The use of medical evidence in homelessness decision-making

The following findings were made by the project:
• The open textured nature of the law means that although some cases were clearly not open to dispute, in many the decision was open and an authority could legally decide the issue of vulnerability either way. Thus there is potentially a lack of consistency both within and between authorities. Accordingly the view of the case taken by the individual officer deciding has a significant influence on the decision made.
• Homelessness officers acted as street-level bureaucrats where “professional intuition” played an influential role in the decision-making. This manifested itself in the way that applicants were “constructed” as potentially vulnerable or not. In particular applicants who seemed knowledgeable about the process and able to take control of the cases were less likely to be viewed as vulnerable. Generally this intuition impacted at an initial stage of decision-making, but such initial impressions were generally not determinative of the final outcome. Individual applicants had very little voice in this process.
• This intuition was also tempered by a high-level of legal consciousness and conscientiousness – officers were well-versed in the tests arising from the relevant case law. They were also aware that the legal consequence of getting a decision wrong was review and potential appeal. It was generally considered better to avoid these consequences by applying the law correctly first time.
• A variety of sources of information was used by officers in decision-making, these included evidence from an applicant’s own doctors (particularly GPs), in house and external advice, information from the internet and some decisions relating to benefits. There was not, as expected, a perceived hierarchy of expertise, but rather a search for an objective view of the evidence which could most readily come from those who were trusted as objective sources. This was most obvious in the two boroughs with in-house advice which was particularly valued not because of the status of the medical qualifications but because of the advisers’ ability to get to know the applicant or understand the case and therefore provide an objective view.
• Accordingly there was little deference to the medical profession – the opinions of the applicants’ GPs were viewed with some scepticism. In one authority this was the main source of information, as no in-house service was available, yet the officers tended to revert to their professional intuition about the case rather than rely on GP evidence as it was felt they were often “on the side” of the applicant.
• The internet was relied upon to a surprising degree particularly to assess types and levels of prescribed medication as indicators of the severity and/or likely duration of applicants’ health problems. Such information was perceived to be objective and where used it was often an important part of the decision-making process.
• Although an external agency was used by two of the authorities, in one authority use was very limited and inconsistent. In the other there was a preference for in-house medical expertise where officers had trust in the individuals and systems concerned.