Housing First: A Solution for Chronic Homelessness in the UK?

Housing First: A Solution for Chronic Homelessness in the UK? Nicholas Pleace and Joanne Bretherton

Housing First Globally • Austria • Belgium • Denmark • Finland • France • Greece • Ireland • Portugal • Sweden • USA • Canada • European Commission • FEANTSA • OECD

Housing First in England • Greater London Authority • Bench Outreach (London) • Brighter Lives (Stoke on Trent, Warrington) • SHP (London, 2 projects) • St Mungos Broadway (London) • Stonepillow (Chichester) • Thames Reach (London) • Wales, Isle of Anglesey Council • Scotland, Turning Point Scotland in Glasgow

Why? • Two main reasons • Unprecedented success rate at housing (tenancy) sustainment with high cost, high risk groups of homeless people, sometimes known as long-term homeless, ‘persistent’ rough sleepers and (US term) chronically homeless people • Evidence and, importantly, expectation of significant cost savings

Housing/Tenancy Sustainment • USA - 88% stably housed @ five years • Canada @ 24 months, Housing First group had spent 73% of their time in stable housing, compared to 32% of a treatment as usual group • Finland drop from 2,190 to 1,070 long term homeless people between 2008-2013 (52% drop) • @ 1 year just under 80% stably housed in Lisbon, over 90% in Glasgow, Amsterdam and Copenhagen Housing First pilots • France, 80% still in apartments @1 year (13 months) • London, Camden Housing First pilot, seven people housed @ 1 year, all had spent at least 3 years in Camden Hostels Pathway, one had spent 20 years, some were in their 40s and had never lived independently

Cost effectiveness • Evidence that Housing First can potentially reduce costs • High lifetime costs of long term and recurrently homeless people with high support needs • ‘Million Dollar Murray’ (New Yorker) • Can be particularly strong arguments when focusing on life course, e.g. someone will cost £X thousands more than an ordinary citizen over their lifespan

Cost effectiveness • Emergency health services • Mental health services • Police and criminal justice system • Sustained and recurrent use of emergency accommodation/direct access which is not designed to provide long stay accommodation

British/European reluctance • Americans can’t teach us anything about homelessness services. For example, in January 2014, New York alone had 53,615 people in its homeless shelters, England accepted 53,160 households as owed the main duty during the entirety of 2013 (obviously the English figure is households, therefore bigger overall, but still…) • That’s very nice, but we’ve had floating support services using ordinary housing for vulnerable single homeless people since the 1980s, thanks all the same.

Considering Housing First • First of all, we need to be clear about what were talking about • Housing First is only for high need groups, that means sustained and recurrent homelessness coupled with high support needs, very often including severe mental illness combined with problematic drug/alcohol use, poor physical health, social isolation, lack of social support, economic marginalisation and sometimes low level, repeated, criminality and/or anti-social behaviour

What is Housing First • Immediate/rapid housing, no stay in hostel or supported housing to be made “housing ready” (hence “Housing First”) • Open ended support and open ended access to housing (secure tenancy and/or commitment to enable/support moves if an existing tenancy ends) • Intensive support (not in the sense it is sometimes meant, we’re talking caseloads of handful of people per support worker) • Personalisation of services (choice and control, including capacity for service users to refuse support) • Harm reduction with a recovery orientation • Separation of housing and support (access to settled, secure housing is not conditional on accepting support at the beginning or at any point) • Human rights, including right to housing, right to exercise choices, must be respected, cannot be judgemental

Types of Housing First • Scattered Housing First using ICM and/or ACT and ordinary flats and houses scattered across a community • Intensive Case Management • Assertive Community Treatment • Communal or congregate models that convert existing homelessness services into self contained flats with ordinary tenancies and deliver ICM/ACT services on site. • ICM only through to “welfare state in miniature”, the original Pathways model in NYC

Using Housing First • Not a panacea • Clearly designed for one aspect of homelessness, which is a high cost/high risk minority, one might use it for high need young people or families, but it does not tackle homelessness as a whole • Contention over the models, the founding persons of Housing First in the USA (and some Europeans) disapprove of the communal/congregate model that converts shelters and hostels into blocks of flats with on-site support, say it emulates and replicates the limitations with the hostels it supposedly replaces. Others, in US and Finland, for example, say communal Housing First works very well. • Some Americans, e.g. Tsemberis, are quite strict in their interpretation what Housing First should be, i.e. very well resourced ACT/ICM model, arguing that only an approach that reproduces their original model can be truly effective. Europeans have started to go in other directions, e.g. still more flexible/tolerant models using ICM only.

Using Housing First • Cost arguments need to be very carefully looked at • There is some evidence that the lifetime costs of high cost/high risk end of homelessness can be reduced, i.e. the ‘bill’ for each individual to welfare, health and homelessness systems can be brought down by stopping recurrence of homelessness or bringing sustained homelessness to an end • Some fixed costs cannot be reduced by ending long term and recurrent homelessness, you can’t have less nurses, doctors etc. just by stopping that group of homeless people from using A&E, because there aren’t enough of those people (probably well under 1% of total activity) to allow for any cuts to be made

The Case for Housing First • Nothing else works so well at producing housing sustainment, it beats everything, even the best resourced and designed services England and the wider UK has seen, e.g. tenant sustainment teams (TSTs) under the latter phases of the RSI, personalised budgets for rough sleepers. Nothing is as effective, nothing has proved itself across so many different contexts.

The Case for Housing First • Housing First produces ontological security and that often improves, health, well-being and other indicators • Guy Johnson et al, writing about chronic homelessness and ontological security in Australia provide a clear definition (2010) Ontological security is the basic need we all have for safety, predictability and continuity in our day-to-day lives. In order to feel ontologically secure, we need to feel there is a sense of order and certainty in our world. Our homes are a crucial site through which ontological security is established and sustained.

The Case for Housing First • Giving long-term and recurrently homeless people secure, adequate housing and appropriate, flexible, non-judgemental, respectful, support within a personalisation framework works • Hardly very surprising when you think about it • Housing First fractures the assumption that homeless people have to be “trained” to be “housing ready” and/or have to be “willing to change” to end their homelessness, a big change for some, but a change that needs to be made

The Case for Housing First • Is Housing First officially the best thing ever? No. • There are gaps in evidence and maybe also sometimes unrealistic expectations as to what can be achieved by the Housing First model, e.g. • Community integration and social support • Economic inclusion • Uneven effects on health/well-being • And while it is a minority of the target group, between approximately 1%-15% do not engage successfully

So… • It may be a matter of reversing things, which is what the founder of Housing First, Sam Tsemberis is now arguing…

Thanks for listening • nicholas.pleace@york.ac.uk • www.york.ac.uk/chp • @CHPresearch • www.feantsaresearch.org/ • www.womenshomelessness.org/

Housing First: A Solution for Chronic Homelessness in the UK?