Building community with Common Ambition

The number of homeless people in the UK has risen sharply in the past couple of years, exacerbated by the cost-of-living crisis and the end of Covid eviction bans. While it is difficult to accurately measure levels of homelessness, it is estimated that one in 208 people in England are currently without a home, and in Brighton and Hove that figure is even higher at one in 78 (Shelter, 2023).

As the European Congress of Psychology comes to the city, delegates may notice Brighton's high incidence of rough sleepers, but sadly this is the tip of the iceberg when it comes to homelessness. Shelter estimates that less than one per cent of the 271,421 people estimated to be homeless in 2022 were sleeping on the streets; the vast majority of those without a home are sofa surfing or living in temporary accommodation.

Temporary accommodation is often far from temporary. People may spend months or even years waiting to be securely housed, and the standards of temporary housing can be very poor, with damp and a lack of safety being common concerns. Being homeless has a devastating effect on mental and physical health, and on the ability to access health services. The average age at death for the homeless population is almost half the national average, at 45 years for males and 43 years for females (Office for National Statistics, 2020). 

Additionally, 62 per cent of the homeless population report a long-term illness, disability or infirmity, and 82 per cent report a mental health diagnosis (Homeless Link, 2022). People's physical and mental health often further deteriorates in temporary accommodation. As one person with lived experience of insecure housing put it to me, 'You have mental health problems because of being in the system'.

Psychologists may come into contact with people experiencing homelessness in various contexts, such as clinical and counselling practice, and will see this devastating impact of the housing system first-hand. Recognising the major role played by people's social and material circumstances in causing their psychological distress is termed 'outsight' by the Midlands Psychology Group (2022). 

They argue that psychologists need to move beyond individualising models and theories, and work towards addressing inequalities and transforming oppressive systems. A community psychology model that focuses on prevention and empowerment, and which is explicitly values-driven is well-placed to take on this challenge.

Key values in community psychology research include social justice, community and stewardship (Kagan et al., 2019). 'Community' as a value underpinning research and practice means being as participatory, inclusive, peer-driven and collaborative as possible. The inclusion of people with lived experience is therefore fundamental, driven by the premise that those who are most marginalised by a system are the best placed to understand it and work towards transforming it. 

As liberation psychologist Martin-Baró (1996) writes: 'To acquire new psychological knowledge it is not enough to place ourselves in the perspective of the people; it is necessary to involve ourselves in a new praxis, an activity of transforming reality that will let us know not only about what is but also about what is not, and by which we may try to orient ourselves toward what ought to be.'

Brighton and Hove Common Ambition (BHCA) exemplifies such an approach of foregrounding the voices of people with lived experiences of homelessness. As the European Congress of Psychology comes to Brighton and Hove, I share some insights from the group's process of working with the hope that this will be of interest to psychologists working in similar fields.

Approach to coproduction: system mapping

In 2021 funding was granted by the Health Foundation for a three-year project to coproduce improvements to healthcare for Brighton and Hove's homeless population, following a successful joint bid by Arch Healthcare, Justlife, The University of Brighton, Brighton and Hove City Council Public Health Department and Brighton and Hove Clinical Commissioning Group (CCG).

The project is run by a project manager employed by Arch Healthcare, a specialist GP surgery and outreach team set up to address the health needs of Brighton's homeless population, and a participation lead from Justlife, a charity that supports people living in temporary accommodation with health and social needs. The interdisciplinary team from the University of Brighton includes principal investigator and social policy expert Dr Mary Darking, and myself as a community psychologist, who regularly attend BHCA steering group meetings, as well as a sociologist and a historian of housing.

The group first met in June 2021 and spent the first couple of sessions creating vision boards for the project, and drawing up a Group agreement that identified behaviours, attitudes and ways of working to ensure everyone felt safe, empowered and productive taking part.

While there is no consensus on exactly how to define coproduction, it is broadly understood in terms of an effort to share power and decision-making abilities more equally between citizens and service providers. Coproduction is increasingly common in health provision in the UK, but people experiencing homelessness have not had the same opportunities to have a meaningful say in service provision as other patient groups. 

BHCA is the first time this patient group has come together, and the importance of this is summed up by a group member: 'People who have not experienced homelessness do not have the eyes to see. People working in the system are focused on their work. They can miss what is obvious to someone with experience of homelessness. They often do not have the scope within their role to create and advocate for system change. People who work outside homelessness services who do not have experience do not have a clue.'

The BHCA steering group's first piece of work was to understand the system in more depth before any decisions were made about what areas to focus on improving. Based on the group's knowledge of services available in Brighton and Hove, two maps were made – one of services (e.g. health, community, housing, substance use) and one looking at the health pathways with the patient at the centre. 

Two additional maps were added to chart multi-agency working in Brighton and Hove, and a funding map (who commissions and funds what services). These helped us visualise a complex and dynamic system more easily and paved the way for the next piece of work of tracing people's journeys through the system, using feedback gathered from frontline workers and service users. 

We identified challenges, prioritised areas to work on and embarked on a six-week 'design-sprint' with a service-design specialist to develop a prototype to address the group's first identified priority area: challenges to accessing systems. Our solution, an online and paper directory named 'Route to roof' by a group member, was presented to stakeholders at an interactive session that ran alongside the Annual Homeless Health Conference in June 2022.

When discussing what to focus on next, the group kept returning to the undeniable fact that the housing system itself needs to be addressed to improve health. So our next major piece of work was to map the Housing pathway in Brighton and Hove. Six 'change spaces' were identified: Being at risk of homelessness; finding support; being assessed by the council; living in temporary or supported accommodation; moving into a permanent home and recovery from experience of homelessness. The different challenges, barriers, and stigma experienced at each of these stages of the pathway were captured, and areas for change were identified and prioritised.

At the end of 2022 the group presented the housing pathway to frontline service workers and, separately, to two of Brighton and Hove's MPs, Caroline Lucas and Lloyd Russell-Moyle and their teams. We were subsequently invited to feed into their manifestos for the 2023 local elections by suggesting tangible ways to improve people's experience of navigating the housing system. Further pieces of work by the group so far include:

• Co-developing a new method for analysis of feedback and experiences
• Forming a Media and Communications group to co-produce project communications, including a social media campaign for World Homeless Day
• Co-producing events to share learnings
• Inputting into Arch Healthcare services: Move-on and outreach
• Developing a 'toolbox' to share our processes
• Co-designing training for local medical students about homeless healthcare with an Arch Healthcare clinician
• Developing training for local organisations on successful coproduction

Working in a trauma-informed way

Working ethically and in a trauma-informed way has been vital throughout our journey together as a group. As one group member puts it, 'We talk about hard stuff sometimes, and members have to remember that when we go home.' We are fortunate in that the funding from the Health Foundation allows the project to hire both a project manager and a participation lead, who can offer support when needed as well as hold regular one-to-one check-ins with group members. 

In addition, BHCA has developed effective ways of working to build trust and foreground voice and experience in a way that avoids re-traumatising. This hasn't always been a straightforward journey, but learning from setbacks has fed into our processes. We check in and out of meetings to make sure we're keeping an eye on emotional well-being. 

We co-developed a set of boundaries we all follow and expanded our rules of engagement for the group into a Visitors policy to be read and signed by anyone visiting the group, such as representatives from the council. This includes requests not to ask personal questions, and to respect the group's outdoor space which is used as a place to retreat to if needed.

The importance of being trauma-informed and being mindful of language also fed into training the group members co-designed with an Arch Healthcare clinician for local medical students about homeless healthcare. This module was received extremely well by the students and a roll-out to a larger cohort is in the works. 

The group's confidence was further bolstered by this feedback from the students, and many group members report positive effects from being part of the steering group, such as Matt who says 'It's restorative… Coming here is like a clear open space. I feel like if you do good, good will come to you.'

Psychological literature on co-production points to potential benefits beyond improvements to service provision, with prior research finding that citizens who engage in coproduction report increased self-esteem and self-efficacy, gain practical and employment skills, and often experience a shift in self-identity to see themselves as valued professionals (Mayer & McKenzie, 2017). With one year of the project left to go, this transition towards professionalism in the group is increasingly evident.

'We're creating a legacy'

Common Ambition members gathered to discuss the way the group works. Some names have been changed at the request of group members.

What would you say are the main achievements of group (so far)?

Jon: The website. It's going to help so many people in my opinion. It will help them find their way on the housing pathway, it will spread the word about us. We'll have a stronger identity.

Steven: For me, it was working with the (medical) university students. Working with Common Ambition and what it stands for means we're making a worthwhile difference and I feel proud of all our work.

Sam: The things we've produced, such as the Route to Roof design; the housing pathway, our maps, as well as showing our work to different people.

Jon: We know that other services are using our maps and that feels good. It's worthwhile to help people with information that we didn't have [when we were at that stage of the housing pathway]. We're creating a legacy. In fact, we can already see the impact we're having in terms of the input into [local MPs/political parties'] manifestos. We wouldn't have thought a year ago that we'd be doing that.

What about personal achievements?

Sam: It sounds a bit dramatic but the main benefit for me has been facing my fears when we've spoken in front of people and done presentations. I was scared of talking in public before, but having people clap at the end of a talk and having that recognition builds confidence.

Bex: Coming to this group has given me a whole set of skills. It inspired me to do a podcast. It's something positive to get out of bed for, and within that process, I've become a better person.

Steven: Coming here gets me out of my own bubble. We're learning from each other all the time. I learn from others in the group and that helps me communicate. I never used to go to groups; never said anything in group settings. But here I have encouragement and I'm making new friends. Standing in front of other people doing presentations has given me confidence. I certainly wouldn't have been able to do that before coming here.

Jon: We've individually grown and grown as a group; I've really noticed changes. We're understanding more about housing and health and processes – and if we can do it, other cities can.

What do you think other cities or organisations could learn from the way Common Ambition works?

Jon: The key thing is being trauma-informed. Having the 'working with' agreement sets us apart – I've never done anything like that before.

Steven: Doing check-ins before and afterwards is very important. These allow us to voice how we actually feel, rather than being polite. Also, giving people space; you can go outside if you need to. The steering group works really well together – what's said here stays here.

Barbara: Flexibility also helps. You don't have to come every week, you can leave a session or come and go if you need.

What challenges have there been in doing this work?

Bex: When I was thinking about writing the blog about mental health and homelessness [for the BHCA website] I went home to think about it and lost the plot for a couple of weeks. That was really difficult.

Barbara: Even though we check out after every session it can hit you later on when there's no one to talk to.

Jude: A challenge for me is valuing my own voice. I find myself thinking that others have great ideas and that can make me less likely to speak up. I have to remind myself that I do have things to say too.

What does co-production mean to you?

Sam: That our thoughts and experiences are valuable.

Jude: It doesn't feel like 'them and us' in this group – it feels properly cohesive.

Steven: I didn't know what the term meant before, but for me it's working with different agencies as you can't do it all by yourself; it's a group effort. And it means not always agreeing.

Barbara: Yes, everyone's voice and experience are valued equally. I think it also works well because it's not just one or two people with lived experience working with lots of professionals. [That scenario] would put a lot of pressure on them to have to represent all people with lived experience. With us, it's about the group.

Matt: To be listened to and taken seriously by academics and professionals lifts our confidence. It also helps us translate our voice into professional language. 

Jon: If we didn't have this group it would be harder to achieve what we've achieved as there would be bits missing – the expertise and voice of lived experience.

Dr Emma Anderson is a Senior Lecturer at the University of Brighton. [email protected]

Read more on the group's work and access the resources mentioned.

Featured image: The group presented the housing pathway to frontline service workers and, separately, to two of Brighton and Hove's MPs, Caroline Lucas and Lloyd Russell-Moyle and their teams.

Key sources

Brandsen, T., Steen, T. & Verschuere, B. (2018). Co-production and Co-Creation: Engaging Citizens in Public Services. Routledge. 
Homeless Link (2022). The unhealthy state of homelessness.
Kagan, C., Burton, M., Duckett, P. et al. (2019). Critical community psychology. Routledge.
Martín-Baró, I. (1996). The role of the psychologist. In A. Aron and S. Corne, (Eds.) Readings for a Liberation Psychology (pp. 72-82). New York: Harvard University Press
Mayer, C. & McKenzie, K. (2017). '… it shows that there's no limits': the psychological impact of co-production for experts by experience working in youth mental health. Health & social care in the community, 25(3), 1181-1189.
The Midlands Psychology Group (2022). Outsight: Psychology, politics and social justice. Monmouth: PCCS Books.
Shelter (2023). Homelessness in England 2022.
Walker, C., Johnson, K. & Cunningham, L. (2017). Community psychology and the socio-economics of mental distress: international perspectives. Bloomsbury Publishing.