Using Housing First in Integrated Homelessness

Using Housing First in

Integrated Homelessness Strategies

A Review of the Evidence

Nicholas Pleace

February 2018

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Contents

Acknowledgements ...... i

Disclaimer ...... ii

Summary ...... iii

About this Report ...... v

1. New Approaches to Homelessness ...... 1 Introduction ...... 1 Changes to the Understanding of Homelessness ...... 1 The Emergence of Housing First ...... 4

2. The Evidence ...... 8 Introduction ...... 8 An Overview of Services...... 8 A Critical Review of the Evidence...... 10 The UK Context ...... 10 Accommodation-based Services ...... 11 Summary ...... 18 Floating Support Services ...... 18 Ending Homelessness ...... 19 Summary ...... 22 Housing First ...... 22 Ending Homelessness ...... 24 Summary ...... 31 Cost Effectiveness ...... 32 Summary ...... 35

3. Discussion ...... 36 Introduction ...... 36 Using Housing First ...... 36 Strategic Integration...... 36 Services for Specific Groups ...... 38

Acknowledgements

My thanks to St Mungo’s for commissioning this evidence review and in particular to Lucy Holmes at St Mungo’s for her support.

This piece of work draws on a range of earlier evidence reviews and research supported by DIHAL, FEANTSA, the Finnish Ministry of the Environment, the Simon Communities of Ireland, the Scottish Government, the Northern Ireland Housing Executive and the then Department for Communities and Local Government (DCLG, now the Ministry for Housing, Communities and Local Government).

Nicholas Pleace Centre for Housing Policy University of York February 2018 i | P a g e

Disclaimer

Views reported in this piece of work are not necessarily those of the University of York or St Mungo’s.

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Summary

Housing First is highly effective in ending there is a shared philosophy, the operational homelessness among people with high and practices of Housing First in the UK are quite complex needs, but it does not constitute a different from Canada or France, as UK solution to single homelessness, or rough Housing First services have much lower sleeping, in itself. The international evidence operating costs and do not deliver support in shows that Housing First services need to be the same way. a part of an integrated homelessness Housing First services perform very well strategy to be truly effective. against inflexible, abstinence-based services An integrated homelessness strategy, that attempt to end homelessness by making characterised by extensive interagency someone ‘housing ready’ before they move working, uses preventative services and a into their own home. However, many UK range of homelessness services (of which services tend to follow a more flexible Housing First services are one group) to model, emphasising service user choice and effectively meet the diverse needs of single working within a harm reduction framework. homeless people. Integrated strategies, The evidence base has limitations, but there incorporating Housing First within a mix of are data and research results that show that service types, have reduced homelessness to existing UK homelessness services often very low levels in Denmark, Finland and effectively address the bulk of the single Norway. homelessness they are presented with. There is strong evidence that Housing First Equally, some services of intensive service can end homelessness among people with provision, such as the Tenancy Sustainment high and complex needs, typically achieving Team model developed under the Rough sustained housing for at least one year for Sleepers Initiative, achieve comparable around eight out of every ten people results to Housing First with people with high Housing First services work with. Housing and complex needs. First has delivered very similar results in UK homelessness services had often adopted North America, Europe and the UK. various core elements of the Housing First However, outcomes in respect of addiction, model before the idea of Housing First mental health, physical health and social and arrived in the UK. Flexible, tolerant working economic integration can be more variable practices, harm reduction and an emphasis for Housing First. on service user choice have been The evidence base for Housing First requires mainstream in UK homelessness service careful interpretation. All Housing First provision for over two decades. services share a common philosophy and To assume that foreign research results on core principles, but operational differences Housing First can simply be assumed to be can be considerable, with services ranging directly applicable to the UK neglects often from intensive, high cost, multidisciplinary important differences, both in how Housing models, through to models that employ First functions and in the operations and forms of intensive case management with ethos of the existing homelessness services lower operating costs. Success in ending with which Housing First is being compared. homelessness is very considerable, but while iii | P a g e

Existing UK homelessness services – both accommodation-based models and floating support – often have more commonalities with Housing First than the existing

homelessness services (‘treatment as usual’) with which Housing First has been compared in North America and in Northern Europe. The evidence base has limits, but the possibility that Housing First does not

outperform existing services to the same extent in the UK as is the case elsewhere needs to be considered.

Housing First is not the only service innovation that can be effective in reducing homelessness among people with high and

complex needs. There is evidence from Denmark and the USA indicating that the Critical Time Intervention approach can also achieve impressive results in ending homelessness.

There are good reasons to employ Housing First as a means to reduce single homelessness among people with high and complex needs in the UK. This includes some people who repeatedly sleep rough and individuals whose needs cannot always be met by existing homelessness services. However, Housing First is not a comprehensive solution to single homelessness in itself. To work well, Housing First must be one element of an integrated homelessness strategy that includes preventative services and a range of different service models to meet the diverse needs of single homeless people. While Housing First works well for most single homeless people with high support needs, for some individuals different forms of floating support (such as critical time intervention) or specialist models of accommodation-based services may be more effective than Housing First.

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About this Report

This report explores Housing First in relation to the people with high and complex needs – which evidence base on services designed to end includes Housing First working in coordination with homelessness among single people (i.e. lone adults) other services – can deliver a ‘functional zero’ in with support needs. Some attention is given to homelessness. The Finnish, Danish and Norwegian prevention and relief services, but this report is strategies show what can be achieved with the use concerned with services for those single homeless of Housing First within a coordinated, integrated people who require support as well as housing. The homelessness strategy which includes a mix of report does not encompass services for homeless service models. families. Crucially, these strategies have shown success by The report has four main objectives: using Housing First alongside a mix of other models of floating (mobile) support and fixed-site supported To critically assess the evidence base for housing, including congregate and communal Housing First and other homelessness models1. This review explores the ways in which services, considering the extent to which the Housing First and other services are best employed case for different service models has been within integrated homelessness strategies. proven or disproven. The report begins by looking at how changes in the

To consider the state of the evidence on the understanding of homelessness and its financial, as efficiency and cost-effectiveness of different well as social, costs have led to the development of service models. new service models and to the emergence of To review the potential for different service integrated strategic responses to homelessness. The models to contribute to an effective, following section then critically explores the integrated strategy to prevent homelessness evidence base for different service models, including and to minimise the risk of homelessness Housing First. becoming prolonged or recurrent. Finally, the report considers the lessons from the To consider how lessons from various service evidence to discuss what the optimal mix of services models might be employed to increase the within an effective homelessness strategy should efficiency and effectiveness of homelessness look like, and how the key lessons and successes services as a whole. from different models of homelessness service might be used to enhance the prevention and ending of Globally, the existing evidence shows that integrated homelessness. homelessness strategies that encompass effective homelessness prevention, rapid re-housing systems for when homelessness first occurs and a range of housing related support services for homeless

1. Benjaminsen, L. and Knutagård, M. (2016) examples from the Nordic countries. European Journal of Homelessness research and policy development: Homelessness, 10 (3), 45-66. v | P a g e

1. New Approaches to Homelessness

Introduction

2 Our understanding of homelessness has changed. high and complex needs – variously described as 3 4 This change in understanding has influenced the ‘chronic’ homelessness , long-term homelessness , 5 design of services and the objectives for strategic entrenched homelessness and multiple-exclusion 6 responses to homelessness. In terms of responses homelessness . This group faces barriers to services to homelessness among single people with support and have needs that long-established models of 7 needs, the key changes centre on the development homelessness service cannot always meet . North of preventative services and the rise of Housing American evidence indicates that around 20 per First. cent of the homeless population may be in these groups, but some European evidence indicates that Changes to the Understanding in countries with highly developed health, welfare and social housing systems, a higher proportion of of Homelessness the single homeless population has high support needs and is recurrently or long-term homeless. North American research and, to a lesser extent, However, there is also evidence that in those work in the UK and in Europe, has altered our countries with a higher rate of complex needs understanding of homelessness radically over the among single homeless people, the total homeless last 30 years. The key findings of this work can be population is – proportionally – much smaller than described as follows: in the UK or North America8. Some UK evidence Evidence of a small group of single homeless suggests something closer to the North American people and people sleeping rough, whose pattern exists here9, though some recent work in homelessness is sustained or recurrent, with Liverpool suggests the figure may be lower in some

2. Busch-Geertsema, V., Edgar, W., O’Sullivan, E. and 6. Fitzpatrick, S., Bramley, G. and Johnsen, S. (2013) Pleace, N. (2010) Homelessness and Homeless Policies in Pathways into multiple exclusion homelessness in seven Europe: Lessons from Research. Brussels: Directorate- UK cities. Urban Studies, 50 (1), 148-168. General for Employment, Social Affairs and Equal 7. Dwyer, P., Bowpitt, G., Sundin, E. and Weinstein, M. Opportunities. (2015) Rights, responsibilities and refusals: homelessness 3. Kuhn, R. and Culhane, D.P. (1998) Applying cluster policy and the exclusion of single homeless people with analysis to test a typology of homelessness by pattern of complex needs. Critical Social Policy, 35 (1), 3-23. shelter utilization: results from the analysis of Busch-Geertsema, V. et al (2010) Op. cit.; Fitzpatrick, S. et administrative data. American journal of community al (2010) Op. cit.; Jones, A. and Pleace, N. (2010) A psychology, 26 (2), 207-232. Review of Single Homelessness in the UK 2000-2010. 4. Pleace, N., Knutagård, M., Culhane, D.P. and Granfelt, London: Crisis. R. (2016) the strategic response to homelessness in 8. Benjaminsen, L. and Andrade, S.B. (2015) Testing a Finland: exploring innovation and coordination within a typology of homelessness across welfare regimes: shelter national plan to reduce and prevent homelessness, in use in Denmark and the USA. Housing Studies, 30 (6), Nichols, N. and Doberstein, C. (eds), Exploring Effective 858-876. Systems Responses to Homelessness. Toronto: Canadian 9. Pleace, N. and Bretherton, J. (2013) Measuring Observatory on Homelessness. Homelessness and Housing Exclusion in Northern Ireland: 5. Hough, J. and Rice, B. (2010) Providing Personalised A test of the ETHOS typology. Belfast: Northern Ireland Support to Rough Sleepers. York: Joseph Rowntree Housing Executive; Jones, A. and Pleace, N. (2010) Op. Foundation. cit.; Dwyer, P., Bowpitt, G., Sundin, E. and Weinstein, M. (2015) Op. cit.; Fitzpatrick, S., Bramley, G. and Johnsen, S. (2013) Op. cit. 1 | P a g e areas10. deterioration in health, wellbeing and social Evidence that this group of homeless people integration as their homelessness persists or 17 with high and complex needs can have becomes recurrent . significant financial costs for society, owing to These findings have led to a changed understanding repeated and long-term use of homelessness of homelessness at policy level. The crucial points services without their homelessness being are: resolved, heavy use of emergency health services (A&E and mental health) and A significant amount of single adult frequent contact with the criminal justice homelessness can be stopped before it system11. occurs.

Evidence of economic and social causes of There is a small, high need, high cost, group of single homelessness, i.e. that homelessness homeless people whose needs are not being can have an economic or social cause and fully met by existing services, whose does not necessarily result from someone’s homelessness is sustained or recurrent and characteristics, support needs or decisions12. who often make expensive use of publicly This means that a large amount of single funded services. homelessness can potentially be resolved These findings created a new set of working through the use of preventative services such guidelines as to what a homelessness strategy as stopping eviction13, family mediation should look like. The evidence indicated that a lot of services14, sanctuary schemes15 and low homelessness could be prevented and that existing intensity tenancy sustainment services16. services were not ending homelessness for a small Emerging evidence that sustained and group of expensive individuals. The answer, based repeated homelessness associated with high on this evidence, was to develop a twin-track and complex support needs can develop strategic response to homelessness that combined a among people who do not initially have high strong preventative framework combined with support needs, but who enter homelessness, specialised services that could tackle the long-term cannot exit, and then experience a

10. Blood, I., Copeman, I., Goldup, M., Pleace, N., 14. Quilgars, D., Jones, A. and Pleace, N. (2004) Safe Bretherton, J. and Dulson. S. (2017) Housing First Moves: An evaluation. York: Centre for Housing Policy. Feasibility Study for the Liverpool City Region. London: 15. Jones, A., Bretherton, J., Bowles, R. and Croucher, K. Crisis. (2010) The Effectiveness of Schemes to Enable 11. Pleace, N. and Culhane, D.P. (2016) Better Than Cure? Households at Risk of Domestic Violence to Remain in Testing the Case for Enhancing Prevention of Single Their Own Homes. London: Communities and Local Homelessness in England. London: Crisis. Government. 12. Bramley, G. and Fitzpatrick, S. (2017) Homelessness in 16. Jones, A., Pleace, N., Quilgars, D. and Sanderson, D the UK: who is most at risk?, Housing Studies, 1-21; (2006) Addressing Antisocial Behaviour: An independent Busch-Geertsema, V. et al (2010) Op. cit.; Jones, A. and evaluation of the Shelter Inclusion Project. London: Pleace, N. (2010) Op. cit. Shelter. 13. Mackie, P.K. (2015) Homelessness prevention and the 17. Culhane, D.P., Metraux, S., Byrne, T., Stino, M. and Welsh legal duty: lessons for international Bainbridge, J. (2013) The age structure of contemporary policies. Housing Studies, 30 (1), 40-59. homelessness: evidence and implications for public Busch-Geertsema, V. and Fitzpatrick, S. (2008) Effective policy. Analyses of Social Issues and Public Policy, 13 (1), homelessness prevention? Explaining reductions in 228-244. homelessness in Germany and England. European Journal of Homelessness, 2 (1), 69-95; Jones, A. and Pleace, N. (2010) Op. cit. 2 | P a g e and recurrent homelessness among a small group of the 2018 Homelessness Reduction Act. Wales24 has high cost, high need individuals. led the way in adopting a prevention-led response and is being followed by England25, Northern This approach to homelessness strategy has been Ireland26 and Scotland27. seen at Federal level in the United States, focused particularly on veteran homelessness, but also in a The move towards Housing First has been slower in broader twin-track policy that combined an the UK28 than in some countries, including France29, emphasis on homelessness prevention with most of the Scandinavian countries, Canada30 and innovative service models targeting ‘chronic’ the US31. However, Housing First has now become homelessness18, including Housing First19 and mainstream policy. It is a major element of Scottish Critical Time Intervention20 models. Scandinavian homelessness strategy32 and a part of the Northern homelessness strategies, in particular in Finland21, Ireland Homelessness Strategy33 and Welsh policy34. but also Denmark and Norway22, have followed this In England, £28 million has recently been allocated same pattern, combining a strong array of by central government to run a three-site pilot (in preventative services with new forms of service the West Midlands Combined Authority, Greater provision, again including Housing First and, in Manchester Combined Authority, and the Liverpool Denmark, Critical Time Intervention23. City Region) with a view to developing Housing First as a national strategic response to rough sleeping35. The UK has adopted prevention, which became a In 2017, a modelling exercise centred around the mainstream service response to homelessness in potential use of Housing First was conducted in the England in the mid 2000s and which will be Liverpool City Region, exploring the use of Housing significantly intensified by the preventative focus of

18. United States Interagency Council on Homelessness UK. International Journal of Housing Policy, 12 (2), 183- (2015) Opening Doors: Federal strategic plan to prevent 203. and end homelessness. Washington DC: USICH. 29. DIHAL (2016) The experimental programme “Un chez- 19. See Section 2. soi d’abord” Housing first main results - 2011/2015. Paris: 20. See Section 2. DIHAL 21. Pleace, N., Culhane, D.P., Granfelt, R. and Knutagård, http://housingfirst.wp.tri.haus/assets/files/2016/04/un- M. (2015) The Finnish Homelessness Strategy: An chez-soi-dabord-EN.pdf. International Review. Helsinki: Ministry of the 30. Goering, P., Veldhuizen, S., Watson, A., Adair, C., Environment. Kopp, B., Latimer, E., Nelson, G., MacNaughton, E., 22. Benjaminsen, L. and Knutagård, M. (2016) Streiner, D. and Aubry, T. (2014) National at Home/Chez homelessness research and policy development: Soi Final Report. Calgary, AB: Mental Health Commission Examples from the Nordic countries. European Journal of of Canada. Homelessness, 10 (3), 45-66. 31. Padgett, D.K., Henwood, B.F. and Tsemberis, S (2016) 23. Benjaminsen, L. (2013) Policy review up-date: results Housing First: Ending Homelessness, Transforming from the Housing First based Danish homelessness Systems and Changing Lives. Oxford: Oxford University strategy. European Journal of Homelessness, 7 (2), 109- Press. 131. 32. Housing First Scotland: Seminar Report (2017) 24. Mackie, P.K. (2015) Op. cit. http://www.ghn.org.uk/shien/wp- 25. Gousy, H. (2016) No One Turned Away: Changing the content/uploads/sites/5/2017/05/Housing-First-Report- law to prevent and tackle homelessness. London: Crisis; 1.pdf. https://services.parliament.uk/bills/2016- 33. Boyle, F. and Pleace, N. (2017) Op. cit. 17/homelessnessreduction.html 34. Barker, N. (10/4/17) Welsh Government considers 26. Boyle, F. and Pleace, N. (2017) The Homelessness Housing First scheme to tackle homelessness. Inside Strategy for Northern Ireland 2012-2017: An Evaluation. Housing Belfast: Northern Ireland Housing Executive. https://www.insidehousing.co.uk/news/news/welsh- 27. https://news.gov.scot/news/homelessness-and- government-considers-housing-first-scheme-to-tackle- rough-sleeping-action-group homelessness-50349. 28. Johnsen, S. and Teixeira, L. (2012) ‘Doing it already?: 35. https://www.gov.uk/government/news/government- stakeholder perceptions of Housing First in the to-lead-national-effort-to-end-rough-sleeping. 3 | P a g e

First at strategic level36. Housing First is also up and use of quite strict regimes, for example zero- running in several areas: a service has been tolerance of drugs and alcohol and fixed commissioned by Newcastle Upon Tyne from expectations around behaviour, which were Changing Lives37; two Housing First pilots, run by associated with these negative outcomes. Service Threshold38 and Inspiring Change Manchester39, are costs were high and results were often either mixed running in the Greater Manchester Combined or poor. Mental health services began Authority; and St Mungo’s is running several experimenting with services that placed former Housing First services commissioned by local psychiatric patients directly into ordinary housing, authorities, including London boroughs40. providing intensive, flexible and tolerant mobile support services and achieving better results43, and The Emergence of Housing First it was this model that became the basis for Housing First. Housing First has become a core element of homelessness policy in much of the economically Housing First has become prominent for four developed world within the last five years41. The reasons: model itself is not new, being pioneered by Sam The evidence, particularly from North Tsemberis in New York in 1992 based on an America, that a relatively small, very high innovative mental health service using a need group of homeless people existed combination of ordinary housing and flexible, whose homelessness was persistent or mobile support services42. recurrent and whose needs were not being Mental health services had been using a ‘step’- met by existing services. This high-risk based approach that moved former psychiatric population also had high costs in terms of patients from ward-like environments through a public spending, because they had high rates series of steps, each more housing-like than the last, of contact with mental health services, with the goal of making them ‘housing ready’ emergency medical services and the criminal through this process. The step model had run into justice system44. Housing First provided a trouble, as former psychiatric patients became stuck potentially effective service model for ending between steps, abandoned services before the homelessness among this group45 and process was complete or were ejected. In North reducing these costs. America, step-based models tended towards the

36. Blood, I. et al (2017) Op. cit. Report (Belgium) Brussels: European Commission; Busch- 37. Geertsema, V. (2013) Housing First Europe: Final Report https://www.newcastle.gov.uk/sites/default/files/wwwfil https://housingfirstguide.eu/website/housing-first- eroot/housing/housing-advice-and- europe-report/. homelessness/newcastle_homelessness_strategy_2014_- 42 Tsemberis, S. (2010) Housing First: The Pathways _full_version.pdf Model to End Homelessness for People with Mental Illness 38. http://thp.org.uk/services/HousingFirst and see and Addiction. Hazelden: Minnesota. Quilgars, D. and Pleace, N. (forthcoming, 2018) Threshold 43. Ridgway, P. and Zipple, A.M. (1990) The paradigm Housing First: Report of the University of York Evaluation. shift in residential services: From the linear continuum to 39. http://icmblog.shelter.org.uk/a-housing-first-future/ accommodation-based services approaches. Psychosocial and see Pleace, N. and Quilgars, D. (forthcoming, 2018) Rehabilitation Journal, 13, 11-31. The Inspiring Change Manchester Housing First Pilot: 44. Gladwell, M. (13/2/2006) Million-Dollar Murray: Why Interim Report. problems like homelessness may be easier to solve than 40. https://www.mungos.org/work-with-us/latest- to manage. The New Yorker innovations/. https://www.newyorker.com/magazine/2006/02/13/milli 41. Busch-Geertsema, V. (2016) Peer Review in Social on-dollar-murray. Protection and Social Inclusion: Housing First Synthesis 45. Padgett, D. et al (2016) Op. cit. 4 | P a g e

A growing body of research that compares charities, such as Crisis53 and Shelter54, are also Housing First with existing ‘treatment as actively promoting the Housing First approach. usual’ services for homeless people with high 55 and complex needs, and consistently reports At European level, the Housing First Guide Europe that Housing First is more effective at ending and the subsequent development of the Housing First Europe Hub56 (which involves several major UK homelessness46. In recent years, the evidence base has been strengthened considerably by homelessness service providers) has been led by large scale experimental trials in Canada47 and FEANTSA, the European Federation of Homelessness Organisations57. The Housing First Guide Europe in France48. informed the development of Housing First in Global evidence of Housing First services England: The principles by Homeless Link58. ending homelessness among people with high and complex needs at a high rate, including These developments mirror the development of Housing First as core homelessness policy in groups (such as entrenched rough sleepers and homeless people ‘stuck’ in emergency Canada, clearly summarised in the Canadian 59 accommodation and temporary supported Housing First Toolkit . In some other countries where Housing First is not yet mainstream policy, housing) with histories of long term and the homelessness sector has mobilised to advocate repeated homeless service use which had 60 hitherto not resulted in a sustainable end to the approach. One example is Housing First Italia , their homelessness49. This includes some organised under the auspices of fio.PSD, the federation of Italian homelessness organisations. small, observational studies, on Housing First pilots in the UK50. Another is in Sweden, where Lund University has pioneered the use of Housing First, working in Evidence that Housing First may be more cost collaboration with the homelessness sector and effective than other homelessness services, in local authorities61. some cases suggesting that Housing First could actually save money, in others that it At the time of writing, Housing First seems represents a more efficient use of unstoppable and it is routinely presented as producing a revolutionary change in homelessness resources51. service provision. Yet some of those who, like the The homelessness sector, represented by Homeless author, advocate the use of Housing First do also Link in England, is actively advocating for the acknowledge that, like any service model, Housing Housing First model through the Housing First First has some limits. Housing First does not England programme52. The larger homelessness represent a solution to all forms of homelessness

46. Tsemberis, S. (2010) Op. cit.; Padgett, D. et al (2016) 54. http://blog.shelter.org.uk/2017/03/putting-housing- Op. cit. first/. 47. Goering, P. et al (2014) Op. cit. 55. Pleace, N. (2016) Housing First Guide Europe 48. DIHAL (2016) Op. cit. FEANTSA: Brussels http://housingfirsteurope.eu/guide/. 49. Padgett, D. et al (2016) Op. cit. 56. http://housingfirsteurope.eu. 50. Bretherton, J. and Pleace, N. (2015) Housing First in 57. http://www.feantsa.org/en. England: An Evaluation of Nine Services. York: University 58. of York. https://hfe.homeless.org.uk/sites/default/files/attachme 51. Culhane, D.P. (2008) Op. cit. nts/Housing%20First%20in%20EnglandThe%20Principles. 52. http://hfe.homeless.org.uk. pdf. 53. https://www.crisis.org.uk/about-us/media- 59. http://www.housingfirsttoolkit.ca. centre/housing-first-press-release/. 60. http://www.fiopsd.org/housing-first-italia/. 61. http://www.soch.lu.se/en/research/research- groups/housing-first. 5 | P a g e and, to be truly effective, needs to be a part of an accepted everywhere, nor is it necessarily the integrated homelessness strategy that includes a dominant service model throughout North America, range of different types of homelessness service62. Australia or much of Europe. As is discussed below, Housing First has also been subject to real, There are some risks that hyperbole will surround substantial criticism which cannot simply be Housing First, presenting it as ‘the’ solution to dismissed out of hand67. homelessness rather than as part of a wider, integrated and comprehensive strategic approach. There are risks in promising too much from Housing Claims based on the modelling of Housing First First, in terms of its effectiveness, the potential services, rather than working Housing First savings in expenditure and, particularly, in anything programmes, have been made that show significant that suggests that the Housing First model – on its financial savings in the UK context63. However, these own – presents a complete solution to single projections are not in line with North American homelessness. There is a need for balanced debate, evidence on working Housing First services, which to consider what can be learned from Housing First, suggest greater efficiency for similar levels of to think through how it is best employed in the UK spending (i.e. Housing First has similar costs but is and to look at those countries that are moving more effective than existing services)64. Equally, the towards a functional zero in homelessness and the international evidence base for Housing First – while ways in which they have incorporated Housing First relatively strong for a homeless service model – is within integrated strategies that employ a mix of sometimes described as having an exceptional level service models68. of social scientific rigour65. In practice, the strength of the evidence base is varied, with many quasi- As this report will argue, it is important to resist any experimental and observational studies having been temptation to simply replace service models that are already in place with Housing First, without conducted, alongside a lot of small scale work66. properly considering the strengths of those services Seizing on Housing First as ‘the answer’ to and whether this is the best use of Housing First or homelessness is entirely understandable. After the best way to prevent and to reduce decades of experimenting with and researching homelessness within an integrated homelessness homelessness services that often have mixed strategy. Over-claiming or placing unrealistic results, being presented with an apparently expectations on Housing First will ultimately unambiguous success is likely to generate a fair bit damage the reputation of the approach, potentially of excitement. Yet Housing First is not simply depriving homelessness policy of an effective means

62. Tsemberis, S. (2011) Housing First: basic tenets of the 65. Mackie, P., Johnsen, S. and Wood, J. (2017) Ending definition across cultures. European Journal of Rough Sleeping: What works? An international evidence Homelessness, 5 (2), pp. 169-173; Pleace, N. (2011) The review. London: Crisis. ambiguities, limits and risks of housing first from a 66. Pleace, N. and Quilgars, D. (2013) Improving Health European perspective. European Journal of and Social Integration through Housing First: A Review. Homelessness, 5 (2), 113-127; Pleace, N. and Bretherton, Paris: DIHAL; Quilgars, D. and Pleace, N. (2016) Housing J. (2013) The case for Housing First in the European First and social integration: a realistic aim? Social Union: a critical evaluation of concerns about Inclusion, 4.4, DOI: 10.17645/si.v4i4.672. effectiveness. European Journal of Homelessness, 7 (2), 67. Johnson, G., Parkinson, S. and Parsell, C. (2012) Policy 21-41. Shift or Program Drift? Implementing Housing First in 63. Blood, I. et al (2017) Op. cit. Australia. AHURI Final Report No. 184. Melbourne: 64. Culhane, D.P. (2008) The cost of homelessness: a Australian Housing and Urban Research Institute. perspective from the United States. European Journal of 68. Pleace, N. (2017) The action plan for preventing Homelessness, 2, 97-114. homelessness in Finland 2016-2019: the culmination of an integrated strategy to end homelessness? European Journal of Homelessness, 11 (2), 1-21. 6 | P a g e to tackle homelessness among people with high and complex needs. Housing First can help tackle homelessness, but it is not a panacea for homelessness69. It is important to examine how the evidence base relates specifically to the UK, to think critically about using Housing First strategically in the UK and, in doing so, to carefully consider how it can enhance strategic responses to homelessness.

69. Tsemberis, S. (2011) Op. cit.; Busch-Geertsema, V. (2011) The Potential of Housing First from a European Perspective. 7 | P a g e

2. The Evidence

Introduction

The section begins by briefly describing – in broad to treatment, care and other services to terms – the range of service models for homeless assemble a package of support that is single people with support needs that operate in the designed to enable resettlement. The model UK. The evidence relating to the effectiveness and, is designed to facilitate resettlement into where available, the cost effectiveness of these ordinary housing; in North America and in service models is considered. The common Northern Europe, services may follow a reference point in this section is the relative treatment-led or step-based model, making effectiveness of the different service models in someone ‘housing ready’ by ensuring their sustainably ending single homelessness. treatment and support needs are being met and that they are reintegrating into normal An Overview of Services economic and social life. In the UK, services may be more flexible and less structured in Homelessness services follow a series of broad their approach, having a similar objective but patterns, but they are designed, managed, delivered not expecting single homeless people to and commissioned in different ways, with follow a strictly defined series of ‘steps’ to considerable variation in operational detail. Services achieve their goal70. Services can be relatively of the same ‘type’ provided by different basic or highly resourced and specialised71, organisations and under varied commissioning and but all are distinguished by being designed to funding arrangements will work in similar, but not have an operational emphasis on ending necessarily identical ways. Broadly speaking, it is homelessness, i.e. accommodation-based possible to describe the homelessness sector as services do not simply provide emergency comprising: shelter. These services are sometimes referred to as hostels or as supported Accommodation-based services that offer housing, but the latter term is avoided here, emergency and temporary accommodation, as ‘supported housing’ is sometimes in purpose-built or modified buildings that interpreted as referring to ordinary housing provide a cluster of studio flats, or single to which floating support is being delivered72. rooms, with on-site staffing. The staff provide direct support designed to enable someone Floating support services include both to live independently and orchestrate access resettlement and tenancy sustainment services, the latter having both a preventative

70. Johnsen, S. and Teixeira, L. (2010) Staircases, http://webarchive.nationalarchives.gov.uk/20120920035 Elevators and Cycles of Change: Housing First and Other 327/http://www.communities.gov.uk/documents/housin Housing Models for People with Complex Support Needs. g/pdf/137794.pdf; London: Crisis; Mackie, P. et al (2017) Op. cit. http://webarchive.nationalarchives.gov.uk/20110404205610/ht 71. During the 2000s, central government upgraded tp://www.homesandcommunities.co.uk/places_of_change. some hostels to ‘places of change’ which had extensive 72. In North America, ‘accommodation-based services’ services, see: DCLG (2007) Creating Places of Change: refers to ordinary housing to which floating support is Lessons learnt from the Hostels Capital Improvement delivered. Programme 2005–2008. London: DCLG; 8 | P a g e

and resettlement function. These services recovery offered by Housing First is distinct place a lone homeless adult in ordinary from that offered by floating support housing as rapidly as possible, i.e. they do not services77. use an accommodation-based stage to make

someone ‘housing ready’, but instead place In addition to the range of homelessness services which are focused on prevention, them directly into housing and provide support to sustain that housing. The approach resettlement and tenancy sustainment, there has its origins in the closure of long stay, large are a range of other services that are less focused on housing need. These include homeless hostels in the 1980s and local authority responses to high tenancy failure education, training and employment services 78 rates among ‘vulnerable’ statutorily homeless of which the St Mungo’s Recovery College services are one example, another being the single people73. There are low, medium and 79 high intensity versions of these case Crisis Skylight programme . There are also management based services, with high specialist medical services, including dedicated medical centres supported by the intensity floating support such as the Tenancy NHS (such as Great Chapel Street in London80 Sustainment Teams developed through the 81 course of the Rough Sleepers Initiative in or Luther Street in Oxford ) and the London74 having a number of operational Pathways integrated care service for lone homeless people and people sleeping rough82. similarities to Housing First. These are also sometimes referred to as ‘housing-led’ Outreach services also engage with rough support services, though this terminology is sleepers and support them to access other homelessness services. The focus of this more common in Europe than the UK75. report is on services that directly alleviate Housing First services, targeted on homeless homelessness, however it is important to people with high and complex needs, remember that the UK provides a wide array entrenched rough sleepers and homeless of support for single homeless people. people with recurrent and sustained experience of homelessness. Housing First This is a broad categorisation of homelessness can be summarised as an intensive, floating services in the UK. There are other models, such as transitional housing, in which a single flat or a house support model, with a strong emphasis on service user choice and control following a in multiple occupation acts both as temporary harm reduction model with a recovery accommodation and a fixed site to which support is delivered. Neither a form of floating support nor a orientation76. The intensive, sustained, choice-led support with an emphasis on purpose-built accommodation-based service, transitional housing sits somewhere between the

73. Dant, T. and Deacon, A. (1989) Hostels to Homes? The 77. Rehousing of Single Homeless People. Aldershot: https://hfe.homeless.org.uk/sites/default/files/attachme Avebury; Pleace, N. (1995) Housing Single Vulnerable nts/Housing%20First%20in%20England_The%20Principle Homeless People. York: Centre for Housing Policy. s.pdf; http://housingfirsteurope.eu/guide/; 74. Lomax, D. and Netto, G. (2007) Evaluation of Tenancy http://www.housingfirsttoolkit.ca. Sustainment Teams. London: Communities and Local 78. https://www.mungos.org/our-services/recovery- Government. college/. 75. Pleace, N. and Bretherton, J. (2013a) Finding the Way 79. Pleace, N. and Bretherton, J. (2017) Op. cit. Home: Housing-led responses and the Homelessness 80. http://www.greatchapelst.org.uk. Strategy in Ireland. Dublin: Simon Communities of 81. Ireland. https://www.oxfordhealth.nhs.uk/service_description/lut 76. http://housingfirsteurope.eu/guide/ her-street-medical-centre/. 82. http://www.pathway.org.uk. 9 | P a g e two main approaches83. Another example is the needs. In broad terms, preventative services in the supported lodgings approach, mainly used for young UK are regarded as a success. The main metric homeless people and young people leaving care, in (measure) used to assess the success of which a live-in landlord takes on elements of homelessness prevention is a reduction in support provision84. Among many others, there is households requiring the main duty under the four also the Commonweal model, in which one sets of homelessness legislation operating in homeless person with support needs acts as a peer England, Wales, Scotland and Northern Ireland. landlord, offering support to the other tenants85. Central government in England reoriented local St Mungo’s can serve as a further example of the authority services towards prevention in the mid range of services provided to single people with 2000s, which resulted in a marked reduction in high and complex needs who become homeless. In statutory homelessness acceptances (households 2016 St Mungo’s provided accommodation-based owed the main duty under the homelessness law). services places to 4,120 homeless people, many of This has kept levels of statutory homelessness, whom had slept rough86. St Mungo’s also operates although they are now rising, at lower levels than in the Clearing House, commissioned by the Greater the 1980s and 1990s. In 2016/17, 200,160 London Authority (GLA) – a partnership with 50 successful cases of prevention were reported in social landlords which provides access to a settled England, along with 15,060 cases of relief (rapid home and tenancy sustainment team services (i.e. rehousing to prevent homelessness being floating support). Alongside these services, St experienced for very long). In total, 105,900 Mungo’s offers specialist, preventative support to households were recorded as being enabled to former offenders with support needs who are at risk remain in their own housing, rather than becoming of homelessness and is also a significant provider of homeless88. Housing First services87. A very significant reduction in Welsh statutory A Critical Review of the homelessness has occurred following the recent, radical reorientation of statutory homelessness Evidence services towards prevention89. England is in the process of implementing a further move towards The UK Context prevention, emulating many aspects of the Welsh approach. Policy in Northern Ireland and Scotland is Homelessness services for people with high support following the same path90. needs in the UK operate within a strategic and policy framework that increasingly emphasises All of the service models reviewed here can homelessness prevention and rapid relief. These potentially offer a preventative service. Each is services, where they work well, should lessen the designed to prevent a recurrence of homelessness extent to which recurrent and sustained experience where it has already occurred, and can also be of homelessness, or indeed any homelessness, is employed in a purely preventative role to sustain experienced by single people with high and complex existing housing when someone with high and

83. Bretherton, J. and Pleace, N. (2015) Op. cit. 87. https://www.mungos.org. 84. 88. https://www.gov.uk/government/statistical-data- http://www.barnardos.org.uk/what_we_do/our_work/su sets/live-tables-on-homelessness. pported-lodgings.htm. 89. Mackie, P., Thomas, I. and Bibbings, J. (2017) 85. https://www.commonwealhousing.org.uk/our- Homelessness prevention: reflecting on a year of projects/peer-landlord-london. pioneering Welsh legislation in practice. European Journal 86. https://www.mungos.org/wp- of Homelessness, 11 (1), 81-107. content/uploads/2017/12/Save_Hostels_Report.pdf. 90. Boyle, F. and Pleace, N. (2017) Op. cit. 10 | P a g e complex needs is at risk of homelessness. Medium England. The survey excludes some specialist to high intensity tenancy sustainment services can accommodation-based services, such as ‘wet’ be employed in this way, triggered when someone hostels and basic night-shelters (which are just is experiencing a risk of homelessness due to unmet emergency accommodation), but includes the support needs. Possible target groups include young following: people leaving care, someone leaving a psychiatric hospital or someone with support needs leaving … accommodation is delivered in a variety of forms which includes single rooms with prison or the military, where a real possibility of shared facilities, bedsit flats or dispersed homelessness is anticipated. move-on houses for when people leave the accommodation. American experience in trying to accurately target preventative services is worth noting here. It has In 2016, Homeless Link estimated there were 1,185 been found that statistical models of homelessness accommodation-based service projects (described prediction, i.e. testing the extent to which a as ‘accommodation projects’) offering 35,727 bed preventative service might be necessary for spaces95 in England. There has been a decline in someone, are not entirely accurate, and nor are accommodation-based services, as a result of the worker assessments91. This is because the presence decision to remove ring-fencing from the former of sets of characteristics, such as severe mental Supporting People budget for England and illness and addiction, are not in themselves an significant cuts to local authority funding from accurate predictor of whether there is a risk of central government96. In 2014, there were recurrent or sustained homelessness. People who estimated to be 38,500 bed spaces in 1,271 do not have significant support needs when they services97. Another recent estimate – also based on first become homeless can develop high and a survey – is somewhat lower, reporting 30,000 bed complex support needs if homelessness becomes spaces for lone homeless people at the end of sustained or is experienced repeatedly92. Addiction, 201598. A recent exercise in Liverpool City Region, for example, can predate homelessness, develop covering the six local authorities that form the during homelessness, intensify during combined authority, found 1,511 units/bed spaces homelessness, or remain constant throughout an of accommodation-based services for lone homeless experience of homelessness93. people, 70 per cent of which offered 24-hour cover as part of their support services99. Accommodation-based Services

Homeless Link, in its annual survey94, covers the bulk of accommodation-based service provision in

91. Greer, A.L., Shinn, M., Kwon, J. and Zuiderveen, S. 95. Ibid. (2016) Targeting services to individuals most likely to 96. National Audit Office (2017) Homelessness. London: enter shelter: evaluating the efficiency of homelessness National Audit Office https://www.nao.org.uk/wp- prevention. Social Service Review, 90 (1), 130-155. content/uploads/2017/09/Homelessness.pdf. 92. Culhane, D.P. et al (2013) Op. cit. 97. Homeless Link (2014) Support for Single Homeless 93. Pleace, N. (2008) Effective Services for Substance People in England, 2014 London: Homeless Link Misuse and Homelessness in Scotland: Evidence from an http://www.homeless.org.uk/sites/default/files/site- International Review. Edinburgh: Scottish Government. attachments/Support%20for%20Single%20Homeless%20 94. Homeless Link (2017) Support for Single Homeless People.pdf. People in England: Annual Review 2016. London: 98. Ipsos MORI, Imogen Blood & Associates and Housing Homeless Link, p. 15 & Support Partnership (2016) Supported Accommodation http://www.homeless.org.uk/sites/default/files/site- Review: The Scale, Scope and Cost of the accommodation- attachments/Full%20report%20- based services sector London: DWP. %20Support%20for%20single%20people%202016.pdf. 99. Blood, I. et al (2017) Op. cit. 11 | P a g e

Ending Homelessness homelessness (i.e. sees homelessness as resulting simply from psychiatric or physical health North American evidence and, to a lesser extent, problems), or at least partially ‘blames’ homeless research from Europe and the UK, has been used to people for their own situation101. The consequences argue there are two distinct limitations to the can include: effectiveness of accommodation-based services in 100 ending homelessness : Abandonment of services by homeless people with complex needs. Evidence that accommodation-based services that have strict rules, i.e. operate an inflexible, Eviction from services for non-compliance ‘zero tolerance’ policy around drug and with rules. alcohol use, require engagement with treatment and set strict requirements around People becoming ‘stuck’ in services because behaviour, only achieve mixed results. These the requirements to be assessed as ‘housing services use a strict, inflexible set of criteria to ready’ cannot be attained within a reasonable determine if someone has been made timeframe. ‘housing ready’. Low rates of exits from homelessness being Evidence that all existing forms of achieved, including services that only prove accommodation-based services can be effective in delivering sustained living in ineffective for at least some lone homeless independent housing for a minority of lone adults with very high and complex needs. homeless adults.

Where both conditions apply, i.e. accommodation- Individuals moving between services based services are operating strict and inflexible repeatedly without their homelessness ever regimes and attempting to work with lone homeless being resolved; caught in a revolving door of adults with high and complex needs, the results service use which, as well as representing a tend to be at their worst. Homeless people with failure to resolve homelessness, can also be complex needs are often unable and/or unwilling to financially expensive. comply with strict requirements in respect of Accommodation-based homelessness services can abstinence from drugs and alcohol, treatment also not work properly when they have insufficient compliance and expectations around behavioural resources to deliver required support or cannot change, often within a framework that medicalises

100. Pleace, N. (2008) Op. cit. Foundation: New York, pp.37-56; Gulcur, L., Stefancic, A., 101. Sahlin, I. (2005) The staircase of transition: survival Shinn, M., Tsemberis, S. and Fischer, S.N. (2003) Housing, through failure. Innovation, 18 (2), 115-136; Busch- hospitalization, and cost outcomes for homeless Geertsema, V. and Sahlin, I. (2007) The role of hostels individuals with psychiatric disabilities participating in and temporary accommodation. European Journal of continuum of care and housing first programmes. Journal Homelessness, 1, 67-93.; Lyon-Callo, V. (2000) of Community & Applied Social Psychology, 13 (2), 171- Medicalizing homelessness: the production of self-blame 186.; Hansen-Löfstrand, C. (2010) Reforming the work to and self-governing within homeless shelters. Medical combat long-term homelessness in Sweden. Acta Anthropology Quarterly, 14 (3), 328-345; Dordick, G.A. Sociologica, 53 (1), 19-34; Hansen-Löfstrand, C. (2012) (2002) Recovering from homelessness: determining the Homelessness as an incurable condition? The "quality of sobriety" in a transitional housing program. medicalization of the homeless in the Swedish special Qualitative Sociology, 25, 1, 7-32; Pleace, N. (2008) Op. housing provision. Chapter from the book Mental cit.; Tsemberis, S. (2010) Op. cit.; Tsemberis, S. (2010) Illnesses - Evaluation, Treatments and Implications Housing First: ending homelessness, promoting recovery Downloaded from: and reducing costs, in I. Gould Ellen and B. O’Flaherty http://www.intechopen.com/books/mental-illnesses- (eds), How to House the Homeless. Russell Sage evaluation- treatments-and-implications. 12 | P a g e secure enough affordable housing102. Here, it may because suitable, affordable housing was not be the design or the requirements set by a difficult to secure103. service that are the issue. Problems can arise for an accommodation-based service that makes people Coordination with health, mental health, ‘housing ready’, but struggles to find any housing to drug/alcohol, social care, social housing and other services is not sufficiently developed, put them in. Equally, an accommodation-based service may find itself working with people with meaning appropriate packages of care and higher levels of need than it was designed for, or support cannot be assembled. Again, this may be related to inadequate levels of resources. experience budget cuts that undermine the service model. Other reasons why accommodation-based Reviewing the international evidence, the criticisms services might encounter difficulties include: of the effectiveness of accommodation-based The support needs of some homeless people services in ending homelessness can be reduced to three main arguments: are too high for certain accommodation- based services to manage effectively. This is There is a design flaw in some about the range, quality and extent of accommodation-based services because they support being provided not being equal to follow exacting, strict requirements that need, i.e. a design flaw in some services. homeless people with support needs are unable and unwilling to comply with. Services are under-resourced, i.e. are not able to provide the support they were designed to There is a design flaw in some be able to. accommodation-based services because they There are issues with securing sufficient, offer insufficient support and/or cannot effectively manage homeless people with affordable and adequate housing to enable lone homeless adults to move on into a high and complex support needs. This centres settled home, e.g. local housing markets are on the sufficiency, range and support that can be provided by services. unaffordable and/or there are constrictions to social housing supply. In 2015, Homeless Link External constraints on service effectiveness estimated that 25 per cent of the people in result in challenges in delivering housing accommodation-based services in England sustainment, chiefly poor coordination and were waiting to move on, but were unable to support from other services and an

102. Rosenheck, R. (2010) Op. cit.; Blood, I. et al (2017) move-on accommodation and support. London: Greater Op. cit. Pleace, N. and Bretherton, J. (2013) Camden London Authority/Resource Information Service; Dant, T. Housing First: A ‘Housing First’ Experiment in London. and Deacon, A. (1989) Hostels to Homes? The Rehousing York: University of York; Culhane, D.P. and Kuhn, R. of Single Homeless People. Aldershot: Avebury; Pleace, N. (1998) Patterns and determinants of public shelter (1995) Housing Single Vulnerable Homeless People. York: utilization among homeless adults in New York City and Centre for Housing Policy. Philadelphia. Journal of Policy Analysis and Management, 103. Homeless Link (2015) Support for Single Homeless 23-43; Culhane, D.P. and Metraux, S. (2008) Rearranging People in England: Annual Review 2015. London: the deck chairs or reallocating the lifeboats? Homeless Link Homelessness assistance and its alternatives. Journal of http://www.homeless.org.uk/sites/default/files/site- the American Planning Association, 74 (1), 111-121; attachments/Full%20report%20- Homeless Link (2013) Effective Action: Resettlement From %20Single%20homelessness%20support%20in%20Englan Homelessness Services. London: Homeless Link; Watkins, d%202015.pdf. L. (2003) Silting up? A Survey of London hostels about 13 | P a g e

undersupply of adequate and affordable to the successes of the highly structured services it housing. was designed to replace110, albeit that there was evidence these services did not work particularly These arguments are based on international well. evidence, not evidence solely from the UK, and there are practical difficulties in relating the first set The important point here is that the idea that of arguments to the UK. The accommodation-based accommodation-based services do not effectively services for homeless people in the UK are often address single homelessness among people with flexible, tolerant and follow a consumer choice complex needs - because they have ‘strict regimes’ - model, with an increasing emphasis on providing does not really stand up to scrutiny in the UK. The services that reflect the ideas of personalisation104, evidence does point this way in North America and co-production105 and psychologically informed in parts of Europe, but not in the UK where many environments (PIE)106 in recent years. Harm accommodation-based services for single homeless reduction has been mainstream policy and practice people with support needs use harm reduction, for decades. Although abstinence based approaches personalisation, co-production and provide PIE; they do still exist and are enjoying something of a are not judgemental, sanction-based renaissance, the idea of enforcement rather than environments111. flexible, cooperative support as a response to homelessness is, for the most part, outside the Criticisms that centre on the idea that some mainstream in the UK107. accommodation-based services cannot cope well with high and complex needs are also uncertain. Something that is important to note here is that the There are two issues here: decision to move away from judgemental, institutional, strict – or even harsh – environments Fixed-site, purpose built services with on-site in accommodation-based services has been ongoing staffing may be able to support people with high and complex needs more effectively, for decades in the UK108. Indeed, there are those who argue that elements of the UK homelessness especially if they have specialised workers sector are now insufficiently interventionist, that and facilities. Someone who is at high risk can be more effectively monitored in a situation more structure and - perhaps - more sanctions are 112 needed to make services more ‘effective’109. This where staff are physically on the same site . argument mirrors some of the original American There is evidence of a UK population with criticisms of Housing First, which saw the Housing high and complex support needs, whose First model as flawed because it lacked the enforced homelessness is sustained or recurrent and behavioural modification that was seen as intrinsic

104. 109. Watts, B., Fitzpatrick, S. and Johnsen, https://www.scie.org.uk/personalisation/introduction/w S. (2017) Controlling homeless people? Power, hat-is. interventionism and legitimacy. Journal of Social Policy, 1- 105. 18. DOI: 10.1017/S0047279417000289. https://www.scie.org.uk/publications/guides/guide51/w 110. Kertsez, S.G., Crouch, K., Milby, J.B., Cusimano, R.E. hat-is-coproduction/. and Schumacher, J.E. (2009) Housing First for homeless 106. http://www.homeless.org.uk/trauma-informed- persons with active addiction: are we overreaching? The care-and-psychologically-informed-environments. Milbank Quarterly, 87 (2), 495-534. 107. Pleace, N. (2008) Op. cit.; Atherton, I. and 111. Homeless Link (2015) Op. cit.; Pleace, N. (2013) McNaughton-Nicholls, C. (2008) Housing First as a means Measuring the Impact of Supporting People: A Scoping of addressing multiple needs and homelessness. Review. Cardiff: Welsh Government; Johnsen, S. and European Journal of Homelessness, 2, 289-303. Teixeira, L. (2010) Op. cit. 108. Dant, T. and Deacon, A. (1989) Op. cit.; Pleace, N. 112. Pleace, N. and Bretherton, J. (2013a) Op. cit. (1995) Op. cit. 14 | P a g e

who engage with homelessness services accommodation-based services, of whom 77 per without their homelessness being resolved. cent made planned departures into ordinary However, disentangling the extent to which housing, sharing arrangements in ordinary housing this is a function of how accommodation- or into other housing-related support services117. based services work, insufficient funding for Longitudinal research on accommodation-based services, inadequate supply of affordable housing, or a combination of factors, is services in the UK has reported high rates of difficult due to limitations in the current tenancy sustainment, with one quite large study reporting 89 per cent of a cohort who were tracked evidence base. over time sustaining their own housing, 55 per cent There are some data on outcomes for of whom were still in the housing they had originally accommodation-based services, although this varies been resettled into. Although young people were across different regions and across the different UK more likely to be unstable and there was some administrations113. British and Northern Irish attrition (loss of participants), only one-fifth (20%) accommodation-based services do appear to end of a group of 265 formerly homeless people with homelessness at a considerable rate, based on support needs, who had used accommodation- current evidence114. When data were still being based services for homeless people, had shown collected at scale on accommodation-based services signs of residential instability, 60 months after in England, rates of success – albeit based on status service contact118. at exit – were quite high. In 2010/11, 119,200 This is a quite different picture of housing outcomes people using housing-related support services funded by the then Supporting People programme from that suggested by some research from outside in England were reported as needing assistance with the UK, where failure to provide a sustainable exit into settled housing can be the most common ‘securing and obtaining settled housing’, 73 per cent of whom were recorded as having a successful outcome for accommodation-based services. The outcome at exit from those services115. A recent UK evidence is not perfect, but success rates – including some longitudinal analysis – of between exercise (covering March 2015 to March 2017), using shared administrative data collected across six and eight out of every ten people engaged with the Liverpool City Region, reported that of nearly being rehoused by UK accommodation-based services looks quite different to some American119, 9,000 single homeless people using accommodation-based services across the region, 60 per cent were placed in housing following service contact116. Over a five-year period, St Mungo’s reported working with nearly 11,000 people in its

113. Pleace, N. (2013) Op. cit.; Pleace, N. and Bretherton, https://www.mungos.org/wp- J. (2013) Op. cit. content/uploads/2017/09/Ending_Rough_Sleeping_SH_R 114. Dwyer, P. et al (2015) Op. cit. eport_0917.pdf. 115. Source: DCLG Table 1405 (2010/11) Supporting 118. Crane, M., Joly, L. and Manthorpe, J. (2016) People Outcomes for short-term services: clients leaving Rebuilding Lives: Formerly Homeless People’s Experiences Supporting People services achieving outcomes, by of Independent Living and their Longer-term Outcomes. support need identified, England, 2010-11 final. This is a London: Kings College London. figure that includes, but is not exclusively, homelessness https://www.kcl.ac.uk/sspp/policy- services and is restricted to status at the end of service institute/scwru/pubs/2016/reports/RebuildingLives2016 contact. Report.pdf. 116. Blood, I. et al (2017) Op. cit. 119. Pleace, N. (2008) Op. cit. 117. St Mungo’s (2017) Ending Rough Sleeping: The Role of Accommodation-based Services. London: St Mungos, 15 | P a g e

Canadian120 and Swedish121 research. UK because aspects of operation that significantly accommodation-based services appear, at least on differentiated Housing First from existing the basis of available evidence, to be able to end homelessness services in North America (including homelessness more effectively than what is (effectively) co-production, personalisation accommodation-based services in some other and an emphasis on harm reduction) have long countries. been mainstream in the UK homelessness sector125.

In part, this may be because accommodation-based There is another reason for caution in interpreting services in some other countries simply work in the international evidence on accommodation- different ways to many of those found in the UK. based services in relation to the UK. North Outside the UK, an accommodation-based service American126 and Australian127 evidence is not may be targeted solely on homeless populations necessarily generalizable to all accommodation- with high and complex needs, particularly in a based services in those countries: it may only be a context like North America where service access partial picture, not necessarily representative of may, for example, require a psychiatric diagnosis. A what is being achieved across the homelessness North American accommodation-based service may sector as a whole. The contexts in which services are be engaging exclusively with very high need groups, working, may not only be significantly different to whereas some UK services will face a more mixed those found in the UK, but also may not represent pattern of needs122. the homelessness sector as a whole. External evidence on service effectiveness may not be typical This said, North American accommodation-based of services as a whole and it may be from services are more likely to be using strict, environments where services face challenges that abstinence based regimes, based on modification of are not present in the UK, or in which they do not behaviour and compliance with treatment, than is exist in comparable forms. the case for services in the UK123. While it is not possible to be definite because no direct In Europe, an accommodation-based homelessness comparison has been attempted, part of the reason service may have far more resources - or far less why UK accommodation-based services apparently resources - than UK services, depending on where it end homelessness more effectively than services in is operating. This makes broad comparisons with North America may be because both their Europe problematic128. A Danish accommodation- philosophy and operational characteristics are often based service will use trained social workers, a very different124. As has been noted elsewhere, highly integrated package of interagency support Housing First seemed less ‘revolutionary’ in the UK and a very high staff to service user ratio129,

120. Aubry, T., Tsemberis, S., Adair, C.E., Veldhuizen, S., 124. Pleace, N. (2008) Op. cit. Streiner, D., Latimer, E., Sareen, J., Patterson, M., 125. Pleace, N. (2011) Op. cit.; Johnsen, S. and Teixeira, L. McGarvey, K., Kopp, B. and Hume, C. (2015) One-year (2012) Op. cit. outcomes of a randomized controlled trial of Housing 126. Tabol, C., Drebing, C. and Rosenheck, R. (2009) First with ACT in five Canadian cities. Psychiatric Services, Studies of ‘supported’ and ‘supportive’ housing: a 66 (5), 463-469. comprehensive review of model descriptions and 121. Sahlin, I. (2005) Op. cit. measurement. Evaluation and Program Planning, 33, 122. Rosenheck, R., Kasprow, W., Frisman, L. and liu- 446-456. Mares, W. (2003) Cost effectiveness of accommodation- 127. Johnson, G., Parkinson, S., and Parsell, C. (2012) Op. based services for homelessness persons with mental cit. illness. Archives of General Psychiatry, 60, 940-951. 128 Busch-Geertsema, V. et al (2010) Op. cit. 123. There is a broad shift towards Housing First in the 129. Benjaminsen, L. (2013) Op. cit.; Benjaminsen, L. and USA, although it may not yet be the dominant form of Andrade, S.B. (2015) op. cit. service provision for homeless people with high and complex needs. 16 | P a g e whereas an Italian homelessness service will simply higher support needs than those who were housed. not have anything like that level of resources130. There was also evidence of a small group within this Even a near neighbour, like Denmark or France, is 40 per cent, of just under 400 in number (4% of the not necessarily the same as the UK – the total), who had experienced four or more environments in which accommodation-based placements in accommodation-based services in a services operate, the ways in which they work and two-year period and who had high needs134. their success rates will differ from the UK. It is difficult to say how far the presence of this There is a need to be very careful in comparing UK, population is a function of the limits of design and European, Australian or North American services. operation of existing accommodation-based This is because like is not being compared with like: services, or how far it is a function of resource operations, resource levels and operational context constraints within services, cuts to services and may all differ greatly from the UK. external, contextual issues, including significant problems with affordable housing supply and joint All this said, there are respects in which the UK is working. The evidence base is insufficient to be like some other countries. There is widespread, entirely clear. However, as discussed in response to international, evidence of a small, high need, high arguments that American accommodation-based risk group of homeless people whose contacts with services are sometimes ineffective, the reasons why homelessness services – mainly in the form of something is not working for everyone are not accommodation-based services – can be sustained, necessarily only about potential flaws in service repeated and fail to result in an end to their design – factors like operational context and funding homelessness. This population is present in the UK; levels may also be important135. So, while there may in contexts with less extensive health, social care be elements of the design of UK accommodation- and welfare systems, such as the USA; in Canada, based services that mean they are less effective for where health service provision is closer to the UK; in some homeless people with high and complex Australia, where again there are similarities as well needs, we cannot be sure that when failures occur it as differences with the UK; and in countries where is just for this reason, as factors like shortages of welfare systems, social housing, health care and affordable housing supply or funding cuts may be as homelessness services are very well-funded and – or more – important. highly developed, including Denmark131 and Finland132. In a recent survey covering 276 homelessness services in England, 73 per cent of services reported 133 Estimating numbers is challenging because the that they were sometimes not accepting single data are limited, but the recent work in Liverpool people with support needs because their needs referred to above found that 40 per cent of a were ‘too high’, and 67 per cent reported that single population of nearly 9,000 using accommodation- people with support needs were sometimes turned based services were not housed following service down because there was felt to be too much risk136. contact. This 40 per cent tended to have somewhat However, 66 per cent of these services also

130. Lancione, M. (2014) Entanglements of faith: 133. Jones, A. and Pleace, N. (2010) Op. cit.; Dwyer, P. et discourses, practices of care and homeless people in an al (2015) Op. cit.; Fitzpatrick, S. et al (2013) Op. cit.; Italian City of Saints. Urban Studies, 51 (14), 3062-3078. Pleace, N. and Culhane, D. (2016) Op. cit. 131. Benjaminsen, L. (2016) Homelessness in a 134. Blood, I. et al (2017) Op. cit. Scandinavian welfare state: the risk of shelter use in the 135. Rosenheck, R. (2010) Service models and mental Danish adult population. Urban Studies, 53 (10), 2041- health problems: cost effectiveness and policy relevance, 2063. in Ellen, I.G. and O’Flaherty, B. (eds), How to House the 132. Pleace, N. et al (2015) Op. cit. Homeless. Russell Sage Foundation: New York, pp. 17-36. 136 Homeless Link (2016) Op. cit. 17 | P a g e reported that they were sometimes unable to than with homeless people with low or provide support simply because they were full up. medium support needs. This may be to do with issues around service design, but may There are innovations in other countries, such as the also relate to factors like resource levels and ‘Common Ground’ model of supported housing shortages of affordable housing. developed in the USA and used in Australia, that have not been tested in the UK. Common Ground, Based on available evidence, accommodation- now known as the ‘Breaking Ground’ model137, uses based services in the UK appear to end congregate housing in a way that follows elements homelessness at higher rates than of the Housing First model (it is described as accommodation-based services in some other following the Housing First philosophy), but countries. Services in the UK are less likely to provides housing for low income working adults, follow a strict and highly structured approach older people, armed-forces veterans and people centred on requiring behavioural changes, with mental health problems, as well as formerly and more likely to use co-production and homeless people. Their schemes do not necessarily harm reduction. accommodate all these groups, but will often mix homeless people and other populations in the same Floating Support Services building. The evidence base on this specific model is limited138, but results were mixed when the model It is not really possible to be precise about the scale was used in Australia139. of floating support services for homeless people. When data on housing related support were still Summary being collected for the former Supporting People programme in England (2010/11), around half of all There is some evidence that accommodation- service use was in the form of floating support and based services that employ strict rules and single homeless people (as they were described in expect abstinence, treatment compliance and the data) represented around one quarter of all modifications to behaviour may be less service users140. An estimate based on these data effective in ending homelessness than more would suggest something around 24,000 lone flexible, user-led services using harm homeless adults using these services in England reduction. Accommodation-based services each year. However, these figures are out of date may be at their least effective when working and there may, because floating support services with homeless people with high and complex have lower operating costs (no dedicated building to needs and using strict, inflexible, abstinence- develop and maintain), have been some increases in based approaches. these sorts of services as cuts have continued across the homelessness sector; although equally, floating There is evidence that a group of homeless support services may sometimes have suffered from people with high and complex needs similar, or greater, levels of cuts141. experience repeated and long-term homelessness. Accommodation-based In 2016, Homeless Link reported that 74 per cent of services may be less effective with this group services for lone homeless adults were using

137 http://www.breakingground.org 140. Source: DCLG 138 Mackie, P. et al (2017) Op. cit. https://www.gov.uk/government/statistics/supporting- 139 Parsell, C., Fitzpatrick, S. and Busch-Geertsema, V. people-client-records-and-outcomes-april-2010-to- (2014) Common ground in Australia: an object lesson in march-2011. evidence hierarchies and policy transfer. Housing Studies, 141. National Audit Office (2017), Op. cit. 29 (1), 69-87. 18 | P a g e floating support, but this is a somewhat ambiguous choice and control for service users, with a recovery figure, because this floating support might have orientation and recognises the human right to been attached to a congregate service or a service housing. It is this intensity of the support provided, using a mix of congregate and scattered within a clearly and consistently defined ethos of accommodation or represent a free-standing service delivery, that differentiates Housing First tenancy sustainment or resettlement service. This from the various models of floating support hitherto reflects the hybridisation of homelessness services, used in the UK146. with various combinations of support being provided, rather than a simple division between Ending Homelessness purely accommodation-based services (fixed site, congregate, with on-site staffing) and floating Comparisons between floating support – as distinct support142. from Housing First – and accommodation-based services are not widespread. For some years, there The Supporting People programme still exists in has been research indicating that low to medium Northern Ireland and has a similar emphasis on intensity floating support can enable lone homeless homelessness143. However, fairly recent data on the adults with support needs to live independently147. Welsh programme show that it focuses more However, arriving at a clear picture of what these heavily on older people, with only around 27 per services can achieve in relation to homelessness is cent of provision being floating support and eight not really possible by using the existing evidence per cent of services focused on ‘vulnerable base. homeless people’144. The challenge centres on the very wide range of The range of services within the floating support services that fall into the category of floating category is considerable. At one end of the support. This is not just a question of the differing spectrum, there are short-term services offering levels of intensity of service – which is also a basic practical support and case management in challenge in relation to looking at outcomes for which the workers might be supporting 30 or 40 accommodation-based services – but also a matter people (or more) at once. At the other end, there of a still wider variation in operation. The crucial are examples of tenancy sustainment teams, such as issue here is whether or not a service is those developed in London towards the end of the freestanding, i.e. it functions by establishing Rough Sleepers Initiative, that offer very intensive, contact, arranging housing and then providing flexible support and which have operational support to sustain a tenancy, or whether it is similarities to Housing First145. By contrast, Housing integrated into a wider programme of support. First services, while they do differ in operational Floating support may be used to support a move out characteristics (see the debates about ‘fidelity’ of an accommodation-based service, which uses described below) all share the same core principles. mobile support as part of a linear process of making Housing First provides intensive support for as long someone housing ready. The service model can be as is needed, within a framework of harm reduction, employed directly in homelessness prevention,

142. Homeless Link (2016) Op. cit. and Quilgars, D. (2003) Supporting People: Guide to 143. Boyle, F. and Pleace, N. (2017) Op. cit. Accommodation and Support Options for Homeless 144. Pleace, N. (2013) Op. cit. Households. London: Homelessness Directorate; Busch- 145. Lomax, D. and Netto, G. (2007) Op. cit. Geertsema, V. (2005) Does re-housing lead to 146. https://housingfirstguide.eu/website/. reintegration? Follow-up studies of re-housed homeless 147. Pleace, N. (1995) Op. cit.; Goldfinger, S.M., Schutt, people. Innovation. 18 (2), 202-226; Tabol, C., Drebing, C. R.K. et al (1999) Housing placement and subsequent days and Rosenheck, R. (2009) Op. cit.; Johnsen, S. and homeless among formerly homeless adults with mental Teixeira, L (2010) Op. cit.; Rosenheck, R. (2010) Op. cit.; illness. Psychiatric Services, 50 (5), 674-679; Pleace, N. Pleace, N. and Bretherton, J. (2013a) Op. cit. 19 | P a g e where a Housing Options team may refer someone A harm reduction approach, with an emphasis assessed as being at risk of homelessness directly to on service user choice and participation, with a tenancy sustainment team, both in the UK and in more recent services following principles of other countries, such as Finland148. When floating co-production and personalisation. support services have been studied in detail, the Low to medium intensity support in most evidence has been broadly positive and, in the context of the UK, services of this sort tend to follow services, with an emphasis on case the principles of service-user choice, management/service brokering, alongside some elements of practical and emotional personalisation, co-production and harm reduction, which the wider evidence base shows to be more support. Worker caseloads may often be effective with individuals with high support quite high, with an individual supporting 20, 30 or 40 people at once. needs149. Broadly speaking, a floating support service, sometimes called a housing-led approach in Time limited services, ranging from between Europe and often referred to as a tenancy three to 12 months. sustainment service in the UK, will have the following broad characteristics150: Alongside the limited UK evidence, there is North American and European evidence which reports two Mobile support delivered to formerly main findings152: homeless people with support needs in ordinary housing in the private rented or Focusing on providing and sustaining housing social rented sector. This housing will tend to – as an integral part of service design – is far be scattered across the community. The very more effective than using floating support first services were developed and run by local focused only on care, treatment and support authorities, focusing on the closure of large needs. When housing is provided, successful hostels and on single homeless people with exits from homelessness can be secured, complex needs accepted as ‘vulnerable’ and although the evidence base is insufficient to in priority need under the homelessness be clear whether these outcomes are legislation151. Floating support services now substantially different to those for have a wider role – which may include accommodation-based services. prevention – and will tend to work across Floating support can be cost effective, in the tenures. sense that it does not have to build or convert

148. Pleace, N. et al (2015) Op. cit. 151. Pleace, N. (1995) Housing Vulnerable Single 149. Pleace, N. (2008) Op. cit. Homeless People. York: Joseph Rowntree 150. Bowpitt, G. and Harding, R. (2008) Not going it Foundation/University of York. alone: social integration and tenancy sustainability for 152. Edens, E.L., Mares, A.S., Tsai, J. and Rosenheck, R.A. formerly homeless substance users. Social Policy and (2011) Does active substance use at housing entry impair Society, 8 (1) 1-11; Franklin, B.J. (1999) More than outcomes in supported housing for chronically homeless community care: supporting the transition from persons? Psychiatric Services, 62 (2), 171-178; Hickert, homelessness to home in S. Hutson and D. Clapham A.O. and Taylor, M.J. (2011) Supportive housing for (eds), Homelessness: Public Policies and Private Troubles. addicted, incarcerated homeless adults. Journal of Social London: Cassel, pp.191-207; Pleace, N. (1997) Rehousing Service Research, 37, 136-151; Tabol, C. et al (2009) Op. single homeless people, in Burrows, R., Pleace, N. and cit.; Busch-Geertsema, V. (2005) Op. cit.; Lipton, F.R., Quilgars, D. (eds) Homelessness and Social Policy. Siegel, C., Hannigan, A., Samuels, J. and Baker, S. (2000) London: Routledge, pp. 159-171. Tenure in supportive housing for homeless persons with severe mental illness. Psychiatric Services, 51 (4), 479- 486. 20 | P a g e

and then maintain purpose-built congregate that point or remain after it, depending on the sites with on-site staffing153. progress towards independent living.

The limits of floating support services closely reflect The goal of CTI is to build a support network using those of accommodation-based services. Without a friends, family, partners, services and community sufficient supply of affordable, adequate housing resources that reflects and reinforces individual offering reasonable security of tenure, floating capacity, i.e. it is a strength-based approach that support cannot function; as a housing-led model emphasises what someone can do, rather focusing this way of providing support to lone homeless on the limits to their capacity. A support network is adults must have access to the right kinds of built around a process of resettlement, so that housing. Equally, there can be limits to what floating access to informal, community and formal supports support can do in terms of meeting high and is put into place while someone is settled into their complex needs, even where coordination with own home155. health, mental health, addiction and care services is excellent, as some individuals may need more help CTI is regarded as an effective service model in the than a low or medium support floating support USA, with research evidence of this intensive, short- term support service effectively building support service can provide154. networks that facilitate an exit from Critical Time Intervention homelessness156. The model has also been successfully employed in Denmark, running Critical Time Intervention (CTI) is an intensive form alongside Housing First services. A Danish cost- of floating support service that can be employed to effectiveness analysis showed that CTI significantly end homelessness among people with high and reduced the use of other services, particularly complex needs. There are operational similarities accommodation-based services and hospital use with Housing First, but the model is less widely used compared to a matched control group157. outside the United States. CTI is a time-limited case management service offering social and practical The mechanics of CTI are similar to those of floating support and the case management/coordination of support, but there is a distinct emphasis on building other services. The model is designed around the an informal and formal network that will sustain idea that people need the most support when someone in their own home following the undergoing a potentially problematic transition into withdrawal of the CTI service. There is a difference their own independent home. This may be from an in emphasis because CTI is designed to leave a institutional setting, such as a psychiatric service or support network in place, whereas floating support prison, or from a situation of homelessness. CTI is is more focused on bringing someone to a point designed around a nine-month timetable, although where they can manage in housing independently. this is approximate as support can withdraw before The emphasis of CTI on network building also makes it distinctive from those accommodation-based services that are more focused on making an

153. Culhane, D.P., Metraux, S. and Hadley, T.R. (2002) 156. Herman, D., Opler, L., Felix, A., Valencia, E., Wyatt, Public service reductions associated with the placement R.J. and Susser, E. (2000) A critical time intervention with of homeless people with severe mental illness in mentally iii homeless men: impact on psychiatric supportive housing. Housing Policy Debate, 13 (1), 107- symptoms. The Journal of Nervous and Mental Disease, 163; Culhane, D.P. (2008) Op. cit.; Pleace, N. and Culhane, 188 (3), 135-140; Kasprow, W.J. and Rosenheck, R.A. D.P. (2016) Op. cit. (2007) Outcomes of critical time intervention case 154. Pleace, N. and Quilgars, D. (2003) Op. cit. management of homeless veterans after psychiatric 155. https://www.criticaltime.org/. hospitalization. Psychiatric Services, 58 (7), 929-935. 157. Benjaminsen, L. (2013) Op. cit. 21 | P a g e individual housing ready. This is not to suggest that there is less clarity around how effective accommodation-based services or other forms of these services are in comparison to floating support are not concerned to promote accommodation-based services. However, social integration, formal and informal support floating support services would be expected networks and economic inclusion. However CTI to have lower operating costs than arguably has a greater focus on ensuring support is accommodation-based services. in place after the service has ended, planning on the basis that the main service provision is time-limited There is evidence that Critical Time Intervention (CTI) can be effective in ending and will be withdrawn. homelessness among single people with high The use and potential for CTI in the UK is yet to be and complex needs, but the approach has not explored. There is a case for testing the model given yet been employed and tested in the UK. that it has achieved successes elsewhere. One potential limit for CTI is in relation to homeless Housing First people with very high and complex needs, whose need for intensive support may be sustained. There is extensive guidance and discussion on the operation of Housing First available elsewhere158. Summary Housing First can be summarised as follows: Housing First provides rapid access to settled, Floating support services, which can include independent housing, often using ordinary tenancy sustainment teams and resettlement private rented or social rented housing. services, exist in multiple forms. They can be freestanding, attached to accommodation- Access to housing is not conditional, i.e. based services and offer low, medium or someone using Housing First does not have to intensive forms of support, case be assessed as ‘housing ready’ before housing management/service coordination. Most is offered. floating support models operational in the UK, based on existing evidence, appear to be Housing, treatment and support are time-limited. separated, i.e. someone using Housing First is not required to show treatment compliance, The evidence base, both in the UK and or changes in behaviour, once they are internationally, is fragmented. As services housed. within this category can vary considerably it is hard to get a sense of the sector as a whole, Support is provided using an intensive floating the problem also extending to the mapping of service, which visits people using Housing this broadly defined type of service. First at home, or at agreed venues, and provides case management, practical and Available evidence indicates that floating emotional support. Caseloads per worker vary support services, which in the UK tend to by service, but will typically be between three follow a co-production, or user-led, approach to eight individual service users at any one within a harm reduction framework, can be point159. effective in ending homelessness. However,

158. Tsemberis, S. (2010) Op. cit.; Padgett, D. et al (2016) http://housingfirsteurope.eu; Canadian Housing First Op. cit. See also: Housing First England toolkit http://www.housingfirsttoolkit.ca. http://hfe.homeless.org.uk; Housing First Guide Europe 159. Pleace, N. (2016) Op. cit. https://housingfirstguide.eu/; Housing First Hub Europe 22 | P a g e

A harm reduction approach is employed. Canadian165 national Housing First programmes. There is an emphasis on ensuring that the possibility of positive change in someone’s life A model using intensive case management is clearly conveyed, without any requirements (ICM) only. This model is used in North being set in relation to behavioural or other America and in the UK and Northern Europe. changes, often referred to as a recovery In the UK and Europe, it will often work with orientation in Housing First services. social landlords (social housing is very limited in North America), although (particularly in

Housing First follows the principles of co- the UK) at least some private rented sector production160 and personalisation161. housing will be used. UK and European Housing First services vary in their operational Housing First services of this type will tend to details, both between countries and within the be targeted on homeless people with high same countries. Variations in Housing First exist in and complex needs, including recurrently and relation to the extent to which the operational long-term homeless people. This will include, detail of the original New York ‘Pathways’ service is but importantly not be limited to, lone replicated and are discussed in terms of the level of homeless adults with a diagnosis of severe fidelity to this original model162. Services can take mental illness. the following, broadly defined, forms163: Models that centre on the conversion of A high-fidelity model (near replica) of the existing homelessness services into original American service, which offered congregate models of Housing First (i.e. assertive community treatment (ACT) from an blocks of flats or apartments where everyone in-house, comprehensive support team, is a Housing First service user). Congregate including mental health and drug models formed the initial use of Housing First professionals directly employed by Housing in the innovative and highly successful Finnish 166 First, and intensive case management (ICM) homelessness strategy , although Finland services, which provided intensive case also employs scattered housing models of management/external service coordination. Housing First alongside a wide variety of The original American model only used other homelessness services. The congregate private rented sector housing, with the and communal versions of Housing First are service itself holding the tenancies, and was probably most common in North America. targeted on homeless people with a diagnosis Advocates of the original model of Housing of severe mental illness. This model has been First criticise this approach, arguing that social carefully replicated in the French164 and integration is undermined because congregate housing is viewed as physically

160. 165. https://www.scie.org.uk/publications/guides/guide51/w https://www.mentalhealthcommission.ca/English/at- hat-is-co-production/. home. 161. 166. Y Foundation (2017) A Home of Your Own: Housing https://www.scie.org.uk/personalisation/introduction/w First and ending homelessness in Finland. Helsinki: Y hat-is Foundation 162. Tsemberis, S. (2010) Op. cit. http://www.feantsaresearch.org/en/news/2017/10/27/y 163. Pleace, N. and Bretherton, J. (2013) Op. cit. -foundation-publishes. 164. http://www.gouvernement.fr/53eme-atelier-de-la- dihal-sur-le-deploiement-du-programme-un-chez-soi-d- abord. 23 | P a g e

separated from the surrounding homelessness strategies169 and evidence of community167. reductions of ‘chronic’ homelessness, particularly among veteran groups in the USA170. The literature The exact scale of Housing First in the UK at the on Housing First – particularly on the Canadian At time of writing is not clear, but there are now Home/Chez Soi programme171 – is extensive. several dozen pilots and commissioned services in place and research led by Homeless Link will aim to While there is a lot of material on Housing First, it map services in 2018. Commissioned services are can be summarised fairly simply when it comes to provided by St Mungo’s in several London boroughs, the effectiveness of Housing First in ending by Changing Lives in Newcastle and by Turning Point homelessness172: in Glasgow, among others. Pilots exist in many cities, including Greater Manchester. Housing First is broadly effective at ending homelessness among single people with high Ending Homelessness and complex needs. This includes:  People with a history of long-term or Housing First was designed specifically to reduce recurrent use of homelessness services homelessness among people with high and complex which has not resulted in a sustained exit needs168. As was discussed in the first section of this from homelessness. report, the realisation that there was a population of long-term and recurrently homeless people,  People with sustained histories of sometimes described as a ‘chronically’ homeless sleeping rough. population, which had high costs for public services, provided fertile ground for the development of  People presenting with severe mental Housing First in North America. illness, addiction, poor physical health, limiting illness and disability and The evidence that Housing First ends homelessness repeated contact with criminal justice – among homeless people with high and complex systems, including individuals in which all needs – is strong. The evidence is also international, these needs are simultaneously present. and this is an important point, because Housing First has worked in Copenhagen, Dublin, Glasgow, Typically, around eight out of every ten Helsinki, Lisbon, London, Manchester, Newcastle, people using Housing First services Paris, Vienna, New York and Vancouver, to name a successfully exit homelessness, using a 173 few cities, alongside the successful use in the measure of sustaining one year in housing . Danish, Finnish, French and Canadian national While the evidence base is new (many

167. Stefancic, A., Tsemberis, S., Messeri, P., Drake, R. HUD‐VASH. Journal of Community Psychology, 41 (4), and Goering, P. (2013) The Pathways Housing First fidelity 505-514. scale for individuals with psychiatric disabilities. American 171. Nelson, G., Caplan, R., MacLeod, T., Macnaughton, Journal of Psychiatric Rehabilitation, 16 (4), 240-261; E., Cherner, R., Aubry, T., Méthot, C., Latimer, E., Piat, M., Greenwood, R.M., Stefancic, A., Tsemberis, S. and Busch- Plenert, E. and McCullough, S. (2017) What happens after Geertsema, V. (2013) Implementations of Housing First in the demonstration phase? The sustainability of Canada's Europe: successes and challenges in maintaining model At Home/Chez Soi Housing First programs for homeless fidelity. American Journal of Psychiatric Rehabilitation, 16 persons with mental illness. American Journal of (4), 290-312. Community Psychology, 59 (1-2), 144-157. 168. Tsemberis, S. (2010) Op. cit. 172. Johnson, G. et al (2012) Op. cit.; Pleace, N. and 169. Pleace, N. (2016) Op. cit. Bretherton, J. (2013) Op. cit.; Pleace, N. (2016) Op. cit.; 170. Montgomery, A.E., Hill, L.L., Kane, V. and Culhane, Padgett, D. et al (2016) Op. cit; Mackie, P. et al (2017) Op. D.P. (2013) Housing chronically homeless veterans: cit. evaluating the efficacy of a Housing First approach to 173. Pleace, N. (2016) Op. cit. 24 | P a g e

Housing First services being relatively recent), health and social integration are more mixed. there is some evidence of sustained exits It is not the case that people using Housing from homelessness for three to five years or First are characterised by universal or rapid more174. improvements in mental and physical health, addiction, or social and economic integration, There is evidence that Housing First services although some improvements do occur180. with varying levels of fidelity (replication) of the original model can all effectively end Housing First is a service model that is specifically homelessness among a high proportion of designed to provide support for lone homeless single people with complex needs175. Some adults with high and complex needs. There is strong, Canadian research is beginning to indicate global, evidence showing that Housing First is that ICM only and ICM/ACT services may have effective in ending homelessness for the majority of similar levels of effectiveness176, although this people it works with, including the robust is disputed by those who advocate high- randomised control trials from Canada and France fidelity to the original model177. and observational research from the UK and Europe. Equally, it is evident that while effective in ending Housing First is not entirely effective for homelessness, Housing First does not work for homeless single people with high and everyone and that the successes in tenancy complex needs; between one and three out sustainment are not always directly paralleled by of every ten using Housing First services do changes in mental and physical health or addiction. not have a successful outcome. There are As has been noted elsewhere, being critical of examples of extremely high rates of housing Housing First for not being a ‘miracle cure’ is hardly 178 sustainment at over 90 per cent , though reasonable181, but at the same time, alongside the the existing evidence suggests that rates of 80 notable successes, there are limitations to the per cent are more typical, with a few model and some reasons to be careful in how the examples of Housing First dipping below that evidence for Housing First is interpreted. level but still achieving housing sustainment for one year with over 70 per cent of service Criticism of Housing First in the USA has been users179. focused on three fronts182:

Outcomes on housing sustainment are strong, Housing First is not necessarily engaging with with some evidence that Housing First can lone homeless adults with the highest support outperform some other services with respect needs, i.e. it may be ‘cherry-picking’ relatively to homeless people with very high and less complex cases than American complex needs. However, outcomes in accommodation-based services (which are respect of addiction, mental health, physical more likely to follow strict regimes with an

174. Padgett, D.K. (2007) There's no place like (a) home: Housing First intervention for homeless people with ontological security among persons with serious mental mental illness. Addiction. DOI: 10.1111/add.13928. illness in the United States. Social science & medicine, 64 177. Greenwood, R. et al (2013) Op. cit. (9), 1925-1936. 178. Benjaminsen, L. (2013) Op. cit. 175. Pleace, N. (2016) Op. cit.; Pleace, N. and Bretherton, 179. Bretherton, J. and Pleace, N. (2015) Op. cit. J. (2013) Op. cit.; Bretherton, J. and Pleace, N. (2015) Op. 180. Padgett, D. (2007) Op. cit.; Johnson, G. et al (2012) cit.; Blood, I. et al (2017) Op. cit. Op. cit.; Pleace, N. and Quilgars, D. (2013) Op. cit.; 176. Urbanoski, K., Veldhuizen, S., Krausz, M., Schutz, C., Quilgars, D. and Pleace, N. (2016) Op. cit. Somers, J.M., Kirst, M., Fleury, M.J., Stergiopoulos, V., 181. Busch-Geertsema, V. (2013) The potential of Patterson, M., Strehlau, V. and Goering, P. (2017) Effects Housing First from a European perspective. European of comorbid substance use disorders on outcomes in a Journal of Homelessness, 6 (2), 209-216. 182. Pleace, N. (2011) Op. cit. 25 | P a g e

emphasis on behavioural modification to timetable and the model does, effectively, allow for make someone ‘housing ready’)183. support to be ongoing for some people, even if the level of that support tends to reduce over time186.

Housing First aims to achieve less than Consistency in service design is an issue, particularly American accommodation-based services. in the USA, but there is evidence that following the The goal is focused on housing stability, with core philosophy of Housing First, rather than an emphasis on using stable housing as the replication of the operational detail of the original basis to which support and treatment is service, tends to generate good results in respect of delivered and social and economic integration tenancy sustainment187. is developed. By contrast, American accommodation-based services aim to bring Being in a position where several of the original an individual to a point where they are arguments against Housing First can be at least housing ready, i.e. can live an independent partially countered by the ever-increasing weight of life184. evidence, it would seem that the case for using the approach in the UK is a very strong one. Yet there is

Housing First is not a coherent model. The still a need for some caution in how the original approach in the USA has not been international evidence is interpreted when followed consistently, meaning there is not a considering the use of Housing First in the UK. single type of service called Housing First, but a series of related interventions. As it is not The first point here centres on what exactly the properly defined or consistent, evidence that evidence is about – which relates back to the Housing First is ‘successful’ needs to be criticisms that Housing First encompasses a range of treated with caution185. service models – and is particularly important in relation to the Canadian and French national There are counterarguments to these points. programmes. There are three points here: Housing First has now been used so widely, with full blown randomised control trials taking place in The Canadian and French programmes are full Canada and France, that arguments that Housing ICM/ACT services, with in-house First is ‘cherry picking’ are hard to sustain. While it is multidisciplinary teams and highly qualified true that Housing First does not work for everyone, staff, including social workers educated to the evidence base – currently at least – does not postgraduate level and medical, addiction and suggest a clear pattern of failures being associated mental health specialists. These services are with people with the highest and most complex heavily resourced compared to the normal support needs. Equally, the goal of the Housing First levels of spending on homelessness in the UK, approach is to bring someone to a point where they particularly with respect to the Housing First ‘graduate’ and become able to live more or less pilots that have been undertaken to date. The independently. This process is completed in their Canadian pilot programme had a budget of own home, rather than in advance of housing being $CAD 110 million (£65 million) covering provided. What Housing First does not do is try to accomplish fully independent living to a set

183. Kertsez, S.G., Crouch, K., Milby. J.B., Cusimano, R.E. 185. Tsai, J. and Rosenheck, R. (2012) Considering and Schumacher, J.E. (2009) Housing First for homeless alternatives to the Housing First model. European Journal persons with active addiction: are we overreaching? The of Homelessness, 6 (2), 201-207. Milbank Quarterly, 87 (2), 495-534. 186. Padgett, D. et al (2016) Op. cit. 184. Stanhope, V. and Dunn, K. (2011) The curious case of 187. Pleace, N. and Bretherton, J. (20130 op. cit.; Pleace, Housing First: the limits of evidence based policy. N. (2016) Op. cit. International Journal of Law and Psychiatry, 32, 275-282. 26 | P a g e

service development and testing in five Canadian programmes only moving beyond the pilot cities188. stage relatively recently.

The Canadian and French programmes are In the Netherlands190, just as in Finland, Housing mental health interventions, i.e. Housing First First is also not the ICM/ACT model seen in Canada is being focused only on homeless people or France, but an ICM-led approach. This is also true with a severe mental illness. In the case of of services in Belgium191, Spain192, Portugal193, Canada, the use of Housing First is equivalent Italy194, Sweden195 and some Housing First in to the NHS developing and funding a Housing Denmark196, alongside the Housing First services First programme targeted on homeless that have, thus far, been piloted and commissioned people with severe mental illness. In France, in the UK197. Housing First can take the following the Housing First programme is led by DIHAL, forms: an interministerial body which has strategic High intensity case management models. responsibility for French homelessness

strategy, and there is a clear emphasis on Intensive Case Management (ICM) only.

using Housing First to reduce the costs of Assertive Community Treatment (ACT) only. ICM/ACT models (including the original homelessness to the French public health and model). mental health systems. Using ICM-led approaches, or some other form of The Canadian and French services are more heavily resourced and have a different focus – relatively intensive case management, without an on homeless people with a psychiatric in-house interdisciplinary team, makes operational sense in the UK and some European countries. This diagnosis – from the Housing First services developed in some other countries. is because, unlike the USA, welfare, health, social care and addiction services are broadly available, Finland has used a lower fidelity model, which is i.e. there is universal or near-universal access, which ICM-led and includes elements of congregate means that a Housing First model that uses case Housing First, broadly targeted on homeless people management to coordinate a package of externally with complex needs who are long-term and provided services makes sense. This approach is also recurrently homeless at national level. Finnish significantly cheaper than providing a dedicated in- achievements in reducing homelessness among house, multidisciplinary team as part of every people with high and complex needs exceed those Housing First service, if the services with which of Canada and France, although the Finnish Housing Housing First is coordinating have sufficient First programme, alongside being more broadly resources to enable effective joint working. targeted, is also further advanced189, the French and

188. of Housing First internationally and in the Italian https://www.mentalhealthcommission.ca/English/at- case. Housing Studies, pp.1-18 DOI: home. 10.1080/02673037.2017.1344200. 189. The Y Foundation (2017) Op. cit. 195. Knutagård, M. and Kristiansen, A. (2013) Not by the 190. Busch-Geertsema, V. (2013) Op. cit. book: the emergence and translation of Housing First in 191. Busch-Geertsema, V. (2016) Op. cit. Sweden. European Journal of Homelessness, 7 (1), 93- 192. Bernad, R. and Yuncal, R. (2016) Introducing the 115. Housing First model in Spain: first results of the Habitat 196. Benjaminsen, L. (2013) Op. cit.; Busch-Geertsema, V. Programme. European Journal of Homelessness, 10 (1), (2013) Op. cit. 53-82. 197. Blood, I. et al (2017) Op. cit. Bretherton, J. and 193. Busch-Geertsema, V. (2013) Op. cit. Pleace, N. (2015) Op. cit.; Quilgars, D. and Pleace, N. 194. Lancione, M., Stefanizzi, A. and Gaboardi, M. (2017) (forthcoming 2017) Op. cit.; Pleace, N. and Quilgars, D. Passive adaptation or active engagement? The challenges (forthcoming, 2017). 27 | P a g e

The successes of Housing First need to be seen in abstinence, i.e. they are the form of homelessness this light. When Housing First is described as ‘ending service that has been repeatedly demonstrated as homelessness’, as it often is, this really means a generating – at best – mixed results in ending the range of services, with differing levels of adherence homelessness of people with high and complex to the original model and – importantly – very needs200. different levels of resources and different client groups. An Italian Housing First service198, as has In the USA and Canada, Housing First is being been the case with British Housing First services, is a compared to ‘treatment as usual’, in the form of mainstream North American accommodation-based small team of Housing First workers providing 201 intensive support to people living in the most services, which, while not an outright failure , suitable and affordable housing available. This is were often not tackling much of the homelessness they were targeted on. In Belgium202, the very different to the interdisciplinary teams, medics, 203 204 addiction specialists, mental health specialists and Netherlands or in France , existing services were social workers educated to postgraduate level found not quite the same, but traditional accommodation- based systems – focused either on basic shelter or in a full-blown ICM/ACT service in the US, Canada or making someone ‘housing ready’ – were the France. services against which Housing First was either The UK and Italy have something else in common. tested or compared. Funding is comparatively scarce and unreliable. While the Italian case is more extreme, the basic UK accommodation-based services are not the same. As was described above, service-user choice, problem of finding money to pilot, develop and sustain a Housing First service exists in both harm reduction and, increasingly, personalisation, countries. Long term funding at a level that could co-production and psychologically informed environments (PIE) are at the core of much existing predictably support an ICM/ACT service has not been available, which has already led – in the UK – service provision. There are traditional services, to Housing First pilots experiencing funding sunsets. which can be very basic, and there are services that follow the strictures of abstinence, treatment Pilots showing success have ended because short term, limited financing ran out199. By contrast, in compliance and behavioural modification, but this is Canada, Finland and France, Housing First was given simply not what a lot of the UK homelessness sector is like. In terms of the international evidence base space to develop and to prove itself on a scale that has not been replicated in countries where funding for Housing First, the successes are being measured for homelessness services is more limited and in relation to existing service models that are not widely used in the UK. uncertain. A North American accommodation-based service However, from a UK perspective, the most important point to bear in mind about the Housing may, in relation to Housing First, be comparably First evidence base is not the variation in what is ineffective in ending the homelessness of people with high and complex needs, but that does not meant by Housing First, but the variation in the other homelessness services that Housing First is automatically mean that a British accommodation- being compared to. In North America, existing based service can simply be assumed to be accommodation-based services tend to follow strict following the same approach, or as achieving the same level of success. The UK evidence base is regimes centred on behavioural modification and

198. Lancione, M. et al (2017) Op. cit. 202. Busch-Geertsema, V. (2016) Op. cit. 199. Bretherton, J. and Pleace, N. (2015) Op. cit. 203. Busch-Geertsema, V. (2013) Op. cit. 200. Pleace, N. (2008) Op. cit. 204. DIHAL (2016) Op. cit. 201. Rosenheck, R. (2010) Op. cit. 28 | P a g e limited, but there is enough data to at least raise the less evident in UK Housing First services207 and in question of whether ‘treatment as usual’ in the UK Housing First in some other countries including is actually directly comparable with ‘treatment as Finland208. It can be argued that the move across the usual’ elsewhere, and that raises questions about Atlantic has brought the emphasis on service-user the extent to which there is clear water between choice to its logical conclusion, taking it beyond the Housing First and some existing UK accommodation- original model and in so doing, changing the based and floating support homelessness services in emphasis and some of the ultimate goals of Housing terms of ending homelessness. First209.

Both the British and the Europeans have been One final point is worth making, which centres on modifying Housing First. In the North American the dilution of the original model, with reference to context, Housing First was a real leap as user-led arguments about the importance of fidelity to the services with a harm reduction framework were Housing First services built by Sam Tsemberis in radically different from many existing services, but New York in the early 1990s. There is evidence that in a country like Finland or the UK, these elements adherence to a set of core principles has generated of service delivery had been pretty much consistent success in ending homelessness across a mainstream well before Housing First started to range of countries210, but there have been cases cross the Atlantic. where services calling themselves Housing First have drifted some distance from the core While it would be quite incorrect to characterise philosophy of Housing First, as well as the Housing First as regressive, there are elements in operational details of the original model. Claims for the original model that reflect the practice from ‘success’ for Housing First, for example in earlier forms of homelessness service. These Australia211, are not always based on services that elements focus on behavioural modification, which, have high philosophical fidelity to the original while not enforced, is actively and continually model. Partially this is about being precise about encouraged through the use of a recovery what Housing First is and what the model can orientation and what in the European guidance is achieve. However, when success is reported with 205 called active engagement without coercion . hybrid models which contain elements of Housing From one perspective, this focus on changing the First, like the one used in Australia, the Breaking 212 person to end their homelessness means that Ground (formerly Common Ground) model or the Housing First does not quite represent the break intensive ‘tenancy sustainment’ floating support from ‘housing ready’ models that is claimed, i.e. model used in the Rough Sleepers Initiative in there is still an implicit assumption that someone’s England (developed without reference to Housing 213 homelessness ultimately comes from their First) , the line between Housing First and some characteristics, needs and choices206. This emphasis floating support and accommodation-based services on changing the person, on working towards becomes less clear. modifying an individual, rather than confining the service goals to sustainably ending homelessness, is

205. Pleace, N. (2016) Op. cit. 209. Pleace, N. (2016) Op. cit. 206. Hansen-Löfstrand, C. and Juhila, K. (2012) The 210. Pleace, N. and Bretherton, J. (2013) Op. cit. discourse of consumer choice in the Pathways Housing 211. Johnson, G. and Chamberlain, C. (2015) Evaluation First model. European Journal of Homelessness, 6 (2), 47- of the Melbourne Street to Home programme: Final 68. Report. Melbourne: HomeGround Services. 207. Bretherton, J. and Pleace, N. (2015) Op. cit. 212. See above. 208. The Y Foundation (2017) Op. cit.; Pleace et al (2015) 213. Lomax, D. and Netto, G. (2007) Op. cit. Op. cit. 29 | P a g e

Bringing all this together, it is possible to make five 5. Some evidence indicates that other points about the evidence base for Housing First homelessness services that incorporate and how it is being interpreted: elements of Housing First (including those which are not designed with any reference to

1. Housing First is effective in ending Housing First) are achieving successes, homelessness among people with high and blurring the distinction between ‘Housing complex needs and has shown that success in First’ and some forms of accommodation- much of northern and western Europe and based and floating-support services. throughout North America. Existing UK pilots and commissioned Housing First services Clearly, it is important to understand precisely what appear similarly successful. is meant by Housing First and what – exactly – Housing First is being compared with. Assumptions

2. Some of the Housing First services that are about what is effective and how effective it is effective in other contexts have very different cannot be based on non-UK evidence, particularly levels of resources to those found in UK when that external evidence has some inherent services, a different focus (on severe mental limits. For the UK, it is vital to be clear exactly how illness) and, unlike current UK services, Housing First is being implemented and the specific employ the ACT model, with specialist, in- goals it is intended to achieve214. Modelling the use house, multidisciplinary teams. of Housing First, as has been attempted in 215 3. The basis of comparison between Housing Liverpool , is one step, but understanding the First and existing services in other countries is reality of working services that are already in place, not necessarily applicable to the UK. Housing alongside proper comparative analysis, will be First has shown very relatively high levels of important in understanding the roles that Housing success, but the basis of the comparison has First can productively undertake. often been accommodation-based services Housing First has clearly been effective in many with strict regimes centred on behavioural countries, but what that means in terms of how it modification and abstinence, or with basic should be used, how it should be deployed in homelessness services. The UK homelessness relation to other services and how it should be sector does not have these characteristics, as implemented needs to be focused on the UK, not use of service-user choice, personalisation, based on simple assumptions drawn from what co-production and harm reduction is happened elsewhere. Beyond this, there are also widespread. limits in what Housing First can achieve and it is 4. While there is clear evidence, mainly from important to manage expectations so that the Denmark and France, that higher-fidelity development of Housing First does not become Housing First services can be effective outside hampered by it being presented as a panacea, North America, the forms of Housing First setting expectations that will – ultimately – be 216 used in Europe and the UK can be shown to be unrealistic . Researchers considering modifications of the original model. The the use of Housing First in Australia have raised greater emphasis on service user choice and lower emphasis on behavioural modification in some services is an example.

214. Orwin, R.G. (2000) Assessing program fidelity in 215. Blood, I. et al (2017) Op. cit. substance abuse health services research. Addiction, 216. Busch-Geertsema, V. (2012) Op. cit.; Johnson, G. et S309-27. al (2012) Op. cit. 30 | P a g e many of the same points that should be raised in particularly the case where Housing First has the UK217: been integrated into national homelessness and mental health strategies, such as in While much can be learnt from Housing Canada, Denmark, Finland or France. In some First it is also clear that in the process of cases, such as Canada, France and the USA, transferring Housing First to Australia important findings have been ignored, Housing First services possess in-house, factors contributing to its success have multidisciplinary teams. been over-simplified and claims about its effectiveness over-stretched. The risk is While Housing First services with much lower that if the outcomes Housing First levels of resource have been successful, the delivers do not match expectations evidence is clearest in relation to well-funded, public and policy interest may evaporate. highly developed services. A greater level of Further, in positioning Housing First as funding, available on a sustained basis, has an effective alternative and ignoring the been a feature of countries where Housing constraints impeding existing responses in Australia, the opportunity to ground First has shown the greatest success. some core Housing First ideas in a more According to the international evidence base, enduring set of systemic-wide principles and policies enabling service Housing First appears to be much more improvements across all programs successful in ending the homelessness of offering housing and support may be people with high and complex needs than missed. existing homelessness services. However, the services with which Housing First is compared Summary are not always equivalent to those found in the UK, often being less likely to use There is strong evidence that Housing First personalisation, co-production and harm can end homelessness effectively for many reduction and with, on the basis of existing single people with high and complex needs, evidence (which has limitations), a lower rate including people who have had repeated or of success than is found in the UK long-term use of other homelessness services homelessness sector. There is also some without ever finding a sustainable solution to evidence suggesting accommodation-based their homelessness and people who are and floating support services that reflect (but entrenched rough sleepers. do not replicate) the Housing First approach While Housing First is often successful in are also achieving successes, potentially ending homelessness for people with complex blurring some of the claimed distinctions needs, there are some people for whom it is between Housing First and other service not effective. Outcomes in respect of social models. The arguments in relation to the integration, mental and physical health and efficiency of Housing First in ending addiction can be positive, but there is also homelessness, relative to existing service variation. provision, may be less clear cut in the UK than in some other countries. Housing First services that have been successful in other countries often have a UK and European Housing First services have high level of sustained financial support that sometimes been modified, including an even has not been available in the UK. This is greater emphasis on service user choice than

217. Johnson, G. et al (2012) Op. cit., p. 17. 31 | P a g e

exists in the original model. These to be viewed as less effective for the people with modifications may sometimes be significant high and complex needs for which Housing First is to determining the effectiveness of Housing designed. The cost-per hour in terms of support First in British and European contexts. costs may also be lower, which means it may be less expensive to support someone via Housing First Cost Effectiveness than in an accommodation-based service, largely because Housing First is often not providing, There have been attempts to model and explore the running and staffing a dedicated building, but cost effectiveness of different forms of Housing instead using ordinary housing. First, with a particular emphasis on contrasting Housing First with other services in recent years. In All of this makes sense, until the underlying the USA, Housing First was sold to policy makers assumptions about what Housing First costs relative and commissioners on the basis that it would to other services are examined more closely. Several deliver a cost saving solution to homelessness conditions need to be true for Housing First to cost among people with high and complex needs218. The less than other forms of homelessness service219: basis for this argument was as follows: 1. Accommodation-based services need to be Homeless people with complex needs can comparatively inefficient, i.e. they must take make repeated or sustained use of existing some time to resolve homelessness where homelessness services, without their they are effective, have higher operating homelessness being resolved. This costs and fail to resolve homelessness on a expenditure does nothing more than regular basis. (temporarily) keep them off the streets. 2. Housing First must have a lower cost per Homeless people with complex needs have hour of support, less frequent contact or repeated contact with mental health and lower logistical costs and must not sustain emergency health services, addiction services intensive contact for very long periods. and with the criminal justice system, all of  Based on actual patterns of service use which creates costs and – again – does not among 86 lone homeless people, who resolve their homelessness. had all been homeless in England for at One argument for Housing First is that, by least three months during 2016, £14,808 effectively ending homelessness, it reduces these had been spent on average on costs. Housing stability creates stability in terms of homelessness service use, equivalent to service contact, so for example if things are working £1,273,488 over the course of one properly then mainstream – rather than emergency year220. – health and mental health services are used (at a  Housing First would need to cost less on lower cost), any offending or any nuisance average, i.e. it would need to resolve behaviour drops off or ceases altogether and this homelessness more often, at a lower also reduces spending. Further, as homelessness is overall cost, to actually reduce this being sustainably ended by Housing First, there is spending. If, for example, an not any unproductive spending on homelessness accommodation-based service effectively services which, for advocates of Housing First, tend resolved someone’s homelessness for a

218. Tsemberis, S. (2010) Op. cit. 220. Pleace, N. and Culhane, D.P. (2016) Better than 219. Bretherton, J. and Pleace, N. (2015) Op. cit. Cure? Testing the case for Enhancing Prevention of Single Homelessness in England. London: Crisis. 32 | P a g e

year, after a three-month long episode of  Lowering the assumed costs of the service use costing £15,000, Housing accommodation-based service has an First would need to cost less for 15 effect. An accommodation-based service months, to achieve the same result, i.e. offering a medium level of support, total costs would need to be less. fewer specialist workers but 24-hour cover and on-site staffing, can  High intensity accommodation services conceivably be working with homeless may have more expensive support costs people with high and complex needs. than Housing First, so a sustained stay in Here, based on the same 2014/15 data, an accommodation-based service of this support costs fall to around £9,630, still sort is likely to cost more than Housing more than Housing First, but again, that First. Based on actual examples of eight differential starts to fall if Housing First is working Housing First services and typically engaging more frequently than accommodation-based services working three hours a week224. in several local authorities in England in 2014/15, this cost differential is clear221.  The cost differential in the UK is based Support costs in high intensity on the use of ICM-only Housing First and accommodation-based services (such as Housing First using high intensity case a 24-hour cover, wet hostel) were management models. A high-fidelity around £17,160 per year. By contrast, a model, following the ICM/ACT approach year of Housing First support costs seen in the USA, Canada and France, will ranged between £4,056 and £6,240, a have significantly higher costs. Using a saving, on support costs, of between high-fidelity version of Housing First £13,104 and £10,920. would reduce the cost differential with accommodation-based services  However, potential savings were based considerably, perhaps (as is the case with on what eight Housing First pilot services some USA services) to near-parity225. reported as their average contact hours – Housing First may, in certain forms, cost three per week – over the course of one as much or more than accommodation- year. This estimate was based around an based services, which would mean it assumption that initially high rates of would need to end homelessness among contact would tail off over the course of adults with high and complex needs at a a year, which is the working assumption significantly higher rate, to continue to of the Housing First model, so that, for make financial sense. example, 12 hours of contact in week 1 might have dropped to a 15-minute chat 3. Housing costs must be lower than in week 52. Put the hours up and the accommodation costs in accommodation- cost differential starts to fall quite fast222. based services. If housing someone in the The more expensive end of Housing First scattered housing that UK Housing First goes to £8,320 at four hours a week, and projects tend to use costs more than keeping to £16,640, if there were eight hours of them in purpose-built accommodation-based contact a week223.

221. Bretherton, J. and Pleace, N. (2015) Op. cit. 224. Ibid. 222. Tsemberis, S. (2010) Op. cit. 225. Culhane, D.P. (2008) Op. cit. 223. Ibid. 33 | P a g e

services, the potential cost advantage of 5. Housing First must not have to build, Housing First may be lessened. redevelop or purchase a suitable housing supply, or must do so in a way that does not

4. People using Housing First must have a incur direct costs for public expenditure, to be combination of high support needs and high cheaper than existing services. If a Housing use of emergency medical services, addiction First programme or service must purchase or services and/or contact with the criminal develop a new housing supply the costs are justice system. obviously considerably higher than if existing  Someone has to cost the State more housing is used. In Finland, conversion, money than Housing First does, before purchase and building of additional housing investment in Housing First – purely from was an integral part of the use of Housing a perspective of efficient use of public First within the wider integrated money and for the moment leaving aside homelessness strategy, as available the obvious humanitarian concerns – affordable housing supply was insufficient to makes sense. This means that they have enable the national strategy to significantly to: a) have significant support needs; and reduce long-term homelessness within the 227 b) be costing more money because they timetable set by policy makers , making the are homeless, e.g. through greater Housing First programme relatively emergency service use or more contact expensive. with the criminal justice system than 6. Housing First must be able to successfully would happen if they were housed. engage with lone homeless adults with high Typically, as in other economically support needs who are recurrently homeless developed countries, long-term and or long-term homeless, or at high risk of recurrent homelessness in the UK tends becoming so, more effectively than existing to cost significant amounts of public homelessness services. money, even if there are some homeless people with high and complex needs  There is good evidence that Housing First who use few if any services and who will is able to engage with long-term and cause a spike in spending if they engage recurrently homeless people who have with Housing First (or indeed any other not been able to exit homelessness homelessness services)226. through the use of other services. This is the strongest element of both the  Housing First does not make economic financial and policy case for employing sense if it provides a higher level of Housing First. Even if Housing First has support than someone needs, or engages equivalent or similar costs to with someone longer than is needed, accommodation-based services, being when other, lower intensity (and less able to end and prevent long-term and expensive) services could meet their recurrent homelessness among people needs. will – at the least – represent a more efficient use of resources. In the USA, research reports that Housing First

226. Pleace, N. and Culhane, D.P. (2016) Op. cit.; Pleace, Geertsema, V. (2013) The Costs of Homelessness in N. (2015) At What Cost? An Estimation of the Financial Europe: An Assessment of the Current Evidence Base. Costs of Single Homelessness in the UK. London: Crisis; Brussels: FEANTSA. Pleace, N.; Baptista, I.; Benjaminsen, L. and Busch- 227. Pleace, N. et al (2015) Op. cit. 34 | P a g e

represents a more efficient use of public whether or not it is ‘cheaper’ than existing services. money, i.e. Housing First cost about the Clearly, public money cannot be spent on something same, but was better at ending that does not work, but the evidence is that Housing homelessness. These findings have been First can enhance existing responses to instrumental in making the case for homelessness, albeit that it does not constitute a Housing First with policy makers228. In comprehensive response to single homelessness in Finland, despite significant expenditure itself. on making housing available for the There is a danger here, as presenting Housing First Housing First programme, the greater efficiency of Housing First in reducing as something that will consistently and significantly long-term homelessness is seen as reduce spending creates an incentive to dilute the model. While it is the case that intensive case justifying the investment229. management Housing First services can be effective, As noted, there are estimates suggesting that alongside the more expensive ICM/ACT model, Housing First will be consistently and significantly Housing First is an intensive service model, with all cheaper than existing homelessness service that implies. Caseloads for a Housing First worker provision in the UK230. However, the international should be no more than four to eight people at any evidence base casts some doubt on this idea, as one point, depending on need levels, not 30 or 40 does some of the evidence about the operational people at once. The Housing First services that are reality of Housing First in the UK. Housing First can effective are – all – comparatively well-resourced in represent an efficient use of resources because it terms of the contact time made available to people can address homelessness among people with high being supported232. and complex needs at a high rate and it may also produce savings for other services, but it may not Summary necessarily save money231. Housing First may have lower operating costs It is important that the total effectiveness of than existing homelessness services, but Housing First is the main criterion on which financial there is a real need for caution. There are efficiency is judged. This means the rate at which many variables that can influence the relative Housing First sustainably ends homelessness, not costs of Housing First, so it should not just be comparisons of what a Housing First service costs assumed that Housing First necessarily per day compared to other forms of service represents a way of reducing expenditure. provision. For single people with high and complex Ultimately the financial arguments about Housing needs, whose homelessness is recurrent or First are something of a distraction. What matters is sustained and whose homelessness may not the human question and the policy question, i.e. be resolved by existing services, Housing First whether Housing First is a viable means to help may be a more efficient use of resources. reduce homelessness that can enhance the effectiveness of the homelessness strategies of England, Wales, Scotland and Northern Ireland, not

228. Culhane, D.P. (2008) Op. cit. 231. Ly, A. and Latimer, E. (2015) Housing First impact on 229. Pleace, N. et al (2015) Op. cit. costs and associated cost offsets: a review of the 230. Blood, I. et al (2017) Op. cit.; Mackie, P. et al (2017) literature. The Canadian Journal of Psychiatry, 60 (11), Op. cit. 475-487; Culhane, D.P. (2008) Op. cit. 232. Pleace, N. (2016) Op. cit. 35 | P a g e

3. Discussion

Introduction

This final section of the report considers the Housing First may generate some cost potential use of Housing First at strategic level in the savings, but in many senses this is immaterial; UK, based on existing evidence. Some wider what matters from both a human and from a questions about the future direction of policy perspective is that it ends the most homelessness strategy and the role of homelessness destructive forms of homelessness at a high services are also discussed. rate.

Using Housing First However, there are a number of points to be considered in relation to the roles that Housing First Strategic Integration should take in an integrated homelessness strategy: Housing First is an effective response for There is a clear case for using Housing First as part homelessness among single people with high of the response to homelessness in the UK. That and complex needs, including people whose case rests on three main points: needs have yet to be met through other The homeless population for which Housing forms of homelessness service provision. First was originally developed exists in the UK. Single homelessness can often be prevented There are single homeless people with high using the array of service models that have and complex needs, including severe mental been developed in the UK, ranging from rent illness, whose homelessness has become deposit schemes through to mediation and recurrent and sustained, because existing support services233. services have not always been able to meet their needs. There is evidence that existing, accommodation-based, UK homelessness There is evidence that, while it lacks the social services end homelessness among single scientific robustness of the trials conducted in people with support needs at comparatively Canada and France, shows that using Housing high rates. Some models of accommodation- First in the UK can end homelessness among based homeless service used outside the UK people whose needs are complex and whose may be less efficient and effective than is the homelessness is recurrent and sustained, in a case for services developed and run by the UK way that other services are not always able homelessness sector. to. There is some evidence of successful use of low and medium intensity floating support services (sometimes called housing-led

233. https://www.gov.uk/government/collections/homelessn ess-statistics. 36 | P a g e

services in Europe) to end homelessness homeless person with high and complex among single people in the UK. needs.

Some international research, which shows The most successful use of Housing First, at strategic Housing First outperforming existing services, level, has always been as a part of an integrated is based on comparisons with homelessness strategy, not as a standalone service, accommodation-based service models that nor as the sole attempted response to single are not widely used in the UK, i.e. abstinence- homelessness. Where Housing First has reduced based services with strict regimes, which are long-term and recurrent homelessness for people uncommon in the UK, and which have been with high and complex support needs effectively, it repeatedly demonstrated to have limited has been employed as an integral part of integrated effectiveness for homeless people with high homelessness strategies where an array of and complex needs. prevention, low intensity, specialist services and accommodation-based and floating support services

Some of the highest performing, high fidelity, are also employed. Housing First services have a much higher level of sustained funding than has been In Finland, Norway or Denmark, where available in the UK. These services, using homelessness is effectively a functional zero, i.e. ICM/ACT models, have significantly higher hardly anyone experiences homelessness and when operating costs than the ICM-only and similar it does occur, it is very rarely on a sustained or models of Housing First used in the UK and in recurrent basis, Housing First is just one element of several other European countries. total service provision. Finland is often described as the leading example of a ‘Housing First’ strategy, a

Housing First is not completely effective, country that has further reduced almost every form there are some people for whom it does not of homelessness234 from already low levels, work. Outcomes in respect of health, including the most enduring forms of homelessness wellbeing and social integration may be associated with high and complex needs. This is not variable. Other service models, such as correct. Finland has an integrated, preventative intensive accommodation-based services, homelessness strategy, of which Housing First is a may need to be employed alongside Housing key, but by no means the sole, component235. First. It is important not to lose sight of what the UK

For homeless people with low to medium achieved in the days before Housing First. Rough level support needs, existing services – sleeping in London, Scotland and elsewhere was including floating support (tenancy almost eradicated through successive programmes sustainment teams) and accommodation- beginning with the Rough Sleepers Initiative, and based services, will often be effective in the UK has pioneered the development of many ending homelessness. Housing First is not elements of homelessness prevention. The designed to be used for homeless people reductions in people sleeping rough were achieved whose needs are not high or complex. by integrated, mixed-service strategies, which did Equally, Housing First is not necessarily the not include Housing First236. Rough sleeping is on only effective, or appropriate, response to a

234. Migrant homelessness can be an issue in Finland. House of Commons Homelessness among native Finns is at very low levels. http://researchbriefings.parliament.uk/ResearchBriefing/ 235. Pleace, N. (2017) Op. cit. Summary/SN07121#fullreport; Fitzpatrick, S.; Pleace, N. 236. Wilson, W. (2015) Rough Sleepers Initiative (RSI) and Bevan, M. (2005) Final Evaluation of the Rough 1990-1999. Commons Briefing papers SN07121 London: Sleepers Initiative. Edinburgh: Scottish Executive. 37 | P a g e the rise again and Housing First is a key part of the be CTI, specific types of accommodation-based solution, but the overall solution will always rest services and a range of floating support, alongside with developing an effective, integrated strategy, Housing First. using multiple service models of which Housing First is just one, not with a standalone ‘Housing First Services for Specific Groups strategy’. As Housing First becomes integrated into wider Many of the innovations of Housing First around strategy, the roles of the Housing First model and service user choice, harm reduction and using a other services need to be considered in relation to housing-led model did not simply arrive in the UK the needs of specific groups of homeless single with Housing First – they were mainstream long people: before Housing First pilots began to appear and are, perhaps, still rather more widespread in the UK There is growing evidence that gender- homelessness sector than in some other countries. specific services, including Housing First, need The UK was not already delivering Housing First to be developed. Women can experience services before the model arrived237, the intensity homelessness for different reasons from men and elements of the core philosophy are new. and also take trajectories through However, Housing First was not a complete homelessness that differ from those of men. revolution in service design, instead Housing First Key concerns include the rate at which resonated with much of what was already being women’s homelessness results from domestic done and extended it. When Housing First arrived, violence and abuse and evidence of a much of the homelessness sector was already on tendency among lone homeless women to the same page, which meant that the gap between use informal support, i.e. friends, relative and existing services and Housing First that was evident acquaintances, to keep a roof over their in North America was not necessarily present in the heads and to sometimes avoid (male- same way in the UK. dominated) services. Provision of gender- specific services, including accommodation- Integration, rather than replacement, is logical in a based services, floating support and Housing context where an array of service provision has a First, where services for women are provided role in preventing and reducing homelessness. This by women, has the potential to provide is the situation in the UK, as it was in Finland and in better outcomes239. A pilot Housing First other situations where Housing First has been service for women offenders with a history of successfully integrated into wider strategy and homelessness, Threshold Housing First, is produced a reduction in homelessness. generating impressive results in Manchester240. The other point to make here is that innovation is, of course, not confined to Housing First. Successes Services designed for young people, including have been reported in the use of CTI services in care leavers, ex-offenders and ex-service North America and Denmark, for example. The most personnel may be more effective than generic effective integrated homelessness strategy may, as services. The development of specific in Finland238, include other innovations, which may accommodation-based services is

237. Pleace, N. (2011) Op. cit.; Johnsen, S. and Teixeira, L. 239. Bretherton, J. (2017) Reconsidering gender in (2012) Op. cit. homelessness. European Journal of Homelessness, 11 (1), 238 Pleace, N. (2017) Op. cit. 1-21. 240. Quilgars, D. and Pleace, N. (forthcoming, 2018) Op. cit. 38 | P a g e

longstanding practice in the UK, but there is scope to explore use of more innovative models for specific groups, such as Housing First for young people241.

241. http://www.feantsaresearch.org/download/samara- jones-deborah-quilgars-and-sarah- sheridan5938179022449888530.pdf. 43 | P a g e

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