A qualitative study of the impact of the UK ‘bedroom tax’

Abstract

Background

The implementation of the ‘Removal of the Spare Room Subsidy’ in April 2013, commonly known as the ‘bedroom tax’, affects an estimated 660 000 working age social housing tenants in the UK, reducing weekly incomes by £12–£22. This study aimed to examine the impact of this tax on health and wellbeing in a North East England community in which 68.5% of residents live in social housing.

Methods

Qualitative study using interviews and a focus group with 38 social housing tenants and 12 service providers.

Results

Income reduction affected purchasing power for essentials, particularly food and utilities. Participants recounted negative impacts on mental health, family relationships and community networks. The hardship and debt that people experienced adversely affected their social relationships and ability to carry out normal social roles. Residents and service providers highlighted negative impacts on the neighbourhood, as well as added pressure on already strained local services.

Conclusions

The bedroom tax has increased poverty and had broad-ranging adverse effects on health, wellbeing and social relationships within this community. These findings strengthen the arguments for revoking this tax.

Introduction

The implementation of the ‘Removal of the Spare Room Subsidy’ in April 2013 formed a particularly controversial aspect of the UK government's wider welfare reforms.¹ Commonly known as the ‘bedroom tax’, it aims to reduce public spending on social housing and affects an estimated 660 000 working age social housing tenants, 81% of whom will lose around £12 of their weekly income from housing benefit as a result of living in accommodation deemed too large for their needs.² Almost two-thirds of affected tenants have a disability.³ Social housing tenants are among the poorest in society, heavily reliant on benefits and particularly vulnerable to welfare system changes;⁴ in 2011–12 social housing tenants' median income was £8996 per year and two-thirds have no savings.³

The government's own Impact Assessment stated that the bedroom tax would have no impact on health and wellbeing.² This is despite evidence demonstrating that loss of income leads to worsening physical and mental health,⁵ and can have lifelong health implications for children.^6,7 Government recommended strategies to mitigate the impact of the tax are: downsize; take in a lodger; increase working hours and/or gain employment.⁸

The bedroom tax forms only part of a wide-ranging series of changes to the welfare benefit system arising from the UK government's Welfare Reform Act.⁹ Reforming the benefit system has been a long-standing aim of successive governments, but the breadth and pace of change arising from this legislation is more intense than in previous years and anticipated to have implications for health and health inequalities.¹⁰ These benefit changes are occurring on top of significant austerity measures introduced as a response to the 2008 recession. Public spending cuts are disproportionately hitting the poorest areas with the worst health outcomes hardest.^7,11

The bedroom tax does not affect all regions equally and North East England is disproportionately affected with some 50 000 households estimated to be ‘under-occupying’.¹ The region also suffers higher levels of unemployment¹² and average household debt (as a proportion of income) than other regions in the UK.¹ Social housing stock varies throughout the country,¹³ in response to local need over long time periods. In the North East¹ and elsewhere^3,13 there is a shortfall of one-bedroomed properties, seriously limiting the options for downsizing.^14–16

This qualitative study aimed to examine the impact of the bedroom tax on social housing tenants in a socio-economically deprived urban locality. We examined the effects on: health and wellbeing; social relationships and the wider community.

Methods

Setting

The study setting was an urban neighbourhood in North East England with a ward population of 11 701¹⁴ ranked in the top 10% most deprived areas of the UK.¹⁵ Sixty-nine per cent of residents live in social housing.¹⁶ Around 650 households were affected by the bedroom tax.

Study design

Qualitative study using semi-structured interviews with tenants (n = 38), one focus group (n = 7) and interviews (n = 5) with service providers.

Sample and data collection

Six hundred and fifty households in the locality identified by the social housing provider as affected by the bedroom tax were invited by letter to three community advice sessions. One hundred and eight tenants attended and were invited to take part in the study, of these 67 consented to be contacted again. Thirty-eight agreed to be interviewed and formed the study sample of tenants. Semi-structured interviews were conducted using a topic guide which examined the financial impact, physical and mental health, social relationships and service use. Interviews took place in tenants' homes and were carried out by four researchers (R.P., S.L., A.D., E.H.). Participants completed a short form to ascertain demographic information. Social housing participants received a £10 store voucher for taking part.

Thirty-nine support organizations and local employers operating in the locality were identified and invited to discuss their views on the impact of the bedroom tax. One employer and 11 service providers took part via five interviews and one focus group (seven participants) in a community centre and workplaces.

Transcription and analysis

Interviews lasted between 22 and 88 min (average 57 min), were digitally recorded and transcribed verbatim. Transcripts were anonymized and checked against recordings for accuracy. Following close reading, a coding scheme for tenants was developed by the team, and modified after being applied to five transcripts. A final coding framework was agreed and applied to the tenant interviews; a separate coding framework was developed and applied to the service provider dataset. Data were imported into NVivo V.10¹⁷ for coding and retrieval. Reliability was ensured by a team approach to coding and analysis. A qualitative interpretive approach was used in which the researcher does not start with pre-determined concepts, but allows these to emerge from the data.¹⁸ This is achieved using line-by-line coding and constant comparison.^19,20 Deviant case analysis,²¹ where we sought out opinions which modified or contradicted the analysis, was used to enhance validity.²²

Results

The impact of the bedroom tax is most fully described by our detailed analysis of four subthemes: (i) meeting basic needs; (ii) health and wellbeing; (iii) family and community support; and (iv) the meaning of home and community.

Participant characteristics

Residents

Twenty-nine of the 38 participants were aged over 40 (Table 1). The sample comprised more women (n = 25) than men (n = 13), more single or divorced (n = 25) than married or partnered (n = 13). Twenty-seven participants were unemployed and nine worked on a part-time basis, with contracts ranging from 0 to 24 h a week. Fifteen individuals lived alone, 15 with one other and the remainder lived in households of more than two. Eleven children under the age of 18 were living in the care of participants. Length of tenancy ranged from 4 months to 33 years and 13 participants had lived in their homes for more than 11 years. All participants were either solely or partially reliant on state welfare benefits for their household income. Twenty participants received state welfare sickness payments for which stringent conditionality tests apply,²³ indicating that they had ill-health or disabilities that affected their ability to work; six were in receipt of unemployment benefit; two received allowances because of caring responsibilities; a further 10 received tax credits or supplementary income due to low wages.

Table 1.

Socio-demographic characteristics of participants

Characteristic	No. of participants
Age at time of interview (years):
≤24	1
25–30	5
31–40	3
41–50	11
51–60	18
Sex:
Male	13
Female	25
Relationship status:
Single	21
Married	9
Partnered	4
Divorced	4
Employment status:
Full-time	0
Part-time	9 (1 also a student)
Self-employed	1
Unemployed	27
Student	2
Household composition:
1	15
2	15
3	6
4	2
Children (<18 years) in residence:
1	9
2	2
3	1
Length of time in residence:
≤1 year	3
1–2 years	7
3–5 years	9
6–10 years	6
11–15 years	5
16–20 years	2
21–25 years	5
26–30 years	0
30 years +	1

Service providers

Of the 12 service providers, six were from the voluntary sector, three from local authority and three from organizations funded by local government, but operating independently; one local employer took part.

Meeting basic needs

Most households lost £12 per week as a result of having one ‘spare’ bedroom, but some were £22 per week worse off due to having two ‘spare’ rooms. All participants reported significantly reducing spending on household essentials, particularly food and utility bills, in an attempt to avoid falling into rent arrears. As illustrated by Box 1, food was one of the first areas cut back. More expensive food was substituted for cheaper items and all respondents stated that they had difficulty in affording fresh fruit and vegetables. A further strategy mentioned was reducing the quantity of food consumed by skipping meals. In particular, parents reported cutting out meals in order to provide for their children, something also observed as widespread practice within the community by service providers.

Box 1: Difficulty meeting basic needs.

1.1 Difficulties affording food

The money that we get, the bills comes out of that and we don't have a lot for food. So we both go on sort of like days … weeks where we don't get enough food in for ourselves … We've lived on, and that's the honest truth, at Christmas, we've lived on just tins of soup (#103, Female, 51)

I think one of the huge issues and worries for us has been the significant rise … [of] the number of people who will go without meals … because they just simply can't afford it and they have to decide when and what they can eat, and more so particularly parents who will go without to ensure that their children have food. (#2, Service provider, voluntary sector)

1.2 Food banks

You think of food banks, you think of soup kitchens and someone living in a cardboard box in the street. That's how I felt. When I compared to where I was five years ago [working], I thought, How have I got in this position? (#39, male, 46)

I felt ashamed because I'd done three jobs … why should I go begging … and that's the way I felt and I only went the once and I never gan [went] again … (#94, female, 51)

1.3 Difficulties affording utility bills

… I got pneumonia twice. I was in hospital for ten days once … I was really ill … because I hadn’t put my heating on … when I contract pneumonia it seems to be round about the cold weather, and obviously if you haven’t got much money and the bills are high anyway you tend to not put the heating on … I have to reduce me energy bills … I find I do spend a lot of time in bed … if you're asleep, one, you're not using the water, two, you're not using the electricity, you're not using the gas, and then I'm not eating the food that is there.(#108, Female, 52)

1.4 Budgeting

I work out my budget and I'm still sitting thinking, ‘Well I've got to find another three or four pounds to pay that bill’. It sounds ridiculous but three or four pounds sometimes can be the difference with getting evicted … and living in your property. (#101, Female, 45)

We had a gentleman come to us quite early on … he'd lost £15 a week [due to the bedroom tax]. Our tutor sat with him and said, ‘Come on, let's have a look at your household budget and we'll see where we can make some savings.’ We honestly went through it with a fine-tooth comb; the gentleman didn't smoke, he didn't drink, he had a basic TV, no broadband, nothing like that, basic pay-as-you-go mobile phone. After all of his essentials, his bills and things had gone out, he was actually left with, I think, £6 a week for food and for travel. How he could have made any savings out of that I do not know. Obviously they're gonna slip into arrears; it's very, very difficult, because as well as losing that £15 they've gotta try and find it from somewhere else. If you've got £6 a week, how do you save £15 a week? (#1 Service provider, voluntary sector)

1.5 Increasing debt and reliance on high interest loans

There's no question that people … are affected and impacted by the lack of finance they have, or find themselves … subsequently having to resort to money lending and even in worse case scenarios loan sharks. (#3 Service provider, independent sector)

The findings on food banks indicated that most participants did not know there were food banks locally. In total, five participants had used a food bank and all expressed shame and embarrassment about doing so, as they associated food banks with deep stigma and a bygone era of absolute poverty and destitution (Box 1).

Uniformly, participants reported cutting back on heating, lighting and cooking in order to save on utility bills (Box 1). Living in cold, damp, unheated homes was associated by several of our participants, with health problems, particularly respiratory conditions.

Paying the bedroom tax compounded struggles of already low-income households and resulted in basic needs not being met. Box 1 highlights that there was little or no room for manoeuvre within weekly budgets. Service provision in the form of budgeting advice to help deal with increased pressure on household income could not address the underlying problem of insufficient money to meet basic needs. Moreover, a commonly voiced concern among service providers across local authority, voluntary and independent sectors, was increased levels of debt and an increase in lending from organizations charging exorbitant interest rates (Box 1).

Mental health and wellbeing

Worries about potential re-location, not being able to provide healthy food for themselves or their children, living in inadequately heated homes and spiralling rent arrears contributed to mental health problems. All participants reported feelings of stress, many recounted symptoms of anxiety and depression, and service providers observed that these were widespread throughout the community. Stress, anxiety and depression were mingled with a sense of hopelessness verging on desperation when people recounted how dealing with the bedroom tax had left them feeling (Box 2).

Box 2: Impact on mental health and wellbeing.

2.1 Stress, anxiety and depression

I felt some of the darkest days of my life took place the last few months [due to the bedroom tax]. I mean it's just terrible … I mean people just don't realise. (#25, Male, 58)

[Regarding anxiety due to the bedroom tax] It ate a lot of my energy. I think life is harsh anyway, like, working and the stressful work and then you want to go come home and relax, to be in a nice home and forget about it, but then … you see your bedroom, the other bedroom, empty bedroom, you walk past it and you think, “What am I going to do with it now? (#90, Female, 53)

Mental health is definitely one [user problem] that's on the increase. The amount of people who come in, ‘I've got depression, I can't cope. I've got anxiety’. It's just awful for them, awful. (#4 Service provider, independent sector)

2.2 Mental and physical health

… sometimes I've been known to wake up at four o'clock or even sometimes two o'clock and it's everything: bills, money, house. I can be sitting reading, trying to read to try and knock myself back to sleep and there are some times when I just can't go back over, so sometimes I'm up from four o'clock in the morning. It does have a knock-on effect because then you feel knackered for the rest of the day, and if you've woken up with that kind of feeling in your head and in yourself you just – I had a tendency just to sit in the corner in the chair. (#16, Female, 54)

It has caused a great amount of stress to me … which affects … ME [chronic fatigue] … obviously stress makes the symptoms worse. (#85a, Female, 35)

I'm fine at the moment, I mean I wasn't last year, I had a heart attack, through the stress of all this. (#74, Female, 52)

As well as mental health problems attributed to the stresses of trying to find the additional money to pay the bedroom tax, a number of participants linked the financial demands of the tax to sleep problems and physical health problems. It was common for participants to describe the ways in which they perceived links between mental and physical health (Box 2).

Family and community support

The difficulties of trying to manage on very low incomes for a sustained period meant that many of our participants were reliant on family, friends, neighbours and the wider community for support. There were numerous examples of informal help from these sources in providing financial aid, childcare, food contributions, as well as emotional support. However, participants recognized that the ability to offer help within any given family, friendship or community network was becoming increasingly restricted as more and more individuals, including those providing assistance, were negatively affected by the bedroom tax (Box 3). There was concern and embarrassment at becoming a financial burden on family and friends, many of whom were also struggling. A combination of personal pride and fear of appearing to abuse family relationships and friendships led to a general reluctance to ask for help (Box 3).

Box 3: Impact of the bedroom tax on giving and receiving family and community support.

3.1 Impact on support networks

I think it's harder this year than it was last year, cos my son used to say ‘oh here, there's a fiver towards it’ cos he works and that, I mean he's got two kids himself, you know, and his wife … she's just come out of employment … you feel as though you're saying all the time ‘oh, I've got nowt [nothing]’ and then he'll say “oh here” and you feel as though … you don't want to ask them (#49, Female, 58)

3.2 Reluctance to ask for help

… my family has said I've looked ill, I said ‘Well, cos I don't eat, I don't eat because I've got no food in’. ‘Oh, here's some food, here's some food’, I don't want your food … it's just, you know, too depressing … I don't like to put on them … even though my dad says ‘Oh I'll just go and buy some pound shop things’, I said ‘Yeah dad but you're struggling too and I don't want you to be struggling’. (#103, Female, 51)

3.3 Reduced incomes directly restricting social interaction.

I just keep myself to myself. Well you cannot go out … I used to, when I used to take the bairn [grandchild] out, just to be granda [grandfather] … I mean them days have long gone you know … they go on about old people and loneliness … Sometimes I never see anybody for a week, you know sometimes longer … and like I say they shut the library so you might have went to the library and met one or two people and it's just nice in the morning to get up and say hello to somebody, good morning you know … Sometimes you're just sitting there and praying the telephone rings just so you talk to somebody. (#25, Male, 58)

3.4 Diminished ability to engage in fundamental aspects of social relationships

Well of course, because I can't go and see them [family]. I can't afford to, like birthdays and everything, times when you want to treat them a little bit. Or even if you want to go and see them, trying to get my bus fare to go and see my son, it's £3.90 on a bus. (#101, Female, 45)

I used to go out to my sister in-law's and then out to my brothers and we used to manage that way, because we used to have our dinner across at their house or wherever. Now we've none of that. (#97, Male, 57)

Reduced incomes directly restricted social interaction (Box 3). Spending on bus fares, coffees or providing meals for others was increasingly difficult. Social situations, no matter how low key, highlighted limited resources. Residents, particularly those without young children at home, recounted becoming more ostracized from the social networks that previously supported them to prevent feelings of loneliness. Lacking the resources for engaging in every-day activities, such as having family and friends to visit or going out to socialize, was a strong feature of our interviews. Participants spoke with great sadness about how reduced contact with family and social networks led to an inability to engage in expected social roles, such as being a grandparent, friend or active club member. Thus reduced resources were linked with social isolation. Participants spoke at length about the ways in which decreased income levels diminished their ability to engage in fundamental aspects of social relationships—interaction and reciprocity—inducing a vicious cycle in which family members, friends and neighbours could not carry out their normal social roles, leading to further social isolation and depression (Box 3).

The meaning of home and community

When participants talked about their houses, they described them in terms of meaning; places full of memories in which they had nurtured and developed relationships over time and which meant much more than the asset value of the number of rooms within a house (Box 4). Moreover, community networks, many of which had been developed over years, provided residents with support from neighbours that was additional to, or instead of, the help received from family. These informal support networks afforded individuals a level of emotional resilience derived from the sense of safety that comes from knowing and trusting people in the immediate locality (Box 4).

Box 4: The meaning of home and community.

4.1 Home is more than a house

That's why it's like part of me, this house. It's part of my family, my kids and my grandchildren … I've lived here a long time. (#16, Female, 54)

There's one lady who has got a three-bedroom house and is having to find £20 a week who we know is already sleeping downstairs because she can't afford to heat the house and is struggling to buy food … she could possibly move house but she's surrounded by people that she's known all her life, and has grown up in that area and doesn't want to do that. So she's decided she'll just find the £20 a week, so obviously that's going to have a huge effect on her, a huge effect. (#6 Independent)

4.2 Support and resilience derived from neighbour and community networks

I couldn't ask for better neighbours. A few weeks ago, I was talking to me neighbour next door there and she says to us, ‘How are you managing?’ I said, ‘Aw, I'm fed up. I'm having to go to a food bank,’ which I had at the time … I came in after I'd been out and she came up with three bags of shopping from Iceland [shop], ‘Here, there you go, that will help you.’ And I just thought ‘oh cheers, bless her’, you know … It's like old school neighbours, they'll do anything for you, they'll look out for you, which you don't see very often these days. (#39, Male, 46)

We like living here. We feel safe around here. We don't get damage to our garden. We don't get vandalism. Everybody tends to watch out. I feel that if we were out for the day and someone tried to break in through the back, one of my neighbours around here would ring the police. They'd want to do something for us and we'd do the same back. (#28, Female, 55)

4.3 Capital investment in homes

I felt like I will be kicked out from the house. It's horrible, you know … we love this house. We made it how we like, and now it will be a disaster for me to move somewhere else. (#99a Female, 42)

… This house has been adapted for my disabilities … it's our home you know, because we love this house. (#85, Female, 55)

4.4 Negative consequences of downsizing on family life

By the rules, my daughter is not 16 years old, and she can share one room with the little one [aged 2]. Again, it is not possible, because the little one is shouting in the night, crying in the day, and there is a big gap between them, an ages gap … They cannot share one room. It is not possible for them, because my daughter studies very hard, and the little one is a baby. They live by themselves in rooms now, but I have to pay because by law, I have a spare room. (#24, Female, 36)

I'm on a mattress on the floor next to them now [following a move from a two-bed to a one-bed flat] … whereas before they had their own bedroom … they're asking, ‘oh, where's our bedroom?’ … I've only been not working for less than a year. (#29, male, 27)

I've heard of a couple of people … who … moved from family homes to smaller properties and they're struggling, they're heartbroken. They've got memories in their family homes and they're stuck in a one-bedroom flat in high-rise flats. So it's just a shame. I don't know how the government and the council and people like that can put people through this sort of pain. (#101, Female, 45)

As well as having strong attachment to living within their community, many participants had made considerable monetary investments in their homes over the years. Either from a voluntary desire to decorate their house, to a more necessary need to furnish and floor empty properties, or to invest in adaptations to make their living spaces appropriate for health problems or disabilities. Participants lacked the capital to repeat such investments, as well as expenses attached to moving and re-furbishing (Box 4).

Most participants did not consider their houses as being ‘too large for their needs’ (p 1).² For many, ‘downsizing’ would eradicate their ability to flexibly accommodate family within their households. This included accommodating children in part-time custodial arrangements, siblings of different ages and needs, children, grandchildren, or having a spare bedroom for carers or couples who sleep apart due to health problems. Moving to a smaller property had negative consequences on family and community life (Box 4).

Discussion

Main findings of the study

To our knowledge, this is the first in depth qualitative study of the impact of the bedroom tax. The findings clearly demonstrate that the tax is associated with a disquieting amount of financial hardship. Coping strategies resulted in poorer diets, inadequately heated homes and restricted opportunities for social engagement, disrupting family and community support networks. Contrary to government assertions,² our participants perceived that their health and wellbeing was adversely affected.

What is already known on this topic

Increasing income inequality leads to worse health outcomes²⁴ and ‘inequalities in mortality and morbidity increase when welfare services are cut’ (p 51).²⁵ UK working age households reliant on welfare benefits are experiencing a drop in income as a result of major reforms to the welfare system, one element of which is the bedroom tax.²⁶ Prior to these reforms, one focus of public health research and policy has been to raise awareness about the relationship between low income and poor health through strategies such as the Minimum Income for Healthy Living (MIHL)²⁷ which provides a benchmark for a safe, minimum living standard for those receiving state benefits and is supported by the World Health Organisation and the Marmot Review.⁵ Such ‘upstream’ public health policies are negated by the impact of current welfare reforms.

What this study adds

Monitoring the health impact of the bedroom tax or other welfare changes is challenging not least because it is not yet possible to disaggregate routine health datasets by benefit receipt.¹⁰ It is also too soon to establish potential longer term effects on health inequalities. This study therefore provides important insights into the day-to-day reality of lowered incomes in a relatively short time after the policy's implementation. The bedroom tax negatively affected individuals, families and communities. Paying the bedroom tax significantly compromised adherence to a healthy diet which is more costly than less healthy options.^28,29 As well as experiencing the shame of poverty with its injurious effects on self-esteem and self-worth,³⁰ we documented extreme levels of anxiety, stress, fear and hopelessness, which, amongst other adults living in poverty in the UK, has been found to threaten the bond between individuals and their social environment.³¹ One of the consistent predictions of the impact of current welfare benefit changes is worse mental health and wellbeing¹⁰ and our findings bear this out. Mechanisms which have been proposed to lead to increased health inequalities include decreased incomes, increased food poverty, increased stigmatization and decreased housing security,¹⁰ all of which we observed.

Uniquely, the bedroom tax requires people in social housing to relocate as though they have less attachment to their homes because they do not own them, yet the social sector is ‘four times more efficient than the market at matching people to homes’(p 152).³ Moreover, we found deep attachment to home and place and saw how disruption to the former diminished frequency of community contacts as well as the quality of social relations.³² Residential stability, civic engagement, trust and social cohesion are important community-level resources for mental health and wellbeing.^33,34 The close connection between individual-level and community-level stressors in areas of high socio-economic deprivation, with ‘the greatest burdens falling on those most unable to shoulder them’ (p 179),³⁵ reinforces the negative effects of this tax on the social fabric of communities.

This study highlights the abject situation of those affected by the bedroom tax and adds to an increasing body of work which shows that conceptualizing poverty as an individual deficit, arising from personal inadequacy is misguided.^31,36,37 The perceived adverse effects on health and wellbeing which we documented are likely to be matched by greater need for services most immediately obvious in primary care and community mental health.³⁸ Evidence to date indicates that the bedroom tax policy is not having its intended fiscal impact¹³ with fewer tenants downsizing than predicted, but there are widespread concerns about the impact of meeting extra payments and evictions on vulnerable people.⁸ Although this may be an unintended consequence, it reinforces the importance of fully considering the equity impact of welfare reform and austerity on public health.⁷

Limitations of the study

Participants were tenants who attended an advice session. We therefore did not recruit residents who were unconnected to local services providing assistance with the bedroom tax. Nor were we able to recruit full-time employees on low incomes. This is an important group to include in future research, especially in the light of the large growth of in-work poverty and continuing reliance of many low income workers on benefits.³⁹ Despite these limitations, the study derived important insights into sensitive topics concerning finance and mental health. Moreover, accounts of those affected by the bedroom tax were corroborated by service providers as being widespread throughout the community, indicating that our findings are not confined only to those tenants we interviewed.

Conclusions

The work emphasizes the negative impact of a national welfare policy on life chances, and demonstrates that, ‘there is a need for political leaders to acknowledge what and who is generating and making inequalities worse’ (p 1236).⁴⁰ The accounts from this study and the government's own interim evaluation⁸ further the case for revoking the bedroom tax due to its impact on health and wellbeing.^7,25 If not withdrawn, the longer term impact of the bedroom tax will be to increase poverty, worsen health and widen health inequalities.^7,10,11,25

Authors’ contributions

S.M. and J.B. conceptualized the study. S.L., R.P., E.H. and A.D. conducted interviews with tenants. J.B. and S.S. conducted the focus group and RP undertook interviews with service providers. S.L., R.P., E.H., A.D. and J.B. checked the transcripts against the audio files. S.M., S.L., R.P., E.H. and A.D. developed the coding framework. S.L., R.P. and E.H. coded the data and conducted initial data analysis. All authors undertook data interpretation. S.M. prepared the first draft of the manuscript. All authors provided feedback and contributed to subsequent revisions of the manuscript. All authors approved the final version of the manuscript.

Funding

This work was supported by funding from Newcastle City Council, Newcastle University's Public Engagement Fund; and Newcastle University's Institute for Social Renewal.