Context: Many day centres for homeless people remained open during the first national lockdown in England following the COVID-19 pandemic. Lacking any official guidance on how to adapt, day centres for homeless people had to navigate risks of infection and changes in the situation of homeless people during this time.
Objective: This small study aimed to discover how some day centres for homeless people approached and experienced the implications of lockdown. The objective was to draw early learning points to inform further research on the future trajectory of day centre provision for homeless people during the pandemic and beyond.
Methods: This rapid qualitative study included semi-structured phone interviews with day centre managers (n = 5) and a systematic search of public facing websites of day centres (n = 10) across four South London boroughs. Data were analysed inductively, using the framework method.
Findings: Findings indicate three learning points 1: the importance of strong networks between day centres with local authorities and other organisations for homeless people to enable services to provide humanitarian assistance, 2: the significance of day centres in their role as humanitarian assistants as a first point of contact for newly homeless people 3: the value of a central information hub.
Limitations: The regional focus on South London and the sample size, which reflects ethical imperatives involved in avoiding undue pressure on day centre staff during the COVID-19 pandemic, limit this study. The findings are to be considered as a springboard for in-depth research into day centres’ support for homeless people during and after the COVID-19 pandemic.
Implications: Findings are valuable as a snapshot of this largely under-researched group of services and service users during the first lockdown. Further research based on the findings could lead to good practice examples to inform the future trajectory of social care provision for homeless people.
Homeless people were – and still are – at increased risk of contracting and suffering from a severe or even lethal outcome of a SARS-CoV2 viral infection, which causes a lung disease called COVID-19 (Kirby, 2020; Tsai and Wilson, 2020). Following the World Health Organization’s (WHO) announcement that COVID-19 can be characterised as a pandemic (WHO, 2020) defined as “an epidemic occurring worldwide, or over a very wide area crossing international boundaries and usually affecting a large number of people” (Kelly, 2011), the English government put in place a first full national lockdown (March – July 2020) to curb the spread of the virus. Day centres for homeless people continued to provide essential services under these difficult working conditions. They had to adapt to the risks of infections from the virus associated with socialising inside as well as to a policy initiative that saw thousands of homeless people temporarily housed during the lockdown. Day centres did not receive official guidelines on how to adjust to this new situation and therefore had to navigate it by themselves.
Homelessness refers to the experience of rough sleeping or living in temporary and/or unsuitable accommodation, including squatting, “couch or sofa surfing,” staying in hostels and not being able to remain in own accommodation for threat of violence or abuse (Shelter, 2018). Many people with experience of homelessness have complex social care needs as well as long-term health conditions, with more than half having mental health conditions or drug/alcohol addictions, or both (Kirby, 2020). The charity Shelter estimated that there were at least 320,000 homeless people in the UK before the pandemic but this number could have been higher because of the “hidden homelessness,” that is people who are affected by homelessness but have not been in contact with any local authority for multiple reasons (Shelter, 2018; Flook et al., 2020). The number of individuals sleeping rough in England increased over seven consecutive years, with London and South-East England seeing the steepest rise (Fitzpatrick et al., 2019). Many homeless people have fallen through the welfare and care safety net (Homeless Link, 2017) and homelessness staff sometimes provide substantial care for them (Manthorpe et al., 2019).
Day centres for homeless people can play a valuable role in tackling the effects and experiences of being homeless by providing social care, support and advice, often on a long-term basis (Homeless Link, 2015; Johnsen et al., 2005). The Homelessness Reduction Act 2017 placed a legal responsibility on local authorities to prevent homelessness and support people who are at risk. For example, under the Act all local housing authorities are under a duty to ensure access to advice and information for potentially and actual homeless people. Day centres for homeless people are often the first point of contact for individuals who are at risk of becoming homeless or are already homeless (Bowpitt et al., 2014). Local housing authorities or authorities with responsibilities for adult social services may refer a homeless individual to a day service for basic help and support, according to what the service offers. Often, they provide opportunities to wash and dress in clean clothes, have a meal, access advice and contacts (e.g. accommodation, work and benefits, addiction or mental health advice) as well as making available basic physical health and well-being services amongst interacting with staff and peers in a “non-judgemental sanctuary” (Johnson et al., 2014; Johnsen et al., 2005). In the UK, day centres for homeless people are usually run by the charitable/not for profit sector and may specify their clientele, such as people aged 18 years or over with or without a history of substance abuse (Johnsen et al., 2005).
In the academic literature, the purpose and outcomes of day centres for homeless people are contested. Johnsen et al. (2005), for example, developed the idea that they can function as both a space of material resource as well as a space of refuge from stigma, social isolation, exclusion and loneliness. However, they also pointed out that day centres for homeless people must not be romanticised as spaces of care totally free of stigma and difficulties; rather, various social and economic factors make them highly complex services and spaces of human interaction (Johnsen et al., 2005; Conradson, 2010). Bowpitt et al. (2014) characterised day centres for homeless people as “places of sanctuary” and “places of change,” in which consequences of multiple exclusions contributing to homelessness can start to be addressed within a welcoming and friendly environment. But Watts et al. (2018) cautioned against identifying them as purely legitimate based on good intentions of staff or even experiences of users. They argued that a robust normative framework and empirically measurable outcomes are necessary to assess their effects and legitimate place within the social welfare system (Watts et al., 2018 p. 247).
In the COVID-19 context, Wood et al. (2020) outlined particular risks affecting homeless people as the pandemic unfolded. These include problems with undertaking prevention and infection control measures such as regular hand washing and hygiene; the difficulty of self-isolating, problems of accessing health care by phone or virtually, reliance on hospitals as sources of health care and treatment, reductions in outreach and other accessible services offering maintenance therapies. In England the National Health Service (NHS) and housing authorities put in place the “Everyone In” initiative in March 2020 to mitigate the effects of the pandemic on people experiencing homelessness, particularly people sleeping rough or sleeping in shared accommodation in hostels. Under the initiative, £3.2 million were made available to local authorities, which, on 26th March 2020, were instructed to accommodate people sleeping rough, people frequently staying in night shelters and people who become newly homeless during the pandemic (Ministry of Housing, Communities and Local Government, 2020a).
Commercial hotel rooms, bed and breakfast (B&Bs) accommodation, and hostels were rented for the purpose of the scheme to provide shelter for homeless people with COVID-19 symptoms and for others. By July 2020, 15,000 homeless people were being temporarily housed, 4,000 of them in London (Ministry of Housing, Communities and Local Government, 2020b; Mayor of London, 2020). The initiative ended in October 2020, with various studies suggesting that it had been highly successful in protecting most homeless people from COVID-19 infections and preventing multiple deaths, albeit with six recorded deaths as a result of a COVID-19 infection among London’s homeless population (Lewer et al., 2020; Fitzpatrick et al., 2020; Mayor of London, 2020). There were 3,444 people sleeping rough on the streets of London between July and September 2020, 55% of who were newly homeless (Crisis, 2020). This is a 14% decrease from the same time in 2019 (Crisis, 2020). On 5 November 2020, a scheme, the “Protect Programme,” was announced by the government to ensure vulnerable people, including individuals sleeping rough, were to be protected during the second wave period of national restrictions and throughout the winter, to run alongside the “Everyone In” campaign (Shelter, 2020).
Under the “Everyone In” scheme, local authorities were encouraged to continue working with homelessness services to provide social care, including delivery of food and sanitary items, in self-contained accommodation. Day centres for homeless people were classed as essential services and were thus allowed to remain open throughout the first lockdown period (March and July 2020). However, in the same government letter of March 2020 that instructed local authorities to house homeless people, they were also advised to stop them congregating in day centres to avoid the transmission of the virus (Ministry of Housing, Communities and Local Government, 2020a). Such instructions were also given in other jurisdictions, such as Australia, where, in the State of Victoria, drop-in services and day meal programmes were deemed non-essential services (Miller et al., 2020). No further official guidance was handed to English day centres to help them adapt to the new situation.
This article reports the findings of qualitative research investigating the responses of day centres and experiences of people working in day centres for homeless people across South London during the first UK nationwide lockdown period. The findings indicate some shared learning experiences across the day centres included in this study and a consensus on challenges when unlocking day centres fully.
This rapid qualitative study (Vindrola-Padros et al., 2020) forms part of a wider study led by the Applied Research Collaboration (ARC) South London social care theme which has mapped day services for people with social care needs, including homeless people, across four London boroughs south of the river Thames pre-Covid-19 (Emmer De Albuquerque Green et al., 2021). This study is registered as minimal ethical risk (MRA-19/20-15084) at King’s College London which was transferred to this current research, as no relevant changes were made to the research method.
Ten homelessness day centres were included in this present study. To ensure anonymity of the participating centres, their main characteristics and their locations within South London are not outlined in this paper.
We contacted eight services that had been identified under our mapping exercise (see Emmer De Albuquerque Green et al., 2021) by telephone and a further two that were located at the boundaries of the boroughs that were included in the mapping report. Following informed consent, we interviewed the managers of five of the services over the telephone between the 10th – 29th June 2020, using a semi-structured topic guide. The questions in the topic guide were designed to answer following broad research question: How were day services for homeless people in South London responding to the COVID-19 lockdown? The topic guide furthermore explored day services’ plans beyond the first lockdown. In addition to the interviews, we systematically searched the public facing websites and social media accounts of the ten local day centres for information on service provision during lockdown/post-lockdown plans and filled out and/or substituted interview templates with information that was provided online. Information regarding day centres’ service provision during lockdown (including hours, type of services and how it was being provided, e.g., outside/inside? With what protective measures?) was available online across the ten day centres, whilst around half of them provided some information on provisional plans to unlock. Data collected on the website were in the form of statements, as outlined in examples included in the findings section.
Interview data were coded using the thematic framework method of analysis (Gale et al., 2013), with codes and categories emerging from the data. For this, the lead author read and re-read each sentence – either of transcribed interviews or statements collected on the websites- as one coding unit to familiarise herself with the data. Sentences were first coded as either providing information about “services and learning during lockdown” or “after lockdown.” Within these first level codes, the various categories emerged, which are reported in the results section below as information regarding service provision and themes. A sample (3) of the interview data was second coded by one of the co-authors and another independent researcher and discussed afterwards. The data collected on the websites were coded using the same coding framework.
The day centres explored in this current study provided a range of building-based services pre-lockdown, including amongst others, provision of breakfasts, tea and coffee mornings; facilities to shower and wash clothes; face-to-face advice services for homeless people; social activities such as film nights; and health consultations with community nurses. Funding for the day centres pre-pandemic originated from mostly multiple sources, including donations, church based funding and local authority/government grants. When lockdown was announced, in the light of official guidelines issued to local authorities to stop people congregating inside day centres and a lack of guidance for day centres on how to operate during lockdown, the day centres navigated the situation independently. This was a process which for some took several weeks.
All-the-day services in this study continued to provide assistance to homeless people, either to people who had been temporarily housed in hotels and hostels under the “Everyone In” initiative and/or to people who became newly homeless during lockdown. They had all discontinued their building-based services, with service users being stopped from entering the premises and with staff working from home or on rotas within the centre. But all provided at least one of the following services during lockdown: handing out one hot meal a day (usually breakfast) as well as support packages stocked mainly with sanitary products; telephone-based advice services; COVID-19 testing for newly homeless people about to be housed in hotels/hostels; support to newly homeless people housed temporarily in hotels/hostels; staying connected to servicer users who were temporarily housed in hotels/hostels, often by handing out pre-paid sim cards and mobile phones; and provision of food packages to homeless people housed temporarily in hotels/hostels.
The following account describes the rolling down of services over a matter of a few weeks:
“We initially kept going 1-hour slots in the morning in our day centre but found that too hard in terms of social distancing. So, we shut the service completely with a focus on keeping in touch with our clients who were housed in hotels or hostels. For rough sleepers, it was difficult to stay in touch in their temporary accommodation, so we gave them mobile phones. We kept up our assistance services via the phone” (Day centre manager 5).
The interviewees and websites for this current study provided an insight into some learning points for day centres for homeless people and beyond which emerged from their experiences supporting homeless people during lockdown. These were: 1) the importance of strong communication networks between the day centres, local authorities and other homelessness organisations, 2) the significance of day centres as first points of contact for newly homeless people and other people staying in temporary accommodation; 3) the value of a central information hub. The sections below provide more detail on each learning point.
The first major learning point mentioned by virtually all the interview participants and/or on the centres’ websites was the significance of a strong network and collaboration between various charities, local authorities, the NHS, volunteers and others to be able to provide support to homeless people during lockdown. Such a network was seen as particularly important for any day centre that wished to stay connected to service users who had been housed in hotels or hostels under the “Everyone In” scheme. The following statement illustrates this:
“We had a lot of good communication with the organisations that had put up people in hotels and hostels. This made our job easier to keep in touch with our service users” (Day centre manager 2).
Here, day centres needed strong communication channels with the organisation leading the resettlement scheme to get access to their service users in terms of finding out where they were being housed and so provide continuity of support. Furthermore, contacts with organisations whose staff were working on the streets, such as outreach workers, were key:
“Over the last few weeks we have been working with the local outreach teams to help assist the effort in getting our homeless off the street and into hotels, so they can self-isolate. Although this has been challenging, we are seeing how this new working relationship is bearing visible fruit.” (Day centre website 1).
Despite the government’s scheme to temporarily house people sleeping rough, homelessness continued throughout lockdown or was being exacerbated by lockdown in the view of some of this study’s participants. Day centres, according to some participants, provided a valuable connection between newly homeless people and the local authorities’ COVID-19 response whilst also still providing essential support to people accommodated under the “Everyone In” Initiative. The day centres that kept on serving hot meals still catered for 40 to 60 people daily, about the same as pre-COVID times. Furthermore, one day centre reported several newly homeless people, particularly women, were contacting them each day. The following statement highlights this:
“We are working with [three local authorities in South London] to get people into accommodation but are seeing new people every day or week who find themselves on the streets for the first time.” (Day centre website 2).
One participant attributed the increasing number of homeless women to not feeling safe at home with their partners or families. A few of the day centres supported newly homeless people to be accommodated as quickly as possible under the “Everyone In” Initiative, working closely with local authorities, organisations coordinating new accommodation and NHS services to enable people to be tested for COVID-19 at the day centres as well as taxi companies to transport people to their temporary hotel accommodation.
Most of those interviewed said how much they appreciated a central information hub; and the charity Homelesslink was mentioned several times. This is a national membership charity for organisations working directly with people who become homeless in England. Its staff rapidly offered advice and peer support in handling the lockdown to homelessness staff, including details about mental health support and physical health counselling. Homelesslink’s webinars and other online resource were a valued and trusted alternative to official guidance. The following statement highlights their value:
“Homelesslink’s webinars and resources were very helpful for us, especially because we didn’t have any government guidance to help us” (Day centre manager 4).
Participants were asked about, and day centres’ websites were searched, for any plans to re-open and resume their full services after lockdown. All participants were unsure how to operate in the future in the light of the virus still circulating in the community (as at 30th June 2020). In particular, two matters were reported to be giving rise to concern. These were: 1) How to keep service users and staff safe; and 2) Funding to make services “COVID-secure.”
The overriding concern of this study’s participants when planning the resumption of services was how to keep service users and staff save from infection. Many participants said that they would not re-open their premises in the near future. This was because the buildings and services provided inside them posed several challenges. These included small rooms in which it would be difficult to physically distance, or toilets and bathrooms which would need to be sterilised after each use and this was not practicable. Several participants commented on a lack of government support on how to address these problems and expressed a desire for guidance. One day centre made plans to re-open its service, but insecurity remained regarding a possible second lockdown, which subsequently was the case:
“We will try to open the day service again for small groups at a time. Assistance will be given per appointment, but it is possible that we will have to shut again if a second wave [of COVID) hits” (Day centre manager 2).
Whilst participants were not so worried about being able to support increased numbers of service users in the future, some of them were concerned about future funding for their service, in particular the cost of adaptions to make premises COVID-secure in the longer-term. One participant, in particular, mentioned how valuable it would be to receive financial support to fund refurbishment, buy Personal Protection Equipment (PPE) and obtain other devices necessary to keep people inside the service safe. The following statement is illustrative of this wish:
“Money to buy plastic screens, funding for PPE, that would be very helpful indeed” (Day centre manager 3).
As mentioned in the methods section, we invited a co-author with experience of homelessness to contribute his view of the situation during the first lockdown to this paper, to highlight the importance of hearing the voices of people who were directly affected (see Box 1).
Box 1: Views of an expert by experience on the impact of reduced day centre services on homeless people during the lockdown
During the first lockdown, day centres continued to operate, but in a vastly different way to the norm. Food was still distributed but only as takeaway, washing and laundry facilities stopped altogether and only a small number continued to provide clothing. The main issues which homeless people faced were accessing toilet facilities and support structures. Daycentres often work as a one-stop-shop linking in the clients to other support mechanisms either informally through peers or formally through recognised professional support structures. These things ground to a halt and a lack of communication between the different services made effective signposting an issue.
There was also a problem getting facemasks. Some daycentres (and hostels) were charging up to £1 for a single disposable mask, which was a deterrent to wearing one. I am not suggesting for a moment the services were profiteering from providing facemasks to homeless people, but it is a clear example of where “fail to fund” meant “funds to fail.” Homeless people are at greater risk of contracting Covid-19 because of their living conditions so not being able to meet this basic level of protection with a face mask was concerning.
Although there has been some success with the “Everyone in” programme, some homeless people found this difficult. A number of evictions took place during the “lockdown” largely due to the hotel structure and the lack of understanding there is around some of the issues homeless people face and how those issues can contribute towards difficult behaviour patterns. Others, who felt isolated, left the hotel they were placed in, returning to the street compromising their own health in return for human interaction.
Covid-19 has shown rather crassly, what homeless people have known for a long time and that is services are unable to fully meet their needs (either because of the increase in numbers or the evolving needs they present with.) Although this example (Covid-19) is extreme, it has shown the shortfalls within the sector and highlighted areas where lessons which can and should be learnt.
Day centres for homeless people in South London adjusted their services during lockdown, taking account of two novel situations – the virus and the offers of immediate housing for many service users, albeit temporary. With a lack of government guidance on how to navigate the lockdown in day centres, but in the context of immediate housing for many of their service users, they found their own ways to continue support for people experiencing homelessness mostly in the sense of being a “resource” but more than that, focusing on a their role as services of humanitarian assistance, defined as action that “is intended to save lives and alleviate suffering of a crisis- affected population” usually on a short-term or even once-off basis (ReliefWeb, 2008).
As mentioned in this paper’s introduction, Johnsen et al. (2005) discussed the implications of day centres as being a material resource, which not only support homeless people to meet their most basic needs but also prevent crime associated with hunger and other basic human requirements for survival (Johnsen et al., 2005). Despite many homeless people in London receiving three meals a day in their temporary accommodation through a catering company (Red Radish, 2020), the number of people who still took up some day centres’ offer of a hot breakfast suggests the value of this service by individuals who for some reason or another did not benefit from the “Everyone In” scheme in London and people who became newly homeless. The resource function was furthermore extended in some cases to help newly homeless individuals receive urgent COVID-19 testing before they could be accommodated under the “Everyone In” scheme. This focus on short-term and in some cases one-off support could be classified as “humanitarian assistance,” providing acute support to save lives and alleviate suffering. Of course, day centres pre-pandemic also took on this role of providing basic necessities for survival. However, findings suggest that during the lockdown their services focussed on this “humanitarian assistance” instead of the wider, more long-term, “sanctuary” and building-based purpose of day centres.
The day centres included in this study saw themselves as a valuable element in providing acute care and support to the changing needs and profile of the homeless community in South London and this was in the context of the closure of many other public sector agencies to public visitors. This impact of these new ways of working could be further explored in future research into the role of day centres for homeless people during the pandemic, including hearing the voices of homeless people, other staff, volunteers, and considering longer term impacts on the sustainability of day centre networks, and exploring the impact of individualised contacts and less group or peer support. Furthermore, future research could investigate this focused role of day centres to offer humanitarian assistance in the face of the pandemic taking hold in England and discuss this in the light of critical theoretical literature that picks up on day centre’s role as “sanctuaries” or “agents for change” with possible implications on debated issues, such as power dynamics and day services’ possible perpetuation of harmful street lifestyles (e.g. Watts et al., 2018; Bowpitt et al., 2017).
Day centres’ work during the lockdown highlights not only the importance of strong networks and working relationships with local authorities, other homelessness services and the NHS, but also the value of a central, sector specific, trusted information hub supporting them with webinars, resources and opportunities to exchange with others. These learning points could usefully inform the future trajectory of post-COVID relationships between day centres and other organisations, for example through in-depth appreciative inquiry into how these relationships were formed and materialised in practice to spell out good practice or as a transferrable case study to model similar organisations and models in other sectors or countries. It also highlights a need to question the relationships between government, local authorities and day services for homeless people, particularly in terms of funding, and how COVID-19 learning could influence these relationships.
Day centre employees were already able to identify emerging concerns about the post-lockdown period. In the months following this research (July–October 2020) they were again managing to adapt to new situations, by re-opening their services with adjustments. Through the COVID-19 Homelessness Response Fund launched in May 2020, the government made available £6 million to charitable homelessness charities, including day centres, to be distributed by Homelesslink. A second round of funding of £5.5 million from The National Lottery Community Fund and Comic Relief opened in July 2020. The Homelessness Response funds were considered useful for the day centres involved in this study, but their deployment was not investigated further in this current research. Again, follow-up, in-depth research could investigate the financial and organisational implications of the COVID-19 pandemic and government policies on day centres for homeless people, exploring some of the concerns raised by providers such as St. Mungo’s (2020) of lack of Personal Protection Equipment (PPE) for homelessness staff and the severe financial implications of the virus on their income streams.
Since data collection for this study was finalised (29 June 2020), the first lockdown period in England was eased and most day centres for homeless people re-opened their services with adjusted procedures and allowing smaller groups on the premises at one time. At the time of writing (mid–June 2021) England was about to fully unlock after suffering further two waves and lockdowns but successfully vaccinating millions of people. As essential services, day centres were permitted to stay open throughout the lockdowns. In the light of this, further research taking the findings of this study forward become pressing to investigate the longer-term situation of day centres and the people using them during and following on from the pandemic to inform their future and links with social care, health and other public services.
Vindrola-Padros and colleagues (2020) captured challenges of conducting qualitative research during the COVID-19 pandemic and balancing ethical and rigorous research with the aim to produce research outputs rapidly to inform policy, practice and research. Rapid studies have several limitations, including this current one. This study’s findings are limited by the number of day centres included, as well as the focus being confined to South London. Many day centres at the time of the research were short-staffed and experiencing unprecedented pressures, so interviews were kept short and sensitive information, such as on their financial situation pre-pandemic, was not collected. In order to obtain a larger, more in-depth sample, further ethics approvals would have been necessary but applying for these approvals would have delayed picking up on some of the valuable shared learning which our interviews have captured.
The study is also limited by providing the view of day centre managers only and does not include the view of homeless people using them or other staff members. Enhanced ethics approval would have been necessary to interview them. However, Box 1 includes a statement of a co-author of this present paper with experience of homelessness and their view on the situation. This was included as a recognition towards the importance of inclusivity of people using day centres for homeless people in research about these services.
Because of the limitations, findings of this study should be interpreted with caution. However, they can be an insightful indication of shared experiences of homelessness day centres in South London during the first lockdown and could be used as a platform to inform further, in-depth investigation of experiences as the pandemic progressed and strategies and guidance to support day centres for homeless people beyond the pandemic.
This rapid qualitative research into 10 day centres for homeless people in South London and their responses to the first national COVID-19 lockdown in England provided a snapshot of how these services adjusted and what they learned from their journey. This can inform future research into day centres for homeless people in England and elsewhere, as well as inter-agency working.
This paper suggests that in addition to the “response” function of day centres during “normal” times, they focused on an additional function of “humanitarian assistance,” particularly for individuals who were not or not yet provided for under the official government scheme to temporarily house homeless people. To provide assistance efficiently, day centres benefitted from strong working networks with local authorities, health providers, and other homelessness organisations. Further research could inquire into how these networks worked in practice to inform future operations of day centres. Day centres also benefitted from a central information and exchange hub, especially in the light of lack of official guidance on how to operate during the pandemic. It is possible that learnings from how this hub drew organisations together and disseminated information could provide a transferrable case-study for other countries or sectors.
Overall, inquiry into the role and value of day centres as resource and humanitarian assistants during the pandemic could perhaps influence the future trajectory of this sector, influencing local and national policy on how to best support people with experiences of homelessness during and beyond times of national emergency.
Caroline Emmer De Albuquerque Green, King’s College London, Kritika Samsi, King’s College London and Jill Manthorpe, King’s College London are supported by the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
The authors have no competing interests to declare.
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