pereira is a person who is vulnerable as a result of mental illness or handicap or for other special reason. Thus, the Council must ask itself whether Mr Pereira is, when homeless, less able to fend for himself than an ordinary homeless person so that injury or detriment to him will result when a less vulnerable man would be able to cope without harmful effects. The application of this test must not be confused with the question whether or not the Applicant is at the material time homeless. If he is not homeless, the question whether he is in priority need becomes academic. The question under paragraph (c) can only arise if (or on the assumption that) he is at the material time homeless. A particular inability of a person suffering from some handicap coming within paragraph (c) to obtain housing for himself can be an aspect of his inability as a homeless person to fend for himself. Such an individual may suffer from some mental or physical handicap which makes him unable to obtain housing unaided and thus makes him unable to cope with home less ness in a way which does not apply to the ordinary homeless person. But it is still necessary, as is illustrated by the decided cases, to take into account and assess whether in all the circumstances the applicant's inability to cope comes within paragraph (c). It must appear that his inability to fend for himself whilst homeless will result in injury or detriment to him which would not be suffered by an ordinary homeless person who was able to cope. The assessment is a composite one but there must be this risk of injury or detriment. If there is not this risk, the person will not be vulnerable.

I have highlighted two terms in this: "homeless" and "fend for himself". It seems that this is the source for those terms as used in the letter sent to Annie. But in Annie's letter, "homeless" had been altered throughout to "street homeless", which as I said above, is usually taken to mean sleeping rough. Mr. Pereira was never "street homeless". He was living with friends, as indeed was Annie at the time of the council's decision, though it was not possible for her friends to provide accommodation long-term. Southwark council assumed that because her mental condition was stable and she didn't need medication while living with friends, she would remain mentally stable and off medication if she had to sleep rough. I am no lawyer, but I cannot see how this could possibly follow from the Pereira judgment, which at no time even mentioned "street homeless", let alone assumed that Mr. Pereira would remain well if he were forced to sleep rough.

The Pereira judgment seems to have become the standard vehicle used by local authorities to evade their responsibility to house vulnerable adults. But by the time Annie's application was refused, such an interpretation of the Pereira judgment had already been deemed legally dubious.

In 2014, the Court of Appeal heard three separate challenges to decisions by Southwark and Solihull councils to refuse housing to vulnerable adults. On reading the facts of these cases, the similarity between the language used in the letters sent to these claimants and that sent to Annie is striking. Here, for example, is a paragraph from the letter sent to Sifatullah Hotak by Southwark Council:

[T]he Council must ask itself whether the applicant, when street homeless, is less able to fend for himself/herself so that injury or detriment will result where a less vulnerable street homeless person would be able to cope without harmful effect.

And this is from the letter sent to Patrick Kanu, again by Southwark Council:

[The Council is] not satisfied that if [Mr Kanu’s] household was faced with street homelessness they would be at risk of injury or detriment greater than another ordinary street homeless person due to Mr Kanu’s wife and son's ability to fend for the whole household, including [Mr Kanu].

There are numerous other examples of the same terminology throughout the letters. Yet Mr Kanu, Mr. Hotak and Annie all had different assessors. If they had all written individual reports, such similarities would be unlikely.

It is hard not to conclude that cutting and pasting paragraphs from a standard document was exactly what the assessors were doing. Rejection, it seems, was the default setting: the job of the assessors was to decide which of the reasons for rejection in the standard document best fitted the individual case. And presumably the wording in the paragraphs cut from the standard document had been cleared by the legal department, so could not be significantly changed. This would explain the strangely repetitive construction of the letters and their poor grammar. It would be interesting to know how many applications from individuals with mental health problems Southwark Council does accept. How ill does someone have to be before they can be housed?

Lord Neuberger at the Court of Appeal was less than impressed with Southwark Council's repeated use of the terms "street homeless" and "fend for oneself":

Certain expressions seem to have entered the vocabulary of those involved in homelessness issues, which can lead to difficulties when they are applied to strictly legal problems. In particular, for instance, “street homelessness” and “fend for oneself” are expressions which one finds, in one or more of the review letters in the present appeals. Such expressions may be useful in discussions, but they can be dangerous if employed in a document which is intended to have legal effect. There are obvious dangers of using such expressions. They may start to supplant the statutory test, which is normally inappropriate in principle, and, when they originate from a judgment, they may be apt for the particular case before the court, but not necessarily for the general run of cases. Additionally, they may mean different things to different people.

 He pointed out that the expression "fend for oneself" was not the statutory test of vulnerability, and observed that "a person may be vulnerable even though he can fend for himself." And he also objected to the term "street homeless" on the grounds that it lacks legal definition:

The expression “street homeless”...seems to have entered into the Court of Appeal’s vocabulary in the judgment of Auld LJ, in Osmani – see paras 23-28 and para 38(7). When Lord Hughes raised the question of the precise meaning of “street homeless” with counsel during argument, it took until the following day before he got a clear answer. The expression can plainly mean somewhat different things to different people. “Homeless”, as defined in the 1996 Act, is an adjective which can cover a number of different situations, and the very fact that the statute does not distinguish between them calls into question the legitimacy of doing so when considering the nature or extent of an authority’s duty to an applicant.

Solihull Council did not insert the word "street" before "homeless". But otherwise, the language in the letter that the council's assessor sent to Craig Johnson is again similar:

She should ask herself “whether [Mr Johnson], when homeless, would be less able to fend for [himself] than an ordinary homeless person so that injury or detriment to [him] would have resulted when a less vulnerable person would be able to cope without harmful effect”, and explained that her conclusion was that he “would not be less able to fend for [himself] than an ordinary homeless person” for reasons she proceeded to give.

Clearly, both councils had relied heavily on Lord Hobhouse's comments in the Pereira case. But Lord Neuberger disputed their interpretation of his comments. Citing case law, he pointed out that the term "ordinary homeless person" was problematic, since the prevalence of mental health problems in the homeless population is extremely high:

The fact that there might be disproportionately many such people in the homeless population would not in itself mean that they were any the less vulnerable within the meaning of section 189 (1)(c) - any more than it would if there were a disproportionately large number of homeless people suffering from severe mental illness. The question of who constitutes the ‘ordinary homeless person’ … cannot be answered purely statistically.” 

And he continued:

In my opinion, properly understood, both Waller LJ in Bowers and Hobhouse LJ in Pereira intended the vulnerability comparison under section 189(1)(c) to be Page 20 with an ordinary person if made homeless, not with an ordinary person actually homeless. That seems to me to be apparent from Waller LJ’s reference to “a less vulnerable man”, as opposed to “a less vulnerable homeless man”. I think it also follows from Hobhouse LJ’s reference (in a passage at p 330 which I have not so far quoted) to “an individual” who “suffer[s] from some mental or physical handicap which … makes him unable to cope with homelessness” as someone who would fall within section 189(1)(c). There was no suggestion that, if such a person could be said to be ordinary in the context of the actual homeless, he would fall outside the section.

This is a crucial point. Annie had a diagnosed mental ill health condition and had recently been hospitalised. She may have been no more vulnerable than other homeless people with mental health needs, but that does not mean she was not vulnerable compared to a person who did not have a diagnosed mental health condition.

Unfortunately Annie did not appeal Southwark Council's decision. Had she done so, the outcome might have been different. But like so many in her situation, she lacked both the emotional fortitude and the legal means to do so. She simply accepted the inevitability of homelessness.

There is little doubt that homelessness contributed significantly to Annie's mental deterioration. Indeed, she said so herself. In December 2016, Annie gave evidence to MPs in which she expressed a clear view that unstable and - following Southwark Council's decision - non-existent housing had contributed significantly to her worsening mental health.

Although in the video she appears bright and articulate, Annie was by then on long-term medication to control her symptoms, and was too unwell to live unsupported. When I saw her nearly a year later, in November 2017, she seemed in a better mental state, though as her mood was extremely variable it was hard to tell whether I had just caught her on a good day. But the medication was causing her weight to balloon, causing her further problems with self-image and self-esteem.

I saw her again in September 2018. She was still on medication, but she had begun to lose weight, was studying again and had recently started as a Citizens Advice gateway volunteer. She seemed to be getting her life back together. But bipolar disorder is unpredictable. In November, everything came crashing down again. Why, I do not know: but I was struck by her comment in her evidence to MPs that she would be living in hostels for another two years. That was nearly two years ago. Perhaps, as her health improved and the end of her hostel tenure approached, she realised she would soon no longer be a housing priority, and could not face returning to the merry-go-round of unaffordable private sector tenancies, bankruptcy, homelessness and hospitalisation?

Whatever led Annie to make the final decision to end her life, one thing seems clear. Southwark council's disastrous decision in 2015 to refuse housing was a key fork in the road that eventually brought Annie to a place where she felt she could no longer go on. Had they decided differently, Annie might still be with us today. Though she did not die on the streets, responsibility for Annie's death nevertheless lies in part at Southwark Council's door.

But we should not forget the underlying issues that are driving up youth homelessness and resulting in an increasing number of people with mental health problems sleeping rough. Deep cuts to council budgets and community mental health services, benefit restrictions for under-25s, and very low wages for many young people, have made decisions like this inevitable. I have no doubt Annie is far from the only vulnerable young person whose life has been put at risk by councils desperate to avoid legal responsibilities they cannot afford to meet. But councils and mental health teams are themselves on the front line. High private sector rents, insecure tenancies and wholly inadequate social housing provision mean that vulnerable people inevitably end up homeless. There is simply nowhere for them to go.

Throughout the 1990s and 2000s, successive governments - of both colours - introduced and expanded schemes to reduce rough sleeping. In 2008, Gordon Brown's government set out a strategy that aimed to end rough sleeping by 2012. And in 2011, the Coalition government announced plans to extend London mayor Boris Johnson's "No Second Night Out" strategy, intended to ensure no-one ever spent more than one night sleeping rough, to the whole country.

The present Government has now produced a "Rough Sleeping Strategy" which sets out its vision for halving rough sleeping by 2022 and ending it by 2027. Surely this is a tacit admission that the story since 2010 has been one of catastrophic policy failure?

The Government is also now putting more money into mental health services, which have suffered deep cuts since 2010. But the money is almost entirely going into acute services, not into the community and preventative services that could improve mental health over the longer-term. They remain pariah services. And councils remain as cash-strapped as ever, and as desperate to wriggle out of legal responsibilities that cost them money. While this remains the case, vulnerable adults like Annie will continue to live on the streets until they end up in hospital under a section, or in prison. Prisons, like the streets, are full of people with mental health conditions. And like community mental health, prisons are a pariah service. They have suffered deep funding cuts in recent years, resulting in sharply worsening conditions for both inmates and staff.

The lack of joined-up thinking in homelessness strategies is remarkable. There is no point in having a strategy to end rough sleeping if you are simultaneously pursuing policies that increase it. And there is no point in pouring money into acute mental health services while pursuing policies that worsen mental health outcomes. Until there is an end to spending cuts and "reforms" that deepen mental distress and drive up homelessness and rough sleeping, the Government's strategies to end rough sleeping and improve mental health are doomed to fail.

I shall let Annie end this post in her own words.

It is abhorrent that we have a Government that does not appear to prioritise the need for its citizens to have safe places to live. It is disgusting that we have so many people living on the streets, many of whom have physical and mental disabilities, who desperately need help to get back on their feet.

Related reading:

Letter to Annie from Southwark Borough Council (Dropbox link) (by permission of her father)
Regina vs Camden LBC ex parte Pereira
Hotak & others (appellants) vs London Borough of Southwark and another (respondent)
Rough Sleeping Strategy - HM Government
<sub><sup>Stop the Scandal - St. Mungo's
Homelessness and the mental health scandal - The Big Issue
A very British disease
The road to the workhouse

If you would like to donate St. Mungo's in Annie's memory, you can do so here: https://www.mungos.org/get-involved/donate</sup></sub>

Image is a still from the video of Annie's evidence to MPs, link in the post.