Housing First Feasibility Study for the Liverpool City Region

Final Report Imogen Blood, Ian Copeman, Mark Goldup, Nicholas Pleace, Joanne Bretherton & Shelly Dulson, Contents

Glossary 4 4.9 Mental health 62 Forewords 6 4.10 Access to health and social care 63 Introduction 8 4.11 Peer support 64 4.12 Asset-based community development 65 Chapter 1: The current homelessness system in LCR 12 4.13 Referral routes and assessment 67 1.1 Current homelessness provision 12 4.14 Estimating demand for the Housing First model in the LCR 68 1.2 Demand for homelessness services in LCR 14 4.15 The cost of the proposed Housing First model 68 1.3 Participants’ views on how existing service provision is working 16 4.16 How will the Housing First service link to the wider Housing-Led system? 69 1.4 Barriers within the wider system 17 4.17 Examples of existing LCR resources which Housing First 70 1.5 Strategic challenges, threats and opportunities for LCR in relation to 19 might support people to access homelessness Chapter 5: Financial and Commissioning Implications 72 Chapter 2: Current provision and use of services by people 22 5.1. Housing First: Commissioning approach 72 with complex needs 5.2. Financial Implications: Potential for cashable savings and 78 2.1 Existing services and initiatives focusing on people with complex needs 22 efficiencies from implementing Housing First in LCR 5.3. Housing First Implementation: Potential transitional and phasing 84 2.2 Homelessness service usage by people with complex needs 23 arrangements 2.3 ‘Revolving doors’ and ‘burned bridges’ 28 2.4 Rejecting the homelessness system 32 Chapter 6: Policy Context 88 2.5 Wider system response to people with complex needs 33 6.1 The current strategic context on homelessness in LCR 88 6.2 The Role of Housing First in the Context of the Homelessness 90 Chapter 3: Developing Housing First as part of a solution 34 Reduction Act to homelessness 6.3 Welfare Reform and Housing First 93 3.1 What did homeless people tell us they valued and needed? 34 6.4 Housing First in Combined Authorities 96 3.2 What is Housing First and how does it respond to these needs? 35 6.5 Housing First and Health and Social Care Policy 98 3.3 The Case for Housing First 36 6.6 Housing First and Criminal Justice Sector Policy 100 3.4 Housing First within Integrated Strategies 41 6.7 International Lessons 102 3.5 Developing a Housing-Led Strategy for LCR 42 Chapter 7: Conclusions 106 Chapter 4: Developing a Housing First and housing-led model in 52 Liverpool City Region Appendix 1: Overview of Liverpool City Region 109 4.1 Definition 52 Appendix 2: The Research Team 114 4.2 Target group for the Housing First service 53 Appendix 3: Methodology 116 4.3 Description of the Housing First service 54 Appendix 4: Costing of proposed Housing First Model 123 4.4 Duration and intensity of support 55 Appendix 5: Detailed Calculations of Sizing the Cohort for Housing First 127 4.5 Access to housing 57 Appendix 6: Method for assessing potential for cashable savings 131 4.6 Hours of operation 58 and efficiencies from implementing Housing First 4.7 Access to housing 59 Appendix 7: Potential for efficiencies: Value for money analysis 140 4.8 Types of properties to be used for Housing First 61 4 Housing First feasibility study for Liverpool City Region 5

Glossary

Assertive outreach is a way of learning disability, which tend to NHS, Housing First typically involves Mainstay is an assessment and organising and delivering care via a interact with each other. case management only (see section referral gateway and database specialised team to provide intensive, 3.3 for a discussion of this). In this for commissioned homelessness highly coordinated and flexible support CRISS (City Region Intensive Support report, we sometimes use ‘High accommodation and floating support for people with complex needs. Service) is government (DCLG: Fidelity’ to distinguish Housing First services across LCR. The focus of the work must be on Department of Communities and Local from lower intensity Housing-led engagement and rapport, building Government) funded service providing services. Property Pool Plus/ Under One Roof: up, often over the long-term, strong assertive outreach during office hours Property Pool Plus is a joint allocation relationships. to those with the highest levels of House in Multiple Occupation (HMO): and choice-based letting system for complex needs in the five authorities in is a property rented out by at least 3 social housing in Liverpool, Halton, (Priority) Band: Councils decide who LCR outside of Liverpool city. people who are not from the same Knowsley, Sefton and Wirral. St Helen’s gets offered housing based on a 'household' (e.g. a family) but share is not part of Property Pool Plus, but ‘points’ or ‘banding’ system. Points and Floating support: visiting support facilities like the bathroom and kitchen. has its own choice-based lettings bands are based on housing need and provided to a person who lives in their Landlords of larger HMOs must be system called Under One Roof. start with the letter A being the highest own property. licensed. priority. Supported Housing can be described Housing-led can be distinguished Liverpool City Region (LCR): Liverpool as any housing scheme where Cashable savings are savings which from “Housing First” by its lower City Region includes the following housing, support and sometimes care make a difference to the budget line, intensity of support, range, duration local authorities: Liverpool, Halton, services are provided to help people to usually by reducing fixed costs. and the lower needs clients it targets. Knowsley, Sefton, St Helens, and live as independently as possible in the In this report, we argue that Housing Wirral. A map and a demographic/ community. Combined authority (CA): comprises First should operate within a ‘housing- housing profile of the region is two or more elected local authorities led system’, in which the the default included in Appendix 1. Waves of Hope is a lottery-funded that collaborate and take collective approach is to support all homeless partnership providing holistic and decisions. people as quickly as possible into Local Housing Allowance: For people intensive case management support independent tenancies with supported renting from private landlords, Housing to people with the highest levels of Commissioned/non-commissioned as needed, by-passing the need for Benefit is based on a flat-rate ‘Local complex needs in Liverpool city. supported housing: ‘commissioned’ compulsory and/or longer stays in Housing Allowance’ (LHA) which is here means that the council funds communal supported housing. based on the 30th percentile of local Welfare Reform describes a package (and therefore monitors) the support market rents, covering areas known as of changes to the benefits system within a scheme – this is true of the Housing First is a system of support Broad Rental Market Areas. introduced by the 2010-15 Coalition vast majority of hostels run by charities for homeless people with high and Government, including Universal and/or housing associations; ‘non- complex needs which is designed Local Lettings Agency: A Social Credit, Benefit Cap, Removal of the commissioned supported housing’ to deliver a sustainable exit from Lettings Agency is a not-for-profit Spare Room Subsidy, and Personal generally refers to private sector HMOs homelessness by helping them to lettings agency which provides a range Independence Payment. (see definition below) which have been access an independent tenancy as of services to private sector landlords classified as supported (or ‘exempt’) quickly as possible and providing the and (prospective) tenants, ranging housing under the Housing Benefit support they need for as long as they from a tenant/ property finding regulations and are therefore able to need it to sustain this tenancy. function right through to a full housing claim higher levels of Housing Benefit; management service. In this report, we we are also aware of a small number ‘High fidelity’ Housing First stays close use the term Local Lettings Agency, of non-commissioned hostels run by to the original Housing First model since our vision for such an agency in religious charities in the region. set up in the US by Sam Tsemberis; Liverpool is that it might also offer a strictly speaking this would include an similar range of services to social as Complex needs means that ‘assertive community outreach’ team well as private sector landlords. people have multiple issues in providing healthcare to Housing First relation to mental health, drug use, tenants; however, in the UK where homelessness, offending and/or healthcare is provided through the 6 Housing First feasibility study for Liverpool City Region 7

Foreword from Jon Sparkes Foreword from the peer researchers

There is overwhelming international evidence that Housing First ends We are a group of peer researchers who have personal experience of homelessness. Resettling someone quickly into a long term home with access homelessness, we were invited to be part of this study to help gather information to the flexible support services that gives them choice and control has shown from people who are currently homeless. It was felt that we could better gather significant improvements in health and wellbeing, and most importantly leads to this information due to our ability to relate to those individuals because of our people sustaining tenancies. At Crisis we are excited to be part of a project that personal experiences. looks at transforming Housing First in the UK to a default solution for addressing homelessness. Whilst our findings were mixed there were some recurring themes that came from the people we interviewed. Several of those we spoke to told us that they With funding from the Housing First Hub Europe and the Department for felt safer sleeping on the streets than in hostel accommodation. The reasons for Communities and Local Government we have commissioned a feasibility study this included issues around substance abuse, intimidation and impact on people’s to look at how Housing First could be implemented at scale in the Liverpool City mental health. Others expressed that they were not given, or able to find the Region. Whilst highlighting the barriers and successes of the current system, right information about services and when they did find them they were not the study has shown there is support for real systems change, to move the City always relevant or accessible, change included access to social housing. Region to a ‘housing led’ approach where Housing First plays a central role. Our interviews highlighted a lack of faith in the current system for addressing This study was commissioned to ask how Housing First might be taken to scale homelessness due to repeated failings and inconsistency. in the Liverpool City Region, but actually goes much further to demonstrate how it can integrate as part of a wider system that prevents homelessness and also Our research has led us to believe that the current system for tackling deals with it quickly and permanently when it occurs. This holistic approach has homelessness is not working for everyone. It is clear that the lack of permanent the potential to completely transform the prospects of homeless people today accommodation and appropriate support for people is preventing them from and in the future. escaping the recurring cycle of homelessness. We believe, if implemented, the recommendations in this report provide viable and realistic alternatives to the Crisis fully endorses the independent findings of this report and stands ready current system that would eradicate homelessness quicker and more efficiently. to assist decision makers and providers in making the proposals a reality. The study has attracted national and international attention and any implementation plan will have the good will and support of experts in Housing First from near Dave, Mohamad, Richard and Rose and far. We hope this report not only shows the feasibility of how services in the The Peer Research Team Liverpool City Region can be redesigned to end homelessness but can be used as an exemplar to be adapted in other areas both within the UK and in other European cities.

The success of the project depends very much on political leadership and co- operation across the Liverpool City Region, as well as housing and homelessness Foreword from Housing First sector reform. We do not underestimate the challenges faced to make this a reality. Let us be in no doubt however, that by putting the outcomes of homeless Europe Hub people at the forefront of difficult and complex decisions, the new Metro Mayor, the six Local Authorities, and all the housing support providers in the City Region have the opportunity to end rough sleeping and other forms of homelessness. The Housing First Europe Hub seeks to promote and support the scaling up of Housing First. This project is an excellent example of how Housing First can be a catalyst for bringing all relevant actors together to reconsider how homelessness can be better tackled, prevented and ended. The Housing First Europe Hub welcomes the work of all those involved in this study and we look forward to using the findings, both in terms of the suggestions and recommendations, and Jon Sparkes the inclusive methodology, with other partners in Europe. We are eager to follow Chief Executive, Crisis the Liverpool City Region as it takes ambitious steps forward towards meeting the challenges of homelessness head on.

Juha Kaakinen, CEO, Y-Foundation Freek Spinnewijn, Director, FEANTSA 8 Housing First feasibility study for Liverpool City Region Introduction 9

services adopting the core Some of those resettled (assuming this philosophy of Housing First, can be done quickly and effectively) others appear to be drifting should not need any support at all Introduction from the model and can be once they have been helped to find a property; some will need lower level described as ‘Housing led’ – and probably time limited – floating approaches due to their lower support to help them settle in; others intensity of support, range are likely to need more intensive and and duration and targeting ongoing holistic support in relation to A consortium led by Imogen Blood & Associates was complex needs if they are to sustain a lower needs clients. A small commissioned by Crisis to carry out this Feasibility tenancy. This last group will be offered number of projects represent a Housing First model with strong Study for the implementation of Housing First in a much greater drift from fidelity to original models. However, Liverpool City Region (LCR). The study has been funded the model, and appear more vitally, we are proposing that the core principles of Housing First should apply by the UK’s Department of Communities and Local akin to floating support with to all who access the whole housing- independent accommodation”. Government and Housing First Hub Europe. Liverpool Principles of Housing First led system. These are: City Region includes the following local authorities: Homeless Link (2015, p.3) Liverpool, Halton, Knowsley, Sefton, St Helens, and 1. People have a right to a home1. People have a right to a home In this report,2. we Flexible present support a vision is in provided 2. forFlexible as long support as it is is needed provided (in for the as case of those Wirral. We have included an overview of Liverpool City which Housingwho Firstare initially is a sub-set assessed of as needinglong lower as it levelis needed floating (in support,the case this can be Region, including information about demographics ‘Housing-Led’increased approaches or extended – in other where necessary)of those who are initially assessed words, it sits3. within Housing a housing-led and support are separatedas needing lower level floating and the housing market, in Appendix 1. system in which4. Individualsthe default haveapproach choice and controlsupport, this can be increased or is to support5. homeless An active people engagement as approachextended is used where necessary) quickly as possible6. The into service independent is based on people’s3. Housing strengths, and support goals and are aspirationsseparated The consortium consisted of Imogen What do we mean by ‘Housing First’ tenancies, by-passing7. A harm the reduction need for approach 4. isIndividuals used have choice and control Blood & Associates, Housing & Support and ‘Housing-Led’? compulsory and/or longer stays in 5. An active engagement approach is Partnership, HGO Consultancy and Housing First is a system of support communal supported housing. This used the Centre for Housing Policy at the for homeless people with high and goes beyond the current scope of 6. The service is based on people’s University of York. Further details about complex needs which is designed existing Housing First projects within strengths, goals and aspirations the team is contained in Appendix 2. to deliver a sustainable exit from the UK. 7. A harm reduction approach is used homelessness, improve health The study aimed to test the feasibility and well-being and enable social of implementing Housing First at scale integration. Housing First uses ordinary within the Liverpool City Region by: housing, such as private rented or social rented flats and is designed to b • Using a wide range of quantitative house formerly homeless people with a c and qualitative data from LCR to high needs in their own, settled homes develop, evaluate and propose a as quickly as possible and to provide model for implementing Housing the support they will need to sustain First at scale within the region; an exit from homelessness in their People have a right Flexible support is Housing and support Individuals have • Assessing the financial and own home. to a home provided for as long are separated choice and control commissioning implications of as it is needed making the transition to this model; Homeless Link (2015)1 distinguishes • Understanding the local and national ‘housing-led’ approaches from policy changes needed to support Housing First: this model; “Current practice in England The wider learning for implementing shows that fidelity to the Housing First at scale in the UK and the rest of Europe will be presented Housing First model is in a separate toolkit. mixed. Whilst there are some An active engagement The service is based on A harm reduction approach is used people’s strengths, goals approach is used 1 Homeless Link (2015) ‘Housing First’ or ‘Housing Led’? The current picture of Housing First in England and aspirations 10 Housing First feasibility study for Liverpool City Region Introduction 11

Although there are examples of these proposed model and the conditions The structure of this report In Chapter 6, we look in more detail at principles being applied in different needed for it to work. This included: Chapter 1 provides an overview of the the relevant local and national policy parts of the current homelessness • Focus groups, phone and current homelessness system within context and how this might support system, we would argue that face-to-face interviews with LCR, including the type and amount or impede the implementation of the significant cultural and policy change 95 professionals from across of supported housing commissioned; model in LCR, or potentially, in other will be needed if these are to be LCR, including local authority the demand for and usage of this parts of the country. applied consistently. For example: commissioners, housing provision, and a summary of key issues and support providers, and and concerns which were raised about Appendix 1 provides an overview • Allocation policies for social housing health and criminal justice the existing models and the systems of the LCR, including a map, are underpinned by a philosophy that professionals; within which they operate. It also demographics and information housing is something to be earned • Qualitative research with a summarises some of the strategic about housing stock and markets. and deserved; diverse sample of 79 people challenges, threats and opportunities • Housing and support is typically with lived experience of for LCR in relation to homelessness. Appendix 2 gives information provided as a combined package: so homelessness, co-produced about the roles and backgrounds people who may not need support by a team of people with lived Chapter 2 focuses on the increasing of the research team. can sometimes end up in supported experience working alongside numbers of people with high and housing because of their need for professional researchers; complex needs who are homeless Appendix 3 summarises our housing; • Analysis of the Mainstay database, within LCR. It presents information methodology and gives details • Support – whether through floating which acts as an assessment and on their use and experience of of the profile of our sample. support or in hostel settings – is referral gateway for supporting homelessness and wider services. typically time limited; housing, outreach and floating Appendix 4 sets out in detail the • Although harm reduction approaches support services across LCR, in Chapter 3 begins to build the case for assumptions underlying our costing are the norm within drug and alcohol order to understand the flow of solutions which are grounded in the of the Housing First model. services, this is not reflected in the people through the system and to views and experiences of people with rules of most hostels; understand the needs and pathways lived experience of homelessness. Appendix 5 presents our detailed • Systems tend to assess eligibility of different sub-groups within this; It summarises the evidence from calculations for sizing the cohort based on deficits, needs and risks. • Phone interviews with eight elsewhere about Housing First and for Housing First. commissioners, policy officers and builds the case for a the development The model we present in this report operational managers from other of a model of Housing First within LCR Appendix 6 presents the details of is a fairly high level proposal for the parts of the UK to draw learning which is integrated within a housing- how we calculated the potential for wider reconfiguration of homelessness from other areas and inform our led system with substantial investment cashable savings within the model. services. We have developed this understanding of the wider policy in prevention. We explore the case for by reviewing a wide range of local context; this through a series of case studies. Appendix 7 provides the details and international evidence and have • Review of local and national policies of our value for money analysis. undertaken significant consultation relating to: homelessness, housing In Chapter 4, we present the model with people with lived and professional strategy, benefits and the future for the Housing First and housing-led We have included anonymised quotes experience in the region. However, funding of supported housing, services – including details about its from our interviews with people with it will require political decisions and criminal justice, health and social staffing structure, assessment and lived experience and professionals. more scoping and planning to develop care, and devolution; referral processes, how housing will be We have changed the names of the a detailed implementation plan that • Review of the existing evidence base sourced and the size of the potential people on whom we have included is agreeable to key stakeholders. We on Housing First; cohort of service users. We summarise case studies. hope that these proposals provide a • Analysis of the potential costs our calculations of the costs of these useful starting point and evidence base of Housing First and the extent services within this section, referring for this process. to which it may be possible to the reader to our more detailed achieve cashable savings and other assumptions and calculations in Our approach efficiencies appendix 4. The study ran from February to June • Assessing the implications of welfare 2017 and included the following reform for Housing First In Chapter 5, we look at the financial activities: and commissioning implications of the A more detailed description of our proposed model, considering potential • Qualitative research to understand methodology, including the profile of cost effectiveness and how – and over people’s experiences of how current our research participants is included in what time period – funding might be service systems work with homeless Appendix 3. transferred from current models to people and to gather views about the Housing First and the wider housing- led model proposed. 12 Housing First feasibility study for Liverpool City Region Current system 13

Figure 1.1. Current homelessness system – housing based ‘pathways’

Homelessness prevention activity Gateways – Local authority housing Current options / other providers

Temporary Advice / system accommodation information

Supported housing system – Mainstream housing accommodation based enanies in Floating upport units units selfontained varies beteen Chapter 1: The current ousing areas non- homelessness system in LCR

This chapter provides an overview Our primary focus has been Table 1.2. Supply of homelessness accommodation based supported of the current homelessness system on commissioned supported housing (2016/17) within LCR, including: accommodation services since these account for the largest proportion of Authority No of Units 24 Hour Cover Young Person • The type and amount of supported local authority spend on this group, specialist units housing commissioned; and a key question for this study is • The demand for and usage of this the extent to which the Housing First/ Halton 105 105 0 provision, housing-led model could act as an Knowsley 102 36 66 • A summary of key issues and alternative to these resources in future. concerns which were raised about We describe the proposed Housing Liverpool 713 510 92 the existing models and the systems First model, the necessary wider Sefton 102 39 0 within which they operate by study changes needed to create a housing participants; and led system and the nature and size of St Helens 107 96 0 • A summary some of the strategic the target cohort for the LCR in more Wirral 382 274 206 challenges, threats and opportunities detail in chapters three and four. for LCR in relation to homelessness. Total 1511 1060 (70%) 364 (24%) Figure 1.1 summarises the current 1.1 Current homelessness provision system, primarily in relation to Source: Mainstay: note we have excluded refuge and family homelessness services. This feasibility study has sought to accommodation responses and related identify the existing range of services pathways. being used by homeless people for The key characteristics of this existing • Of the units which are not supported whom a Housing First/housing led Data from Mainstay identifies that there supported housing are: 24 hours a day, there is a significant service response is likely to be suitable, are 1,511 units of accommodation- amount of dispersed accommodation: exploring the extent and nature of based supported housing for people • 47 per cent of the total number of 351 units in total across LCR. existing needs and ascertaining the who are homeless across the LCR units are located in Liverpool, with level of current resource commitment, (2016/17) (excluding refuge and family 25 per cent in Wirral; The provision of accommodation- and the potential for reallocation of provision but including that for young • 1060 (70%) of the total number of units based supported housing has been resources. people). Table 1.2 breaks this down by have 24-hour cover available; and developed historically based on the authority and broad scheme type. • 364 (24%) are designated provision local commissioning priorities of each for younger people. of the six local authorities within LCR. 60% 8848 5296 people were placed people assessed in accommodation over the last 2 years

40% 3552 people were not placed in accommodation

14 Housing First feasibility study for Liverpool City Region Current system 15

Supply of homelessness accommodation in Liverpool City region 2016/17 Homelessness assessments in Liverpool City Region

60% 8848 40% There are 1511 5296 people people assessed 3552 people were hostel bedspaces in 70% of these have were placed in over the last 2 years not placed in Liverpool City Region 24-hour cover accommodation accommodation

Source: MainStay database Source: MainStay database March 2015 to March 2017

There are variations between the local entitled to services, because they are authority areas in terms of: ‘sofa-surfing’, or because they do not Number of multiple supported accommodation placements trust ‘the system’ or want the services in past four years in Liverpool City Region • The extent of provision of supported that are available. housing with 24-hour cover as a percentage of overall provision; • In the two-year period from March • The starting dates and length of 2015 to March 2017, 8848 different contracts for these services; clients were assessed by the Mainstay 379 • The pathways and access system across LCR. people in the arrangements to independent • Of these, 5296 (60%) people were past 4 years housing to move to and from placed in accommodation; 3552 supported housing; and (40%) were not. • The extent to which supported • There is evidence that many of those housing services are an integrated who were not placed have high part of a wider coordinated approach levels of need: of the 3552 people to preventing and responding overall who were assessed but not to homelessness, including placed, 44 per cent were described commissioned floating support and as having current mental health outreach services. issues and 20 per cent having been assessed by a psychiatrist at 1.2 Demand for homelessness some point. services in LCR • The Mainstay data will not, by Had 4 or more Headlines from our analysis of the definition, include those who have hostel placements Mainstay system paint a picture of high withdrawn from ‘the system’, or the demand (including significant unmet region’s ‘hidden homeless’: those need) for hostel services, including who are ‘sofa-surfing’ or form substantial numbers of people with ‘concealed households’ living within complex needs. other households. The findings of our qualitative research suggest that These figures are likely to under- some of these will become the next represent the real scale of demand, cohort of rough sleepers. since many ‘homeless’ people will • Neither will Mainstay include those not have approached services for a who have no recourse to public Mainstay assessment, either because funds due to their immigration status, Some had as many as 10 they will not or believe they will not be who we heard and observed make Source: MainStay database Not all of these moves within supported accommodation are negative. Some moves are a result of being closer to employment or family or going down to a lower level of support. ‘When I first went into [a hostel], I thought ‘it won’t take long’, then 6 months I just got shipped out of the hostel…hostel….hostel…hostel…so I just went around the hostels for about 5 or 6 years. […] and you can get bin bagged at any time’

16 Housing First feasibility study for Liverpool City Region Current system 17

up a significant minority of LCR’s needs in relation to mental health, • People in relationships or those “At the moment, rough sleepers2. Without Housing drug use, homelessness, offending trying to retain or rebuild contact Benefit, there is little on offer for this and/or learning disability, which with children; People who do not a lot of effort is group, though there is some support tend to interact with each other. We have recourse to public funds; from non-commissioned services. consider this - and its implications - • Those who cannot demonstrate spent on assessing • There is substantial ‘churn’ in the in more detail in the next chapter. a local connection; homelessness system: 379 people • There are successes from the current • People who have previously been – all the doors are had 4 or more hostel placements in homelessness pathway in LCR: excluded due to behaviours, the past 4 years: some had as many 38 per cent of individuals placed7 substance use, or previous debts shut and assessing as 10. were supported to move to (often linked to problems with someone as not • At April 2017 there were 567 independent or long-term supported benefits claims); people in LCR living in 24 hour housing, including RSL and PRS • Those who are working; eligible for anything accommodation or supported by tenancies, sheltered and other long rough sleeper outreach services who term supported housing, according People with lived experience reported seems like an had been registered on Mainstay for to outcomes recorded on Mainstay.8 a lack of consistent, accessible over 12 months.3 information and advice about the adequate response • Levels of homelessness – including 1.3 Participants’ views on how homelessness system. People rough sleeping - are increasing: existing service provision is working described their journeys through this within the current according to official rough sleeper Many of those who had used system as feeling very ‘hit and miss’: it counts (DCLG4), there has been a homelessness services were keen to had been a question of being ‘lucky’, system.” 140 per cent increase in rough praise individual members of staff who getting to the ‘right person’, and ‘being sleeping in LCR from 2015 to 2016, had supported them. The physical in the right place at the right time’. Health professional with an average of 43 people environment in hostels was described A recurring theme in the interviews sleeping rough in the region each as varying enormously in its quality; with people with lived experience was night. Half of these are in Liverpool but some of the smaller, recently re- that there was insufficient publicity Professionals highlighted many city; a quarter are in Wirral. furbished schemes were felt to provide for services, both those that aimed to examples of policies in one part of the • These figures are likely to excellent accommodation. prevent homelessness and those that system creating barriers or challenges significantly under-represent the responded to it. in other parts. For example, welfare scale of the problem (Crisis 20175). However, both professionals and reform policies such as the removal Mainstay shows that an average of people with lived experience said that There are a lot of agencies working of Spare Room Subsidy reduce move- 93 new rough sleepers are the current supported housing system with homeless people in LCR, but on options in areas where there is presenting across LCR each month.6 is not working well for many significant as a result of differing eligibility a limited supply of 1-bedroomed • There is both quantitative and sub-groups of people, including: criteria there are still a lot of gaps properties; regular moves within the qualitative evidence to demonstrate • People with complex needs, as we between them. There was confusion hostel system disrupt the continuity of increasing numbers of people with will explore in more detail in the about whether and under what care within the NHS. ‘complex needs’ – that is, multiple next chapter circumstances services could be accessed by those who could not 1.4 Barriers within the wider system demonstrate a local connection, Across LCR, health services and 2 A total of 35% of those completing a first contact form in 2016-7 at Crisis Skylight Centre Merseyside did not have British or Irish citizenship, including 10% with EU/ EEA citizenship, 16% with either refugee especially where people came from local authorities increasingly have status or leave to remain; 8% said they had ‘no citizenship’. other LCR authorities. aspirations and strategic aims to 3 Clients are registered on MainStay if they need access to floating support/accommodation and work in a more multi-disciplinary and although these clients had accessed 24 hour cover or rough sleeper services at the end of the period In the interviews and focus groups integrated way, often moving towards it does mean that they all accessed this level of support throughout this period. 4 Department for Communities and Local Government (2017) Rough sleeping in England: autumn with professionals, this picture of a locality-based ‘hub’ delivery models. 2016 and the equivalent publication for the previous year, https://www.gov.uk/government/statistics/ complex, criteria-based system – or We explore this policy context in more rough-sleeping-in-england-autumn-2016 ‘maze’ – was confirmed, spanning the detail in chapter 6. 5 Fitzpatrick, S., Pawson, H., Bramley, G., Wilcox, S. & Watts, B. (2015) The Homelessness Monitor: England 2017. London: Crisis/JRF. various service systems with which 6 This is the monthly average (mean) of new clients assessed on Mainstay as rough sleepers since homeless people have contact. Some We heard about specific challenges in the records began. (We have made allowance in this for the phased introduction of Mainstay across participants with lived experience relation to different parts of the system: LCR). This figure is based on the judgement of the person completing the Mainstay assessment. It is possible that the desire to receive priority for supported accommodation causes over-reporting of were clear to distinguish between rough sleeping at this point. ‘being helped’ (i.e. offered something Housing 7 NB: this is individuals as opposed to placements, since some individuals had more tangible) and ‘being passed on’ (i.e. A recurring theme from the interviews than one placement signposted); whilst from professionals’ with people with lived experience was 8 This is in contrast to the last available national analysis of outcomes from supported housing (the Client Record Form), which showed that 52% of people left to move to independent or long-term perspectives, interventions like just how difficult it is to get back into supported housing on average in 2010-11. However, it is more closely aligned with the findings of assessment or signposting have independent housing once you have Homeless Link’s 2016 Support for Single Homeless People in England, Annual Review 2016, which become outcomes in themselves: lost it. Barriers include: found that 35% of people moved into independent or supported accommodation. 18 Housing First feasibility study for Liverpool City Region Current system 19

• Restrictions within the Property or loss of benefits (e.g. disability housing which can take ‘After about a month [of Pool Plus allocation policy for those benefits). months or years.’ being homeless] and after I with a recent history of serious and (Hostel resident) attempted to take my life I was unacceptable behaviour (ranging We heard (and observed) that people put in hospital for my mental from 8 weeks’ arrears or more, to with no recourse to public funds convictions for violence or drug make up a significant minority of ‘I came out of jail in November health, I was there for over a dealing - although in practice, we those on the streets of LCR. Some are and this is where I am now month. I couldn’t be released heard that any offence within the new arrivals from EU countries who - all the hostels were full because I had nowhere to go previous 12 months excludes people have not yet been able to establish apparently’. and at the hospital they have in practice, as does anti-social themselves with a home and work; behaviour or leaving a property in a others have been in work and housing (Man living in a tent a duty of care so they couldn’t poor condition9); but have lost both and fallen through on the streets) release me. It was from the • The challenges of bidding for the limited welfare safety net for EU good grace of a friend, they properties online through Property migrants. ‘Given the restrictions on had a spare room and let me Pool Plus (or Under One Roof in St Helens); Criminal Justice Property Pool Plus [for move in.’ • The high cost of deposits and rental Prison release was highlighted as a offenders], there just aren’t (Man now living in an advances required by private sector particular weakness in the system. positive housing options for independent tenancy with landlords; Some of our interviewees who had people……. I have been in post floating support after period • Accessing furniture and appliances been in prison complained of a lack three years and I think we have in hostels) even if you are able to find a of information in relation to housing. property. Those working in prison to help people only three times managed to secure housing told us they were get an address for someone There was a clear consensus amongst We heard that a lot of time and energy frustrated by a lack of housing options straight from prison’. all those who participated in our is spent by support workers building and referral routes to post-release (Prison Housing Worker) research that the current system is relationships with housing providers support. They explained that different not working well: to secure move-on accommodation authorities had different policies for their clients, but that there is no in relation to accepting prisoners Health and Social Care “The system is clogged up a consistent approach to brokering due for release as homeless: most We heard from people with lived nd the people working in it housing for homeless people. required them to come and present experience that admission to acute as homeless on release in order to health care had at times led to their are frayed and embattled”. Benefits start the process. Local authorities needs being identified and them being (Health professional) A recurring theme from the qualitative told us that the uncertain timing of signposted to support on discharge, research was that the introduction of prison release and the often short or but that this felt very hit and miss. 1.5 Strategic challenges, threats and welfare reform, including Universal changing notice they received made Health professionals described a opportunities for LCR in relation to Credit, the removal of Spare Room it very difficult to respond within an number of challenges here, including: homelessness Subsidy, changes to disability benefits overstretched hostel system. There are a number of key drivers and and increased use of sanctions in • Where people have been drinking, pressures facing LCR local authority relation to Job Seekers’ Allowance ‘Having spent time in custody, they need to sober up before they commissioners and their partners in is causing a number of challenges can be effectively assessed (but they considering their future homelessness for people trying to get back into (or that takes you out of the often discharge themselves before strategies. remain in) housing. These included: system and forces you into this is possible); hostels and you can’t get social • Lack of coordination and The future of homelessness services • A lack of 1-bedroomed or shared housing for 12 months after communication between hospital was a key issue within the recent room rate accommodation in some and the community, exacerbated by LCR mayoral election. In our focus areas; you come out of prison, and long waits for social care and other groups with local authorities across • Delays and errors in the payment of then if you stay in the hostel assessments LCR, we heard how political pressure Universal Credit or the setting up of for 12 months, then they kick • People who are medically fit for – prompted by the high numbers Alternative Payment Arrangements you out. You’re starting from discharge but do not have suitable of people visibly on the streets (to pay rent directly to the landlord); housing and need support but do – is increasing the appetite for a • People getting into debt as a result of scratch again to get social not meet the (raised) threshold for radical rethink of the response to benefit reductions, delays, sanctions social care input. homelessness. As a commissioner in one authority (outside of the city) 9 These restrictions are detailed in S.3.2.3.2 of Property Pool Plus: Sub-Regional Choice-Based explained: Lettings Allocations Scheme, see: https://www.propertypoolplus.org.uk/NovaWeb/Infrastructure/ ViewLibraryDocument.aspx?ObjectID=1225 20 Housing First feasibility study for Liverpool City Region Current system 21

“There is a corporate and There is recognition amongst ‘Everyone has different ideas, political knock-on from people participants of the need to take a but we are all small so it is congregating in the town more strategic approach across local good to have a safety net and, centre and around the hostels authority boundaries within the LCR if we can create something and with other partners: NHS, criminal – so there is a political driver justice, and public health services to where there is a shared from this to try something prevent and respond more effectively structure, with resources, different”. to homelessness. back-office, guidance, etc but that can be quite flexible at a “We need to stop thinking local operational level, then it This is set within a context of ongoing about routes through requirements to reduce local authority absolutely makes sense to us. If spending. For example, Liverpool City services – it is so difficult to there is more honesty between Council is having to make plans to engineer this across trusts the LCR authorities, then we reduce its total spending by a further and departments - we need a figure everyone is less likely to £90 million over the next three years. system that builds protective Meanwhile, at the time of writing, ‘dump’ complex clients on each we are awaiting confirmation of the care around the person” other!’ proposed significant changes to (Health Professional) the future Government funding of supported housing, which includes Liverpool City Region’s devolution existing hostel provision, and is deal was agreed in 2015, with further likely to take place within a relatively amendments made in 2016. Some short timescale, by April 2019. We participants felt there should be discuss the likely implications of this opportunities, through devolution, to for the development of housing-led develop the more joined-up approach approaches in more detail in chapters that is needed. four and six. “In a devolved context, there A key concern raised in relation to the will hopefully be opportunities feasibility of housing-led approaches focused on the supply of suitable to set up multi-disciplinary housing. Much of the LCR housing teams, especially around market is characterised by relatively mental health provision for low demand, so the key barriers here homeless people, which is relate to local and national housing and benefit policies, i.e. currently a huge gap” (Local authority commissioner) • A lack of 1-bedroomed properties, where the removal of Spare There was generally a positive attitude Room Subsidy regulations prevent towards the idea of a cross-LCR homeless singles or couples being approach to homelessness: although placed in larger properties, even in some authorities were more cautious low demand areas; than others, pointing out that they • A lack of affordable shared properties would need to be very careful that a in which to house those under regional response worked for them 35, given the restriction to shared locally. A precedent for regional room rate within the Local Housing collaboration on homelessness Allowance for this age group; initiatives has already been set by • Regional policies and local practices the development of the Mainstay in relation to the allocation of social system and the roll-out of No Second housing which are – as we have Night Out. The argument in favour of heard - risk averse in relation to regional collaboration was summed up those with histories of offending, by one commissioner: anti-social behaviour, or arrears. 22 Housing First feasibility study for Liverpool City Region Current services 23

at the time of assessment. mental health issues The second evaluation report of the project, which was conducted by Ipsos and they are often in 11 MORI, was published in April 2017 . and out of prison.” City Region Intensive Support (Local Authority Current Service (CRISS) The CRISS service operates in the five Commissioner) authorities of LCR outside of Liverpool city providing assertive outreach Quantitative data during office hours to people who This trend was borne out in have typically experienced multiple our analysis of Mainstay data, services exclusions from services and have notwithstanding the almost inevitable issues with three of more of the ambiguity around how we define following: homelessness, mental ‘people with high and complex’ needs. health problems; substance misuse For example: (including alcohol); and offending. CRISS is currently funded by DCLG People being assessed by Mainstay Single Homelessness Fund up to who meet Waves of Hope criteria: Chapter 2: Current provision autumn 2017, and an evaluation of the service is due to be published shortly. • 1104 of the 8848 people assessed and use of services by people by Mainstay during the last two years 2.2 Homelessness service usage by (12.5%) met the basic Waves of Hope people with complex needs criteria for referral (though not all with complex needs In our interviews and focus groups, went on to become Waves’ clients). commissioners, providers and other • This is likely to significantly under- professionals consistently reported estimate the scale of the problem: This chapter focuses on the increasing numbers of that the numbers of people with commissioners at Liverpool City people with high and complex needs who are homeless multiple problems in the homelessness Council alone were also concerned system – and the complexity of their that there are: within LCR. It presents information on their usage of problems – is increasing: services and the challenges they face in accessing the “An estimated 190 individuals rest of the system. “The type of clients in the city who had been homeless for 3 years or has changed over more and had had various 2.1 Existing services and initiatives users to claim welfare entitlements; time – there are placements, many had focusing on people with complex and supporting those with additional addictions and complex needs in LCR learning and physical disabilities. To be accepted on to the Waves more heavy drug physical health needs and Waves of Hope project a client has to have an and alcohol users, mental health problems, but Liverpool Waves of Hope is part of identified high level of need in relation did not meet the Waves of the Big Lottery Fund’s Fulfilling Lives to at least three of the four domains including more Hope criteria” programme to support people with of homelessness, mental health, multiple and complex needs and is substance misuse and offending, women, more of funded up to 2019. Support is provided measured by a scoring system called • 774 (70%) of the group meeting by a partnership of local organisations the NDT10. Although Waves’ focus whom have a dual Waves criteria were placed in in the city, and includes: intensive and is on complex needs, rather than accommodation; but 330 (30%) personalised help with health issues, homelessness per se, our analysis diagnosis with were not. including substance misuse recovery of Mainstay data shows that around programmes; finding suitable and safe three-quarters of those accepted as accommodation; supporting service meeting Waves criteria were homeless

10 The NDT was developed by the South West London and St.George’s Mental Health Trust as part of 11 Ipsos MORI and Institute of Psychology Health and Society, University of Liverpool (2017) Liverpool the Adults Facing Chronic Exclusion programme: a score of 27 or more is the current threshold for Waves of Hope Evaluation: Year 2 – Evaluation Report, https://liverpoolwavesofhope.org.uk//app/ acceptance onto Waves of Hope uploads/2017/03/LWoH-Year-2-Local-Evaluation-Report-May-2017.pdf 24 Housing First feasibility study for Liverpool City Region Current services 25

Proportion of people meeting domains were rated as ‘medium’ Support needs of longer term service users Waves of Hope criteria (complex or ‘high’ for the overall cohort (this in Liverpool City Region needs) in Mainstay from March 2015 compared to an average of 68 per cent to 2017 for the cohort that met Waves criteria). • Of the group of 567 who had been in services for 12 months or more 567 at 2017: people who had been 12.5% • 27 per cent had a disability; registered on Mainstay • 68 per cent had a current over the last 12 months of clients had mental health problem; high levels of • 37 per cent had been assessed complex needs by a psychiatrist in the past; • 68 per cent had convictions (nearly half of whom had committed a violent offence); • 16 per cent were on a current Probation Order; or • 37 per cent said they were currently using drugs; 30% • 25 per cent had been sleeping Living in Supported by of these clients rough prior to being assessed 24-hour cover rough sleeper were not placed in for accommodation; services outreach services accommodation • 6 per cent had been in custody prior to being assessed for accommodation; and Of this group (of 567) Source: MainStay database • 10 per cent of them had had 5 or more hostel placements, with the highest number of 27% had a disability Complex needs amongst longer term placements being 10. homeless people: Housing data for Waves of Hope 68% had a current mental health problem • At April 2017 there were 567 clients people in LCR living in 24 hour 37% had been assessed by a psychiatrist accommodation or supported by • About a quarter of the 220 people in the past rough sleeper outreach services that Waves supported between who had been registered on 01/01/2016 and 31/12/201712 were 68% had convictions (nearly half of whom Mainstay for over 12 months. living in supported housing, with had committed a violent oence) • There is some overlap between this a further 17 per cent in temporary group of long term users and the accommodation (presumably group assessed as meeting Waves mostly B&Bs and Houses in Multiple 16% were on a current Probation Order criteria: 155 out of 567 were also in Occupation in the private sector). the sub-group that met the basic Waves has, however, been successful 37% said they were currently using drugs criteria for Waves. at supporting around a quarter of • We conducted detailed analysis of its clients to remain or resettle in levels of needs and risks assessed on independent tenancies in both the 25% had been sleeping rough prior to being Mainstay across a range of domains social and private rented sector. assessed for accommodation (including, for example, drug and alcohol use, offending, mental and The key messages from this data are: 6% had been in custody prior to being physical health) and found that on • There are significant numbers of assessed for accommodation average, for this group of long term people entering the homelessness homeless, 50 per cent of individual system (or trying to enter it) who 59 of them had had 5 or more hostel scores across all the different need have complex needs, even by placements, with the highest number of placements being 10. 12 Data supplied by Waves: NB: Although housing data has changed during the course of individuals’ placements with Waves, we have used the accommodation that they were accommodated in for the Source: MainStay database highest percentage in the last quarter. 26 Housing First feasibility study for Liverpool City Region Current services 27

the strictest definitions; there are this can be extremely stressful for ‘When you start over- determination to move successfully likely to be many more who could anyone who is trying to stay abstinent; monitoring people then they through the ‘staircase’, with its be described as having complex suffers from anxiety; or is vulnerable just get more standoffish and assessments, rules and uncertainty, needs, given the causal relationships due to age, disability, life experience or think well ‘I don’t want to stay especially if you are battling with between homelessness, mental other diversity. Ironically, some people mental health and/or addictions: health and substance use. contrasted this with the camaraderie in here because there are too many rules and regulations’. • There is evidence of high unmet they experienced on the street, where ‘The structure – there’s need, with nearly 1 in 3 of those they felt they had more control over Now the thing that brought certain things you’ve got to do with the highest complex needs who they mixed with than in hostels most of us here is not being not receiving an accommodation where they are ‘lumped together’. otherwise you can lose your able to deal with rules and placement. place. I don’t mean like service regulations…’ • There is evidence of high levels of ‘I had been dry for 2 months charges, I mean like courses multiple needs amongst the longer and then I had a night of sleep (Man with hostel placement) term service users. and group and meetings…’ • The intensive support provided by deprivation from the other As in the report by the Homeless (Man with hostel placement) Waves for people with complex residents on the landing – they People’s Commission (Groundswell needs appears to have relatively high were all drinking, doing drugs 201114), homeless people, including ‘It’s stressful living in a hostel success rates in relation to sustaining and I had an abscess and was those with complex needs, generally because you’ve only got a this group within accommodation, told us they preferred smaller hostels including their own tenancies. full of flu so I thought ‘if you to larger ones: certain amount of time before can’t beat them join them’. So you got to move. Then you are Qualitative evidence I went and bought a quarter ‘I think that if hostels are panicking, thinking “where Evidence gathered from stakeholders bottle of vodka and got have I got to go now?!” and across the sector suggests that hostels going to work, they need to are struggling to meet the needs of rotten drunk’ be smaller, then they are a bit when you’ve got mental this cohort, for a number of reasons. (Woman with hostel placement) calmer and don’t have to be health problems like I have quite so tightly regulated’. and you’re thinking “I’m going Reductions in local authority ‘I got called a grass because I (Man in emergency shelter) back to another hostel” and support funding since the end of went round to the staff – well you’re getting more and more the Supporting People (Homeless Link 2016)13 have led to cuts in the I asked them to tell the person The ‘linear’ or ‘staircase’ hostel depressed because you want staffing structure in many hostels and to stop banging on my door system which operates in LCR and is your own little nest – do you in the capacity of other organisational every twenty minutes so I typical of the UK can create a series understand? You want it the partners to provide support. As one could sleep. So the next day of challenges and barriers for many way you want it, not the way provider argued: people with complex needs. This they called me a grass and I model essentially involves ‘progressing’ they told you they want it’. “I think it is the under- just came down to their level homeless people through a series (Man with hostel placement) because I was so tired and of separate residential services – staffing in hostels which frustrated I just needed to emergency shelters, short and longer- Whilst in hostel placements, a key means they are not able term supported housing – towards message was that there is a lack of explode. I got sent to my room independent living. Progress up the appropriate mental health, substance to work as effectively like a child by the staff’. ‘staircase’ is conditional on acceptable misuse and emotional and/or with some of the more (Woman with mental health behaviour, compliance with treatment psychological support: and support programmes, and, complex needs.” condition describing previous hostel placement) typically, sustained abstinence from substance misuse (Tsemberis (2010)15, However, others – including many of Johnsen and Teixera (2010))16 the people with lived experience we In order to manage communal settings interviewed – attributed many of the with significant proportions of people People with lived experience told us challenges to the congregate nature with high support needs and relatively that it can take a lot of tenacity and of the model. We heard that the main lean staffing structures, most hostels challenge of living in hostels is the have a lot of rules and a key role of 14 Groundswell (2011) The Homeless People’s Commission: Full Report, Groundswell resident community within them – staff is to ‘police’ these: 15 Tsemberis, S. (2010) Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction Hazelden: Minnesota 16 Johnsen, S. & Teixeira, L. (2010) Staircases, Elevators and Cycles of Change: ‘Housing First’ and other 13 Homeless Link (2016) Single Homelessness Support in England: Annual Review Housing Models for Homeless People with Complex Support Needs, Crisis/ University of York 28 Housing First feasibility study for Liverpool City Region Current services 29

“For those with mental health/ As a result of these challenges and Some people told us that they would However, his reflection on this dual diagnosis issues, we are barriers, people with complex needs sometimes deliberately get themselves period is: often setting them up to fail are at high risk of: frequent evictions arrested so they could get a safe bed in hostel placements due to from hostels, getting ‘stuck’ within the for the night with no responsibilities. ‘[All the individual hostels hostel system, or rejecting services issues accessing a good multi- altogether. We explore each of these Case study are] alright, it’s just the agency offer” scenarios below: The diagram overleaf summarises way that it’s run, it’s run (Local Authority Commissioner) John’s homelessness pathway, which 2.3 ‘Revolving doors’ and ‘burned illustrates a ‘revolving door’ of hostel totally wrong…… Instead bridges’ placements. of putting you in [hostel “The staff don’t have enough The terms ‘revolving door’ and 1] then shipping you to time to spend providing ‘burned all their bridges’ were used ‘When I first went into [a emotional support because frequently in our interviews and group another hostel, why don’t they are too busy behind the discussions with professionals to hostel], I thought ‘it won’t describe the pathways of people with they try and get you a scenes, running the system. take long’, then 6 months complex needs: flat……… They could It’s not a criticism of the staff I just got shipped out have done it sooner’. personally – they have been “In terms of mental health and of the hostel…hostel…. great to me – it’s just the way complex needs, we are seeing hostel…hostel…so I just it is set up”. the same people coming (Man interviewed in day centre) went around the hostels through the system time and for about 5 or 6 years. time again – the numbers Key challenges here are that mental […] and you can get bin health services will not assess aren’t huge, but they take up someone who is under the influence so much of everyone’s time, we bagged at any time’ of drink or drugs; and the mental are really keen to find ways of health conditions of many are not working with them differently. When we met John, he had moved sufficiently severe to trigger eligibility into an independent tenancy in the for treatment or support. Those We often fund extra services, private rented sector with intensive working in hostels explained that, but it all falls down”. floating support from the CRISS team: even where they finally manage to (LA Commissioner) access mental health assessments for ‘I can do what I want, I can residents, a lot of assessments seem This was reflected in our analysis to simply result in ‘filtering people out’. of Mainstay data, which confirmed come and go when I want…I’ve Mental health professionals often do that a significant number of people got a tenancy agreement, got not seem to understand this client had received multiple assessments the leccie on, get my food and group and their tools do not fit. One and hostel placements. 379 all that, everything’. support worker summed this up by different people had received four saying, ‘What they bring is not quite or more separate assessments for right’. Meanwhile: accommodation within a four -year John accepts that he was responsible period, with the highest number of for the repeat hostel evictions: “The amount of medication recorded assessments during this time period being 12. delivered to our services ‘It was me that mucked that – people have become This ‘churn’ is related to very high up…. it was me when I was dependent on this, they levels of evictions (1,523 since 2013) drunk being a divvy. I can’t demand it, professionals from and abandonment of hostel knock the hostels for that…. places (1,495 since 2013). Together when I get drunk I do lose my keep prescribing it because these make up 28 per cent of the total it’s easier and past trauma is number of placements coming to an head a little bit’. simply not being dealt with end. A further 1,981 left supported for many of these people.” housing to live with family and friends, which will represent another step in a (Hostel support worker) cycle of housing instability for some. 30 Housing First feasibility study for Liverpool City Region Current services 31

Many people were described by the probably some who have been professionals we interviewed as having in there for about a decade’. ‘burned all their bridges’ with different (Local Authority Commissioner) landlords: hostel Awaits Awaits placement “Some stay in hostels because This approach can be linked to a culture of low expectations: during the move-on options are our interviews, several professionals limited – they have burned expressed the view that it was not their bridges with all the local realistic to expect some of this cohort Is housed in hostel 3

Goes back to ever be able to live independently. to hostel 1 in own flat landlords – alcohol misuse is As one said, whilst describing a hostel Gets placement often high amongst this group” resident: ‘This is the best it is ever (Local Authority Commissioner) going to get for him’. supplies behaviour behaviour We met some individuals who told of hostel 2

for drunken for drunken “It’s often through no fault of

due to drunken due to drunken us that they thought life in hostels Gets kicked out Gets kicked Gets kicked out Gets kicked Organises white goods and power the providers but this bigger was easy in terms of not having any challenge around housing responsibilities for bills, housework, etc.: supply can end up keeping

Is o
ered people trapped in the system”. Is moved

Goes back “I’ve always been lazy. I’ve to hostel 1 Crisis team to hostel 2

support by the (Local Authority Commissioner) never paid a bill in my whole intensive floating life, that’s why I’ve always “One of the gaps is for more turned to hostels because

passes wraparound support for people in order you just pay the rent and then 6 months placement paperwork Gets hostel Prepares to with complex needs outside of you’re all done then aren’t you”.

move in by getting communal settings – there is floating support, but it just isn’t Some of the people we interviewed intensive or long term enough had spent many years – if not all Gets a a private a private of hostel Is o
ered their adult lives – in unstable housing in hostel 1 rented flat placement for some people.” circumstances, punctuated by periods Gets kicked out Gets kicked (Local Authority Commissioner) in hostels.

In some authorities, where there are For example, Lisa (who has Asperger’s

services stricter time limits on different stages and depression) told us about a Accesses homeless 1-bed flats 5 years plus of the hostel pathway, this may lead decade of housing instability: period of about continual over a The process was Pool Plus due to high demand for Spends long time

in Band B Property to people ‘hostel-jumping’; in other authorities, where the pathway is more “I first became homeless when relaxed, people can end up living in I was 19, my mum and step dad sharing’

Remains the same hostel for years: homeless

Loses home kicked me out. From then until Begins ‘couch ‘In principle, people can spend now – over 10 years - I been up to 2 years in the hostels [in moving around and about and this borough] but we have got never staying anywhere for property more than a couple of years.

Lanlord sells people who have been in the hostel system for years and I’ve been moving from hostel years - either going around to hostel, from different houses in Band E of the ‘revolving door’ or, in the with different partners, I’ve Spends long time Property Pool Plus Living in case of [one scheme], there are never settled anywhere. The own tenancy John’s homelessness journey John’s 32 Housing First feasibility study for Liverpool City Region Current services 33

reason why I ended up in a using alternatives like poor quality “They don’t help you, Where people have multiple needs, hostel this time is because my housing in the private rented sector. they put you in a hostel a lot of time and energy can be Some of this group had become spent trying to determine what relationship broke down and and quite well, they set he kicked me out so that’s how ‘institutionalised on the streets’ as the underlying diagnosis is, which one put it. This group were the most you up to fail…. I’ve been ‘category’ they fit in and, ultimately I ended up here”. negative about services, though some which agency (if any) is responsible. appreciated the ‘life lines’ provided by out of the system now 2.4 Rejecting the homelessness outreach services. for 3 years and the more “There are lots of debates system you try to go the right operationally about what The uncertainty of short term “On the streets, you’re placements, combined with way, the more it comes to is causing what and which experiences of exclusion, bureaucracy, the one making decisions category people fit under you – but, they’ve left me rules and complexity have led some for yourself whereas in – so, if someone is doubly people – most of whom have alone now’. incontinent, is that caused complex needs - to reject ‘the system’ hostels they are all made Sharon altogether. by substance misuse or by for you” physical health problems”. For some, this was a short term Outreach worker ‘I’m not being funny, I’d Local authority commissioner decision (or at least at the point at which we met them). For example, we Case study: rather do jail than go Another described the challenges met one woman bedding down for Bob and Sharon are a couple in their back to the [hostel]. It’s trying to set up accommodation and the night in a doorway who told us 50s who are now living in very poor the other people, and support for a homeless person with she had a hostel place but felt safer quality private accommodation, where Korsakoff’s syndrome and tuberculosis: sleeping out. Others had disengaged we interviewed them – as Sharon says: what it is – I drink – a over much longer periods of time, ‘it’s dilapidated to say the least’ – they bit – but the main ones “Where all agencies’ budgets preferring instead to spend long receive support from the CRISS team. periods of time sleeping rough or in the [hostels], they’re are reduced, no one wants to mainly crack heads’ take responsibility for high risk Bob people.” Local authority commissioner Sharon Bob Meanwhile, some professionals 2.5 Wider system response to people described a lack of clarity over the • Describes herself as an alcoholic • Was living in PRS HMO with complex needs target population for hostels: the • Most of her family apart from her • Becomes homeless following All of the local authorities in LCR support needs of many residents seem daughter have died assault by other tenants are very aware of those with the either to be too high or too low: • Prison release and re-arrest • Suffers depression and stress highest levels of complex needs • History of sleeping rough • Homeless for 4 years on and off who are taking a lot of resources or “I think there are some • Has had ASBO in the past because • Gets kicked out of accommodation not engaging with services at all and she was not supposed to drink on because Sharon gets evicted and for whom sustainable successful challenges about homelessness the street he tries to sneak her in outcomes are not being achieved. versus complex needs. Are we • Has avoided the hostel system for • In and out of a series of hostels – In most areas of LCR, multi-agency just accommodating people about 3 years now because she but does not feel safe in them panels have been set up to try and in supported housing because feels they are set up to make her • Was refused a home by the council find ways of supporting these people, they are homeless? But at the fail because of rent arrears especially those who also have social • Says she’s been in for treatment • Is struggling in the current place care needs. We heard examples of same time, we have ended up but timings are not clear where he and Sharon live because individual solutions being set up for with a lot of people who have • Is now living with Bob in very of the stairs long term homeless people with care complex needs”. poor condition PRS property with needs, which might include domiciliary Supported housing provider support from CRISS outreach team care and intensive support being provided to someone living in a hostel setting or an independent tenancy. However, these are happening in an ad hoc, case-by-case and time intensive way. 34 Housing First feasibility study for Liverpool City Region Housing First 35

We heard how homelessness can and go independently and at your own cause people to sink into a vicious time is really appreciated. circle of shame: one woman told us that, when she had lost her previous Not being judged, punished or treated home on the outer edges of LCR, like a child. she had moved into the city centre Housing of Liverpool because she did not Opportunities for rehabilitation and want to bring shame on herself – or longer term planning: some of those her family – by being on the streets interviewees who felt they were on a in her home town. Lasting solutions positive trajectory told us they valued to homelessness must empower residential rehabilitation; or support homeless people, giving them from coaches or mentors, since these First opportunities to make a contribution had helped them to set personal goals, and rebuild family relationships, and and build their resilience. treating them like adult citizens with rights and responsibilities, not just Structure and purpose: opportunities recipients of charity. to volunteer and make a contribution, to learn or take qualifications or work We also heard about the towards getting (back) into employment. Chapter 3: Developing Housing overwhelming focus on day-to- day survival, particularly for street A focus on social integration: the First as part of a solution to homeless people. People described importance of the social connection deciding to beg so as to avoid which exists within communities of criminality; taking drugs or drinking homeless people (and the fact that these homelessness to help them sleep. When people are can be positive as well as negative) is in this ‘survival mode’ and especially often overlooked; some people were if they have been in it for many years, afraid of the prospect of being lonely In this chapter, we begin by presenting the core it can be very difficult to think ahead and isolated in their own home. components of solutions to homelessness, based on the or articulate their aspirations. People need time, opportunities for respite, A swift and flexible response to views of people with lived experience. We argue that the and gradual, consistent relationships people with addictions who are principles on which Housing First is based align well with with people they can grow to trust if at the right stage in the cycle of they are to make informed decisions motivation was a recurring theme in these and we summarise the evidence from elsewhere about their futures. Some of the rough the interviews. on how this model can work, before describing how it sleepers we interviewed who were could and should should be integrated within a wider heavy drug users and drinkers said 3.2 What is Housing First and how they felt they needed to ‘get away from does it respond to these needs? housing-led homelessness strategy in LCR. it all’ in order to stand a chance of Housing First is a system of support changing their lives. for homeless people with high and complex needs which is designed 3.1 What did homeless people tell Many described the stigma of The homeless people interviewed for to deliver a sustainable exit from us they valued and needed? being looked down on and judged this study told us that solutions for homelessness, improve health When interviewed for this study, by members of the public and them and others need to include: and well-being and enable social people typically described their professionals, especially those in power: integration. Housing First provides experiences of homelessness in Emotional support: many homeless immediate, non-conditional and terms of shock, stigma, shame and “I don’t like it when you go people have experienced trauma, loss secure accommodation and uses survival. Some people described the and abuse yet there is limited access ordinary housing, such as private shock of becoming homeless and the to places and you feel like to talking therapies or basic emotional rented or social rented flats. It is subsequent dislocation from ‘normal they are looking down at you support for this group. designed to house formerly homeless life’: for some, it was something they and you feel like you’re being people with high needs in their had never thought would happen to judged. It’s not nice.” Peer support: from others who own, settled homes as quickly as them. Having the opportunity to return have themselves been through possible and to provide the support to ‘normal life’ must, therefore, be a (man currently living in hostel) homelessness. they will need to sustain an exit from key part of the journey of recovery homelessness in their own home. from homelessness. Independence: Being able to come Housing First uses a mobile team of 36 Housing First feasibility study for Liverpool City Region Housing First 37

workers, who visit formerly homeless However, Housing First is not passive, Housing First services successfully with treatment21. Expenditure on these people in their own homes, providing it does not simply offer housing on ending homelessness for between services was high, but only between practical and emotional support an unconditional basis to homeless seven and nine out of every ten people four and six people out of every ten and acting as service brokers, or people with complex needs. Housing they work with, levels that approach with complex needs were sustaining case managers, who help arrange First workers engage with service users double the success rate of some earlier exits from homelessness. There was access to any services that someone within a harm reduction framework models of homelessness service19. also clear evidence, from both the using Housing First needs, such as and follow a recovery orientation, As we saw in chapter 1, the current USA and from Swedish research, that psychiatric services, drug services, centring on providing people using success rate (if we take move-on into people were getting ‘stuck’, unable to health care or social work support. Housing First with the idea that mainstream housing as our primary complete all the steps that a Housing Housing First will also ensure someone positive change in their lives, in respect success indicator) for services within Last approach expected them to is housed adequately and has the of ending homelessness, improving LCR is less than 40 per cent - and, follow and ending up spending years required range of household goods health, building relationships and for most on Mainstay, this only gives in services that were supposed to and furniture to live independently, becoming part of the community is destination data, not any longitudinal end their homelessness within weeks also providing help with budgeting and possible and emphasising that support follow-up on the success of these moves. or months. This has been borne out day to day living skills where needed17. is available. in our analysis of how services are Alongside the successes of Housing currently working in LCR. In practical terms this means: To be clear, Housing First does not tell First, there is clear evidence of cost the homeless people with complex effectiveness. Housing First may There are some debates about what • Immediate or rapid housing in a needs using the service how to sometimes be less expensive than exactly Housing First should be. The settled home. behave, it does not tell them not to other forms of homelessness service. arguments centre on the level of • No requirement to stay in a homeless drink or take drugs, but the workers However, it is probably more accurate fidelity that a Housing First service hostel, nor in any form of congregate emphasise that positive change – as to say, based on current evidence, that should have with the original model, or communal temporary supported and when someone chooses to make while levels of spending on Housing as developed by Sam Tsemberis in the housing, prior to housing being it – is possible and will be supported. First may ultimately be similar to those 1990s. Some argue that only very high provided. for other forms of homelessness fidelity (near-replication of the original • No completion of courses, training Peer support, where Housing First service for people with high and approach) can achieve real success, or other expectations in respect uses people who are ‘experts by complex needs, Housing First ends which is the approach taken by the of demonstrating ‘readiness’ for experience’ and have achieved a homelessness more effectively. In national Housing First programmes housing are required before housing sustained exit from homelessness, short, a pound spent on Housing First in Canada and in France22. However, is provided. can be important here. There is a tends to achieve more than a pound others argue that while the core • No requirement for compliance broad emphasis on a strength-based spent on other services designed principles of Housing First must always with treatment, including psychiatric approach, focusing on what the for homeless people with high and be followed, the operational details and drug/alcohol treatment, before people using Housing First can achieve complex needs20. We expore this in can be allowed to vary by context23. housing is provided. for themselves, what they are capable more detail in our cost effectiveness of, and avoiding any judgements analysis of the potential Housing First A Europeanised version of Housing Housing First is also distinctive in terms about how someone became model in LCR in chapter five. First was developed in consultation of the degree of choice and control homeless18. with Sam Tsemberis, who was part of given to service users. Someone using Housing First emerged in part because the team working on the Housing First Housing First is supported to design 3.3 The Case for Housing First ‘Housing Last’ was not working Guide Europe and who advised on the their own package of services and very well. Within a ‘Housing Last’ Key Principles of Housing First England. help, they design their own process The history of Housing First system, access to housing for a single One key difference with the original of exiting homelessness. This control Housing First is an unprecedented, homeless person with high support model of Housing First was that extends to whether or not someone global, success. Since the original needs is only given when they have diverse types of property were used: using Housing First chooses to engage experiments led by Sam Tsemberis in completed all the steps required in in the original model, all Housing First with treatment, including drug/alcohol New York in the 1990s, the Housing an institutional setting, are behaving properties were self-contained, usually treatment and mental health services. First approach has become a core in the ‘right’ way and are complying a one bed flat if someone is living Both access to housing and retention aspect of homelessness strategy in of housing are not conditional much of the economically developed 19 Pleace, N. (2008) Effective Services for Substance Misuse and Homelessness in Scotland: Evidence on complying with treatment or world. In contexts as diverse as from an international review Edinburgh: Scottish Government; Pleace, N. (2016) Op. Cit.; Padgett, D. behaving in certain ways, housing and Portugal, Denmark, Ireland, Italy, et al (2016) Op. Cit. support are separated in the Housing Austailia, Japan, Finland and Canada 20 Culhane, D.P. (2008) The Cost of Homelessness: A Perspective from the United States European First model. success has been reported, with Journal of Homelessness 2(1) http://works.bepress.com/dennis_culhane/82/; Bretherton, J. and Pleace, N. (2015) Housing First in England: An Evaluation of Nine Services Homeless Link. 21 Pleace, N. (2008) Op. Cit. 17 Pleace, N. (2016) Housing First Guide Europe Brussels: FEANTSA http://housingfirstguide.eu/ 22 Padgett, D. et al (2016) Op. Cit. 18 Padgett, D.K.; Henwood, B.F. and Tsemberis, S (2016) Housing First: Ending Homelessness, 23 Pleace, N. and Bretherton, J. (2013) ‘The Case for Housing First in the European Union: A Critical Transforming Systems and Changing Lives Oxford: Oxford University Press. Evaluation of Concerns about Effectiveness’ European Journal of Homelessness 7(2), pp. 21-41. 38 Housing First feasibility study for Liverpool City Region Housing First 39

alone, not in immediate proximity successful, there are reports of very to 75 per cent reporting these strategy is directly linked to the to other Housing First tenants. In strong results from Housing First levels of familial contact as Housing reduction in long-term homelessness. the European model, congregate services using a case management First service users, a 50 per cent Finland recorded 2,628 long-term models (using self-contained flats with approach25. In England, seven out of improvement. homeless people in 2012 and 2,047 tenancies) and properties in which two every 10 service users were housed • Falls in involvement in anti-social in 2016, a drop of 23 per cent 32. or three people had a shared tenancy at one year by five Housing First behaviour, from 78 per cent reporting • The major Canadian national pilot, were sometimes used. Sometimes this pilots26, in the Netherlands, Finland, involvement a year before using the At Home/Chez Soi programme, was as a result of individual needs and Portugal and Ireland, similar or better Housing First to 53 per cent as has been determined to be a major preferences; often it was driven by the results were achieved by Housing Housing First service users. success. In the last 6 months of a nature of housing markets and welfare First services that followed a case study which compared Housing First benefits systems. Also, in the original management model. The international evidence shows that: service users with a ‘Treatment as model, mental health support models, usual’ group33, the following results assertive community treatment (ACT) Outcomes from Housing First • Finnish experience in using Housing were obtained: and intensive case management The clearest measure for success in First as an approach to long-term (ICM), were specified, which involves the use of Housing First lies in the and recurrent homelessness, has Table 3.1. Outcomes of national considerable direct provision of evidence that it sustainably ends been extremely positive and lain Canadian Housing First pilot services by Housing First when homelessness. The evidence in respect at the core of a sustained national supplying ACT (used for homeless of improvements to health, well-being strategy that has brought Finland Housing status in last 6 Treatment Housing people with the very highest needs). and social integration is more mixed27, to a point where homelessness is months of trial as Usual First but there is evidence of positive becoming a functional zero. The Housed all of the time 6% 62% Thus far, UK Housing First experiments outcomes in these respects as well28. concept of functional zero can be Housed some of the time 23% 22% have been a case-management only summarised as a state in which Housed none of the time 46% 16% version of Housing First. Here, as in The evaluation of Housing First pilots experience of homelessness is rare the original model, there is a relatively in England completed in 201529 found and, where it does occur, short- high amount of contact between that, among 60 users of Housing First term, with Finland having levels of In France, the pilot of Housing First workers and Housing First service services: homelessness that are extremely (Un Chez-Soi d’abord programme users, but health, drug, alcohol, mental low by UK standards30. Housing First (2011-2016)) in four cities was led at a health and other support needs are • 43 per cent reported bad or very bad is successful in Finland because it is national level by the inter-ministerial handled primarily through referral physical health a year before using a a part of an integral homelessness body responsible for the national and support with using external Housing First service, with 28 per cent strategy which includes a strong homelessness strategy. Overall, services24. In other words, UK Housing reporting the same poor levels of emphasis on prevention and an array 85 per cent of Housing First service First services have, thus far, ensured health as Housing First service users of lower intensity services: a point to users retained housing over the course someone has a doctor, makes sure (i.e. a 15% drop in reports of bad or which we return below. of two years and the programme was they attend appointments and get the very bad physical health). • The first stage of the Danish extended to 16 cities34. treatment they need, works to get any • 52 per cent reported bad or very bad Homelessness Strategy from 2009- help wanted with drugs and alcohol mental health a year before using a 2013 was one of the first large-scale Health, Well-Being and Social from specialist services and arranges Housing First service, dropping to Housing First programmes in Europe Integration other treatment and support on the 18% when surveyed as Housing First and housed more than 1,000 people, The core goal of Housing First, what same basis, connecting people with service users. the intensive case management it seeks to achieve as a model, is to services, rather than providing those • Uneven results in respect of drug and versions of Housing First reported use housing as a basis from which to services directly. alcohol use, but some evidence of a 74 per cent housing retention pursue integration into mainstream improvement for individuals. rate, with a 95 per cent rate being social and economic life. What this Broadly speaking, while the trials of • 25 per cent of Housing First service achieved by assertive community means in practice is that Housing First ‘high fidelity’ Housing First in Canada users reporting daily, weekly or treatment models of Housing First seeks to improve the following aspects and in France, using the original monthly contact with family one year (Benjaminsen, L (2013)31. of an individual’s life: ACT/ICM model have proven highly before using Housing First, compared • The Finnish use of Housing First within an integrated homelessness

24 Bretherton, J. and Pleace, N. (2015) Op. Cit. (74% of service users housed for 1 year or more) 25 Busch-Geertsema, V. (2013) Housing First Europe: Final Report http://housingfirstguide.eu/website/ 30 For further details, see: Pleace, N.; Knutagård, M.; Culhane, D.P. and Granfelt, R. (2016) ‘The Strategic wp-content/uploads/2016/03/FinalReportHousingFirstEurope.pdf Response to Homelessness in Finland: Exploring Innovation and Coordination within a National Plan 26 Bretherton, J. and Pleace, N. (2015) Op. Cit. to Reduce and Prevent Homelessness’ in Nichols, N. Doberstein, C. (eds) Exploring Effective Systems 27 Johnson, G., Parkinson, S. and Parsell, C. (2012) Policy shift or program drift? Implementing Housing Responses to Homelessness Toronto: Canadian Observatory on Homelessness. First in Australia, AHURI Final Report No. 184, AHURI: Melbourne; Pleace, N. and Quilgars, D. (2013) 31 Benjaminsen, L (2013) Policy Review Up-date: Results from the Housing First based Danish Improving Health and Social Integration through Housing First: A Review DIHAL. Homelessness Strategy European Journal of Homelessness 7.2, pp. 109-131 28 Quilgars, D. and Pleace, N. (2016) Housing First and Social Integration: A Realistic Aim? Social 32 Source: ARA http://www.ara.fi/en-US Inclusion, 4 (4), pp. 5–15 33 Goering, P. et al (2014) National At Home/Chez Soi Final Report Mental Health Commission of Canada 29 Bretherton, J. and Pleace, N. (2015) Op. Cit. 34 http://www.home-eu.org/85-percent-homeless-persons-france-keep-home-two-years/) 40 Housing First feasibility study for Liverpool City Region Housing First 41

• Social integration reducing use of drugs and alcohol support levels are expected to fall over part of homelessness prevention, • As part of a community (though not necessarily ending use time for each service user, the service taking referrals for high-risk individuals • Developing positive in the short to medium term) and contacts becoming infrequent, or the (for example people with high and friendships, family enabling people to live more socially service becoming dormant, even if complex needs and a history of relationships, having a partner integrated lives, with better emotional someone does not formally graduate36. homelessness) to minimise the risk of • Economic integration supports. sustained homelessness or recurrent • Paid work where possible 3.4 Housing First within Integrated homelessness. • Progress towards paid work Moving to Independence Strategies e.g. education, training The promotion of independence Housing First is a specific model There are risks in using Housing First • Structured and meaningful has sometimes been a challenging of support for a specific group of inappropriately, these include using activity question for Housing First. One of homeless people, i.e. those with high too many resources on homeless • Health and Wellbeing the reasons why the approach has and complex needs, it is not designed people who do not require the level • Mental health not been more widely adopted in for all forms of homelessness. of support offered by Housing First in • Physical health the UK is that homelessness services, However, where Housing First has a context where funding is restricted. • Drugs and alcohol alongside being faced with sustained been used most successfully, one Referral and assessment must be cuts in funding in many areas, are example being Finland, others being carefully organised to avoid this risk. Housing First will not achieve total commissioned on the basis that Denmark, France and Canada, it success in every case, no service interventions to tackle homelessness has been part of a wider integrated Another danger lies in loss of fidelity, is perfectly effective and there are are short or medium term. This is one strategy to end homelessness37. In where many services, including low individuals for whom Housing First of the key aspects of the Housing Last other words, Housing First has been intensity forms of support, all start to is not the right service model. Some approach, the model being based on offered as part of a range of services, badge themselves as ‘Housing First’. people may want more structure, making someone ‘housing ready’, i.e. including preventative services, The risk, which is something that was for example, rather than wishing to capable of living independently in their lower-intensity support services (for experienced in the USA, is a loss of engage with a Housing First service own home, whereas Housing First is homeless people with less complex focus. This can undermine the idea of model that essentially requires an built on the idea that homelessness needs), services for specific groups Housing First, where services that are individual to determine and build their can be quickly ended, but support (which can include tailored versions of not Housing First - but which describe own support package, albeit with needs may continue to be present for Housing First, specifically for groups themselves as such - begin to fail or whatever assistance the Housing First some time. like homeless women, young people, underperform, potentially tarnishing service can provide. or former offenders) and various Housing First as a whole38. This is expressed in Housing First measures to maximise access to Housing First will also take time to providing support for as long as affordable and sustainable housing. The final risk in relation to strategic have an effect and the effect it has someone needs, but in practice this integration is that being outside an will sometimes be limited. This is does not mean support continues It is within an integrated homelessness integrated homelessness strategy about realism in terms of expectations to be delivered at high intensity. strategy that Housing First has the means that Housing First does not for Housing First, i.e. someone with Over time, contact with service greatest potential for positive effects, have a defined role in relation to that a history of recurrent and sustained users will tend to drop, reducing to both in the sense of achieving strategy. If it is not clear how Housing homelessness, severe mental illness much lower levels as they stabilise, reductions in homelessness among First is working alongside prevention, and addiction is unlikely to suddenly and Housing First can go dormant, people with high and complex needs low intensity and emergency ‘get better’ within a few months and with service users able to contact and in the sense of making sure that accommodation services, enabling no longer require support. There are support if they should require it, but those people are not inappropriately the delivery of a cohesive whole, then dangers in expecting Housing First otherwise leading an independent (and inefficiently) using services that Housing First becomes vulnerable. to deliver a more or less immediate existence. The concept of ‘graduation’ cannot meet their needs. In practical terms, this involves what improvement in terms of every from Housing First was introduced in the Americans refer to as funding aspect of individual need, though the Sam Tsemberis’s original model, i.e. Integration of Housing First means sunsets, where a pilot service, in this expectation is perhaps understandable transitioning to a point of complete efficient triage, making sure that instance Housing First, is supported, as Housing First does deliver a rapid, independence, yet while this is a goal, those for whom Housing First is most prospers and delivers good results, but sustained, end to homelessness for there is not a set timetable, e.g. within suitable are quickly directed to an operates in semi-isolation from wider the great majority of the homeless a year or three years, instead Housing assessment and access to the most homelessness strategy. people with complex needs it First remains engaged until it is no appropriate service. There is scope works with. Nevertheless, there is longer needed. Importantly, however, for Housing First to also be used as evidence that Housing First can while Housing First does provide deliver improvements in every area support for as long as is needed, the 36 Tsemberis, S. J. (2010) Housing First: The Pathways Model to End Homelessness for People with 35 , improving health and wellbeing, model is designed on the basis that Mental Illness and Addiction Minneapolis: Hazelden. 37 http://housingfirsteurope.eu 38 Pleace, N. (2011) ‘The Ambiguities, Limits and Risks of Housing First from a European Perspective’ 35 Quilgars, D. and Pleace, N. (2016) Op. Cit. European Journal of Homelessness 5(2) pp. 113-127. 42 Housing First feasibility study for Liverpool City Region Housing First 43

Without a clearly defined strategic immediately filled by others waiting In order for Housing First to have the housing-led strategy, and in order role – supporting the policy goals for places. It becomes even more of a required impact on the reduction of to reduce the reliance on high-cost and other homelessness services – challenge to make this stack up where homelessness, a wider set of system supported housing. We present a case Housing First pilots may not evolve Housing First is targeted at people who changes are required as part of a study to illustrate each of these groups into permanent service provision, are not currently in the hostel system housing-led strategy. before considering the most effective because without a strategic role, – those who are rough sleeping or in service response to their needs. continuing to fund Housing First may prison: both of which we would expect Introducing four sub-groups within not be a priority. Of the Housing First to make up a significant proportion of the homeless population Case studies: Group 1 People for pilots assessed in 2014/15, a few lost the caseload. The analysis underpinning this whom the current provision is funding and either changed shape feasibility study would suggest that ineffective and results in long-term or disappeared, it was those pilots Given this, it is crucial that Housing there are at least four relevant sub- homelessness. Since this is where that shifted gear and moved towards First be part of an integrated groups within the large and growing we have attempted to focus the strategic integration, demonstrating prevention strategy, so that as many population of homeless people: target cohort for Housing First, we their worth in the homelessness people as possible are diverted away have included two case studies and strategy and thereby accessing local from homelessness at the earliest 1. People for whom the current presented these as flowcharts on the commissioning funds, that endured. opportunity. provision is ineffective and results following pages. Examples of these Housing First in long-term homelessness – this is services include the Camden Housing Since Housing First is a relatively where we have attempted to focus First we present Rachel’s homelessness First project, operating on the basis intensive and expensive intervention, the target cohort for Housing First; pathway. The difficulties she of handling ‘hard to reach’ cases it is important that it is targeted 2. People who first come into contact experiences with communal living first where homeless people with complex only on those who need it: the cost with homelessness services after arise when she moves into a refuge needs were not getting the right effectiveness of Housing First hinges they have lost accommodation – the option for a suitably supported support from the existing systems and on it not being used by those who which could probably have been dispersed property at this stage could Changing Lives in Newcastle, which could be supported by lower intensity sustained had they accessed high well have helped her stabilise much became part of the City’s strategic services (a point we explore further quality and timely housing advice earlier. It is likely that stabilising in her response to homelessness, which in chapter 5. Without sufficient lower and advocacy; own housing would have reduced are likely to enjoy a future and see intensity services and good access 3. People who are offered supported or prevented the number of Rachel’s expansion39. to independent tenancies, there is a housing because this is seen as subsequent hospital admissions and risk that Housing First is swamped by the only option- but who really do contacts with the criminal justice 3.5 Developing a housing-led referrals of people who do not really not need any additional support, system. Strategy for LCR need this level of support, just because they just need access to affordable In order to mainstream Housing First the service is the only gateway to housing. For some, this is due to into commissioning in the current independent tenancies and floating restrictions in Property Pool Plus funding climate, it will need to be support for homeless people. policies, for others it may be due done in such a way that allows local to a lack of affordable, suitably authority support funding to be If, for example, a new priority band for sized and/or accessible housing. In transferred from current spending Housing First was to be introduced to the current system, there is a risk on hostel services. In other words, the social housing allocations policy, that this cohort will develop higher Housing First needs to be done at but the existing barriers to offenders support needs the longer they stay sufficient scale and in such a way that and those with previous history of homeless40. some current hostel provision can be tenancy breakdown are not reviewed, 4. People who are largely similar to safely closed, albeit in the future and then a two-tier system would be the group 3 but who do have some following a period of external funding created in which there is a perverse need for support or assistance to and evaluation. incentive to refer people to Housing secure and maintain independent First as a means of getting a property, accommodation, probably on Our analysis of Mainstay data highlights regardless of whether or not they need a short-term basis to establish the huge, increasing and often unmet the support. Even if these referrals themselves in independent demand for homelessness services in were filtered out by good assessment, accommodation. LCR. Given the significant unmet need the service would use too much of for accommodation and support, it is its resources gatekeeping and there is These groupings are all significant hard to imagine a scenario in which a risk that those who really need the and require a change or development any hostel places freed up by people service would be overlooked. in service provision as part of a new moving to Housing First were not 40 Culhane, D.P.; Metraux, S; Byrne, T.; Stino, M. and Bainbridge, J. (2013) ‘The age structure of contemporary homelessness: evidence and implications for public policy’ Analyses of Social Issues 39 Bretherton, J. and Pleace, N. (2015) Op. Cit. and Public Policy 13(1), pp. 228-244. 44 Housing First feasibility study for Liverpool City Region Housing First 45 placement Overdoses Gains hostel Gets violently rough sleeping assaulted while assaulted Moves in with friend Finds the communal to drink again. Violent. setting di†cult. Begins setting di†cult. place on of hostel Becomes own flat Kicked out Kicked entrenched Placed in a rough sleeper Trying to get Trying Is oered hostel Rough sleeping Rough conditional basis Discharged to rough through Begins to sleep women’s refuge the summertime hostel placement to calls from refused hostels streets in total) to hospital Sleeping rough Continues to be to tensions the hostel place Loses family regularly (spends services to access six winters on the Has not responded Is repeatedly kicked kicked Is repeatedly Overdoses and out of hostels due to begins to access connections due is referred to MH alcohol and MH issues violent oences, drug, Gets assaulted by Gets assaulted emergency shelter and is re-admitted friend and overdoses As winter approaches in prison Released Released Presumed Mainstay Spends time Stays with Deemed not no fixed abode no fixed rough sleeping suitable for SH Access hostel placement via another friend Is in temporary accommodation Becomes homeless with support worker victim of in prison Hostel place with residents domestic abuse to heroin while related violence related due to incident Becomes repeat Becomes repeat Evicted after two after Evicted Loses placement months for alcohol oered for release Becomes addicted on conditional basis and alcohol services Relapses and is evicted Relapses pending accessing drug for violence. Review possible for violence. Review Gets in HMO in prison Released half years hostel on Spends time Accepted to released to a Arrested and and lives with friend’s house Meets a partner him for two and conditional basis accommodation went downhill from this point Overdoses. No needs too high’ Gets sanctioned local connection and states that life that and states Alcohol is a feature. Alcohol is a feature. Hostel place refused and arrest for breach Loses custody of son intoxication, ‘support intoxication, accommodation but is accommodation based on violence and Is accepted for floating Is accepted for floating locally barred. Overdose admission. NHS try to find Friend assaults her. Hospital her. assaults Friend place due to past behaviour continuously refused hostel support and resettlement but sleeping leaves job Eventually admission Loses home Has a mental 2nd hospital breakdon and breakdon Homeless and to avoid rough rough sleeping Goes into detox accesses a hostel complications Suers a series mortgage arrears of family illnesses, so leaves job due to deaths and relational and relational deaths Mother becomes unwell Mother becomes unwell child care issues. Gets into influence while under the outreach team. and violent to sta using class A drugs Gets kicked out for Gets kicked abode despite NHS Discharged no fixed Discharged no fixed Is accepted by intensive flat with son flat Living in own referrals as barred locally. referrals as barred locally. responsibilities significant family High powered job and Rachel’s homelessness journey Rachel’s Jeff’s homelessness journey 46 Housing First feasibility study for Liverpool City Region Housing First 47

Jeff’s pathway (on the previous page) had the right assistance at the my arm or a can in my hand and car and says that everything went similarly shows the ‘revolving door’ right time. to get anywhere with them. downhill from there. of prison, hostels and psychiatric No offence to other people but hospitalisation. Jeff has lots of stays Steve and Joanne have a child and I’m not like some of the other He had a tent set up in an abandoned in hostels, but is excluded from one became homeless because the building and lived in there for 8 weeks; after the other. Jeff told us that, when landlord wanted to sell the flat they people you see on the streets, using a charity-run day centre for he has been offered places in hostels were living in. Joanne said that she I’m just like – normal.’ somewhere to eat. He felt stuck in it has typically ended up as a ‘total simply did not have the information to the area where the charity operated disaster’ because he knows everyone know where to turn, she describes it He also described how, in order to because it was the only place he could there and this sends him ‘straight back as a scary time and the worst situation maintain the benefit payment for the get something to eat: he could not to square one’. she has ever been in; she says she hostel, he was having to reduce his use foodbanks as he had nowhere to ‘just didn’t have a clue about what to working hours. The limitations on cook. He explains that this situation He likes the idea of having his own do’. Steve, who works full time, did saving for a deposit are obvious here. increased his level of isolation from his place but is clearly will need support the information finding between his He states that he has the opportunity social networks: if this is to be successful: working hours and they are both now to earn £10 an hour and get a monthly in separate hostels while their child bonus at his place of work if he was ‘To be honest with you, I didn’t “But the likes of me, I’m stays with Joanne’s mother. This is to take it, but as he does not want to really tell many people. People particularly hard for Joanne because jeopardise the placement he cannot, embarrassed to say it, but she cannot have her son stay over with so continues to earn a basic wage thought I still had my job and I think I do need support. her in the hostel. whereby his wage tops up the service I was still carrying on because There’s too many vipers out charge and pays for him to get to and I was just embarrassed. It was there who will take advantage Both spent time in different from work and for his son, who is living just an embarrassing situation of you and if you’re going emergency night shelters to get their with his partner’s mum. He is currently places in the hostels. Joanne’s issue unable to see or make any financial for myself because I’ve worked through problems and you’re with the system is that she does not contribution towards his two children all my life.’ at your weakest moment, these really need any support other than from a previous relationship because people know how to home in to get a home, but wishes there had he cannot earn enough while in the He accessed the one-stop-shop, but on you. Without the support been more information available hostel. He notes that when he does there was a 3 week wait to get an to understand what to do when leave the hostel he could start making appointment to get onto the Property you’re a deer in the headlights faced with homelessness. Steve as much as £500 extra a month. Pool Plus waiting list. He had to – you’re just going to get had difficulty in getting his hostel find and produce all the relevant knocked down. And a lot of place as he missed out on an earlier Steve and Joanne would presumably information he needed - ID, 3 months’ them don’t get back up”. opportunity as although he answered have been classed as statutorily bank statements. Darren said he gave the call from the hostel while at work homeless, had they been given the these documents to them and the and agreed to take the offered place, right advice at any point along this wait still seemed to drag on. He said: He has clearly suffered a lot of trauma when he went to sort out the details journey – presumably this has been ‘It didn’t seem like anybody gave in his life and does not appear to have on his day off the next day, the room overlooked by the emergency hostel one really’. received any useful emotional and had been allocated to someone else. services they have been in touch with psychological support for this: Steve also faced difficulty in accessing because these services are geared up The local authority put Darren in ‘Band the night shelter due to doors closing to working with singles and have not E’ and although he expresses dismay “When you’ve been doing it before Steve’s working shift finished, noticed that they are actually working at being in the lowest band, he also luckily he was able to make a special with the members of a family who felt a sense of guilt that people were [homelessness] for 15 years – arrangement with the night shelter want and need to be living together. less fortunate than himself. However, I had a hard life as it was – a to let him arrive after he finished his getting somewhere warm became lot of violence in the family working shift at 9pm. He expressed his Group 3 case study: People who are his one priority because he became so there’s always been a lot of frustration at being penalised for being offered supported housing because ill while living on the streets and was violence in my life and there’s an ordinary working person without a this is seen as the only option – but beginning to access A & E services. home: who really do not need any additional no hope”. support, they just need access to He accessed the emergency night ‘So because I was working I affordable housing shelter and continued to stay there Case Study: Group 2: People for around 3 – 4 weeks. He also who first come into contact with felt like I was hitting a wall Darren lost his job due to a (physical) went there in the day if it was raining homelessness services after they have all the time – I felt like they medical condition: he had initially because they would let him in. He then lost accommodation which, in theory, wanted me to walk around returned to work but was then off for describes his luck at eventually getting could have been sustained if they had with a needle hanging out of a further six months and so lost his flat a place in the hostel: at the time of the 48 Housing First feasibility study for Liverpool City Region Housing First 49

interview he had been staying there he described it as ‘a nice hostel, staff A system which responds effectively embedded. Overleaf, we show how for 3 weeks. are really friendly, give everybody to each of these groups these blocks could fit together and all the support’. These are the building blocks of the which pathways we might expect our However, he reflected: integrated homelessness strategy four different sub-groups to take: ‘It has been hard going from in which Housing First should be “For somebody like myself having a house with my who’s just lost my job, this partner, then end up being on [system] isn’t necessary for the streets and being homeless. me…. all you need is a base It did have its moments and and then you can get back to now I’m on a steady thing […] I Housing First work’. So it would just be short want to try and do something • See Chapter 4 for detailed overview of this service time, because that’s all you fresh, get my flat eventually need is a couple of months to and then employment but I’m get yourself set back up, get just going to wait until I’ve your own pad, you’ve got your settled down’ Floating Support own postcode – just simple things like going for interviews, However, significant barriers stand in • Based on Housing First principles: strengths-based, you can’t get an interview if the way of Chris finding permanent choice & control, etc you’ve got nowhere to live. housing. The need for a deposit and • Lower intensity and probably time-limited but enough Unfortunately, this is the a month’s rent in advance is a barrier flexibility to personalise and respond to changing needs in the private sector, combined with • Good signposting and links with mentoring, ETE, etc. process you’ve got to go down the way in which landlords ‘judge and it can take months”. and label’ those who are not working. Meanwhile, he describes Property Pool Group 4 case study: People who Plus as a ‘waiting game’. are largely similar to the group 3 but Access to Affordable Housing who do have some need for support Chris remains close to his family or assistance to secure and maintain and is particularly keen to maintain • Review of mainstream allocations policies and systems independent accommodation on contact with his nephew and his three • Flexible, large scale local lettings agency which will: a short-term basis to establish children, however the fact that they • Acquire (and where desired) manage social & private themselves in independent are not allowed to visit the hostel and rented portfolio accommodation. he has little disposable income makes • Housing management in partnership with support this difficult. Chris worked previously providers Following a split with his partner, Chris in catering but left as a result of • Opportunities for training, employment, volunteering moved to London where he ended up experiencing bullying and harassment. to improve sub-standard properties sleeping rough. In London he accessed Chris is grateful for the support he has homeless services, then returned to had to date, both from hostel staff and Merseyside where he stayed with his others in homelessness services. He mum for a while. He then began to recognises that he would ideally need access the emergency night shelter some support if he were to get his and, from there secured a place in a own place: Housing Options Advice and Advocacy hostel where he had been for the last 3 months. ‘I’d love to be given a chance to do • In line with the requirements of the Homelessness Reduction Act that [Housing First] and prove to • Case management approach: co-produced action plan (which might Chris has no issues with drugs or myself that I can take on some of that include mediation, debt/benefit advice, advocacy with landlords, alcohol misuse. He describes hostel responsibility. That’s what I’m looking lenders, utility suppliers, etc) life as ‘tough’ in terms of ‘not knowing for, even though I’ve got support with • Well-publicised and accessible people around here’, and ‘not knowing key workers, it’s when I move onto the • Inclusive: available to all, regardless of local connection, what to expect’: he felt this ‘knocked outside to keep having the support still’ priority need, intentionality him back’ when he arrived. However, 50 Housing First feasibility study for Liverpool City Region Housing First 51

Pathways through the proposed system

Housing First

On Streets/ Emergency/ Housing + Homeless short-term Local Lettings Agency Floating accommodation support Triage for support

Assertive Outreach (by or in close Outreach will case Housing partnership with manage and broker Only Housing First team)

NB: People can be referred between these Support to remain tiers should their support if possible needs change over time. Housed/ Threatened Housing Options: with homelessness Advice & Advocacy

NB: Housing First might involve specialist congregate but tenancy-based models delivered in partnership with NHS/ Adult Social Care/Criminal Justice where risks and needs are very high. 52 Housing First feasibility study for Liverpool City Region The model 53

• Offering a flexible Housing First already concern from commissioners service to homeless people who are in Liverpool that the Waves of Hope likely to need intensive and ongoing criteria excludes significant numbers support in order to settle into and/or of people who have been homeless for sustain a tenancy. a number of years, have had various placements and have multiple needs The model Tenancy sustainment is the primary but are not scored highly enough outcome by which the performance on the chaos index. Others raised of this service should be measured concerns that, although the scoring and judged. system gives the appearance of quantitative measurement, it is still very “If you can get tenancy subjective and is insufficiently service user-led. Chapter 4: Developing a Housing sustainment right, everything else flows Criteria for inclusion: First and housing-led model from this – so you need “I think people have got to in Liverpool City Region to measure your success be willing to move into the in tenancy sustainment property. That’s about getting and what that takes information to people again In this chapter, we set out our proposed Housing First and costs.” – this needs to be broadcast: that there will be a good solid model for Liverpool City Region. Manager of Housing First service in another area network of support” Interviewee with lived experience This has been developed and evaluated personalised support and case The Housing First service will sit through engagement with relevant management to homeless people within an integrated strategy for the stakeholders and analysis of Mainstay with multiple and complex needs’ prevention of long term homelessness • A significant history of unstable data. It is also informed by the existing (Homeless Link 2016). as outlined in the previous chapter. housing and/or homelessness evidence from the implementation and • A judgement that other service evaluation of Housing First elsewhere The LCR Housing First model will be 4.2 Target group for the Housing options either have presented or in the UK, Europe and North America, based on the following principles41: First service would be likely to present a risk to as summarised in Chapter 3. As stated We recommend using the following the individual or others they might in the Introduction, we recognise 1. People have a right to a home criteria for identifying those who will share with, or have provoked / might that this proposal would need both 2. Flexible support is provided for as benefit from the Housing First service. provoke anti-social behaviour to the political decisions and more scoping long as it is needed However, recommendations about detriment of the individual and/or and planning to develop a detailed 3. Housing and support are separated suitability should be made by skilled community implementation plan that is agreeable 4. Individuals have choice and control and trained professionals as a result of • A history of at least one of the to key stakeholders. Our intention was 5. An active engagement approach triage, in which the individual would following: to give enough detail at this stage to is used be supported to play an active role. • Repeated substance misuse; allow readers to get a sense of how 6. The service is based on A multi-agency group should ideally • Enduring mental ill-health; this model might work in practice in people’s strengths, goals and oversee the assessment process as • Profound learning difficulties; LCR, but we certainly do not wish to aspirations detailed in section 4.12. • Long term and deteriorating preclude further debate and decision- 7. A harm reduction approach is used physical health; making about the operational detail. We have avoided recommending use • Repeat offending. Housing First in LCR aims to reduce of chaos and vulnerability indices • The person’s choice: assertive 4.1 Definition and prevent recurring and long term which have been used as criteria outreach teams would engage Housing First provides ‘a stable, homelessness and other homelessness for acceptance onto some Housing with people over time to help them independent home and intensive associated with high support needs by: First schemes and the Waves of decide what is right for them and Hope project in Liverpool42. There is what support/ type of housing they 41 These are the principles which have been developed by Homeless Link, based on the international evidence and aligned with the core principles of the FEANTSA Housing First Guide Europe (www. housingfirstguide.eu), but adapted for the UK where necessary. See Homeless Link (2016) Housing 42 Current eligibility for Waves of Hope involves scoring 27 or more points on the NDT (New Directions First in England: The Principles Team) Chaos index, used across the Big Lottery Fulfilling Lives programme 54 Housing First feasibility study for Liverpool City Region The model 55

would need to make Housing First • Emotional and psychological support what they are good at, and how As explained in chapter 3, the original Case study work for them. However, nobody (using, for example, psychologically they can be supported to make a North American model of Housing We interviewed Lee at an emergency shelter. He told us he had been in several hos- would or could be forced to accept informed approaches, motivational contribution. The aim here is to build First used two models of support, tels in the past and that, following a stay in one hostel, and having stopped using Housing First, since they need to interviewing and attachment-based people’s longer term resilience – the assertive community treatment (ACT) Heroin, he had been set up with a flat of his own: accept the rights and responsibilities approaches); abilities and support networks which and intensive case management (ICM), of the tenancy. • Practical support to set up and can help them adapt to adversity, Case management only Housing First maintain a home and manage challenge, loss and relapse. services, which have predominated in “I did manage to stop using during the time I got that place – I just kept myself to As emphasised in Chapter 3, ensuring finances; • The Housing First model is one of the UK in the pilots attempted so far, myself. I was there for about 6 years. I was on Methadone and I didn’t get into trouble that Housing First operates in a wider • Help and advocacy to access recovery and the team will maintain have much lower operating costs than with the police or anything, but it was tough because I didn’t get any support while I system in which there is effective benefits and NHS services; a fundamental outlook of hope ACT/ICM teams and there is an was in the flat. I didn’t need someone supporting me all the time but when you need ‘triage’ with speedy access to housing • Support in relation to building and in people’s capacity to change argument that as the NHS and other some support, you need to be able to see someone but you have to go back to square and lower levels of support for those sustaining positive social networks their behaviours, re-build broken services provide universal support to one with appointments and waiting lists – you have to start again”. who do not need the intensity of the and meaningful activity, which might relationships, or learn new skills. all the public, Housing First should pure Housing First model is key. If include relationships with family, concentrate on ensuring that service Housing First is the only way to access friends, peers and neighbours; 4.4 Duration and intensity of users get the help they should be housing and support quickly, it will be volunteering opportunities; and/or support entitled to as citizens43. One point to swamped with referrals of people who education, training and employment. A key success factor for the service note is that while a case management do not really need the service and this will lie in achieving the right balance model, the proposed Housing First will not prove cost effective. This support would be delivered in a between holding on to its clients and service would still provide relatively way that is consistent with the Housing letting them go, both at any one time high levels of service user contact, 4.3 Description of the Housing First First principles set out section 4.1 and over time. The ultimate aim of the with workers providing emotional, Service above. In practice, this means that: service is to (re-)integrate people into psychological and practical support, The success of the Housing First communities. alongside facilitating access to the support service rests on its ability to • If someone refuses or fails to engage external services someone may recruit, retain and manage effectively a with the support, they are not ‘struck In order to achieve this, the small choose to use. small and consistent team of workers off’; nor is their tenancy threatened stable team of support workers needs with excellent engagement skills who by this. The team is proactive, whilst to be able to access a wide ranging A recurring concern during our are able to work to the principles respecting people’s right to privacy. support network in the community. qualitative research was that an outlined at section 4.1 above. We In practice, this means trying again ongoing, wraparound service risks expect that this will require very later or the next day and perhaps The idea of a skilled team working creating ‘dependence’. This is not careful recruitment and selection trying a different approach, or using holistically and directly as much as borne out within the current research from a pool including people working a different member of the team. possible, rather than spending most evidence44. Rather than seeking to in other sectors and those with lived • As tenants, Housing First clients have of their time trying to refer to and promote independence by imposing a experience, and a strong commitment a set of rights and responsibilities, as navigate other systems was popular time limit on services (as is the traditional to upskilling successful applicants. any other tenants would. If there are with many professionals and homeless approach in services), the Housing First concerns in relation to the tenancy, people we spoke to. However, there service will achieve this by: This team would work together flexibly the Housing First team will work with is a danger here of creating an • Maintaining a strong value base to support a protected caseload of housing managers and landlords to expensive and unsustainable ‘bubble’ which treats the people it supports as Housing First tenants, connecting mediate, negotiate and support. around Housing First tenants, rather adults and equal citizens (not people them into mainstream services and • Freed up from ‘policing the rules’ (as than influencing wider policies, who need to be ‘rescued’, ‘protected’ community resources and networks is often the case in hostels or other commissioning and practice by using or ‘taught’); wherever possible. We anticipate a homelessness services), workers mainstream services as much as • Mapping the existing resources caseload of between 3 and 8 service are aiming to collaborate with the possible. Our analysis of data from that are relevant and local to each users per full time support worker, individual and support them to the Waves of Hope project shows that individual (this might include a range depending on progress and mix of find and implement solutions, not this cohort needs to access a wide of centres, hubs, charities and social support needs. However, it is the impose a plan on them: this fits with and varied range of other facilities enterprises as well as arts, leisure, quality of the relationships, as much the concepts of co-production and and services in order to achieve some health, public transport resources as the amount of support which personalisation. degree of stability: it would be neither – workers should be urged to also will really distinguish it from current • Where traditional models of support possible nor desirable for the support think outside of ‘services’). We models. A key principle here is that have focused on identifying needs team to try and meet all these present some examples of existing the relationship with the team is the and deficits, a key element of the needs directly. enterprises at the end of this chapter service. As they build this relationship, strengths-based model proposed the team will have the skills, support here will be to find out and build 43 Pleace, N. (2016) Housing First Europe Guide Brussels: FEANTSA. and networks to provide to the tenant on what the person does not need 44 Lee, B.A., Tyler, K.A. and Wright, J.D. (2010) The New Homelessness Revisited, Annual Review of (as and when needed): help to do, what keeps them strong, Sociology 36 pp.501-521; Pleace, N. (2016). Researching Homelessness in Europe: Theoretical Perspectives. European Journal of Homelessness, 10.3, pp.19-44. 56 Housing First feasibility study for Liverpool City Region The model 57

in section 4.14, which might form “I did manage to stop using • If it is to succeed in the long term, In our focus group of people with the starting point of such mapping; during the time I got that the Housing First service must be lived experience, it was agreed that it • Working at the pace of each place – I just kept myself to integrated into a comprehensive is better to build relationships with a individual to link them into the myself. I was there for about preventative homelessness strategy, few different workers (provided this resources they want and need to outlined in section 4.1. If this is small team is consistent both in terms access. This may involve the worker 6 years. I was on Methadone working effectively and ‘graduates’ of personnel and approach) since ‘you – or a volunteer – accompanying and I didn’t get into trouble of the Housing First system have would get different things from each them, at least initially, and advocating with the police or anything, been given clear information about of them’. It should be noted however, for them where necessary but with but it was tough because I the access points to it, they should that this caseload would need to be the aim to withdraw (gradually and be able to re-enter prevention built up gradually and monitored flexibly) where possible; didn’t get any support while services quickly. carefully, since it is likely that people • Where there are gaps or barriers to I was in the flat. I didn’t need will need very intensive support in the these resources, using a combination someone supporting me all the 4.5 Team structure early weeks. of spot purchasing through a small time but when you need some As the following chart shows, we are flexible budget (we discuss this proposing teams of four workers, The consensus from our engagement idea in more detail in sections 4.8 support, you need to be able supervised by one team leader and event with support providers was and 4.12) and strategic influencing to see someone but you have supporting between them a caseload that, in order to recruit a team that to stimulate commissioning, e.g. to go back to square one with of around 20. This reflects the can deliver this service according through social prescribing or the appointments and waiting lists caseload size in other Housing First to the Housing First principles, NHS’s self-care agenda. – you have to start again”. schemes around the country and the it will be necessary to focus on • Excellent managers supervising small shared team caseload approach should values, behaviours, attitudes and teams of four workers to support avoid the need for outside cover to aptitudes during recruitment and and challenge the promotion of A two-pronged approach seems be brought in (especially as the team selection. Although there will be independence, through a culture of necessary if people are to be supported leader could step in where necessary). advantages in recruiting a team with positive risk-taking. We have costed during crisis and further episodes of on the basis of a 1:4 team leader: homelessness prevented, i.e.: staff ratio, which we recognise makes the service more expensive than • The Housing First service should Each Housing First team like this will other models, but we believe this have enough flexibility to taper Components of have access to the following (shared will be key to its success. support or allow cases to stay Housing First Team with other Housing First teams): dormant without being closed. We expect support to taper for As in the Camden example, even most people as they are linked those who have graduated can into other networks, activities and be encouraged to get in touch, Team Housing brokered services, however this should happen especially if they encounter a crisis or Leader by Local Lettings organically rather than being imposed a relapse, or their tenancy is at risk. Agency by commissioning targets. The response to this might range In the interviews with people with from a one-off session to intensive lived experience, we heard how support through a crisis, so the (option for seconded) some of this cohort had previously caseload management will need 4 x Housing Support workers (including with Mental Health worker: sustained independent tenancies for to factor in some flexibility here. for 2nd tier support long periods of time but had then lost Assuming that the individual had lived experience) these following a crisis, which typically been successfully linked into other involved or triggered a relapse into networks first time around, this drug use or an episode of poor support should be complementary Wellbeing 24/7 mental health. to this, rather than a wraparound Work as a team to facilitator / work and on call substitute for it. This policy can be support 20 people learning coach service Case study supported in practice by ongoing, We interviewed Lee at an emergency low-key ways of keeping in touch shelter. He told us he had been in with ‘graduates’, these might include several hostels in the past and that, use of social media, texts, occasional Input from volunteer following a stay in one hostel, and phone calls, social events or drop- and trainee having stopped using Heroin, he had ins, the sending of Christmas and peer mentors been set up with a flat of his own: Birthday cards, etc. 58 Housing First feasibility study for Liverpool City Region The model 59

a range of experience, both lived and to manage performance and either across the service or in individual housing officers; and professional, and from across a caseload effectively. To enable this, individual cases. individual charities are trying number of specialisms and sectors, the we have deliberately kept team sizes to build relationships with ability to engage people with complex small, with each team leader line One challenge identified by some individual PRS landlords. needs, to work in a strengths-based managing four paid members of professionals and people with lived way and be open to self-reflection and staff. The team should also receive experience was that some potential Everyone is spending a lot of development should be ranked the ongoing, regular team and individual Housing First tenants might be time on this and the result is highest on the person specification clinical supervision. We anticipate that vulnerable to exploitation, harassment a slow inconsistent, lottery: nd for these posts. This reflects the the project’s 2 tier mental health or abuse from others. This might there is no immediate cohesive evaluation of Camden Housing First specialist (see further details in section include: current or former violent (Pleace & Bretherton 2013)45 which 4.9) would facilitate case-related partners; individuals or gangs to whom system for brokering housing”. found that recruiting workers with the supervision with the team, but that debts are owed; harassment from Support provider right experience and attitudes had external personal supervision should neighbours or local youths; or other been a key success factor. Using these also be available to support staff drinkers/ drug users who might try to Efficient access to suitable housing criteria should also remove some of the members.. take advantage or invite themselves is absolutely critical to the proposed barriers to the inclusion of people with around. The Housing First service will model of a Housing First scheme lived experience within the Housing 4.6 Hours of operation work collaboratively with the individual embedded within a wider housing-led First team – a point we discuss in more We anticipate that the team would pre-tenancy, on sign-up and over time response to homelessness. detail in section 4.11 below. operate a flexible rota, covering to develop and implement personalised early evenings and weekends strategies, which might include: Initial engagement with local These roles should be relatively between them, as and when this is Registered Providers, the Liverpool well-paid if they are to recruit and felt necessary to respond to tenants’ • Selecting a property type and Private Sector Licensing Scheme retain the best people. We suggest needs. The capacity to respond 24 location to maximize safety, Manager and the National Housing costings for the model in Chapter 6, hours a day within the community (i.e. anonymity and distance from Federation suggests there may be and these allow for a pay scale which outside of hostel settings) was felt to previous peer groups; an appetite amongst both social and is significantly higher (£27-£30K per be a missing part of the current system • Target-hardening work, which might private sector landlords to support annum) than the current market rate by support workers providing outreach include the installation of security the proposed Housing First model. for homelessness support workers or trying to facilitate move-on from equipment in some properties, However, local authorities and (£20-25K per annum according to the hostels into independent tenancies for perhaps to link in with the existing homelessness support providers providers we consulted). people with complex needs. telecare system; have highlighted the challenges in • Training people to manage access acquiring properties for this client In addition to the standard topics (e.g. Outside of normal office hours, there to their homes; group in the current climate, given the safeguarding, health & safety, equality will be an emergency call system. • Monitoring and/or responding to combination of welfare reform (and a & diversity, etc), the team(s) will need A basic telecare system fitted into security challenges through a joint lack of 1-bedroom / shared housing in initial and ongoing training on the Housing First properties, would allow problem-solving approach with some parts of LCR), and the allocations following: tenants to call for assistance out of the tenant, drawing in the support policies and ‘risk averse practice’ of • Psychologically informed hours. We expect this out of hours of housing provider, police and many Registered Providers. approaches, motivational contract to be held by an existing call community safety teams, etc. interviewing, attachment-based handler, working to a call protocol where necessary. Registered Providers highlighted their approaches, etc; developed in conjunction with the Such strategies would need to be need for reassurance in relation to the • Working with people with complex Housing First staff and tenants. The sensitive to any concerns of the tenant level, quality and ongoing nature of the needs, including mental health, call handler might contact a range (e.g. not wanting to appear to have support which tenants would receive substance use, homelessness and of people in response to different called the Police) and aim to build their and, in particular, how support around offending; scenarios: emergency services; a peer capacity to manage their own property mental and other health would be • Asset-based community mentor, friend or family member; a assertively. levered in. We cover these points in the development and strength-based Housing First manager who is on call remaining sections of this chapter. In- practice; (our expectation is that an on-call rota 4.7 Access to housing depth work with prospective tenants would operate across all Housing First during assessment for Housing First Excellent management and supervision teams in LCR); or partnerships with “At the moment, housing should also include consideration will be essential in order to: understand 24-hour crisis counselling helplines, of how problems with any previous and implement the Housing First such as Samaritans or Alcoholics ‘brokerage’ is happening in a tenancies might be ‘designed out’, ethos, vision and culture consistently, Anonymous could be established, really ad hoc way – individual by location, support and personal support workers are trying strategies. to build relationships with 45 Pleace, N. and Bretherton, J. (2013) Camden Housing First: A Housing First experiment in London York, Centre for Housing Policy, University of York 60 Housing First feasibility study for Liverpool City Region The model 61

Learning from other Housing First include: commercial landlords (who normally be found in the market, model. If we can make this projects suggests that finding housing are attracted by the prospect of a and working closely with either the complement the homelessness can be extremely time-consuming for longer term lease with guaranteed Housing First service or other floating strategy, then all the better”. support workers and would be best rental income and a management support services and community done outside of (but in partnership agreement); institutional or individual resources. with) the Housing First support team. property owners who are interested Renovating empty properties could One approach would be for the in putting properties to ethical use; A larger scale agency potentially generate training and employment Housing First model to employ one owners of empty properties; or brings greater flexibility, though opportunities for Housing First tenants or more housing brokers, who would social landlords who do not have the we are conscious that a number of – or perhaps even for EU migrants build relationships with individual capacity to manage properties for local social lettings agency models who are fit for work but currently Registered Providers and private higher risk tenants. The SLA might are being developed by Registered ineligible for benefits. sector landlords to find properties for also use its portfolio to attract social Providers in LCR, so establishing a individuals. This approach has been or private investment in order to buy flexible partnership model to ensure 4.8 Types of properties to be used successful for a number of existing some properties outright. Longer coordination (rather than competition) for Housing First projects in Liverpool, e.g. the PRS term leasing or outright ownership across the region will be important. access scheme at Whitechapel, the of properties should enable the SLA We also envisage a role for sub- “Even if it was just 2 houses Crisis Housing Coach, and Local to offer greater security of tenure contracting some services from here and blend them in with Solutions in Liverpool, who told us that than the standard Assured Shorthold Registered Providers – for example they had succeeding in finding around Tenancy. repairs services – or for SLAs to be the other houses, so they’re not 100 tenancies for their AIMS project • The types of properties sourced provided as offshoots or wholly- pointing and say ‘oh that’s the supporting younger homeless people – these could, for example, owned subsidiaries of existing housing estate where the people off the (see details at the end of the chapter). include flats, small family homes, providers, with the expertise and street live’ do you get what multi-occupied properties, and infrastructure they bring. However, However, in order to access properties properties with resident landlords we expect that there will need to be I’m saying?” at scale for a housing-led response – the capacity to cross-subsidise either a central coordinating body or to homelessness, the consensus was by making a surplus on some a partnership agreement for these “Yeah but the areas, what that a different approach was needed market-rented properties will almost across LCR. area would you be put in – within the system. This should include: certainly be key to the business plan. say round here is Kensington, • The groups of tenants it works with There was strong initial support for • A review of allocation policies of (as well as Housing First tenants, this the idea of an SLA model to improve which is renowned for its Property Pool Plus (and Under One should include all singles, couples access to properties across LCR, alcohol, drugs, prostitution, Roof in St Helens) and eviction and families who are (potentially) though a clear business model would thieving and so if you are process in view of the negative homeless; and possibly other groups, need to be worked up separately and going to throw them all in impact which they seem to be having such as people with disabilities, who, protocols developed to address in on this cohort; as our recent separate study for detail key questions about how this this place, no one is going • The development of a Local Lettings Liverpool City Council found, often might work with, involve and draw to get better”. Agency46 approach to facilitate the struggle to access suitable properties properties from Registered Providers, Interviewees with lived supply of and manage private and within the current system; and landlords’ associations and PRS experience social tenancies for the Housing • The range of packages it offers Licensing Schemes in the region. First service, for other homeless (or to landlords, which might include There was some appetite to find ways The consensus from the engagement potentially homeless) people and for taking on a partial or full housing to use some of the empty properties to inform this study was that there other groups of people in housing need. management role on behalf of the in the region within the Housing First needed to be a flexible menu of owners; furnishing and maintaining and/or Local Lettings Agency model. housing options which could be drawn In order to build a business model that the property or even – in the case One Local Authority Strategic Housing on to house Housing First (and others draws on multiple sources of funding of empty or sub-standard properties Lead explained: who need housing but with lower and cross-subsidy, the Local Lettings – improving them. The approach to levels of support), rather than a one- Agency model needs to be very housing management undertaken “We have Empty Property size-fits-all model. flexible in terms of: by the SLA would be “sympathetic” Dwelling Orders on about six - exercising a degree of tolerance This might include: • Where and how properties are and understanding of tenant needs properties in the borough at sourced – this could, for example, beyond and above what would present, at least one of which • Individual flats or houses in different is a one-bed flat, so we hope to areas across LCR: for some people 46 We are using the term Local (instead of the more common Social) Lettings Agency since we anticipate renovate these and bring them it will be important to stay close to both private and social rented housing being managed within this model. Crisis has produced two existing networks; others need to get publications on good practice in relation to Social Lettings Agencies: see https://www.crisis.org.uk/ into a future social lettings as far away as possible; some people ending-homelessness/housing-centre/housing-centre-guides/social-lettings-agency-guide/ “Maybe a mentor – yeah. Somebody who’s got experience in your situation – so, if you have got an alcohol problem, somebody who can tell you, “Look, these are the things that they have had to go through to better themselves and carried on – a peer maybe like that.” Interviewee with lived experience of homelessness

62 Housing First feasibility study for Liverpool City Region The model 63

are likely to achieve better outcomes soft furnishings, or appliances. This dedicated (and possibly seconded) people to access mainstream health in ‘nicer’ areas; some may find this might be through: mental health specialist whose roles services, i.e. helping them to register daunting and feel more at risk of will include: with and access NHS services via their not fitting in or being rejected by • Personal budgets: this approach has local GP. Support from the team may neighbours; been used successfully by Camden • Organising or delivering ongoing include accompanying people to • Housing First in mainstream Housing First and Local Solutions learning and development to the appointments, chasing up referrals, sheltered tenancies might be an AIMS project in Liverpool, where Housing First service in relation to helping people to organise their option for older homeless people clients have used flexible budgets psychologically informed approaches prescriptions and helping them to with complex needs. Mainstay data to decorate their properties, buy and tools; remember and respond (according to for LCR shows that 5 people have televisions or black-out blinds; • Supporting the team(s) to develop their own wishes) to medical advice. presented for assessment following • Support to choose or even restore and implement psychologically- loss of sheltered tenancies and a furniture items through upcycling informed tools and strategies with A significant minority of those who further 59 have moved into sheltered projects; individual tenants, mostly through meet the criteria for Housing First are tenancies from the hostel pathway • Accessing help or resources to second tier clinical supervision but likely to have long term physical as well in just under 4 years. We know from improve their home through a with some direct assessment where as mental health conditions48. A our research in Liverpool, that there Timebanking scheme (as described this is felt to be necessary; recurring theme from our focus can be tenancy sustainment, social in section 4.12 below). • Providing regular team case- groups with local authority integration and staff training issues based supervision (though clinical commissioners was that there are here and that many schemes now 4.9 Mental health supervision for individual team increasing numbers of long term have minimal warden support. members might be best brought in homeless people with multiple health • Shared tenancies have been found “We need confidence in these externally); and conditions, giving rise to the need for to work in some cases within other changes – at the moment, • Building strong referral relationships, personal care. Some of this group will Housing First projects and should not advising the service and assessing have care needs which are too high to be ruled out, as they can make more people are waiting 26 weeks / advocating for tenants where be moved into an independent desirable areas affordable within for a mental health assessment there is or may be a need to access tenancy; congregate Housing First may Local Housing Allowance rates and and this makes us nervous in mainstream prescribing and/or work for some; other Housing First can help to counter social isolation, if relation to sustainability.” secondary mental health services. tenants are likely to develop care tenants are well-matched (ideally by needs over time. each other) and properly supported. The strengths-based principles of The work of Housing First Italia, a “Health and mental health Housing First will run through this part The need to be able to access (and, consortium of Italian homelessness has to be a significant part of its work, i.e.: for many, re-access) detoxification and service providers, fio.PSD and of the jigsaw”. rehabilitation services was a recurring academics, has centred on how to • The Housing First team will assume theme in the qualitative research with use shared housing (as the Italian Registered Providers that all behaviour (even that which people with lived experience. Some benefits and social housing systems is perplexing or might be construed felt they would need to do this before will not supply lone adults with self- Gaps in the current provision of as ‘difficult’ or ‘challenging’) has taking up a tenancy; but it is also contained housing on a predictable mental health support for the potential a function and that it their job to possible that a supervised home detox basis). Specific management Housing First cohort were a recurring work with the individual to seek to with access to recovery communities issues arise, focusing on managing theme in the engagement and, if not understand this function; and emotional and psychological relationships with neighbours and addressed, these were highlighted as • The team will work holistically and support from the Housing First team with service users sharing the same key risks to the project by housing and collaboratively with the individual, would work well for some. space, but some successes have support providers. drawing on both psychological tools been achieved47. and wider community resources During the engagement for this study, • Some people will need accessible The proposed model responds to the and networks to help them build a number of existing resources were properties. often unmet need for psychologically their resilience. This approach highlighted which could potentially informed emotional support for this is designed to complement any support the work of Housing First in A basic furniture package would cohort by skilling up the Housing necessary medical interventions, accessing health and social care for its need to be provided to Housing First First team, with whom individuals such as prescription medication or tenants. These included: tenants. However, it makes sense to will already have built consistent psychiatric assessment. create opportunities for choice and and trusting relationships, to provide • Community Matrons: experienced, a sense of personal ownership in this support directly. The service will 4.10 Access to health and social care skilled nurses (accessed via GP acquiring additional goods, such as receive second tier support from a The Housing First service will operate referral) who will coordinate all the on the general principle of supporting health and social care needs of

47 http://www.housingfirstitalia.org/en/ 48 Homeless Link (2014) The Unhealthy State of Homelessness, Health Audit Results 2014 64 Housing First feasibility study for Liverpool City Region The model 65

patients who suffer with complex Integrated Programme Manager with experience into paid Housing First of Hope and Crisis Skylight volunteer long term conditions and currently responsibility for complex needs, but support worker roles. The person recently established traineeship have a very high intensity use of more detailed mapping of relevant specification criteria, with their focus programme that could potentially health care. post holders and initiatives across LCR on values, attitudes, behaviours provide a source of managed and • Social Care in Practice (Halton): will need to be undertaken if this is to and aptitudes, rather than on supported volunteers for the Housing This project, which is jointly be achieved at the city region level. formal education or professional First programme, which would avoid commissioned by Halton MBC and experience, should remove some the need to set up and manage an in- CCG, bases a Community Care There was also some discussion of the barriers for this group and house programme, at least in the early worker in each GP surgery in Halton about the need for trained, specialist this approach has been put into phases of development. to identify social care needs and domiciliary care workers to support practice by Turning Point Scotland’s arrange for these to be met. Housing First tenants who have Housing First Service in Glasgow. 4.12 Asset-based community • Occupational Therapists – who can personal care needs. There seems Lived experience should be valued development play a key role supporting people to to be gap in the market here, within the selection process but it live independently with mental health which might be filled by an existing should not ‘trump’ the ability to work “I don’t like my own company, – as well as physical – conditions. domiciliary care agency recruiting, in accordance with the Housing First so I need people around me training and developing some staff to principles. Feedback from professionals work with people with complex needs, • Progression routes to help people and I also need support like highlighted the learning and or by a housing or support provider with lived experience to build emotional support, and also to development needs of many health with experience in the homelessness confidence, and develop and go on the courses they do”. professionals in relation to working sector seeking registration with the demonstrate their abilities to support with people with complex needs. Care Quality Commission. others are also essential if applying for and being selected for these “One of the support workers The Brownlow Health Centre in 4.11 Peer support posts is to be a realistic proposition from Crisis came round to the city centre holds the current for many people with lived experience. visit me weekly, and we would enhanced GP service for the homeless “Maybe a mentor – yeah. go out and just have a cup of and hostel-dwelling population in Somebody who’s got Inspiring Change Manchester offers Liverpool and the practice has nurses a full career development pathway for coffee somewhere and each and clinicians experienced in working experience in your situation – people with lived experience through time we would go a little bit with the potential Housing First cohort. so, if you have got an alcohol its GROW traineeship programme. further afield. He just got me In the future model for homelessness problem, somebody who can Many of those on the 12 month paid talking and socialising with services in LCR presented here, we tell you, “Look, these are the GROW traineeship scheme were other people, and that saved take the view that there is an ongoing previously working as volunteer peer need for the direct provision of this things that they have had to go mentors but, having applied and been my life”. enhanced service, where people through to better themselves interviewed for the highly competitive Interviewees with lived are on the streets or in very short- and carried on – a peer maybe GROW placements, are now being experience of homelessness term hostel placements awaiting like that.” paid to work in a range of settings, re-housing. However, we can also whilst receiving training, support and envisage a key role for Brownlow in Interviewee with lived development opportunities. See http:// Fear of isolation or rejection by the training and development – supporting experience of homelessness icmblog.shelter.org.uk/grows/ for community within a Housing First mainstream services to work with further information, including a short model are key concerns of both Housing First tenants and Housing First Many of those we interviewed – both film made by the trainees. people with lived experience and workers to provide health advocacy those with lived and professional the professionals that support them. to those they support. experience – felt that peer mentors The Housing First service could Several raised concerns that resettled could and should play a key role in the provide volunteering and trainee people will drift back to town and Health professionals argued delivery of the Housing First service. placement opportunities to city centres – perhaps to beg and that the tools of integrated care However, others raised a number of supplement the work of the paid buy drugs – but also because that should underpin Housing First if concerns – about this being tokenistic, support workers. This is a model used is where their community is. As one it is to succeed in the effective or poorly managed, or about the risk by Waves of Hope in their Peer Mentor professional argued: case management of people with that some recovered addicts will take a Service - a team of trained volunteers complex needs, including long term hard line on abstinence. To respond to with lived experience who are ‘Our systems tend to ignore the conditions. These should include: these concerns, we propose a model matched to a client and will support fact that we are social beings good information sharing protocols, which includes: them by sharing their own experiences case planning meetings and reviews, and coping mechanisms, as well as – so any model needs to really hospital avoidance plans, etc. Liverpool • Positive action to encourage the accompanying clients to informal address this if it is to succeed’. CCG has recently appointed an recruitment of people with lived activities or appointments. Both Waves 66 Housing First feasibility study for Liverpool City Region The model 67

Over time, the Housing First service’s organisations. People can then ‘spend’ scenarios and budgets, so in some to key members of the panel to ability to link people into alternative these credits on activities and services settings, the rent-free volunteer is make decisions between meetings and mutually supporting communities provided by supporting organisations replaced with a community hub. should be established. It should be and facilitate resettled homeless – these might range from a haircut noted that this multi-agency approval people to make a contribution will or sports massage to guitar lessons A KeyRing might not work for Housing process will only be required for entry be a key success factor. Ideally, the or a ticket for a football match. This First tenants from the outset, but this to the Housing First (intense and Housing First team would connect model has been used with homeless could be a possible mechanism for ongoing case management) service, with some form of asset-based people in a number of settings, organising mutual support between not to the process of fast-tracking community development. Local including the Broadway Timebank those tenants who want to be involved, homeless people into tenancies with Area Coordination49 or other Asset- and a number of projects run by Just especially if and when their need for or without lower level floating support. based Community Development50 is Add Spice51 In the evaluation of the support from the service tapers. Some This system aims to promote better operating in some parts of the UK, Broadway scheme, the model was version of a KeyRing network might be information sharing and buy-in to working to connect individuals, not very successful in engaging flexibly a way of connecting those in recovery Housing First, but also to protect the only to services, but also to each other with people experiencing a range of with a mix of other local people (e.g. investment in and cost effectiveness of via shared interests. There may be support needs, which fits alongside older people or people with disabilities) the more intensive service. similar projects in LCR but this study the ethos of Housing First (Bretherton in their communities who need some has not discovered any. However, there & Pleace, 201452). A Timebank could support and can offer some in return. Learning from the Fulfilling Lives are a significant number of existing cover Housing First tenants only, or be (Big Lottery) programme suggests enterprises offering volunteering and open more widely to those who are 4.13 Referral routes and assessment that there are benefits in closing and ETE opportunities and opportunities to or were homeless, or include others If Housing First is to function efficiently reviewing the referrals process after become part of a recovery community. from local communities.The Richmond as part of a wider preventative the first 2-3 months of operation. We have identified (and listed at the Fellowship is developing a Timebank strategy and housing-led response This should allow the opportunity to end of this chapter in section 4.17) across Liverpool, particularly aimed at to homelessness, excellent triage check that the right people are coming some of the promising enterprises people with mental health challenges. by outreach and Housing Options into the service and to revise referral within LCR which Housing First tenants teams will be vital, so that people are processes where necessary. might access to help them develop their KeyRing: KeyRing Suppork Networks53 referred appropriately for a housing- resilience and meet positive peer groups. have been running in the UK for only response; a lower intensity Whilst getting people into independent 25 years. The simple model was support intervention or a Housing tenancies as soon as possible should Flexible personalised budgets have initially designed to support people First service. Interviewees stressed the be the service’s aim, our interviews been used successfully in other with learning disabilities living in the importance of clear referral routes with Housing First projects in other Housing First projects to allow community, but has been adapted to to Housing First from criminal justice areas and with homeless people tenants (with approval from support other client groups, including people and health agencies, as well as from themselves has shown the need for workers) to access a range of leisure with mental health challenges, older homelessness outreach and Housing and importance of significant and opportunities – including camping people and those who have been Options services. high quality pre-tenancy engagement. trips, football matches, music concerts involved in the criminal justice system. To ensure continuity, the Housing and cinema tickets. A typical network involves 10 people Once referrals have been made, First team should begin to work with living in individual properties dispersed assessments should be under-taken someone as soon as they are referred, Other models which might usefully be within a neighbourhood; nine of these by the Housing First service and ideally whether they are on the streets, in stimulated, provided by Housing First have support needs, the tenth is a approved by a multi-agency panel temporary accommodation, or in or commissioned to run alongside it volunteer (who typically lives rent-free). operating in each authority, so as to prison or another institution. Through include: The network members are supported secure the commitment of a range of this they can: by the volunteer but, more importantly agencies to supporting this individual A Timebank: a Timebank (or skills are facilitated by them to support each (and to the scheme as a whole). There • Build a relationship; exchange) allows its members to other and to link in with things going are a range of existing multi-agency • Help the individual to understand earn credits by undertaking voluntary on in their local communities. The panels across the region, including how Housing First works and work to assist other individuals or model has been adapted to fit different those which consider cases of people what their options, rights and with complex needs or other high responsibilities are within it, and to priority/ risk housing panels, which make an informed decision about 49 See http://lacnetwork.org for further details 50 See http://www.nurturedevelopment.org/wp-content/uploads/2016/01/ND-training-offer-Recovery- could be used or adapted for this whether they want to do it; Asset-Based.pdf for further details purpose. • Consider the type and location of the 51 Social enterprise, Just Add Spice works with organisations across the UK to help them set up and run property and other things that might TimeBanks: their web site includes case studies and toolkits: http://www.justaddspice.org/our-work It will, however, be important that The following case study is of a homeless man benefitting from a timebank: http://www.justaddspice. help to ‘design-out’ any problems org/case-study/volunteering-helps-gary-feel-confident entry to Housing First is not delayed that have occurred with previous 52 Bretherton, J. & Pleace, N. (2014) An Evaluation of the Broadway Skills Exchange Time Bank, Centre by the need to await the next panel, so tenancies; for Housing Policy, University of York a mechanism for delegating authority • View and choose properties. 53 See http://www.keyring.org for further information 68 Housing First feasibility study for Liverpool City Region The model 69

Whilst entering short-term Table 4.1. Estimated demand for will serve a wider cohort than those First service and the rest of this system accommodation should not be a Housing First 2018-2028 people supported by Housing First. will be key to the success of both. condition for assessment or for In this section, we propose the key acceptance onto Housing First, short Year No of Units The other components consist of: components of the linkages between term housing will need to be provided the two. as an option for rough sleepers, 2018 310 • Access to 24/7 on call system with while this process is completed 2019 346 response service as necessary We have emphasised the importance and properties are found. Learning 2020 410 • Second tier mental health support of the ‘high fidelity’ Housing First from other areas suggests that this • Wellbeing support and coaching for model being effectively targeted 2021 468 engagement and property finding learning and work skills at those with the highest needs. period can take several months, 2022 519 However, we recognise that, in though we would hope to speed this 2023 543 We have sense tested the likely costs practice, it is not so easy to distinguish up with the Local Lettings Agency 2024 555 of this model, particularly in relation this group from everyone else in model. We discuss this further to staffing, with local stakeholders, a clear-cut way: Whilst many of 2025 554 in Chapter 6 under transitional including both commissioners and the people in the homelessness arrangements. 2026 538 existing providers of housing and system have some degree of issue 2027 514 support for homeless people in with mental health, substance use, 4.14 Estimating demand for the 2028 480 the LCR. disability, offending, etc and that Housing First model in the LCR these needs often interact with each There are three elements to estimating From these, we have projected the other and typically fluctuate over the demand for Housing First across Initially the numbers required reflects overall cost for the proposed Housing time. In addition, there are a group of the LCR: the significant backlog of need. Over First model. Based on the operating people approaching services with a time this dissipates as the numbers of model of 20 clients per core staff need for just housing related support • Estimating the current unmet the initial clients decreases, and after team, the projected annual cost (for 20 and access. The system will need to demand for Housing First based on the seventh year of the programme clients) is £252,141. The assumptions provide a housing-led solution for an analysis of Mainstay; the number of units required begins and calculations are shown in full at them to prevent spells of insecure • Estimating the newly-arising demand to reduce. However, this projection is Appendix 4. This equates to a cost per accommodation and rough sleeping for Housing First year on year using dependent on the rest of the system client per annum of £12,607. which then, typically, lead to the assumptions built into a recent needs – the prevention activities and the development of other support needs. assessment exercise for Liverpool housing-led offer to those who do not However, if a more personalised City Council; need the more intensive Housing First model was subsequently introduced, If the system is to effectively engage, • Estimating the proportion of people support. If these are not functioning for example as in some other Housing triage and respond flexibly to the who would cease to use Housing well, the demand for Housing First First schemes where clients have access needs of all homeless people, the First over time based on the result of would increase. to a ‘personal budget’, this would following will be necessary: Housing First evaluations to date potentially be an additional cost if it was 4.15 The cost of the proposed not built into the ‘core’ support. • Consistent application of the This enables the estimated demand Housing First model Housing First principles: across the to be calculated for the number of The costs associated with Housing First 4.16 How will the Housing First system, ie. in housing-led floating housing units required for Housing in the LCR are based on the proposed service link to the wider housing- support services, outreach/ Housing First at any one point.The detailed model that has been developed with led system? Options teams and in emergency method used to calculate the local stakeholders, as set out above. In Chapter 3, we discussed the accommodation/ triage. Where a estimated demand for Housing First The key elements of the proposed importance of the Housing First timely offer of housing is seen as across the LCR is shown at Appendix model that need to be considered system sitting within a wider reformed the requirement for anyone whose 4. Based on the three elements set out in terms of costing are based on the system, which focuses on the homelessness cannot be prevented above and the detailed method set out following core components: prevention of homelessness and takes regardless of their level of need in Appendix 4, the estimated demand a housing-led response to it wherever for support. for Housing First ‘units’ (i.e. capacity) is • The core Housing First staffing team, possible. If this wider system change • A shared understanding of how shown in table 4.1. i.e. the support service, including does not occur, then Housing First the homelessness systemworks an allowance for the organisational can only have limited and short term by all those working in it, but also overhead to support them success as any capacity freed up in the by relevant statutory and voluntary • A local lettings agency (LLA) to system will rapidly be filled by others sector agencies across LCR: this deliver access to (and potentially not receiving the appropriate access will require the development management of) the housing to independent accommodation. and implementation of a clear required for Housing First to operate; Consistency, clear pathways and good communications strategy. although it is assumed that the LLA communication between the Housing • Minimised and well-managed 70 Housing First feasibility study for Liverpool City Region The model 71

handovers: Our research with service will need training, ongoing Addaction works across Merseyside PSS runs wellbeing activities and people with lived experience has professional development and offering a range of services helping recovery focused courses at its three highlighted the risks and challenges performance management if they are people overcome their problems with hubs across Liverpool. These include in relation to referral and transition to understand and effectively apply drugs and alcohol through specialised courses on self-management, creative between services. The more people these principles. support and advice. Support can arts, digital technology, physical health are ‘passed’ through a number of • Supply of housing: we anticipate also be offered around employment, and peer support. different teams and services, the that the local lettings agency (or housing, debt and family relationships. http://www.psspeople.com/how-pss- less likely the system is to work. This agencies) will be pivotal in supplying https://www.addaction.org.uk/ can-help/look-after-my-health/and- will need to be considered carefully housing through the system: both help-me-change-the-way-i-think both in deciding how to commission to Housing First and housing-led Central Liverpool Credit Union is services and in setting up operational clients. In order for this to deliver a non-profit making, financial co- The Spider Project is a creative arts, policies and procedures. Sometimes consistently and at scale, it will need operative that exists solely for the health and well-being recovery project it can help if workers in different to be flexible in relation to how it benefit of its members. It provides based on the Wirral. The project parts of the system work for the works, particularly with Registered members with banking services, supports people recovering from same organisation, however Providers – there should not, for affordable loans, help with money substance misuse and/or mental health shared vision, clear handover and example, be a requirement that all management and aims to encourage problems. information sharing protocols, joint requests for housing go through the regular savings and provide financial https://www.spiderproject.org.uk/ training and regular meetings are agency where direct arrangements assistance as required. absolutely critical if people are to can be made with landlords. In http://www.centralcu.co.uk/index.asp Tomorrow’s Women Wirral is a be moved ‘up’ or ‘down’ smoothly fact, we would hope that, following charity-run community centre for between the more intensive Housing a review of allocations policies Crisis Skylight Centre works across women – some of whom are serving First and the less intensive Housing- more arrangements can be made Merseyside, offering housing, community sentences, but many led floating support services. through Property Pool Plus or education, work and life coaching; of whom have referred themselves • Flexible commissioning of services: directly with landlords. Although the educational, vocational and because of social isolation, low we discuss the way in which services lettings agency can offer housing recreational courses; volunteer self-esteem or simply to find a new need to be commissioned in more management this is only an option and paid trainee opportunities for direction in life. The centre offers a detail in Chapter 5. Although this for social landlords and one which people who are homeless or have non-judgemental mutually supportive is most pertinent in relation to can be reviewed and revised over experienced homelessness. community; a range of courses, Housing First, the commissioning time. For example, a Registered https://www.crisis.org.uk/get-help/ activities and access to specialist help; and contract management of Provider without sufficient capacity merseyside/services/how-we- and a beautiful garden tended by its housing-led floating support will also to provide housing management for can-help-you-at-crisis-skylight- members. need to be such that it can support someone deemed ‘high risk’ might merseyside/ http://www.tomorrowswomen.org. genuine flexibility. People’s need for choose to ‘buy’ this service from uk/home/about-us support in order to sustain a tenancy the local lettings agency, but might Local Solutions runs the AIMS within the housing-led services wish to take this back in house if the (Accommodation, Intense Mentoring, YMCA Liverpool’s Dutch Farm is an will vary both in terms of intensity person has been stable for a long time. Skills) to support young homeless urban farm project which engages and duration. The system needs to people (aged 18-24) in Liverpool service users in therapeutic and be able to respond to this so that 4.17 Examples of existing LCR and Knowsley to transform their meaningful activity, growing organic artificial boundaries do not create resources which Housing First might lives. From its hub on the North side vegetables and keeping chickens. perverse and ineffective referrals. support people to access of the city centre, AIMS runs skills http://www.liverpoolymca.org.uk/ For example, someone who needs Action on Addiction has set up the training programmes (offering a £5 about-us/dutch-farm/ relatively low level support being first dry (non-alcoholic) bar and daily attendance allowance and travel referred to Housing First simply venue – The Brink – in the centre of expenses), access to leisure activities, St Helens Gateway is a community because they have needed this for Liverpool. Open during the day and holistic support from mentors, access to hub of information, bringing together more than 12 months and this is the into the early evening, The Brink is a internet/ IT, washing machines, breakfast all health, social care and wellbeing cut-off for floating support. social enterprise which has its roots and a positive environment in which to information into one central place. It is • Workforce development: in Liverpool’s recovery community relax, socialise and get things done. an independent, confidential and free Underpinned by this more flexible but is used by a wide cross-section service provided by the Millennium approach to commissioning (and of people. It runs a programme of Everton in the Community provides Centre and is available online, by email, staff management) staff working events – from big screen football to sports and other social activities across over the phone and face-to-face. throughout the system – in Housing meditation and Tai Chi, live music Merseyside. There are a range of http://www.sthelensgateway.info/ Options, housing providers, events, support and discussion groups, projects to get involved in with a focus about-us/ outreach, in emergency hostel and exhibitions of local art works. on health, sports, employment and provision, and in floating support, http://thebrinkliverpool.com/support. education. as well as in the Housing First php http://www.evertonfc.com/community 72 Housing First feasibility study for Liverpool City Region What will it cost? 73

approach, i.e. seeking to make for Housing First could be based on available housing with support to an existing service but with bespoke people who are homeless or at risk response protocols developed of homelessness specifically for Housing First clients. • Housing First as a discrete but integrated component of this 2nd tier mental health support could be What will ‘housing led’ approach provided in different ways, including • A reduction in the provision of 24/7 seconding a role from NHS services hostel type supported housing to support the core Housing First for homeless people with residual staff team or including this element provision of this type of supported alongside the ‘core’ Housing First housing as the service model for team as part of what needs to be it cost? people for whom none of the other commissioned. options suit their needs • Some retained supported housing Similarly, the provision of wellbeing without 24/7 cover. support and work/learning coaching could be provided as part of existing The proposed model for Housing services supporting homeless people First has been used as the basis for or alongside the ‘core’ Housing First Chapter 5: Financial and establishing what may need to be team. Based on the evidence from commissioned to realise the model discussions with local stakeholders and Commissioning Implications in practice. The key elements of the from other Housing First services the Housing First model that have been minimum requirements of the model identified as necessary to deliver the that will need to be commissioned are: model consist of: In this chapter, we suggest the implementation • The core Housing First staffing team, arrangements for the most feasible approach to • The core Housing First staffing i.e. the support service that is part of component consisting of a Team Housing First, including an allowance establishing the proposed Housing First model across Leader with 4 Housing Support for the organisational overhead to the LCR as part of an integrated strategy for preventing Workers (for every 20 people support them. supported by Housing First), • A local lettings agency to deliver homelessness. including an allowance for the access to (and potentially the organisational overhead to support management of) housing (although this team. as noted this will be of use to a Housing First is intended to support across the LCR. This is based on work • Access to housing and potentially wider cohort). that strategy through meeting the with a wide range of stakeholders to the management of such housing requirements of a pool of high need develop the proposed Housing First through a local lettings agency. Whether the other elements that people stuck in the existing systems, operating model and the likely size and • Access to 24/7 on call system and support the Housing First model will providing more comprehensive nature of the potential cohort intended response. need to be commissioned alongside coverage for high need groups and to benefit from Housing First. • 2nd tier mental health support. these two primary components will largely paying for itself by allowing • Wellbeing support and work/learning depend on whether, and the degree to hostel provision to be significantly In considering what needs to be coaching. which, they can be drawn from and/or reduced over time, whilst recognising commissioned and how, it is also based on existing service provision. that some emergency and specialist necessary to ‘contextualise’ the It is possible to view the Housing First services still might be required. proposed approach to Housing model as a discrete service consisting Evidence from other Housing First First as part of wider ‘housing led’ of all the elements listed above, services and studies 5.1. Housing First: Commissioning strategy to preventing and managing however, some of these elements Existing research has shown that approach homelessness, as set out in Chapter 3. are also part of supporting the wider Housing First pilots in the UK can be The key changes envisaged to the system. For example, we expect vulnerable to insecure funding streams What needs to be commissioned? current system include: that the local lettings agency would when they are run as experiments, We have identified what will need to broker access to housing for the wider rather than as an integral part of a be commissioned to establish the • A comprehensive approach to housing-led system and potentially for coordinated homelessness strategy. proposed Housing First model, and the homelessness prevention by local other client groups, such as people To secure funding, Housing First potential commissioning arrangements authorities with their partners with disabilities. The provision of a must be making a clear contribution required to implement this model • The adoption of a ‘housing led’ 24/7 on-call service and response to tackling long-term and recurrent 74 Housing First feasibility study for Liverpool City Region What will it cost? 75

homelessness, facilitating savings • The strong consensus amongst Table 5.1 Potential commissioning options for implementing Housing First in existing hostel and temporary local stakeholders that the current supported housing provision which homelessness system is not working Option Summary Description Implications can be redeployed to support well, especially for this group; and increased preventative activity and that a more strategic and innovative 1 Commissioning by each of the six • Local control over commissioning arrangements to support Housing First itself54. approach involving working across local authorities separately but to an • Unlikely to be sufficient demand in all six local authority areas for the agency and authorities boundaries is agreed Housing First model, proposed model In effect, this would mean a Housing • Risk of lack of consistency in how the Housing First model is commissioned Commissioning arrangements needed. First model being commissioned by and delivered across the LCR with potential for people to ‘gravitate’ to those and options • The significant changes proposed by each local authority for its area authorities with greater Housing First provision. It is necessary to appraise the Government to the future funding of • Less likely to address strategic cross-boundary issues affecting commissioning options for a supported housing, which includes homelessness that have been identified by stakeholders Housing First model across the existing hostel provision, within a • Partner organisations, mental health services, drug/alcohol services, criminal justice agencies, would need to work with a locally commissioned LCR to determine the most feasible relatively short timescale, by April Housing First service in each local authority area option. Based on feedback from a 2019. • Access to and the provision of suitable housing would need to be managed range of stakeholders, the following • Concerns about both the availability within each local authority area commissioning options have been of and access to 1-bed self- • Local connection within the LCR would remain a barrier identified: contained housing for people who • Ability to personalise the delivery of the service to clients may be easier at are homeless. local level • Very limited scope for economies of scale • Commissioning by each of the six local authorities separately but to In this context, the potential 2 Commissioning by ‘groups’ of local • This is a way of commissioning an agreed Housing First model across 2 or 3 an agreed Housing First model. commissioning options for authorities, e.g. across two groups cross-local authority areas to deliver a greater degree of consistency of 3 local authorities or another • There is scope to better address and manage variations in demand across • Commissioning by ‘groups’ of local implementing a Housing First model, combination different local authority areas authorities, e.g. across two groups and their implications, are set out • There is greater scope to commission and configure Housing First to better of three local authorities or another below. These options are presented to In effect, a degree of commissioning align with partner organisations, i.e. mental health services, drug/alcohol combination. differentiate the approaches that could of a Housing First model across local services, criminal justice agencies • Jointly commissioned by all six local be adopted; and are not intended to authority boundaries • There are different cross local authority boundary ‘permutations’ that may be possible for commissioning purposes (e.g. Liverpool, Knowsley and authorities across the whole LCR. be exhaustive. Table 5.1 summarises Sefton) but no established existing model for such commissioning the implications of each option. • Although this approach would better address strategic cross-boundary All these options assume that issues affecting homelessness, it would not necessarily provide a consistent local authorities will be the ‘lead’ pan-LCR approach commissioners of the proposed 3 Jointly commissioned by all six local • Commissioning an agreed Housing First model pan LCR would deliver a Housing First model, but that this will authorities across the whole LCR. consistent approach which could still be ‘tailored’ to suit local requirements be done in close partnership with NHS, • This approach would enable a Housing First service to be flexible in adapting criminal justice and other partners. In effect, a single Housing First to differing levels of need across different local authority areas approach covering the entire LCR, • It would require pan LCR governance arrangements but this would need to commissioned by or on behalf of all allow for local flexibility and responsiveness Key drivers and pressures LCR authorities • Some local authorities may be concerned about loss of control if the joint As we saw in Chapter 1, there governance arrangements are not robust are a number of key drivers and • More likely to address strategic cross-boundary issues affecting pressures facing LCR local authority homelessness that have been identified by stakeholders commissioners and their partners • Provides a more consistent and coherent approach to securing engagement of partner organisations, i.e. mental health services, drug/alcohol services, in considering the commissioning criminal justice agencies options for a Housing First model. • Provides a better opportunity to align the approach to commissioning and These include: implementing Housing First with the potential for additional powers being devolved to the LCR Combined Authority • Increasing levels of homelessness • Access to and the provision of suitable housing would need to be managed across the LCR; this could be challenging but could also provide economies including rough sleeping; of scale for a local lettings agency model • The high numbers of people with • Would need to consider how to ensure the service is still personalised to complex needs, who tend to get the individuals within a pan LCR commissioned approach. poorest outcomes from the system, • May take time to establish the necessary pan LCR commissioning often moving around a ‘revolving arrangements door’ for years.

54 Bretherton, J. and Pleace, N. (2015) Op. Cit. 76 Housing First feasibility study for Liverpool City Region What will it cost? 77

Option 1. Whilst this may result in a Considerations to test out wider approaches to “There is this huge political version of an agreed Housing First Service delivery and outcomes personalising Housing First. discourse – and it’s particularly model being commissioned in each Option 3 means the commissioning prevalent in the NHS - around of the six local authority areas, this of the proposed Housing First model Governance implications compliance – that people with approach is less likely to provide jointly by the six local authorities so A commissioning approach as outlined a strategic pan-LCR approach to there is a consistent approach across in Option 3 would require pan-LCR complex needs have ‘brought addressing the key drivers and the LCR. Based on the evidence of the governance arrangements to be it on themselves’ and are pressures facing LCR local authority nature and complexity of client need, established, not solely for the purposes therefore ‘undeserving’. This commissioners. It is less likely to there would need to be sufficient of implementing Housing First, but is combined with the fact that be effective in securing partner flexibility to allow for local sensitivity also to deliver the wider homelessness organisation engagement (mental and responsiveness to differing client prevention strategy. This is likely to housing is now a ‘market’ and health services, criminal justice, etc) requirements. In addition, it does not mean either a pan-LCR commissioning something to be ‘earned’, not where these agencies will need to deal necessarily mean a single Housing ‘board’ for homelessness prevention a basic human need or right with six separate Housing First ‘offers’ First service or service provider, rather and services or the use of a pre- which has to be provided”. across the LCR. that the authorities can determine existing pan-LCR group for this jointly how it will be delivered, i.e. purpose; possibly with one local Option 2 addresses some of the the number of service providers that authority taking responsibility for Another professional explained that limitations of Option 1. There is more may be recruited to operate Housing undertaking any procurement activity the allocation policies for social scope to address the variations in local First and whether this is done through on behalf of all the LCR authorities. housing (through the Property Pool demand for Housing First and there working with existing providers to Plus system in five of the six authorities is greater scope to commission and develop the model or through a more Commissioning for a culture change in LCR) “won’t reward bad behaviour”. configure Housing First to better align traditional procurement approach. Developing Housing First ‘at scale’ People with lived experience told with partner organisations. The key will require not only smart systems us about having to ‘play the game’ challenge for Option 2 is which cross Having a larger scale approach to thinking, determined partnership to demonstrate that they are local authority partnerships would Housing First does allow variations working and the implementation of deserving of help. Meanwhile, those best support the delivery of an agreed in local need to be balanced and new models of service delivery but in homelessness services often talk Housing First Model, e.g. two groups makes it more feasible to move a a very real change in the culture of about ‘those who are willing to help of three local authorities or three wider ‘housing led’ approach with services. The current dominant culture themselves’ and those who have ‘made groups of two local authorities. less or reducing use of existing hostel in services is shaped by political a lifestyle choice’: ‘tough love’ was said based accommodation. The primary discourse, national and local policy to work for some; for others, living in Option 3 seeks to address the limitation outcome measure would be successful and it will be challenging to change it. a hostel was felt to be ‘the best it will of Options 1 and 2 in terms of delivering tenancy sustainment. ever get for them’. a consistent approach to Housing Neale (in Burrows et al 1997, p.3655) First, being able to flexibly manage Personalisation argues that, We have seen in chapters 3 and 4 that variations in demand and demand Housing First is intended to offer highly “Where homelessness has been Housing First proposes a very different across local authority areas whilst also personalised, flexible and open-ended interpreted as a function of structural way of working with people: a rights- offering a single coherent model for support alongside access to housing. factors beyond individual control, based, non-judgemental, strengths- partner organisations that works across By its very nature, Housing First is a homeless people have often been based approach that emphasises local boundaries within the LCR. ‘personalised’ intervention. However considered deserving of assistance. citizenship and builds resilience. whichever approach to commissioning Conversely, where individuals have Although these options are not is adopted, there is scope to consider been deemed responsible for their In order to commission this very different exhaustive and some degree of ‘mix ways to ‘deepen’ and extend this homelessness, they have frequently approach, it will be necessary to: and match’ is possible, Option 3 on personalised approach, for example been considered less worthy of balance, is likely to provide the most through making available some of support.” • Work in partnership and through realistic and feasible opportunity to the funding for support in the form dialogue with providers and people implement the proposed Housing of ‘personalised’ budgets where an In the qualitative interviews, we with lived experience to develop the First model in a consistent way across individual exercises control over how heard about and observed some of specifications for these services – local authority boundaries within the that element of the budget is used to the political discourse around the the value of hearing the perspectives LCR and address the key pressures best meet their support requirements. ‘deserving’ and the ‘undeserving’ of frontline workers, people with facing local authority commissioners. It is beyond the scope of the feasibility within the way policies and cultures lived experience (at different stages However, the consequences of study to determine such approaches in operate in the homelessness system. of their homelessness journeys) and adopting Option 3 should not be detail, however a phased approach to As one professional explained: a range of professionals has been a under estimated in terms of the implementation offers the opportunity commissioning capacity resources for the local authorities in the LCR required. 55 Neal, J. ‘Theorising Homelessness: contemporary sociological and feminist perspectives’ in Burrows, R., Pleace, N. & Quilgars, D. (Eds) (2013) Homelessness and Social Policy, Routledge 78 Housing First feasibility study for Liverpool City Region What will it cost? 79

key process finding from this study; 5.2. Financial Implications: Potential Whilst the original study based the It is also worth noting the findings • Train staff at all levels and across for cashable savings and efficiencies Housing First support costs on three of American research in this field. sectors to work in a strengths-based from implementing Housing First hours, these were small pilot services This has suggested that Housing way; recruit and develop housing sometimes operating with limited budgets. First and similar models may not support staff on the basis of their This section sets out: The average of three-hours of contact be inherently cheaper than single ability to work in this way, as discussed per week over a year may have reflected site supported housing with on- in Chapter 4, and look to set up • The cost evidence from other Housing operational constraints, rather than have site staffing, but that results are communities of practice as a way of First services to provide context been what would be regarded as the better with respect to providing a building and embedding culture change. • An analysis of the extent to which optimal level of support. Second, these sustainable end to homelessness. In • Take a flexible approach to contract Housing First as part of a housing-led were average costs from a small number other words, while Housing First may monitoring: both the commissioner system may provide cashable savings of pilots in a small number of areas and cost a similar amount, or even slightly and the provider of the LB Camden • An analysis of the extent to which the costs for supported housing were more, it represents a much more Housing First service spoke about Housing First may provide improved also averages taken from a limited number cost effective use of public money the importance of building a close value for money compared with of areas, i.e. actual operating costs will because homelessness is ended more and trusting relationship between current types of provision vary from these figures. Finally, it is efficiently and more sustainably. commissioners and providers, in important to note that the operational order to move away a focus on Cost evidence from other Housing reality of Housing First may be quite The support costs of Housing First are monitoring outputs. First services different from what were pilot services, significantly lower than the support costs • Set out clear shared values at the outset Research on nine Housing First pilots there may be additional costs, i.e. there of homeless hostels with 24 hour cover. and ensure there is proper multi- in England in 2014/15 reported that may be a need for more contact hours agency governance around these. the total costs of providing one hour as a Housing First service engages with a Housing costs were not included in • Build a ‘coalition of the willing’; a of Housing First support, including greater range and number of homeless this analysis, and it should be noted ‘tribe’ of Housing First champions so administrative costs and salaries, people with high and complex needs. The that rents in supported housing may that change comes from a number ranged between approximately £26 costs reflected in the table have therefore be higher than for one-bedroomed of levels, not just top-down. an hour and £40 an hour. These data increased the number of support self-contained accommodation in the were based on actual operating costs hours to six to reflect these factors. social rented and private rented sectors. “Commissioning would shared by the pilot Housing First need to be really flexible – services. The report estimated that, from discussions with Housing First Figure 5.1. Costs of Housing First relative to supported housing based on commissioners would need service providers, over time, typical the 2014/15 Evaluation of nine Housing First pilots in England (support to be quite open-minded and contact might average at something costs for one year) really buy-into the whole like three hours a week over one year. vision. At the moment, it’s This was based on the assumption that support would be more intensive £20,000 all about units, move-on, at first, enter a steady state and then £17,160 throughput, so this would tail off, eventually become infrequent need to change”. or effectively dormant. In other £15,000 words, during initial use of the service someone might be seen every day “It’s almost about ‘de- for several weeks, but that contact £10,608 £10,608 £10,608 £9,360 commissioning’!...... KPIs can might then drop to once a week and £10,000 really get in the way if you’re eventually to less frequent meetings as independence grew. not careful.” £5,096 £5,000 The following table compares the “There needs to be a load of mid-range of Housing First costs dialogue before procurement from these pilots (i.e. £34 an hour at 2014/15 prices, at six hours contact per £0 (or whatever model you Low Mid High use) – ideally, like today with week over one year, making a total of £10,608 per annum) with the actual people from a range of roles – running costs of low/ medium/ high upported ousing Housing First id range frontline, operational, strategic, intensity supported housing. ‘High’ lived experience”. intensity refers to hostels with 24 hour Source: Based on Bretherton, J. and Pleace, N. (2015) Housing First in England: An Evaluation of Nine Quotes from the provider cover; ‘low’ where there is little more Services York: Homeless Link/Changing Lives (analysis by original authors). The original support costs were than food, a bed and minimal staff cover. based on an average of three hours a week over the course of a year. The graph above is based on costs of focus group six hours a week over the course of a year. See further explanation in section 5.2. 80 Housing First feasibility study for Liverpool City Region What will it cost? 81

Potential for cashable savings A summary of the method used for The estimated residual need for The cost of Housing First is set out in In this section, we model two different assessing the potential for Housing supported housing with 24-hour cover Chapter 4. The figures for supported scenarios for the development of First to deliver cashable savings is is the current level of need, reflecting housing are based on the costs of Housing First, both of which include presented. The full method used and the need that is being met by Housing a sample of current LCR supported the development of Housing First units associated calculations are shown at First; this will include access to housing schemes. This includes both to the level we have assessed as being Appendix 5. emergency short term 24/7 supported the support funding currently paid needed. housing. by local authorities and the excess To project the likely costs of in rental income over the LHA level. In scenario 1, despite reductions to implementing the proposed model The residual need for other non 24- The figure for housing-led provision is fund Housing First, there is significant it is necessary to make use of the hour forms of supported housing is based on the calculated cross-subsidy ongoing investment in supported estimated demand within the LCR driven by relatively high levels of need for the Local Letting Agency, set out in housing. We have assumed that the that could be met by Housing First for housing and support more widely the costing of the Housing First model majority of this might be non-24/7 alongside the predicted costs of the across the LCR. However, it should be (but with the additional assumption since, with Housing First in place, it model in practice. Chapter 4 identifies noted that these estimates of need that only possibly half the units will should be supporting people with the estimated demand for Housing for supported housing are based on actually be secured through this route). lower levels of needs. First across the LCR in terms of the a complex model and, for example, This is the cost of providing access number of housing units required over increased effectiveness of other to alternative mainstream housing In the second scenario, all of the non- the period 2018 – 2028. homelessness prevention activity (as for people not included in the other 24/7 supported housing has been set out in our idea pathways map in categories (who may or may not need decommissioned and replaced with a A complex modelling of estimated section 3.5) may result in reductions in additional floating support). ‘housing led’ approach, as envisaged need for Housing First alongside the these levels of estimated need. by the model we proposed in chapter other forms of provision (see Appendix Using the projected need (table 5.2) 3. Our modelling suggests that this 5) identified as part of the housing-led In order to test whether the modelled and the service cost assumptions (table approach could potentially generate system (section 3.5) was undertaken to estimate of need is affordable, 5.3) enables a projection of current much larger savings than the first compare current need with estimated benchmark costs are assumed for and projected costs to be made scenario; however, this approach need by 2023/24. each of the service options identified (table 5.4). hinges on the capacity to supply in the explanation of the Housing significant amounts of housing. The need for other forms of provision Led strategy (section 3.5). The cost Table 5.4 Cost comparison – current Other scenarios, somewhere along and for Housing First in 2023/24 and assumptions used are shown in system and costs vs proposed the continuum between these two, in comparison to current levels of table 5.3. system and costs could be modelled. provision is shown in table 5.2 Table 5.3. Service cost assumptions Service Type Current Projected Cost Costs 2023/24 Table 5.2. Projected need for Housing First and other service provision Service Type Benchmark (£m) (£m) Cost (£ per unit n/a 6.85 Service Type Current Level of Calculated Need for per annum) Housing First need 2023/24 (housing Supported housing 14.4 6.21 units) Housing First 12607 (including emergency Housing First 0 543 Supported 17523 provision) – 24-hour housing cover Supported housing 822 355 (including (including emergency Supported housing – 5.96 5.05 emergency provision) – 24-hour Cover non 24-hour cover provision) – 24- Supported housing – non 662 561 hour cover Housing-led – access 1.07 24-hour cover to housing Supported 9000 Housing-led – access N/a 3184 housing – non Total 20.36 19.18 to housing 24-hour cover Based on these relatively conservative Housing-led 335 assumptions this would indicate – access to that, a Housing First/housing-led housing system could generate savings of approximately £1.18m by 2023/24. 82 Housing First feasibility study for Liverpool City Region What will it cost? 83

In practice, the length of time taken alternative to 24-hour supported • The proportion of people receiving are still in settled housing at the end to implement Housing First to match housing. the intervention who will achieve the of the 2 years. projected demand will be influenced specified outcome; by the degree of effectiveness of On this basis, a more ambitious • The proportion of people receiving Cost of Housing First the Housing First model, the pace financial outcome by 2023/24 may for the comparator intervention who will The calculated cost of Housing First, at which commissioners wish to example be based on offering all those achieve the specified outcome; including the estimated subsidy to a implement a Housing First model and who in Table 5.4 who were housied in • The cost of the intervention being Local Lettings Agency, is £12,607 the resources that are available to non-24 hour cover supported housing evaluated; per year. fund this approach. To achieve greater a combined package of access to • The cost of the comparator savings will require commissioners to mainstream housing and a more intervention. For the purposes of this exercise we proactively reduce further the use of intensive floating support service56. therefore assume that the housing and supported housing which is likely to be We look at each of these in turn. support intervention for the 80 clients significantly dependent on successfully This would require within 5 years The calculation is based on a notional who are sustained successfully for the scaling up the prevention activity of an access to an additional 1122 scenario of 100 clients receiving full 24 months will cost 2 x £12,607 = Housing Options teams, increasing properties per year, which would Housing First and 100 continuing £25,214. access to mainstream housing with a represent a significant challenge. to receive services as of now. floating support offer as an alternative However, the costs of those who do to the non-24 hour supported housing Table 5.5. shows the potential effect Achieving the specified outcome not succeed in meeting the outcome and/or increasing the numbers of of modelling this scenario. with Housing First also need to be taken into account as people using Housing First as an The various Housing First evaluations costs of the intervention. However, by cited in chapter 3 have indicated that definition this is not for the full 2 years. between 70 per cent and 90 per cent Elsewhere, we have estimated that Table 5.5. Cost comparison – current system and costs of clients placed in housing were still the breakdown of tenancies occurs vs proposed system and costs in settled housing at the end of the on average after 9 months, so we also evaluation period, with a tendency to assume this here and therefore for Service Type Current Costs Calculated Projected Cost be at the higher end of this scale. For each of the clients who do not meet (£m) Need for 2023/24 this exercise, therefore we will take a the outcome, the assumed costs are 2023/24 (£m) conservative assumption and assume £12,607 x 0.75 = £9,455. (housing units) that 80 Housing First clients were still in settled housing at the end of 2 years. Costs of Existing Homelessness Housing First n/a 543 6.85 Services Supported 14.4 365 6.21 Achieving the specified outcome with This is complicated by the reality of housing (including existing homelessness services service usage. Almost by definition the emergency In our analysis of Mainstay, we found cohort that Housing First is aimed at, provision) – 24 that, out of 1,104 people who had a dip in and out of services – sometimes hour-cover high level of need in relation to 2 out living in hostels, sometimes living of 3 of the domains – mental health, on the streets or in other temporary Housing-led – 5.96 4406 3.28 substance misuse and offending (a settings, while using outreach or day access to housing proxy for those that Housing First centre-type services on a sporadic Total 20.36 16.34 is aimed at), 170 people had been basis. The research by Pleace and successfully resettled into some form Culhane57, based on interviews with of mainstream accommodation. This 86 homeless people, made an attempt Based on these more ambitious methodology has been used to assess represents approximately 15 per cent to track this based on analysis of the assumptions (table 5.5), this would the potential value for money offered of this cohort of people. services that this sample of 86 had indicate that a Housing First/Housing by the proposed Housing First model consumed over a 90-day period. This Led system could generate savings of in comparison to existing forms Assuming that all 15 per cent do was then grossed up to produce an approximately £4.02m by 2023/24. of provision. The full rationale and then successfully hold on to that annual cost of £14,808 per person. method for this approach is shown at accommodation for two years (and Potential for efficiencies: Value for Appendix 6. There are four elements in reality it may be significantly less), However, this is potentially misleading money analysis to the proposed cost effectiveness for the purposes of this exercise, we because the hostel element of the A cost effectiveness analysis calculation: will assume 15 of the 100 clients who costs included the full rental payment ‘continue to receive existing services’ and most Housing First clients will be

56 A more intensive floating support service might for example be based on an average of 5 hours per week at £18 per hour for an average of 6 months (not necessarily consecutively) plus the exra Local 57 Better than Cure? Testing the case for Enhancing Prevention of Single Homelessness in England, Lettings Agency charge in 50% of cases Pleace and Culhane, 2016 84 Housing First feasibility study for Liverpool City Region What will it cost? 85

equally dependent on benefits to meet retention rate for people successfully • Set up costs for implementing this supported housing services by their rental payments (up to the LHA being resettled under the current phase of Housing First (section 6.2) between 287 units and 373 units level). In order therefore to ensure that system was taken into account. This would be a minimum of £0.63m per (based on an assumed average cost we can discount this element of the complements the conclusions reached annum based on 50 service users in per unit per annum of £17,523). rental from both sides of the equation in the previous section on financial year 1 and £1.26m per annum based we have therefore deducted the LHA modelling – a housing-led strategy on 100 service users in year 2 (based Phase 3 (years 5–10): summary of rate of £90 per week for the estimated built around Housing First can be on £12,607 cost per service user per key elements 60 per cent of users in the Pleace and delivered at no net cost and far higher annum). These effectively represent Culhane study who made use of a hostel in terms of effectiveness and cost- double running costs whilst existing • Full implementation of Housing during the set period. This reduces effectiveness. supported housing provision remains First commissioning plan to meet the estimated annual cost by £2.808, unchanged. projected demand producing a total of £12,000. This will 5.3. Housing First Implementation: • Additional ‘pump priming’ funding for • Full implementation of amount to £24,000 over 2 years. Potential transitional and phasing this phase will be required for it to be reconfiguration of existing supported arrangements feasible housing services across the LCR For 15 clients, however there is The outline implementation • Initial delivery focus possibly over • The cost of delivering up to 480 assumed to be no cost because for arrangements are set out covering the 2-3 local authority areas in year 1 and Housing First service users is this exercise they are assumed to be phasing over 10 years: over all local authority areas by end estimated to be £6.05m per annum housed at the beginning of the 2-year of year 2 (based on an assumed cost per period and remain so throughout • Phase 1: period covering first 2 • Necessary to produce a detailed service user per annum of £12,607). (although in reality there will be other years including initial transitional commissioning plan for scaling up • For this level of Housing First inputs to sustain them – so again this arrangements of Housing First implementation service users to be feasible, it would is a conservative assumption). • Phase 2: period covering 2-5 beyond year 2 and reconfiguring be necessary to reconfigure (i.e. years including the completion of existing supported housing provision decommission) 345 units existing Putting these assumptions together transitional arrangements and associated support services. 24/7 supported housing services we produce the following results: • Phase 3: period covering 5-10 years. Commissioning plan needs to (based on an assumed average cost identify contractual notice periods as per unit per annum of £17,523). Phase 1 (years 1-2): summary of applicable (i.e. contracts for existing Table 5.6. Cost of Housing First compared to existing key elements supported housing services due to Reconfiguring existing supported homelessness services be reconfigured). housing services: implications for • Develop and implement new commissioners and providers prevention protocols using extended Phase 2 (years 2-5): summary of Phase 1 envisages up to 100 Housing Housing First Existing brief for Housing Options teams if key elements First service users, operating alongside Homelessness necessary existing supported housing provision. Services • Implementation for initial 50 Housing • Commence implementation However, during this phase, a detailed Cost of Service (25,214 x 80) + 24,000 x 85 First service users in year 1 and 100 of full pan-LCR Housing First commissioning plan is required (9,455 x 20) = £2,040,000 service users in year 2 commissioning plan as part of wider for scaling up of Housing First = £2,206,225 • Evaluation of these first waves of LCR approach to homelessness implementation for Phase 2 including Housing First clients, especially since prevention reconfiguring existing supported Achieving 80 15 this gives us an opportunity for a • Commissioning of between 400 housing provision and associated sustained naturally-occuring control group and 519 Housing First supported support services. tenancy of people who will continue to be tenancies by year 5 accompanied Cost Per £27,578 £136,000 supported within the current system. by an equivalent decrease in 24/7 In practice, this will mean LCR Successful • Would operate alongside existing supported housing provision commissioners specifically: Outcome homelessness supported housing • The cost of providing for 400 provision Housing First service users is • Identifying existing 24/7 and non- • Establish Local Lettings Agency estimated to be £5.04m per annum; 24/7 supported housing provision In cost effectiveness terms Housing (or specification / template for the cost of delivering for 519 Housing that will either be remodelled or First is shown to be 4.93 times as cost Agencies); may be possible to First service users is estimated to be decommissioned as Housing First is effective as existing service provision, secure initial housing units from £6.54m per annum (based on an rolled out as part of a wider ‘housing as well as being 5.3 times as effective housing providers including housing assumed cost per service user per led’ approach. in achieving the desired results. associations annum of £12,607). • Undertaking an assessment of the Importantly this conclusion has been • Establish cross LCR commissioning • For this level of Housing First needs of individuals who are using based on defensible but conservative and governance arrangements for service users to be feasible it this supported housing provision to assumptions. In reality, it could be even Housing First and wider provision of would be necessary to reconfigure identify the proportion of service more cost-effective if the tenancy services for preventing homelessness (i.e. decommission) existing 24/7 users who can be supported through 86 Housing First feasibility study for Liverpool City Region What will it cost? 87

Housing First and the proportion the proposed LLA, and support Figure 5.7. Risks and mitigations of implementing Housing First of service users who may need an as appropriate, before a provider alternative, e.g. independent housing proceeds with either option (a) or (b). without the same degree of intensive Risk Mitigation support. As an example of a ‘case study’ for • Aligning the increase in capacity option (c) above and what this could Avoiding loss of supported housing Phase 1 is intended to provide for initial double of Housing First sufficiently to mean for hostel providers, in Glasgow, service capacity before Housing First running of Housing First with existing level of 24/7 accommodate people who were Big Society Capital is seeking to work model is established and demonstrated supported housing provision to allow sufficient time living in or were at risk of moving with hostel providers to make available to be effective. for Housing First to become operational and effective to existing 24/7 supported housing short-term loans (over 2-3 years) provision. which enable housing providers to Avoiding loss of skilled staff during the Phase 1 is intended to provide for initial double • Agreeing with providers of purchase self-contained properties transition phase running of Housing First with existing level of 24/7 existing provision a phased that are suitable for accommodating supported housing provision to allow sufficient approach to remodelling and/or Housing First service users, with the time for Housing First to become operational and decommissioning in line with the roll loan being repaid once the hostels effective and for commissioners to agree a detailed out of Housing First. are no longer in use and the receipt comsmioing plan including consultation with from the sale of the hostel property providers The implications for supported housing being used to repay the loan. This may providers operating hostels during this be based on sales of several hostel Ensuing levels of homelessness, It will be necessary to agree common monitoring transition process are likely to be: properties reflecting differing sites particularly rough sleeping, decline as arrangements across the LCR to assess levels of and sales values. This loan funding Housing First is implemented homelessness and rough sleeping specifically. • Utilising and building on the skills of can also be used to meet non-capital current support workers and applying transitional cost incurred by housing Insufficient 1-bed housing units are The commissioning of a Local Lettings Agency is them to a housing led system providers. The purpose of the funding available to ensure the Housing First intended to provide a mechanism to source and • Transitioning from supported from Big Society Capital is to make model can be delivered. manage housing to be used by Housing First service housing to a housing led model. available capital that facilitates this users and others. During phase 1 there may also • Identifying a different cohort for ‘system change’ in a manageable way be scope to source housing directly from housing whom existing properties are for housing providers. providers including housing associations when the suitable. numbers of service users is relatively low • Selling hostel buildings and using the Implementation considerations capital receipts to purchase housing including risks and mitigation Commissioning plan for phases 2 and/or It will be necessary to put in place robust governance that can be used by Housing First 3 is not delivered. arrangements that include all the LCR local service users. Key risks are likely to include: authorities and other commissioning partners to agree a detailed commissioning plan and an To ensure that these changes are implementation programme beyond phase 1. implemented in a way that benefits service users, will require that commissioners and providers agree how providers will make the transition in a carefully managed way as Housing First is implemented.

Case studies As an example of a ‘case study’ for options (a) or (b) above, providers would need to undertake or use existing assessments of service users to identify alternative housing and support requirements for those service users who do not require a Housing First reponse. This will require identifying and putting in place the necessary housing, potentially through 88 Housing First feasibility study for Liverpool City Region Policy context 89

experiencing homelessness. Key elsewhere in Merseyside. The council’s priorities include to: priorities include: • Develop and co-ordinate services to • Review and revise the current service deliver a comprehensive approach offer for people sleeping rough. towards homelessness and • Review the provision of all supported prevention. accommodation which will include Policy • Respond to and prevent rough those for single to identify shortfalls sleeping. and gaps in current service provision • Ensure that homelessness is for women and single young people. recognised as a priority for action • Joint working with neighbouring within the Health and Wellbeing local authorities across the Board. Merseyside region; in particular, context • Develop a business case to formalise efforts will be made to extend a single practice approach to address existing collaborations to end rough the housing and health care needs of sleeping across the region. vulnerable homeless people. The St. Helens Council Plan 2017/2020 Knowsley Metropolitan Borough sets out the key objectives the council Council homelessness strategy (2016- aims to achieve over the next three Chapter 6: Policy Context 21) aims to: years. The council’s priorities include:

• Reduce levels of homelessness • Ensuring the best possible outcomes • Prioritise the prevention of for children, families and vulnerable In this chapter, we consider the policy context – and homelessness; adults. the key drivers and potential barriers and enablers to • Ensure sufficient accommodation is • Work to sustain improvements in available for homeless people (the health and reduce health inequalities. the approach we have approached here. We begin by focus here seems to be on access to • Supporting communities to feel safe considering the local strategic context in relation to mainstream housing) and resilient, particularly children and vulnerable adults. homelessness in LCR, then move on to considering It focuses on the importance of • Work to increase the range, choice different relevant themes in relation to the national effective information, advice and and quality of housing provision. policy context, teasing out the potential implications advocacy and satisfactory resources to tackle homelessness. There Wirral Council Homelessness Strategy of these for Housing First. are a number of actions within 2013-18 focuses on homeless the council’s five year action plan prevention, but acknowledges which could potentially support the that there will be instances where 6.1 The current strategic context on wider preventative and housing-led implementation of our proposed homelessness cannot be prevented homelessness in LCR system. They are: Housing First strategy. For example: and there is a requirement to ensure The local authorities from the LCR assessing the effectiveness of services that appropriate housing and support have homelessness strategies, as • Adopt an early prevention and aimed at single homeless people, is available to respond to this. The well as other relevant plans such intervention approach directed continuing but maximising the homelessness strategy is intended to as ‘2020’ strategies, which cover particularly towards single people efficiency of floating support services, ‘fit’ within a wider policy framework different timeframes and have differing and childless couples and exploring the feasibility of a local across Wirral and the wider Merseyside emphases. However, they all to • Develop and encourage economic lettings agency. area. The council’s priorities include: differing degrees create a supportive resilience, including through access policy environment within the LCR to to affordable settled housing Sefton Metropolitan Borough Council • Strengthening collaboration with establish and implement a Housing • Address the needs of people who are Homelessness Strategy 2013-18 sets other councils to ensure that the First model as part of a comprehensive homeless and have complex needs. out the objectives and the actions that housing and support needs of approach to eradicating homelessness. will be taken tackle homelessness. more challenging client groups are Halton Borough Council The strategy recognises that there met when homelessness cannot Liverpool City Council homelessness homelessness strategy 2013-2018 is a diverse range of community- be prevented including working strategy (2016-20) has three key sets out its approach to collaborative based services for street homeless together to end rough sleeping. priorities, all of which fit with the and integrated commissioning to people and single homeless persons, • Plans to respond to a number model of Housing First set within a deliver improved outcomes for people albeit that many are located in the of issues including personalising neighbouring local authority, or responses for the needs of people 90 Housing First feasibility study for Liverpool City Region Policy context 91

who are regularly sleeping rough. • There is an established precedent for priority need for a single adult is prevention and relief duties to all • Improving access to the private cross-LCR collaboration in relation determined through the concept of eligible households, regardless of rented sector as a solution for those to homelessness and housing – ie. ‘vulnerability’. priority need status. New, universal, who are homeless. No Second Night Out, Mainstay and homelessness prevention and relief • Taking a strategic commissioning Property Pool Plus (though it should Pressures on the statutory duties are placed on English local approach to homelessness which will be noted that St Helen’s has its own homelessness system and a broad (housing) authorities, extending the increase multi-agency partnership choice-based lettings system, Under social policy focus on attempting requirement to assist someone at risk working. One Roof) and some strategies to prevent sustained or recurrent of homelessness within 28 days to 56 (for example, Knowsley’s) explicitly experience of social and economic days. In Wales, this shift to prevention Key overarching points on LCR mention the possibility of joint exclusion, brought a major involved a major change in what homelessness strategies commissioning with neighbouring reorientation towards homelessness local authorities did in response to authorities and the desirability prevention in English homelessness homelessness. In England, because of • There is significant variation of securing devolved control of policy during the early 2000s. Local the earlier adoption of homelessness regarding the level of strategic homelessness policy through a authorities were required to produce prevention from 2003/4 onwards, development across LCR: some future Merseyside Homelessness homelessness strategies with a the change is less radical, but it is still authorities have commissioned Commission. A tripartite agreement preventative emphasis, employing a significant. The Act is also designed external reviews and consultations is already being developed between Housing Options Team model that to enhance referrals to preventative and have current homelessness Liverpool, Sefton and Knowsley in aimed to stop homelessness before services, creating duties for public strategies with accompanying action relation to joint commissioning and it occurred and rapidly rehouse those services to make a referral to local plans; others have not had the the sharing of information systems. who had become homeless. authorities if they think someone is resources to revise their strategies. at risk of homelessness. • Most of the homelessness strategies 6.2 The Role of Housing First in Levels of statutory homelessness, i.e. aim to focus on early prevention the Context of the Homelessness households found to be owed the The homelessness relief duties in the and intervention, and the need Reduction Act main duty in England, fell very sharply Act are also important. Anyone who to improve access to mainstream from 2003/4 onwards, and while those is homeless is entitled to assistance housing (including both PRS and The Homelessness Reduction Act levels have increased in recent years, to secure accommodation (the social housing) for homeless people. The Homelessness Reduction Act they have not yet approached the entitlement is to assistance, not a duty These are all key tenets of the model alters the nature of the homelessness levels seen prior to the preventative to provide housing). This includes proposed here. legislation in England. While the shift in English homelessness provision of interim accommodation, • Supported housing is clearly a original 1977 Act has undergone a policy58. While the preventative shift if necessary, when an individual or means of delivering councils’ current number of significant changes as reduced overall levels of statutory household is found to be in priority response to single homelessness a result of later legislation, England homelessness, it was not clear that need. The duty lasts for up to 56 days. (and some councils have made has, unlike Scotland and Wales, not preventative services were sufficiently significant capital investment in some experienced a legal change on this accessible or adequate to meet the The Act and Housing First of the schemes they commission, scale before. needs of single homeless people and The implications of the Homelessness which will need to be considered as there were concerns that ‘prevention’ Reduction Act for Housing First are these assets are reviewed), however, Single homeless people have tended was being used as gatekeeping for the linked to the wider points made in it is not an integral part of these to face greater barriers to the statutory statutory system59. this report about the fundamental strategies, many of which refer to the system in England than has been the importance of strategic integration need to review the effectiveness of case for homeless families. One reason The Homelessness Reduction of Housing First services into the the current service offer. for this is the resource level available Act, which centres on formalising homelessness strategy for the • There is a general trend in most to local authorities, both to implement homelessness prevention within the Liverpool City Region. Housing First authorities towards locality-based the legislation and because of often statutory system, was developed with must play a clearly defined role in models and hubs – for access to limited access to affordable, adequate support from an independent panel the wider homelessness strategy for and co-location of council services housing. To qualify for the main duty, convened by Crisis60. investment in Housing First services (e.g. Sefton), for the delivery of which in England is technically a to make logistical and financial sense. integrated health and social care responsibility to provide temporary The Act draws heavily on the policy Integration is also, as is discussed (e.g. Knowsley), or floating support accommodation until settled housing established by the Housing (Wales) elsewhere, a prerequisite for Housing (Liverpool). This trend may support becomes available, a single adult must Act (2014), which requires Welsh local First services if they are to access the implementation of a housing-led demonstrate they are homeless, i.e. authorities to extend homelessness relatively secure and sustainable model, both as a multi-disciplinary have no accommodation they can point of access to services, but also reasonably be expected to occupy, 58 https://www.gov.uk/government/collections/homelessness-statistics in terms of supporting homeless are not intentionally homeless and 59 Dobie, S., Sanders, B. & Teixeira, L. (2014) Turned Away: The treatment of single homeless people by people who have been resettled. are in priority need. In most instances, local authority homelessness services in England. London: Crisis. 60 Crisis (2016) The homelessness legislation: an independent review of the legal duties owed to homeless people London: Crisis. 92 Housing First feasibility study for Liverpool City Region Policy context 93

funding streams and be part of the • When someone is experiencing living for the LCR authorities is again evident, Previous research has shown networks providing the treatment rough on a recurrent or sustained when Housing First is not suitable sometimes harsh treatment of single and other support that Housing First basis, the evidence indicates that for someone, there must be clarity homeless people by the benefits service users will require. The roles of they are likely to have high and around what their other options are. system and drawn associations Housing First in the context of the Act complex support needs62. While This again links to the need to consider between benefit sanctions (removal of centre on three core functions: Housing First should not be the sole how Housing First will interrelate to benefit for not seeking work actively response for anyone sleeping rough, lower intensity tenancy sustainment/ enough) and homelessness65. One • Providing homelessness prevention providing a clear track to Housing housing-led floating support services potential impact on Housing First is for individuals and households First as the main intervention to be and single-site congregate/communal that both the accessibility and level of assessed as being at high risk employed when someone with high supported housing, defining a clear welfare benefit support available to of sustained and recurrent support needs is living rough appears role for Housing First services within Housing First service users is reducing, homelessness. The prediction of logical, based on current evidence63. the wider, strongly preventative, i.e. it has become harder to claim a who will experience these forms Technically, authorities in the LCR homelessness strategy for LCR. relatively smaller amount of money. of homelessness is far from being might choose to employ Housing This means challenges in relation to a precise science. However, where First only where a rough sleeper has 6.3 Welfare Reform and meeting living costs and coping with for example someone has a history been found to be in priority need, Housing First limiting illness or disability may be of homelessness and high and but there is a case for direct referral greater than was the case when more complex support needs, assessment – without a statutory assessment – The Benefit System money was available on a more for Housing First – as a preventative where needs and a history of living The benefit system is experiencing open basis. intervention – makes sense. In rough are clearly established. the introduction of Universal Credit the context where prevention is • Providing a route to resettlement and at the time of writing. A number of Restrictions on support with housing the core of homelessness policy tenancy sustainment for ‘vulnerable’ new restrictions on the accessibility costs are also potentially significant. and strategy, restricting Housing individuals found to be owed the and level of benefit paid to people The removal of the spare room First to a role of resettlement main duty under the Act, where with limiting illness or disabilities subsidy has made it unaffordable for following homelessness, when there referral and assessment procedures have been introduced and there are households to occupy a property is scope to employ the intensive indicate this is the best option. restrictions on benefit to meet housing which is larger than they are assessed case management to prevent costs. Universal Credit is a work- as needing: we heard that this is a homelessness, seems illogical. The Housing First can be employed orientated welfare policy that requires particular challenge for those who manual for the Pathways Housing within the new operational context individuals to seek work, operating are seeking to be reunited with their First model (which is the basis for created by the Act as a preventative within a wider benefit system with children, for example, following a the Canadian and French national service in its own right, as a potential the same orientation, using sanctions stay in prison. There are further age strategies) notes: fast-track response to sustained when someone is assessed as not restrictions here: most adults aged Client referrals are often and recurrent rough sleeping and making sufficient effort to seek under 35, without a partner and/ received from drop-in centers as the service provided to statutorily work. The welfare system has been or children can only secure enough [sic], soup kitchens, shelters, homeless people whose support widely criticised for defining people support to rent a room in a shared hospital emergency rooms and needs are best met by the Housing as ‘work ready’ when this would not house, or will be ‘taxed’ for having other programs [sic] that aid the First model. The focus of Housing First, necessarily be the opinion of medical a two or more bedrooms if they are homeless. In recent years the as discussed elsewhere in this report, professionals, with government data in social housing. Partial exemptions range of referrals has expanded is on homeless people with high and showing that over 40,000 people are made for homeless people who to include people who are complex needs, so it is not practical (or had died within a year of being tested have experience of living in a hostel homeless and currently in economic) to provide a full Housing to see if they were ‘fit for work’, by or temporary supported housing for long-stay psychiatric hospitals First intervention to any lone adult the benefits system64. Equally, when at least three months, removing the or who are incarcerated. PHF at risk of homelessness or who has someone has support or treatment requirement to share private rented [Pathways Housing First] also become homeless. needs, but is assessed as able to housing if under 35, but potential receives referrals from the work, they may be sanctioned (i.e. Housing First service users may not mental health courts that Here, the importance of ensuring lose benefit for a set period) where, a have accumulated this amount of time use PHF as an alternative Housing First is properly integrated few years ago, they would have been in hostels66. to incarceration.61 into the wider homelessness strategy assessed as unable to work because of support needs. The requirements in relation to sharing housing if aged under 35 are likely 61 Tsemberis, S. (2010) Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction Hazelden: Minnesota, p. 36. 62 Busch-Geertsema, V.; Edgar, W.; O’Sullivan, E. and Pleace, N. (2010) Homelessness and Homeless 64 DWP (2015) Mortality Statistics: Employment and Support Allowance, Incapacity Benefit or Severe Policies in Europe: Lessons from Research, Brussels: Directorate-General for Employment, Social Disablement Allowance London: DWP. Data refer to a period between May 2010 and February 2013. Affairs and Equal Opportunities. 65 Beatty, C., Foden, M., McCarthy, L. & Reeve, K. (2015) Benefit sanctions and homelessness: a scoping 63 Bretherton, J. and Pleace, N. (2015) Housing First in England: An Evaluation of Nine Services York: report. Sheffield: Sheffield Hallam University University of York/Homeless Link. 66 DWP HB/CTB A12/2011(Revised). 94 Housing First feasibility study for Liverpool City Region Policy context 95

to be extended to new social rented The restrictions on benefit support Benefit System Payments for Rent funding will be reallocated in the tenants. This is alongside a series of with meeting the costs of renting in Supported Housing first instance, with local authorities changes that will reduce the security housing potentially undermine the The benefit reforms which will receiving an amount that is supposedly of tenure in the social rented sector effectiveness of Housing First in LCR. reduce the amount of rent paid to equivalent to the extra benefit and bring social rented tenants into There are limits to what the local supported housing tenants, i.e. living payments that covered the total cost the same position as people renting authorities can do in response to in congregate or communal settings, of supported housing rents. This privately. The UK private rented sector these restrictions, one alternative is or in core and cluster schemes were will allow local authorities to ‘top offers poor security of tenure and to provide supplementary funding to first proposed in 2011, becoming more up’ the benefit system payments is amongst the least affordable in compensate for the limitations of the specific in 201671. Supported housing (equivalent to the accepted level of Europe67. benefit system, which obviously adds often charges an additional premium private rented sector rent) when they to the cost of Housing First. The other on rent to help cover operating costs assess supported housing schemes as The Housing First model is built is to combine with other interested which are higher than in general requiring an additional rental payment. on the idea that resettlement and parties and lobby for exemptions needs housing. Technically, since the reintegration into society following around the bedroom ‘tax’ in social short-lived Supporting People reforms Government proposal for this model homelessness is centred around rented housing and limiting benefits to in England, funding for support of ‘top-up’ funding have indicated ‘ring providing someone with their own, a room in a shared house if under 35, and housing costs (rent and service fencing’ of these funds to meet the settled ordinary home. Being required when someone has been assessed as charges) have been separated, but in additional cost of supported housing. to share with others, particularly eligible for a Housing First service. reality part of the funding for allowing However a concern is that this form when someone may well have high supported housing to function has of change has been experienced treatment and support needs if The viability of Housing First as a come from the housing benefit system before. Enhanced rates of benefit rehoused in the private rented sector, strategic level response to single paying higher rents and service charges. paid to people in supported housing, or having to subsidise rent costs homelessness and rough sleeping, which covered both housing and with welfare benefits designed to is brought into question when many The reforms, at the time of writing, are support costs, were replaced in 2003. pay for food and fuel, if living alone potential service users face benefit scheduled to come into effect in April Rent was paid by the benefit system in social rented housing with two restrictions that will not enable them 2019, reducing payments to the levels and a separate ‘Supporting People’ bedrooms, potentially undermines to live independently in their awarded to eligible tenants in the budget, to cover support costs, was the Housing First model. Housing own home. private rented sector, i.e. at applicable created. This Supporting People First forms the backbone of the local housing allowance (LHA) rates, budget nominally made the same Canadian and French strategies to The restriction of the housing cost which are generally lower than the amount of funding available (again tackle recurrent and repeated single element of Universal Credit for 18- current rent levels for much supported administered by local authorities) homelessness associated with severe 21 year-olds also has a potential housing. Supported housing will to pay support costs, previously mental illness68, strategies that would impact on Housing First. While there however be exempt from the paid for by the benefit system. The not have been attempted if there are exemptions for 18-21 year- requirements for people aged under Supporting People budget, which still were doubt that service users would olds - which include experience of 35 to share housing and from the exists in Wales and Northern Ireland, have enough income to meet the homelessness - the main criteria restrictions to claiming welfare benefits was first cut significantly and then, housing and subsistence costs. In the centre on a young person not being to meet ordinary housing costs, being effectively, abolished in England74 original model of Housing First in New able to live with their parent or parents. applied to 18-21 year-olds72. when the ‘ring fencing’ was removed. York, referral criteria had to centre Debates about the appropriateness of Cuts to supported housing provision on eligibility for a specific Federally using Housing First for young people Homelessness service providers for homeless people followed75. provided welfare benefit, conditional are ongoing70, but clearly, further operating supported housing, Theoretically, this exercise could follow on having a psychiatric diagnosis, benefit restrictions are not helpful. As alongside those social landlords and the same pattern, the ‘premium’ paid to ensure service users had enough with the exemptions for adults aged charities providing rented sheltered for supported housing rents at first money to contribute towards the rent 22-34, requirements for experience of and supported housing for older being separated as a distinct budget and to live on69. homelessness potentially undermines people and people with disabilities, and then subjected to cuts, possibly the use of Housing First as a have voiced concerns about this ceasing to exist as a specific funding preventative intervention. change73. It is important to note that stream at some point thereafter.

71 https://www.gov.uk/government/consultations/funding-for-supported-housing 72 Wilson, W. (2016) Paying for Supported Housing House of Commons Library Briefing Paper Number 6080, 28 December 2016. 67 Kenna, P., Benjaminsen, L., Busch-Geertsema, V. and Nasarre-Aznar, S. (2016) Pilot project – 73 National Housing Federation (2016) Submission: A proposal for a strong and sustainable future for Promoting protection of the right to housing – Homelessness prevention in the context of evictions supported and sheltered housing London: National Housing Federation. Brussels: European Union 74 Pleace, N (2008 Changing Supporting People funding in England: Results from a pilot exercise, 68 Pleace, N. (2016) Housing First Guide Europe Brussels: FEANTSA. London: Communities and Local Government 69 Tsemberis, S. (2010) Op. Cit. 75 See the Annual Reviews of single homelessness support in England compiled by Homeless Link 70 Gaetz, S. (2014) Can Housing First Work for Youth? European Journal of Homelessness 8 (2) http://www.homeless.org.uk/facts/our-research/annual-review-of-single-homelessness-support-in- pp.159-175. england 96 Housing First feasibility study for Liverpool City Region Policy context 97

These changes are a potential driver which has become economically To build Housing First into a service, LCR, along with other CAs, provides for the development of Housing First defunct due to the changes to the which can offer the full range of a context in which Housing First can across the UK. It is possible that at welfare system. However, the general potential support, including peer potentially flourish and in which it can least some single-site supported pressure to drive down costs may support, perhaps some specific mental make a real and positive difference to housing provision will close, while create a context in which there is health and addiction services and long-term and recurrent homelessness some planned schemes may no longer pressure to dilute Housing First, or have the time and space to secure and stopping potential homelessness be developed. Housing First, which remove certain elements from the housing supply and build networks among people with high and complex uses ordinary housing and does not service model, and there is a need to ensure packages of support are in treatment and support needs. There meet operational costs by charging an for caution here. Low fidelity Housing place, a certain level of resource is are several reasons for this: enhanced rent, may become a more First, that does not offer intensive, needed. However, Housing First can economically viable model than some flexible support to people with high be effectively delivered, literally, by a • Combined authorities cover large forms of higher intensity supported and complex needs, tends to be less couple of skilled workers with a small populations and contain sufficient housing for homeless and potentially effective76. caseload78. numbers of homeless and potentially homeless people with complex homeless people with high and needs. Alongside this, lower intensity 6.4 Housing First in Combined Much of the experience of Housing complex needs to make a clear housing-led and tenancy sustainment Authorities First in the UK in 2017 is confined to case for the development of a teams, also using floating support and A combined authority (CA) comprises small, quite recently developed pilot Housing First service. There is a ordinary housing, may become more two or more elected local authorities services and small scale evaluations of clear rationale, based on existing commonly used than existing low and that collaborate and take collective those services. There are exceptions, work around cost effectiveness medium intensity supported housing decisions. Alongside LCR, there is the Changing Lives79 has been running a and the ongoing analysis (some of models. nearby Greater Manchester Combined Housing First service in Newcastle since which is contained in this report) Authority, Sheffield City Region and the 2012, which is now commissioned for using Housing First to maximise In addition, when local authorities in West Midlands Combined Authority. by Newcastle City Council. Turning efficiency in the use of local the LCR receive the supported housing CAs are not necessarily confined to Point Scotland who developed the first authority resources in preventing and ‘top up’ funding from April 2019, cities, but tend to contain large urban working Housing First service in the reducing homelessness. Housing effectively the difference between areas, an example of a mixed urban UK, has firmly established Housing First has the potential to stop high the applicable 1-bed LHA rate and and rural CA is the West of England First in Glasgow80 and other small cost, high risk forms of homelessness the actual rent and service charges Combined Authority. Several CAs scale pilots, like the first service run from occurring and to reduce the in supported housing schemes, have directly elected mayors, with in London, Camden Housing First81, sometimes very high costs when commissioners will be receiving this some executive and policy making have been scaled up. Work is also people, whose needs could be funding for, in some circumstances, powers across the whole of their area, underway in other CAs. Two Housing met by Housing First, get caught supported housing that has never LCR is one example, the Manchester First services, one run by Threshold in a revolving door of expensive, been formally commissioned. This is Combined Authority is another. and concentrating on homeless sustained and ultimately ineffectual typically HMO provision that has used women with high and complex use of services that cannot meet the current specified accommodation Housing First can, as previous research needs82, who often have a history their needs in the same way. To a housing benefit regulations to claim in England has demonstrated, be run of offending, the other by Inspiring CA, like LCR, there is considerable far higher rates of benefit than would on a relatively small scale and at a Change Manchester83, concentrating evidence to suggest that Housing be paid under LHA. Commissioners relatively low cost77, but at the same on homeless people with the most First makes financial and strategic from April 2019 will be in a position time, it is a service model that can complex needs are operating within the sense. to decide whether to continue to potentially benefit from economies Manchester Combined Authority. • Collectively, a combined authority fund this type of ‘non-commissioned’ of scale. The key issue here is that can bring together the resources supported housing they will become Housing First is not a service for the However, some Housing First to fund Housing First in a way responsible for funding, or to redirect bulk of homeless people, it is a service pilot services have closed or been that might be challenging for an this funding into more attractive model built for those potentially and remodelled. Cuts to local authority individual local authority. The cost models such as Housing First. formerly homeless people whose commissioning budgets and of delivering Housing First can be needs are high and complex, who uncertainties in relation to the future shared, providing there is a clear The financial pressures across the require comparatively intensive availability of funding have caused benefit in homelessness prevention benefit system are unlikely to go support for what can be longer periods some Housing First pilots to close. and reduction for each participating away. Housing First services may than are offered by other models of become more economically attractive homelessness service. and be seen increasingly as the only 78 Pleace, N. and Bretherton, J. (2013) Camden Housing First: A Housing First experiment in London alternative to any supported housing York, University of York. 79 http://www.changing-lives.org.uk 80 http://www.turningpointscotland.com/what-we-do/homelessness/glasgow-housing-first/ 81 Pleace, N. and Bretherton, J. (2013) Op. Cit. 76 Pleace, N. (2016) Op. Cit. 82 http://thp.org.uk/services/HousingFirst 77 Bretherton, J. and Pleace, N. (2015) Op. Cit. 83 http://icmblog.shelter.org.uk/housing-first/ 98 Housing First feasibility study for Liverpool City Region Policy context 99

local authority. Combining to Operationally, practically and in terms partner to local communities and As part of the commissioning build and deliver an integrated of cost-effectiveness and viability, voluntary organisations arrangements for Housing First across homelessness strategy, or at least Housing First benefits from working • More care should be delivered locally LCR it will be necessary to ensure that to develop shared initiatives of on a bigger canvas. Housing First can within multi-speciality structures and commissioned health services are mutual benefit across coordinated be run, as small-scale services, by integrated with social care: a shift in appropriately targeted at the Housing homelessness strategies, such as individual authorities and there are investment from acute to primary First cohort. Housing First, has many advantages. a few local authorities that are big and community-based care. In countries such as Finland and enough and have sufficient spending There is considerable interest across the Netherlands, cities and other power to run medium-sized Housing Under the Health and Social Care Act the UK in ‘strengths-based’ approaches local authorities have combined First services of their own. But these 2012, reducing health inequalities to care and support. The Care Act resources to extend and enhance small services will often be working is a requirement. CCGs have a duty 2014 requires English local authorities their responses to homelessness. with restricted budgets, not able to to provide services for all patients in to ‘consider the person’s own strengths In the Finnish context, coordination engage with very many people at their locality, whether registered or and capabilities, and what support might was led by central government, but once and can be constrained in what not, including services for homeless be available from their wider support in the Netherlands, the process was they are able to offer service users, people. Those who are homeless face network or within the community to initiated by the four largest cities, the particularly if the offer is to extend extra barriers to accessing healthcare help’. This approach is consistent with G4, combining resources. beyond comparably intensive forms and have health needs often different the proposed Housing First model. • From a service provider perspective, of case management. There may also to those of the general population. the two most immediate risks in be issues in securing housing supply, The current approach to health and investing in Housing First are that indeed there almost certainly will be, The Merseyside Directors of Public social care integration across the LCR, sufficient funding to make the if operating within a relatively small Health commissioned Liverpool Public with oversight by pan-LCR governance service work properly will not be area. The potential precariousness of Health Observatory to undertake structures, provides a consistent basis available and that funding will not be funding where Housing First is a small- a homelessness health needs for aligning a LCR wide approach sustained. Housing First, in England scale, specialist service supported by a assessment across the Liverpool to Housing First specifically and in 2017, is too frequently a case of single local authority is also a concern, City region85, published in May 2014. managing homelessness more small services with limited capacity both in terms of ensuring Housing Liverpool City Council’s Homelessness generally, within a supportive health whose sustainability is in doubt. First plays a clear role within integrated Review (2015) reflects the concerns and social care policy context. If there is the option to develop a homelessness strategies, and in terms highlighted by the Merseyside service that can take on more cases, of service providers taking the risk in homeless health assessment and audit: Following endorsement of the LCR offer more services and which has developing and running Housing First substance misuse issues amongst Devolution Agreement in June a future, at least in the medium to begin with. the single homeless population 2015, health and social care leaders term, moving into Housing First or constitute a significant homelessness across the LCR have been pursuing expanding existing services becomes 6.5 Housing First and Health and risk and physical health problems are greater collaboration and potentially more viable. Social Care Policy considerably more prevalent amongst devolution of health and social care. • The coordination possible in a CA Within the NHS, the key policy driving Liverpool’s homeless population than The LCR local authorities have already also creates opportunities in respect strategic and operational change is comparable national data. started to put in place cross boundary of access to suitable housing supply. the Five Year Forward View (FYFV)84. approaches to integrating health and In reality, a Housing First service will All the LCR Clinical Commissioning Across Liverpool City Region, social care. In order to progress and face challenges in finding enough Groups (CCGs) are implementing specialist healthcare for homeless develop integration opportunities adequate, affordable housing, with plans based on the national FYFV. The people is provided in Liverpool, further, Knowsley, Liverpool and a reasonable security of tenure, with potentially relevant linkages at a local St. Helens and Wirral. There is no Sefton have begun to work together sufficient speed to ensure housing level between these health plans and specialist homeless healthcare in to support the process of integration really is delivered quickly to service the implementation of Housing First Halton, Knowsley and Sefton. This and development of a place based users. Affordable housing supply is include: demonstrates the importance of system of care. The proposal includes inadequate across most of England. implementing Housing First based on building upon the locality based When authorities combine housing • The need for a radical upgrade in the comprehensive model proposed delivery models which are built around resources, in terms of housing prevention and public health (Chapter 4), including the suggested the key principle of organisations advice, local lettings schemes for the • When people do need health specialist health input, in order to working together to manage common private rented sector and choice- services, patients will gain far greater effectively address the significant resources to improve the health and based lettings and other shared control of their own care – including health inequalities and health risks wellbeing of a geographically defined social housing allocation schemes, the option of shared budgets experienced by the cohort for whom population. The proposed locality the possibilities in terms of finding combining health and social care Housing First is the intended response. delivery model of care is designed to suitable housing will increase. • The NHS will become a better

85 Homelessness in Liverpool City Region A Health Needs Assessment; Janet Ubido, Louise Holmes and 84 https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf Alex Scott-Samuel: LPHO Report series number 96, May 2014 100 Housing First feasibility study for Liverpool City Region Policy context 101

radically alter the way that residents National Offender Management needs such as housing for offenders. prison leavers accessing housing, access social care. Service (NOMS) between 2013 and resulting from allocation and 2016, following the white paper of the These findings are reflected in the homelessness policies; and the very Prevention will be at the heart of same name, issued in May 2013. TR is National Audit Office’s (2016)88 analysis limited implementation to date of the model, with a focus on early concerned with the supervision and of survey data from across four CRCs: ‘Through the Gate’ initiatives in LCR, intervention and support at the point rehabilitation of offenders in England they found that user dissatisfaction which were intended to promote where it is the most beneficial to and Wales, and covers work in prisons was highest in relation to: obtaining continuity between prison and individual, family or community. This and in the community. help with housing; having to repeat community. type of model of integrated health information to different people; the and social care services based on TR’s ambitious reforms, intended to level of support that supervisors The recent Supported Accommodation defined localities with a preventative reduce reoffending, replaced the provided to offenders; and help with Review commissioned by the focus, will be better able to provide a previous 35 individual Probation finding employment. Departments of Work and Pensions coherent local health and social care Trusts with a single National and Communities and Local response to individuals housed and Probation Service, responsible for the An earlier review, conducted in 2014 Government (Blood, Copeman supported through Housing First. For management of high risk offenders, by the HM Inspectorates of Prisons and & Finlay 2016 a) identified limited example, Knowsley CCG is developing and 21 outsourced Community Probations to inform the development funding for housing-related support a ‘Neighbourhub’ model which will Rehabilitation Companies (CRCs). of TR, followed a cohort of 80 from the Criminal Justice System. create primary health and social care The CRCs are responsible for low-to- offenders from prison through the gate The Ministry of Justice funds the teams delivering locality based physical medium risk offenders and, following into the community and identifies their Bail Accommodation Support and mental health and social care for an extension to their duties under the accommodation and occupation status Services contract which provides the population including prevention Offender Rehabilitation Act 2014, are shortly before release, on release and accommodation for those who do and lifestyle focused interventions also responsible for the supervision one and six months later. This review not have suitable accommodation to through integration with community, of prisoners on release from short- concluded that: which they can be bailed or sentenced voluntary and other services. The sentences (less than 12 months in to Home Detention Curfew orders. The integrated model will deliver same prison). Another key aspect of the TR “Shortages of affordable rented National Probation Service manages day access appointment(s) and home reforms was that offenders serving accommodation, references, a small estate of Approved Premises, visits giving patients a responsive, short sentences and those with less a lack of resources to pay focused on higher risk offenders. flexible service 8am until 8pm, five than three months to serve should deposits and rent in advance, Cantley89 argues that, where days a week and extended access at be held in ‘resettlement prisons’, in or and the practical problems criminal justice-funded supported weekends through a variety of modes. linked to the area where they would of arranging accommodation accommodation was originally driven be released. CRCs are expected to from inside prison, meant that primarily by social and housing needs 6.6 Housing First and Criminal help offenders address their offending rented accommodation in this has, since 2001 shifted to a much Justice Sector Policy related needs including housing and the private or social housing stronger focus on risk management. The links between homelessness education, training and employment. sectors was not an option One professional interviewee described and offending are well-established for any of the offenders we the emergence of a two tier system in literature, with about a third of Access to housing followed. Often offenders in which there are far fewer housing offenders being without a home either However, a government review of TR were able to move in with options for CRC than NPS clients. before or after imprisonment86. in September 201687 concluded that family/friends on release, even the reforms are ‘far from complete’. if just as a temporary measure; The Supported Accommodation Housing has been recognised for Specifically, it found: the three in our sample who Review90 found that, although some time as one of the key factors did not have this option were some local authorities are still that can reduce re-offending and • Wide variation in the quality of forced to rely on emergency commissioning specialist supporting was identified as one of the seven arrangements to provide continuity shelter immediately after housing schemes for offenders (with Reducing Re-Offending Pathways between rehabilitation within prison release”. an estimated 4,500 units in total across established by the Reducing Re- and the community. England); many have withdrawn or Offending National Action Plan in • One of the biggest challenges lies in As presented in chapter 1, very reduced these contracts in the wake of 2004. This is still used as the basis accessing services outside the direct similar themes emerged from our local authority cuts. In that study, one for much intervention with offenders. control of NOMS and the CRCs, such conversations with both professionals national provider felt that some local as housing. The report recommends and users within the criminal justice authorities had expressed a hope that Transforming Rehabilitation (TR) was that CRCs will need to influence system in LCR. These included: the these contracts might be picked up by rolled out by the Ministry of Justice/ partner organisations to address structural barriers for offenders and CRCs, however, in their experience,

86 Accommodation for ex-offenders: Third sector housing advice and provision - Third Sector Research 88 National Audit Office, Transforming Rehabilitation, April 2016 Centre - Working Paper 77, Dina Gojkovic, Alice Mills and Rosie Meek, March 2012 89 Cantley, L (2015) The Role and Purpose of Independent Approved Premises, NAPA 87 Report on Transforming Rehabilitation to the House of Commons Public Accounts Committee from 90 Blood, I., Copeman, I., and Finlay, S. (2016) Supported accommodation review: The scale, scope and 12th September 2016. cost of the supported housing sector. DWP/DCLG 102 Housing First feasibility study for Liverpool City Region Policy context 103

the commissioning of supported to reduce street crime and anti-social randomised control trial across four services in Malaga, Barcelona housing is ‘not even on CRCs’ radars behaviour and successes have been cities. This major exercise was focused and Madrid98. yet’. Despite this national strategic shift, reported92. on the use of Housing First to reduce Liverpool City Council has continued • The Threshold Housing First service, homelessness among people with a Collaboration between central to commission support within a which is rolling out across the severe mental illness, with a specific government, local government, social number of specialist housing schemes Manchester Combined Authority goal to bring down the costs of this landlords and the homelessness sector for offenders, which offer a total of over the course of 2017-2020, has form of homelessness for public is highly developed within the Finnish 74 bed spaces in a mixture of 24-7 reported positive early results in health services. Led by DIHAL, the National Homelessness Strategy. Here, supported schemes and dispersed reducing recidivism and promoting French interministerial body for Housing First is part of a networked properties. housing stability among homeless national homelessness strategy, Un strategic response that includes women with complex needs and chez-soi d’abord, achieved 85 per cent preventative services and an array of What might this mean for the a history of offending behaviour, tenancy sustainment for the 703 supported housing, housing-led and implementation of a housing-led the programme having originally homeless people with complex needs other homelessness services. Finland system? been developed in collaboration using Housing First over two years94. has, through this multidimensional, Many of those who are repeat with Cheshire & Greater Manchester Following the successful results from integrated response to all forms of offenders, often on a series of short Community Rehabilitation the pilot, the programme is now being homelessness, in which Housing First prison sentences for low to medium Company93. extended across France. At the other has a clearly defined role in tackling risk offences, will fall within the target extreme, in Portugal there is a small, but ‘long-term’ homelessness (effectively group for Housing First. Mainstay data The ongoing implementation of TR – highly vocal Housing First movement homelessness among people with suggests that 61 per cent of those particularly the supervision of prisoners centred around the Casa Primeiro high support needs), reached a point who have been accessing hostels on short sentences in and on release (Housing First) project in Lisbon95. where eradication of homelessness and other homelessness services from prison by CRC workers – should is a realistic goal99. In Denmark too, in LCR for 12 months or more have create opportunities for referral and In Italy, Housing First Italia is integration of Housing First into some level of need in relation to preparation for Housing First or other a collaboration between the homelessness strategies has been offending. Housing First – integrated housing-led options. However, it will homelessness sector and academics, effective100. within a wider housing-led strategy be vital to establish a shared ethos for working collectively to promote could fill the current housing and this work – as one interviewee with lived Housing First in a context where The core lessons from European support gap for this low to medium experience pointed out, ‘[Housing First] finding resources to prevent and experience highlight the value in risk cohort and create efficiencies mustn’t feel like a continuation of prison’. reduce homelessness can be a real regarding Housing First as a strategic down the line for local authorities and challenge. Annual conferences and response to homelessness within their criminal justice sector partners: The huge barriers for offenders in summer schools share experiences a wider, integrated, homelessness police, rehabilitation services, courts, relation to social housing allocation and information and Housing First strategy. Where Housing First has and prisons where long term housing policies remind us of the importance is becoming an operational reality been most successful, for example stability is achieved. of Housing First being not just an across the Italian homelessness in Finland, it has been used as a core addition to the current system for sector96. In Sweden too, Housing component of wider strategy, not There is international evidence of the a minority of people but part of First development is being led by developed on an ad hoc basis with impact which Housing First can have wider system change. Underpinning a collaboration involving service precarious funding. The innovative on offending. For example: this must be a recognition of the providers, local government and Lund development of Housing First in importance of housing in enabling University97, from the ground up, Italy, Portugal, Spain and Sweden is • There are reports of the successful the rehabilitation of offenders, and a rather than development being led by inherently less secure and has covered use of Housing First to reintegrate cultural shift from seeing housing as central government. Elsewhere, as in less distance, because it has yet to be former offenders into the something to be earned or deserved to Spain, Housing First is being developed integrated into wider policy, with the community. In Calgary, Canada, a fundamental human right. on the basis of joint work between political support and, crucially, the the Adult Housing Reintegration individual homelessness service funding streams that such integration Program (AHRP) uses a Housing First 6.7 International Lessons providers and individual cities. The delivers. In England and the wider UK model and has reported successes in Implementation of Housing First in RAIS Fundación has been developing too, Housing First is in some senses housing sustainment and reductions Europe has not been consistent. At in recividism91. one extreme, there is the French 94 http://www.home-eu.org/85-percent-homeless-persons-france-keep-home-two-years/ • In the Netherlands, a core function national programme, Un chez - soi 95 http://faciam.org/wp-content/uploads/2015/01/PRESENTACIÓN_M.-Teresa-Duarte-de-AEIPS.pdf of the Housing First programme was d’abord, which involved a full scale 96 http://www.housingfirstitalia.org/en/ 97 http://www.soch.lu.se/en/research/research-groups/housing-first 98 https://www.raisfundacion.org/en/what_we_do/habitat 91 https://www.calgaryjohnhoward.org/AdultServices/AHRP.html 99 Pleace, N.; Knutagård, M.; Culhane, D.P. and Granfelt, R. (2016) ‘The Strategic Response to 92 Wewerinke, D., Al Shamma, S., Dries, L., and Wolf, J. (2013) Housing First in Nederland. Onderzoek Homelessness in Finland: Exploring Innovation and Coordination within a National Plan to Reduce naar opzet en uitvoering [Housing First in the Netherlands. Research on Design and Implementation]. and Prevent Homelessness’ in Nichols, N. Doberstein, C. (eds) Exploring Effective Systems Responses (Nijmegen: Netherlands Centre for Social Care Research, UMC St Radboud Nijmegen) to Homelessness Toronto: Canadian Observatory on Homelessness. 93 http://thp.org.uk/services/HousingFirst 100 https://www.slideshare.net/FEANTSA/evaluation-of-the-danish-homelessness-strategy-mixed-results 104 Housing First feasibility study for Liverpool City Region Policy context 105

still in a relatively fragile position, – to generate inconsistent and because it remains outside mainstream potentially poor results, undermining policy and is, with only a handful of the credibility of the model as a whole exceptions, not really operating on any and causing serious questions to be sort of scale with at best somewhat asked about the viability of Housing precarious funding arrangements. First102.

Even where Housing First is very This report explores how Housing well funded and being delivered on First can be developed, designed and some scale, the French Un chez- soi integrated by several local authorities d’abord programme being an example, working together, it is an examination wider strategic integration is still of the shape Housing First can take an issue. Housing First is present in and how it can fit into wider strategy. France, but resistance from elements There are political considerations, of the homelessness sector to its there are practical ones and while mainstreaming, makes it vulnerable101. aspects of the work are specific to the This vulnerability is political in the English or the wider UK context, this French context, because it may report does provide an exploration of mean that if the secure and extensive the questions around how Housing financial support Housing First has in First should work in complex context place disappears, or is reduced, there of a developed welfare regime. More may not be a broad constituency to broadly, the report explores how fall back on for political and financial Housing First can be developed in a support. As long as Housing First is context where support from central isolated from wider policy – operating government is restricted and local as a small service on the side or government finance has to be used. as something at one remove from broader homelessness strategy – long term survival of the model in England is not guaranteed.

The other risk, which is where the example of the United States is useful, is in what might be termed uncontrolled policy integration. This essentially means rebranding and reclassifying responses to homelessness as ‘Housing First’, so that entire homelessness strategies supposedly become led by what was only ever intended to be a specific response for a clearly defined and relatively small group of people with complex needs. The key concern here is loss of fidelity, so that far less intensive services, those not following the core philosophy of Housing First or working with the same group of people rebrand themselves as ‘Housing First’ and begin – inevitably

101 Houard, N. (2011) The French Homelessness Strategy: Reforming Temporary Accommodation, and Access to Housing to deliver ‘Housing First’: Continuum or Clean Break? European Journal of Homelessness 5 (2). 102 Pleace, N. (2011) ‘The Ambiguities, Limits and Risks of Housing First from a European Perspective’ European Journal of Homelessness 5, 2, pp. 113-127. 106 Housing First feasibility study for Liverpool City Region Conclusions 107

A high-fidelity Housing First model • A first phase for up to 2 years needs to be accurately and fully involving: costed and funded in order to deliver • Establishing cross LCR an approach that is likely to be most commissioning and effective in eradicating homelessness governance arrangements amongst the target cohort. The for Housing First and wider Conclusions evidence from this study and other provision of services for Housing First evaluations suggest that preventing homelessness; the costing approach needs to take • Implementing Housing account of: First for an initial cohort of service users whilst • A skilled, well trained and supported operating alongside existing Chapter 7: Conclusions core staff team; homelessness supported • A responsive and flexible on-call housing provision; service; • Securing ‘pump priming’ • The costs of securing and managing funding for this phase for it This feasibility study has identified and tested the housing used by Housing First to be feasible and to bridge evidence of how a Housing First model can be service users; the transition to subsequent • Access to 2nd tier mental health phases; and developed and implemented effectively across the LCR. support; and • Producing a detailed The conclusions that can be drawn from this evidence • Access to learning and work commissioning plan for coaching. scaling up of Housing First are set out here. implementation beyond year The proposed Housing First model 2 and reconfiguring existing for the LCR is most like to be feasible supported housing provision We have presented evidence in this • The development of clear pathways and deliverable at the scale required and associated support services. report as to why change is needed and between the criminal justice system to meet the identified demand if it is • Subsequent phases involving: how Housing First can play a key role and NHS provision and the system jointly commissioned by all six local • Full implementation of in achieving this change, if and only if for preventing and responding to authorities across the whole LCR. The Housing First commissioning it is part of a wider transformation to a homelessness. evidence is that this: plan to meet projected ‘housing-led’ system for the prevention demand; and of and response to homelessness. In order to achieve the required • Would deliver a consistent Housing • Reconfiguration of supported change in systems and culture, First approach which could still be housing services across the LCR. This wider system needs to include: detailed implementation planning ‘tailored’ to suit local requirements; • Managing effectively the implications needs to emerge from dialogue and • Would require pan LCR governance of such an approach including: • A consistent approach to accessing collective problem-solving involving: arrangements but that also allow for • Identifying existing 24/7 mainstream housing for those local flexibility and responsiveness; and non-24/7 supported experiencing or threatened with • Local authority commissioners • Would provide a more consistent housing provision that will homelessness: we suggest this (including social care and housing and coherent approach to securing either be remodelled or might be through a local lettings strategy as well as homelessness and the engagement of partner decommissioned as Housing approach, however, a wider review of housing-related support officers); organisations, i.e. mental health First is rolled out as part of a allocations policies in the region will • Providers of existing homelessness services, drug/alcohol services, wider ‘housing led’ approach; also be needed; services, including staff as well as criminal justice agencies; and • Aligning the increase in • Significant investment in prevention managers; • Would require the provision of capacity of Housing First services, which meet the • Landlords – both registered suitable housing to be managed sufficiently to accommodate requirements of the Homelessness providers and private sector landlords across the LCR; this could be people who were living in Reduction Act and are inclusive of and the bodies that represent them; challenging but could also provide or were at risk of moving all those experiencing or threatened • People with lived experience; economies of scale for a local to existing 24/7 supported with homelessness, regardless of • Health (including mental health lettings agency model. housing provision; and legal status; and substance use) professionals, • Agreeing with providers of • Sustained or renewed investment in providers and commissioners; and To implement and deliver the existing provision a phased floating support services, which fit • Criminal justice professionals, proposed Housing First model at scale approach to remodelling and/ with the basic principles of Housing including rehabilitation workers (CRC across a large area such as the LCR or decommissioning in line with First in terms of ethos and approach; and NPS), prisons, police and courts. will require a carefully planned and the roll out of Housing First. managed phased approach: 108 Housing First feasibility study for Liverpool City Region Appendices 109

The study has been funded by We would also like to thank the Housing First Hub Europe and the following organisations and groups Appendix 1: Overview of UK’s Department for Communities for their participation in the study: and Local Government. It does not Aintree University Hospitals NHS Trust Liverpool City Region represent the views of Government. Big Life Company Big Society Capital The researchers would like to thank Brownlow Group Practice those listed below for their invaluable Camden Council Liverpool City Region Demographic Overview input as members of the Steering Cheshire Police Group for the study: City of Westminster Council Freek Spinnewijn - FEANTSA Crisis Skylight Merseyside The area and governance which make up the Liverpool City Juha Kaakinen – Y Foundation CRISS The Liverpool City Region (LCR) is Region Combined Authority: Liverpool (Finland) Department for Work and Pensions located on the coast of North West City Centre, Sefton, St. Helens, Wirral, Liv Kristensen - Husbanken (Norway) DISC England, nearing the border to North Halton and Knowsley. On the 4th May Mike Allen – Focus Ireland Excel Housing Solutions Wales within the counties of Cheshire 2017, LCR elected Steve Rotheram MP Patrick McKay – Turning Point Scotland Halton Borough Council and Lancashire and is approximately as the first Metropolitan Mayor as part Rick Henderson – Homeless Link Halton Housing Trust 30 miles east of the City of Manchester. of the Cities and Local Government Peter Fredriksson – Finnish Inspiring Change Manchester LCR consists of six local authorities Devolution Act 2016103 Government Interserve CRC Samara Jones – Housing First Europe KHT Hub Knowsley Metropolitan Borough Taina Hytönen – Housing First Europe Council Liverpool Hub LHT Light for Life Sefton The researchers would also like to Liverpool CCG thank those listed below for their Liverpool City Council St. Helens invaluable input as members of the Liverpool Volunteer Street Outreach Wirral project board for the study: Teams Aydin Djemal – Wirral Ark Liverpool YMCA Halton Andy Carberry – Regenda LMH Anne Doyle – Liverpool City Council Local Government Association Knowsley Cath McAndry – Riverside Local Solutions Dalite Lucy – Knowsley Council Magenta Living Darren Stockton – Big Life Company One Vision Housing David Carter – Whitechapel Centre Plus Dane David Pugh – Liverpool YMCA Public Services Lab Gary Morris – Waves of Hope Regenda Kevin Cairns – St Helens Council Riverside Neil Woodhouse – Sefton Council Sefton Council Patricia Preston – Halton Borough SHAP Council Shelter Peter Jamieson – Department for South Liverpool Homes Work and Pensions St Helens Council Sheila Jacobs – Wirral Council St Helens YMCA St Mungo’s Thanks also to the following Local Transforming Choice Authorities for their participation in Waves of Hope this study: Whitechapel Centre Halton Borough Council Wirral Ark Knowsley Council Wirral Council Liverpool City Council Wirral YMCA Sefton Council Your Housing St Helens Council Wirral Council

103 http://www.legislation.gov.uk/ukpga/2016/1/pdfs/ukpga_20160001_en.pdf 110 Housing First feasibility study for Liverpool City Region Appendices 111

Population and ethnic diversity Ethnicity Economic deprivation Housing According to population data extracted LCR as a whole has a local economy Population from the UK 2011 Census105, LCR’s worth around £20 billion106. The index Housing Stock Population data 2016104 for the ethnicity in rounded percentage terms of Multiple Deprivation (IMD) 2015107 The following table outlines the supply Liverpool City Region stands at a total is shown in the following table: states that LCR (sharing geographic for affordable housing lettings in LCR population of 1,533,350. For illustration parity with the region’s Local Enterprise between 2015 and 2016109. purposes, this is broken down across Partnership (LEP)) is the most deprived the six local authorities as follows: Ethnicity Table 2 of England’s 39 LEP areas for Income, Employment and Health & Disability LCR Population by local authority Description of % of indices. IMD 2015 rank of average Chart 1 Ethnicity population scores per local authority, list Knowsley for LCR and Liverpool in the top 5 most deprived local authorities in England White (incl. British, 94.1% with Knowsley being 2nd and Liverpool Irish and Other) being 4th. All other areas of LCR come Mixed 1.5% within the top 100 in England with Halton ranked at 27, St. Helens at 36, Asian / Asian 2.1% Sefton at 76 and Wirral ranked at 66. British (incl. LCR has above the national average for Population Indian, Pakistani, people claiming benefits.108 Bangladeshi, Chinese, Other) Affordable Housing supply by property type Table 3 Black / Black British 1% (incl. Black African, Black Caribbean, Property Halton Knowsley Liverpool St Sefton Wirral Total Other) Type Helens Other (incl. Arab, 0.6% Bedsit 1 0 24 n/a 14 4 43 Halton Liverpool Other Ethnic 1 bed flat 288 264 753 n/a 350 219 1874 nosley t Helens Group) 2+bed flat 20 95 294 n/a 280 206 895 efton irral Source: Liverpool City Council, Table P5, 2014 1 bed house 0 0 6 n/a 0 2 8 2 bed house 191 183 573 n/a 121 139 1207 LCR Population by local authority 3 bed house 268 280 671 n/a 297 297 1795 Table 1 4+ bed house 31 47 58 n/a 39 21 196 LA Number % Bungalow 432 89 91 n/a 80 29 721 Halton 126,903 8.27% Total 1231 958 2470 n/a 1181 899 6739 Source: Liverpool City Region Housing Strategy, 2016 Knowsley 147,915 9.64% Liverpool 484,578 31.60% St. Helens 178,455 11.63% Sefton 274,261 17.88% Wirral 321,238 20.95% 106 Liverpool City Region, 2016, ‘Liverpool City Region Context’, Liverpool City Region Housing Strategy, Liverpool City Region http://www.knowsley.gov.uk/knowsleycouncil/media/Documents/LCR- Source: Liverpool City Council, 2016, Population tenancy-strategy.pdf Statistics 107 http://liverpool.gov.uk/media/10001/1-imd-2015-executive-summary.pdf 108 Liverpool City Region, 2016, ‘Appendix A: Liverpool City Region key housing trends’, Liverpool City Region Housing Strategy, Liverpool City Region http://www.knowsley.gov.uk/knowsleycouncil/media/ 104 Office for National Statistics licensed under the Open Government Licence, Liverpool City Council, Documents/LCR-tenancy-strategy.pdf http://liverpool.gov.uk/council/key-statistics-and-data/data/population/ 109 Liverpool City Region, 2016, ‘Appendix A: Liverpool City Region key housing trends’, Liverpool City 105 Liverpool City Council, 2014, ‘Table P5’, Source: Office for National Statistics, 2011 Census, Crown Region Housing Strategy, Liverpool City Region http://www.knowsley.gov.uk/knowsleycouncil/media/ Copyright available http://liverpool.gov.uk/council/key-statistics-and-data/data/population/ Documents/LCR-tenancy-strategy.pdf 112 Housing First feasibility study for Liverpool City Region Appendices 113

Housing Tenure Average House Price Liverpool City Region released its According to the UK House Price Housing Strategy for 2016-2019110 Index England: April 2017111, the presenting the region’s key housing average house price in England stands trends. 680,000 dwellings make up the at £236,519. By comparison, the 6 regions total with 78 per cent in private local authorities making up LCR has ownership and 22 per cent for social an average house price of £134,096. rent. LCR is below the national average Notably, Knowsley saw an average for the share of total housing stock house price increase over the last but above the national average share year of 10.4 per cent, almost double available for social rent. Private renting the average price change for England levels are much higher in Liverpool at which stands at 5.7 per cent. Average 23 per cent compared to St Helens, house prices by local authority are Knowsley and Halton at 10 per cent. as follows: The proportion of social renting accounts for 28 per cent in Liverpool, 27 per cent in Knowsley and 15 per cent Average House price by Local in Sefton. Authority Table 5

Local Authority Avg. House Tenure (%) Table 4 price Halton £135,367 Local Owned Owned with Shared Social Private Other Total Authority Outright mortgage ownership rented rented Knowsley £123,178 Halton 27.08% 36.31% 0.60% 25.21% 9.78% 1.01% 100% Liverpool £123,811 Knowsley 26.14% 35.65% 0.51% 26.63% 9.75% 1.30% 100% Sefton £152,719 Liverpool 21.21% 25.73% 0.53% 27.84% 23.38% 1.31% 100% St. Helens £118,904 St Helens 33.29% 33.98% 0.56% 20.59% 10.21% 1.35% 100% Wirral £150,599 Sefton 35.90% 34.60% 0.56% 14.47% 13.40% 1.07% 100% Wirral 33.29% 34.17% 0.51% 15.17% 15.84% 1.01% 100% Source: HM Land Registry, 2017 Total 28.78% 31.88% 0.54% 21.55% 16.07% 1.18% 100% North West 31.04% 33.48% 0.52% 18.29% 15.38% 1.29% 100% England 30.57% 32.77% 0.79% 17.69% 16.84% 1.34% 100%

Source: Liverpool City Region Housing Strategy, 2016

111 HM Land Registry, 2017, Official Statistics: UK House Price Index England: April 2017, https://www. 110 Liverpool City Region, 2016, ‘Appendix A: Liverpool City Region key housing trends’, Liverpool City gov.uk/government/publications/uk-house-price-index-england-april-2017/uk-house-price-index- Region Housing Strategy, Liverpool City Region http://www.knowsley.gov.uk/knowsleycouncil/media/ england-april-2017 Documents/LCR-tenancy-strategy.pdf 114 Housing First feasibility study for Liverpool City Region Appendices 115

undertaken work research on Housing Peer researchers: Dave, Mohamad, Appendix 2: The Research Team First for the Finnish and French Richard and Rose conducted Governments, Simon Community interviews with people with lived of Ireland and Homeless Link. He experience and contributed to the Imogen Blood (IBA) has been the meeting the housing need of our is currently evaluating the Threshold analysis of key themes. Director of Imogen Blood & Associates ageing population (for LGA); Hearing Housing First and Inspiring Change for 8 years. She is a qualified social the Voices of Older People in Wales Manchester Housing First projects, Paul Connery (Crisis): supported worker who began her career working (for Social Services Improvement with Deborah Quilgars. the LCR fieldwork by identifying and in hostels and then in prisons as a Agency); Evaluation of housing engaging key stakeholders, organising drug and alcohol worker. Imogen has brokerage for adults with visual Joanne Bretherton (University of York, and co-facilitating some of the group seventeen years’ experience designing impairment (for Thomas Pocklington Centre for Housing Policy) led the discussions and supporting the peer and delivering research, evaluation Trust). Housing First England study on nine researcher/ lived experience research. and consultancy projects across the Housing First pilots during 2014 and public and not-for-profit sectors Ian was responsible for the was co-author of the report on the David Pugh (YMCA) and his colleagues and she has led and contributed to a determining the costing approach, first service to become operational in interrogated Mainstay to produce a wide range of high profile research commissioning arrangements, London, Camden Housing First which series of detailed quantitative reports. projects. These include the recent implementation and phasing options, is now one of the more established Supported Accommodation Review overview of the financial elements and Housing First services in the UK. She Lizzie Peters (IBA) provided input on (for Department of Work & Pensions/ contributed to the policy review. has also undertaken research on the Criminal Justice policy. Department of Communities & introduction of Housing First in the Local Government); EU Joint Action Mark Goldup (HGO Consultancy) Republic of Ireland. Joanne is an on Dementia: Evidence Review on Mark has been a freelance consultant expert in the evaluation of services Dementia Friendly Communities (for specialising in housing, care and for homeless people with complex the Department of Health); Hearing the support for 19 years. He has a long needs. She co-directs the Women’s Voices of Older People in Wales (for history of developing models for Homelessness in Europe Network, a Social Services Improvement Agency); undertaking needs assessments and collaboration between the University and A Better Life (Joseph Rowntree developed a generic methodology that of York and Trinity College, Dublin. Foundation). Imogen is particularly was used by around a third of local interested in inclusion, strengths-based authorities under the old Supporting Nicholas and Joanne played an practice and how systems respond People regime. He recently refreshed advisory role, reviewing and presenting to people with multiple and/or high this approach for the National Housing relevant evidence on Housing First support needs. Federation, and is now building on from elsewhere and contributing to this with them by identifying the cost the review of the wider policy context. Imogen managed the project team, led consequences of the gap in provision. on the development and evaluation of Shelly Dulson (IBA Research Assistant) the model, conducted the professional Mark has led on the quantitative transcribed and analysed the data stakeholder research, peer researcher data analysis, cohort size and cost from people with lived experience, training and some of the ‘outreach’ effectiveness/ value for money produced case studies, and collated interviews with rough sleepers; modelling for the study. the overview of the LCR. contributed to the policy review, and edited the report. Nicholas Pleace (University of York, Lyndsay McAteer (IBA Researcher) Centre for Housing Policy) is currently carried out qualitative interviews Ian Copeman is Director of Housing Deputy Director of the Centre for with people with lived experience, & Support Partnership. He has over Housing Policy. Nicholas has been alongside our team of 10 years experience of undertaking working on the resettlement and research and consultancy working tenancy sustainment of homelessness for Government, local authorities, people with complex needs since the supported housing providers, housing mid 1990s. He is a member of the associations, voluntary organisations core research team for the European and has led and contributed a Observatory on Homelessness, wide range of projects. Recent and operating under the auspices of current examples include Supported FEANTSA, the European Federation Accommodation Review (for of Homelessness Organisations and DWP/ DCLG); Housing our ageing is the author of the Housing First population: Learning from councils Guide Europe housingfirstguide.eu. He 116 Housing First feasibility study for Liverpool City Region Appendices 117

Appendix 3: Methodology Profile of the respondents 5. Ethnicity: 1. Location of interview: Identity No.

Location type No. African 1 Lived experience data collection • What has been/would be helpful Black African 1 At the outset, we met with a group in relation to these services? Hostel 27 of 7 people with lived experience • What has not been helpful? Day Centre 22 Black British 3 of homelessness, who are currently • Explain the Housing First model: British 2 working as volunteers either for Crisis could this work for you/other Outreach 21 or Waves of Hope. Our intention was people? Rehabilitation and 9 English 1 to share the Housing First model with • What would need to happen to Treatment Centre Mixed British 1 them, and seek their advice on where make it work? Total 79 we might gather the views of homeless • What would you need to make it Mixed Race 2 people in LCR on this model. However, work for you (now or in the past)? Scottish 1 once they had heard about and 2. Gender: discussed the model, they became so Paul Connery (Crisis) contacted Sudan-Africa 1 enthusiastic about it, they told us they support providers across LCR and Men Women Trans Total Blank White British 55 would like to be more actively involved identified opportunities for us to / DNA in this aspect of the study. engage people with lived experience White Irish 1 57 18 1 76 3 in different settings. We worked in White Polish 3 We delivered a half day training session small teams – including professional for those who wanted to be involved and peer researchers – for safety 4. Age: White / British Arab 1 and four peer researchers then and support. We gave interviewees Total 73 worked alongside Lyndsay McAteer, a £10 shopping voucher to thank Age range No. Imogen Blood and Paul Connery to them for their input and, for each Blanks / DNA 6 19 – 30 14 conduct the remaining interviews. The session they attended, the peer group gave feedback on the research researchers received a £20 voucher 31 – 40 22 tools – topic guides, demographic and refreshments. 41 – 50 30 6. Sexuality: questionnaires, and consent forms. We 51 – 60 5 met at the end of the fieldwork period We spoke to 79 people: 14 completed Over 60 5 Sexuality No. to identify key themes from the data as a short questionnaire and the a group. remaining 65 took place as in-depth Total 76 Bisexual 2 one-to-one interviews carried out at Blanks / DNA 3 Heterosexual / straight 70 The questions used in the lived LCR hostels, a day centre, a treatment experience research were: centre and in public spaces with Lesbian / gay 1 outreach services. Of the 65 one-to- Prefer not to say 2 Your story one interviews, 57 were recorded and 8 were written up as notes by the lead Total 75 • Tell us how you became homeless. researcher. Blanks / DNA 4 What were the things that led to your current situation? Given limited time and resources, • What has been the biggest hurdle/ summary (rather than full verbatim) 7. Health and disability: barrier so far, in terms of accessing transcriptions and coding of these homelessness services and access to transcripts and notes under five basic Do you have a health No. a home? nodes was undertaken by Shelly condition or disability? • How are things for you now? Dulson. The node headings were: YES 40 Your views about services/ • Current provision is working NO 34 Housing First • Current provision is not working Total 74 • What would be needed to make Blank / DNA 5 • What have been your experiences of Housing First work homelessness services? • Backstories: what is causing • How do you view homelessness homelessness services? • Access to health/ mental health services 118 Housing First feasibility study for Liverpool City Region Appendices 119

8. Descriptions of health conditions and disability: 10. To draw out a long term view On the streets of time spent in homelessness, Stay range No. Health & disability descriptions No. interviewees were asked how long they had been homeless in total: Less than a week 3 Mentions of: mental health, depression, anxiety, PTSD, self-harm 21 More than a week but less 2 ADHD 2 Range No. than a month Asperger’s Syndrome 2 Less than a month 8 1-3 months 4 Bipolar 3 More than a month but less 23 3-6 months 2 than a year Epilepsy 2 6-12 months 1 1-2 years 18 OCD 1 1-2 years 0 2-5 years 15 Learning Difficulties 3 More than 2 years 0 5-10 years 7 Mentions of mobility issues including arthritis, back problems and 7 Total 12 MS More than 10 years 3 Blanks / DNA 0 Type 2 diabetes 1 Total 74 Single sided deafness 1 Blanks / DNA 5 Heart and lung condition 3 11. Interviews asked how long they Liver or Kidney disease 1 had been staying or living in the Addiction or drug and alcohol related 3 place they are currently staying. We present a selection of these Blanks / DNA 45 breakdowns here, where numbers are sufficient: 9. Interviewees were asked where they were staying at the time of the interview: In a Hostel

Staying / living: No. Stay range No. Housing association tenancy 4 Less than a week 1 In a hostel 28 More than a week but less 5 than a month In emergency accommodation / sit-up 9 1-3 months 14 On the streets 12 3-6 months 4 Other / Rehabilitation Centre / programme 5 6-12 months 3 Other / Supported Accommodation 4 1-2 years 1 Other / Asylum seeker accommodation 1 More than 2 years 0 Other short stay / flat 3 Total 28 Staying with friends / family 3 Blanks / DNA 0 Private rented tenancy 5 Total 74 Blanks / DNA 5 120 Housing First feasibility study for Liverpool City Region Appendices 121

Professional Interviews Mainstay Analysis 2. An analysis of specific sub-groups in We interviewed a total of 95 Mainstay was originally developed terms of the level of need and risks that professionals within LCR, and a further for LCC as an assessment and they presented 8 from outside of LCR, through a referral gateway for commissioned mixture of focus groups, phone and homelessness accommodation and The sub-groups were with an face-to-face interviews. 18 were floating support services: it went live explanation for their selection: interviewed, either face-to-face in the city on the 01/07/13. Outcome or by phone. The IBA team were and support planning data was working on a parallel commission for subsequently added for both of these Sample Group Reason Liverpool City Council on the Future services: a full dataset for both services Clients assessed but not placed The primary concern is to try and get more information of Supported Housing and some has been recorded since October about this group so that a judgement can be made as to of these interviews covered topics 2016. Knowsley started using in full the extent to which if some people are taken out of the for both projects. The remainder of in Oct 2015, St Helens in July 2014, homelessness system they will not just be replaced by this professional participants attended one Halton in Oct 2014, Sefton in Dec group. of 12 group discussions: 2014, and Wirral in Jan 2015 Clients re-housed to mainstream The concern here is to identify the characteristics of those • A 3-hour workshop for supported We asked the YMCA, who are accommodation people who do seem to be benefitting most obviously housing providers across LCR commissioned to manage the Mainstay from the current accommodation system, and therefore • 6 x focus group discussions with system, to undertake to four levels of to inform judgements about the future role of the existing local authorities (one in each of the analysis on the Mainstay system on our provision within the overall new service configuration. 6 LAs) behalf. Clients in receipt of floating support The interest here is to get a sense about the level of • A 3-hour workshop for Registered needs being met by floating support – again to inform Providers 1. An analysis of the overall flows considerations of the future balance of provision within a • A focus group for health within the homelessness system as a new service configuration professionals, organised by Liverpool whole including Clinical Commissioning Group • A group discussion within a CRISS • Number of unique individuals Clients living in 24 hour cover One of the bases for defining the cohort for Housing First (City Region Intensive Support receiving an Assessment services or being supported by is the length of time homeless. 12 months known to the Service) team meeting • Numbers of individuals with 1, 2, 3 or rough sleeper outreach at the end Mainstay system was taken as the proxy basis for identifying • A focus group with Crisis Skylight 3+ Assessments in the. of the period, who have been on the “long-term” homeless. It was further assumed that being team • Number of Assessments by Reason system for at least 12 months in 24 hour cover accommodation was more likely to be • A group discussion at the Outreach for Assessment and by Housing connected to higher levels of need or risk, and therefore providers’ forum Status awarded it was right to spilt this group into 2 sub-groups. Those • Number of Placements. currently being supported by rough sleeper outreach The breakdown of these professionals by sector • Number of unique individuals services were subsequently added to this group, as it was is shown in the following table: receiving a placement in the period felt logical to include them within this cohort • Number of placements by last Clients living in 9-5 cover services See above known accommodation Sector No. at the end of the period, who have • Numbers of placements by numbers participants been on the system for at least 12 of previous placements on the Local authority officers (Housing and 25 months system. Social Care) • Number of First Assessments that do Clients meeting the basic Waves of The alternative way of identifying the cohort for Housing Housing and/or supported housing 38 not lead to a Placement Hope criteria for referral – people First is to use some kind of needs based measure. In this providers • Number of placements in 2013-14, scored as having high need in 2 instance we decided to use the criteria for referral to Waves. Complex needs/ outreach workers 21 2014-15, 2015-16 still in a placement out of 3 domains (mental health, It is not possible to use the additional criteria on Needs (CRISS, Waves, Outreach Forum, Crisis) at current date offending, substance misuse). Index scores – so this group is not the same as those who Health 7 • Number of departures by end reason would be eligible for a waves-type service. The next stage • Average length of stay of the analysis looks in further detail at those people who Criminal Justice Sector (Probation, 5 • Number who move in a planned or were actual Waves clients and therefore met the additional Police, Prisons) unplanned way Needs Index score criteria. Other UK Housing First projects 4 • Number of departures by what type National policy officers 4 of accommodation they move to 122 Housing First feasibility study for Liverpool City Region Appendices 123

3. A more detailed analysis of 2 of the sub-groups. Those who: Appendix 4: Costing of proposed • Had been using 24 hour hostel or Housing First Model outreach services for at least 12 months • Had been assessed as having a high level of need in 2 out of 3 domains All of the costs components set out (mental health, substance misuse or in 4.15 are used to build a projected offending) overall cost for the proposed Housing First model based on the operating These were initially regarded as model of 20 clients per core staff possible proxies for a defined Housing team. This is shown in full in the table First cohort below.

The data included Cost assumptions associated with proposed Housing First model. • Presenting Needs • Agency Contacts Model Cost assumptions Projected cost per 20 Housing First • Events recorded component clients (per annum) • NDT scores • Services accessed The ‘core’ Housing Housing Support Worker role £33.6k £33,600 x 4 = £134,400 • Support Plan details First staffing team p/a @ 4 posts Team Leader role £45.4k p/a @ 1 post £45,400 4. A more targeted set of queries Organisational overhead allowance Subtotal = 179,800 intended to support estimates of charged at 15% Total including 15% overheads = £206,770 • The numbers of people currently in the system who could be targeted A social lettings Assumed to be a cost of £777 per £777/52 weeks = £14.94 per unit p/w for Housing First agency annum per unit £17.94 x 20 units x 52 weeks = £15,540 • The numbers of people who were p/a possibly misplaced in supported housing because their need levels Access to 24/7 on Telecare package - £5 p/w per client £5 x 20 units x 52 weeks = £5,200 p/a were not really high enough call system Response service – 4 hours p/w at 4 hours x £17.46 x 52 weeks = £3,631 £17.46 per hour p/a

2nd tier mental £40k p/a @ 0.3 FTE £12,000 p/a health support

Wellbeing support £30k p/a @ 0.3 FTE £9,000 p/a and work/learning coaching

Total £252,141 p/a 124 Housing First feasibility study for Liverpool City Region Appendices 125

The basis for the costings for the of the model could be provided on a etc. Market rent properties are provided proposed Housing First model as set ‘seconded’ basis from other services with a housing management service - out in the table above: on the basis of 0.3 FTE role per 20 the other costs are borne by the owner. clients (drawing on evidence from a • It is possible that some housing units • The ‘core’ Housing First staffing related service for rough sleepers in for Housing First clients are provided team, including an allowance for the Liverpool and based on discussion directly by social landlords and therefore organisational overhead to support with local stakeholders) The these costs may represent a prudent and this ‘core’ team. Housing Support assumed cost of this seconded role marginal overestimate. Worker costs are assumed locally is £40,000 per annum FTE including to cost above current market rates on-costs. The following variables and assumptions for such roles due to the complexity • Wellbeing support and work/ are used. of the Housing First clients. Annual learning coaching. Feedback from costs are assumed to be £33.6k112 per local stakeholders has been that Property Portfolio post FTE per annum including on- the provision of wellbeing support costs. A Team Leader role is assumed and work/learning coaching could Affordable One Bed Flats 100 to cost £45.4k113 FTE per annum be provided as part of existing Small family Homes 40 including on-costs. It assumed services supporting homeless people that management/organisational alongside the core Housing First Multi-Occupied Units 280 overheads of 15% are applied to team. The assumptions used for these staff costs. costing is on the basis of 0.3 FTE role Market One Bed Flats 50 • A local lettings agency (LLA) to per 20 clients (based on discussion Small family Homes 25 deliver access to housing and with local stakeholders). The potentially the management of such assumed cost of this role is £30,000 Multi-Occupied Units 100 housing. It is anticipated that will be per annum FTE including on-costs of use to a wider cohort. The costs (based on other services working of the LLA are based on a number of with homeless people in Liverpool. Other assumptions include: variables and assumptions that are set out below. Rental Levels Affordable set at LHA level. Market set • Access to 24/7 on call system. It is Costing a local lettings agency with reference to Home.co.uk website assumed that an existing 24/7 on model. Management Fees 25% for Affordable call system would be used with a For the purposes of modelling the level 15% for Market response service provided either by of subsidy that might be required the an existing service provider or by the social lettings agency is assumed to Voids and Bad Debts 10% across all properties core Housing First staff team on a have the following features: Housing Management 0.7 hours per unit per week for rota basis once sufficient scale has affordable been achieved. Assumed costs are • A balanced portfolio of properties, 0.25 hours per unit per week for market £5 per week114 per client for provision with some market-rented but more (This is based on a previous piece of of a basic telecare service (based on affordable. work undertaken) costs of similar services locally) and • A size that could only be achieved Service & Maintenance Costs for Maintenance - £350 per property an assumed on call response of up to after the project has been Affordable Properties Servicing Costs - £265 per unit 4 hours per week per 20 clients this operational for some time Furniture & Equipment - £110 per unit will need to be tested and refined in • A portfolio of properties which practice) at the core staff team cost includes 1 bed flats, small 2 bed Additional staffing (the costs are total Includes the following additional of £17.46 per hour (Housing Support family homes and 4 bed multi- costs of employing the staff including staffing: Worker assumed cost expressed as occupied properties (It is not not just standard on-costs but also CEO @ £54,017 an hourly rate). assumed that the latter will be used office, equipment, training costs etc) 2 x Housing Supervisor @ £38,398 each • 2nd tier mental health support. Local by Housing First) Finance Manager@ £41,522 stakeholder feedback has suggested • All properties are managed on behalf Property Finder @ £38,398 that the core Housing First team will of the owner. Affordable properties Comms Manager @ £38,398 be trained to be sufficiently skilled are fully managed including all day in supporting clients with mental to day maintenance, furnishing & All staffing costs include allowance for health needs and that this element equipping, servicing of equipment travel, equipment, office costs, office space 112 £28.5k annual salary plus 18% on costs 113 £38.5k annual salary plus 18% on costs 114 Riverside telecare cost from £3 per week 126 Housing First feasibility study for Liverpool City Region Appendices 127

This produces the following costs: Appendix 5: Detailed Fee Income £479,612 Calculations of Sizing the Housing management £298,185 Costs Cohort for Housing First Other Property Costs £231,000

Infrastructure Costs £277,081 There are three elements to benefit straight away from a Housing Shortfall £326,654 this process: First offer. It is acknowledged that this is probably an under-count because Cost Per Affordable £777 per year • Estimating the current unmet it does not take account of people Unit demand for Housing First based on who for a number of reasons do not an analysis of Mainstay present themselves for a Mainstay • Estimating the newly-arising demand assessment and effectively are “hidden for Housing First year on year using homeless”. We have not however assumptions built into a recent needs found any reliable basis to take this into assessment exercise in Liverpool City account in the numbers modelled and • Estimating the proportion of people so at the moment these people are not who would cease to use their counted in the sizing of the cohort. Housing First over time based on the result of Housing First evaluations This produced a total of 260 separate to date individuals.

As one of the key criteria is also that 1. Estimating the current unmet the individual is sufficiently engaged demand with services at that point in time to An analysis of Mainstay was carried accept the offer of Housing First it is out as to ascertain the number of reasonable to discount this number individuals who met the following on the basis that say 20 per cent of criteria: the individuals will not over a year ever get to a point where they would Criterion 1: People who have be able to accept an offer. This is an presented at least four separate times estimate which would need to be for accommodation assessments since validated once Housing First had been the Mainstay system began operational for some time. The idea AND would be to maintain contact with Criterion 2: Those whose most recent these people and build a relationship Assessment is less than 12 months ago such that ultimately, they may accept AND an offer. Criterion 3: Those who were, in their most recent assessment, assessed as With this assumption, it gives an having a high-level need in relation to estimate of the inherited potential at least one of the following: cohort for Housing First of 208 people.

• Physical Health 2. Estimating newly arising need • Emotional and Mental Health We have recently undertaken a full • Offending needs assessment exercise for housing • Drugs and Alcohol misuse support services for Liverpool City • Social Networks Council. As part of this we already made an estimate that, in Liverpool, This is then assumed to be the basis 71 new people next year falling to 57 for the calculation of the people per year within 5 years and 44 per year currently in the system who would within 10 years would meet the criteria 128 Housing First feasibility study for Liverpool City Region Appendices 129

for housing with ongoing long-term 3. Estimating Cumulative Need An estimate of the proportions of associated support (i.e. Housing First). The cumulative need is the number Housing First clients who are in these Some of these people would be part of of housing units required for categories and the average duration the 20 per cent assumed to be unable Housing First at any one point. This is of service for these groups have been at the moment to respond positively to cumulative because as this is a non- modelled as follows: an offer of a Housing First place. time-limited service each year the total number increases, unless some other Sub-Groups Estimated % of Average time The projected annual reduction factor intervenes. customers reflects an assumption that numbers would fall as other interventions In reality other factors do have to be People who withdraw from the 20% 9 months become more effective and less taken into account, and the calculation Housing First people fall into the trap of long-term of cumulative need does need to take People who no longer need the homelessness. We have then assumed into account not only the numbers intensive support package offered that, in line with the analysis already of new Housing First arrangements 20% 5 years because of changes in their done, that maybe 80 per cent might coming on-stream, but also the circumstances be prepared to accept a Housing First number of arrangements that would offer during that year. cease to be active support cases. People whose health deteriorates to the point where they have to move 10% 3 years If we use the number of Liverpool This would include people who ceased to an enhanced care facility – or they clients known to Mainstay between to receive the service because they: pass away 2015 and 2017 as a proportion of the People who continue to need the total number of LCR clients within • withdrew from the Housing First 50% 10 years support offered the same period (whether placed or service as they no longer wished to not) as the basis for a multiplier for receive it the LCR as a whole this would involve OR These assumptions are based on the multiplying the above figures by 1.8. • no longer needed the intensive results of the largest UK evaluation of support package offered because Housing First, which was of the Depaul Across the LCR this would mean that of changes in their circumstances / service in Northern Ireland115. the estimates of numbers of HF units capacities – though these people needed for newly arising (or newly will still need an ‘open door’ and/ Based on these assumptions in presenting) need would be as follows: or follow-up lower intensity floating practice the numbers of Housing support. First arrangements assumed to be Next Year 71*0.8*1.8 = 102 OR operational at the end of Year 1 is • were deceased or whose health reduced by 20 per cent, at the end in 5 Years 57*0.8*1.8 = 82 Per Year deteriorated to the point where they of Year 3 is reduced by a further In 10 Years 44*0.8*1.8 = 63 Per Year needed to move to an enhanced 10 per cent, and at the end of Year 5 health or care facility by a further 20 per cent. By the end For the purposes of modelling we of Year 10 for modelling purposes assume that these numbers change on it is assumed that all the initial a consistent basis so for example the arrangements have ceased, although number of new cases for the first in reality some may go on for much 5 years is assumed to be as follows: longer – this is an average length of service. This would mean that for the Year Number of new initial cohort of Housing First (the cases people already in the system) the numbers of service arrangements that 2018-19 102 would be in place at the beginning of 2019-20 98 each year would be as follows: 2020-21 94 2021-22 90 2022-23 86 2023-24 82

115 Boyle and Palmer, The efficiency and effectiveness of the Housing First Support Service piloted in Belfast by Depaul, 2016 130 Housing First feasibility study for Liverpool City Region Appendices 131

Year No of Units Initially the numbers required reflects the significant backlog of need. Over Appendix 6: Method for 2018 208 time this dissipates as the numbers of 2019 166 the initial clients decreases, and after assessing potential for cashable the seventh year of the programme 2020 159 the number of units required begins 2021 152 to reduce. At some point in the future savings and efficiencies from this will reach a plateau. – a state of 2022 145 equilibrium – but projecting more than implementing Housing First 2023 124 10 years is unlikely to be realistic.

2024 103 Potential for cashable savings In practice, the length of time taken 2025 82 In order to project the likely costs of to implement Housing First to match implementing the proposed model projected demand will be influenced 2026 61 it is necessary to make use of the by the degree of effectiveness of the 2027 40 estimated demand within the LCR Housing First model, the pace at which that could be met by Housing First commissioners wish to implement 2028 19 alongside the predicted costs of the a Housing First model and the model in practice. Projected future resources that are available to fund this This exercise is then completed for demand is covered in detail in Chapter approach. each of the cohorts that arise from the 4 so only the relevant elements for newly emerging need and this allows a costing the model are shown here. The table below illustrates the cost calculation to be done for the total number Chapter 4 identifies the estimated implications of seeking to meet the of units needed in each year as follows demand for Housing First across the projected demand for Housing First LCR in terms of the number of service based on a phased implementation Based on these assumptions the users over the period 2018 – 2028. over 5 years and using the estimated cumulative need for Housing First This is based on: cost of the proposed Housing First Units has been calculated as follows: model per client per annum. 1. Estimating the current unmet Year No of Units demand for Housing First based on an analysis of Mainstay 2018 310 2. Estimating the newly-arising demand 2019 346 for Housing First year on year 2020 410 3. Estimating the proportion of 2021 468 people who would cease to use their Housing First over time based 2022 519 on the result of Housing First 2023 543 evaluations to date 2024 555 2025 554 Assumptions also need to be made about the implementation and 2026 538 take-up of Housing First in practice, 2027 514 particularly during the earlier phases 2028 480 of implementation. For the purposes of costing the model over the period 2018 – 2028 it has been assumed, To explain this further the numbers based on discussion with local of units required in 2023 is made stakeholders, that: up of (the numbers starting in 2018*50%) +(the numbers starting in • It may take up to 5 years for a 2019*70%) = (the numbers starting in Housing First response to be scaled 2020*70%) +(the numbers starting in up to meet projected demand; 2021 *80%)+(the numbers starting in • There will be year-on-year increases 2022*80%) +(the numbers starting in in the capacity of Housing First over 2023) the first 5 years. 132 Housing First feasibility study for Liverpool City Region Appendices 133

Cost implications of meeting estimated demand for Housing First Service Type Benchmark Cost in the LCR 2018-2028 (£ per unit per annum) Housing First 12607 Year Projected demand Projected build-up Projected cost of for Housing First of Housing First Housing First per Emergency & Specialist Congregate 17523 (no of service capacity (no of annum Housing – 24 Hour Cover users) service users) (£m) Emergency & Specialist Congregate 9000 2018/19 310 60 0.76 Housing – Other 2019/20 346 130 1.64 Housing-led – access to housing 335 2020/21 410 210 2.65 2021/22 468 300 3.78 The cost of Housing First is set Liverpool City Council on the need 2022/23 519 400 5.04 out in Chapter 4. for housing support services. We have grossed up the results of this 2023/24 543 543 6.85 The figures for Emergency & Specialist for the LCR by using a multiplier of 2024/25 555 555 7.00 Congregate Housing are based on a 1.8. This is based on the fact that the sample of current LCR schemes. This total number of users of the current 2025/26 554 554 6.98 includes both the support funding accommodation services in the LCR is 2026/27 538 538 6.78 currently paid by local authorities and 1.8 times those of Liverpool alone. the excess in rental income over the 2027/28 514 514 6.48 LHA level. This model uses the following 2028/29 480 480 6.05 assumptions. The figure for housing-led provision is based on the calculated cross-subsidy • The total number of people at risk Note: no allowance for cost inflation is In order to test whether the modelled for the LLA, set out in the costing of of homelessness across the LCR is built into the projected costs reconfiguration of services in support the Housing First model (but with the assumed to be 9477 in 2023/24, of of Housing First is affordable and will additional assumption that only maybe which 85 per cent are anticipated This indicates that the cost in year 1 sustain this additional expenditure on half the units will actually be secured will present for assistance (this is (2018/19) would be £0.76m. The cost Housing First we have to assume a through this route). based on a complex modelling of would then rise proportionately as benchmark cost for each of the service a wide number of pathways into modelled until supply and demand are options identified in the explanation of It is an important part of the overall homelessness). in equilibrium by year 6 in 2023/24, the housing-led strategy in Chapter 3. strategy to include the provision • The various interventions proposed when the annualised cost is projected The following is a proposed set of of floating support to facilitate the are anticipated will have an to be £6.85m. assumptions. prevention of people losing their 80 per cent success rate in terms accommodation, people moving of ending people’s homelessness From this point the projected cost into alternative accommodation, and (this generates a number of re- fluctuates reflecting changes in people moving on from the residual presentations for assistance of which estimated demand. However, in reality congregate accommodation. At the it is assumed that 30 per cent of service costs do not typically fluctuate moment however we do not have unit people will come back into the in this way as the actual cost is based cost information for these services. system through the congregate on the metric of 20 service user of However instead we provide a cross- emergency and specialist housing Housing First (per core staff team) so check below which indicates as to initially) any increase/decrease in scale and whether this model presumes an • The average length of stay in costs will tend to reflect changes increase in floating support provision emergency and specialist housing based on this metric. or not as we do have figures for total may be up to 6 months depending usage across the LCR. on client need. • 41 per cent of people needing some We have modelled a possible service additional support with their housing configuration as at 2023/24, as this is will be able to have their need met the point where we suggest Housing in mainstream accommodation with First should be meeting the identified time-limited floating support. This is need. We have used as our starting based on an analysis of support plan point a recent study undertaken for scores on Mainstay – 41 per cent of 134 Housing First feasibility study for Liverpool City Region Appendices 135

people housed in supported housing It should be noted that it is not easy actually had an assessed level of to compare the need for access support need no greater than the to housing under Housing Led average for floating support users. arrangements, because currently the • 38 per cent of people in need of six LCR local authorities are already some short-term emergency & very successful in finding alternative specialist housing will need 24 hour accommodation as a way to avoid cover. This is based on an analysis homelessness. In 2015-16 there were of the risk levels assessed for people 3,684 recorded cases of this across using supported housing services the LCR. How much this work overlaps currently. with what is projected above is quite difficult to ascertain, but there is The modelling projects the probably a large degree of this. following: The model also estimates that Total Number requiring floating around 905 of those people would support to achieve this benefit from a floating support service to help them settle in to that People whose housing alternative accommodation. Using can be sustained with 3545 1582 the benchmarks already explained to prevention interventions translate this into total costs produces the following results. To help interpret the achievability of these assumptions we have Service Type Current Costs Projected Cost compared these numbers to the (£m) (£m) recorded numbers of prevention of Housing First n/a 6.85 homelessness by helping people stay in their accommodation that local Emergency & Specialist Housing – 14.4 6.21 authorities are already achieving. 24 Hour Cover Across the LCR in 2015/16 the six Emergency & Specialist Housing – 5.96 5.05 authorities in the LCR recorded 1510 Other cases in which they achieved this. Housing-led – access to housing 1.07

The remaining need for other forms of Total 20.36 19.18 provision in 2023/24 according to this model and in comparison to current levels of provision was as follows: As a cross-check we have also estimated the assumed level of floating Service Type Current Level Calculated Need for support that this might indicate. This is 2023/24 (housing units made up of 3 elements as follows: not people) Housing First 0 543 Circumstance Number of People Emergency & Specialist 822 355 Preventing homelessness 1582 Housing – 24 Hour Cover Assisting resettlement straight into 905 Emergency & Specialist 662 561 mainstream housing Housing – Other Assisting resettlement from emergency & 673 Housing-led – access N/a 3184 specialist housing (50% of users moving on) to housing Total 3159 136 Housing First feasibility study for Liverpool City Region Appendices 137

This should be compared in total to supported housing schemes through This was then amended by taking the 5,942 users of floating support Housing Benefit above the one bed into account the fact that the average recorded on Mainstay between LHA rate will be recycled to local support plan score of people currently 2015 and 2017, and would thus authorities through some version receiving a supported housing service only represent a small increase, and of the supported housing funding was equal to or higher (i.e. lower level therefore without significant budgetary reforms. It makes no such assumption, of support needs) than the floating implications. however, about non-commissioned support average score in 41 per cent supported housing currently receiving of cases. It was therefore assumed Overall this would indicate that with above LHA rates of rent. that only 59 per cent of the 23.99% all these assumptions a Housing First/ needing access to housing with housing-led system could generate Notes covering calculation of support actually needed congregate savings. Potential for Cashable Savings supported housing, while the other The Potential for Cashable Savings was 41 per cent could manage with direct It is however significantly dependent based on calculations as at 2023/24 access to alternative mainstream on being able to successfully scale in the following way: housing and a time-limited floating up the prevention activity of Housing support package. This resulted in Options teams, and without the Initially the conclusions from the the revised percentages used for capacity to do that the whole strategy Liverpool City Council Housing Needs modelling purposes. is likely to unravel. This will obviously Assessment were captured. This itself require additional resource, which divided those who were calculated Service Intervention Global % of the at risk population is more difficult to estimate, but within to be at risk of homelessness into Prevention intervention to preserve existing 20.7 + 16.7 = 37.4% the above modelling results there proportions in terms of the required housing with or without floating support would appear to be some scope to service responses (this is represented dedicate resource to this. as a global figure but was made up of a number of different potential pathways Access to alternative housing with or 23.8 + (23.99*0.41) = 33.6% One final note of cation should be into homelessness – these were without without additional floating support struck. This modelling does assume described as the populations at risk). that money that is currently paid to Access to housing with support (all types) 23.99 * 0.59 = 14.2% Assumed not to present for assistance 15.5% The percentages needing the following service responses in this analysis was as follows We calculated that the total numbers Service Intervention Global % of the at of people at risk of homelessness risk population across the LCR would be 9477 (based on the number in Liverpool x 1.8) the Prevention intervention to preserve existing housing 20.7% multiplier reflected the proportion of Prevention with associated floating support 16.7% total mainstay placements that were Access to alternative housing without additional support 23.8% made in Liverpool City. The numbers Access to housing with support (all types) 23.99% requiring the above interventions is therefore calculated as follows: Assumed not to present for assistance 15.5%

Service Intervention Global numbers in need of this intervention Prevention intervention to preserve existing 37.4% * 9477 = 3544 housing with or without floating support Access to alternative housing with or 33.6% * 9477 = 3184 without additional floating support Access to housing with support (all types) 14.2% * 9477 = 1346 Assumed not to present for assistance 15.5% * 9477 = 1,468 138 Housing First feasibility study for Liverpool City Region Appendices 139

We then assumed that 20 per cent This leaves a further 1832 people in The figure for Housing First is of all interventions failed to achieve need of an intervention. explained in Chapter 4. The figures for their objective of stabilising people’s Emergency & Specialist Congregate housing situation and that 30 per If we assume an average length of stay Housing are based on a sample of cent of those people as a result re- of 6 months then this means that a current LCR schemes. This includes presented for some form of housing total number of 916 housing units are both the support funding currently with support intervention. This means needed for these people. paid by local authorities and the excess that in addition a further 6 per cent of in rental income over the LHA level. the total at risk population would in We then make a calculation as to what fact end up in Housing with Support percentage of these units should be 24 The figure for housing-led provision is based on the calculation 0.2*0.3. Hour Cover. This is based on the fact based on the calculated cross-subsidy that 55.4 per cent of the current units for the LLA, set out in the costing of The total percentage in need of are 24 Hour Cover but a finding from the Housing First model (but with the a housing with support option is Mainstay was that only 70 per cent of additional assumption that only maybe therefore 14.2 + 6 = 20.2 per cent. current users had a high risk rating. half the units will actually be secured This amounts to a total of 1914 people. The percentage that should be 24 through this route Hour Cover was therefore calculated This is the number of new people as 0.554 * 0.7 which was rounded up The total number of units required who present in this year who need a to 38 per cent. and projected cost was therefore housing for support service. We have calculated as already assumed that 82 of these The cost per unit for the different people will need a Housing First interventions was assumed to be Service Type Calculated Need for Total Budget response. 2023/24 (housing Cost (£m) units not people) Service Type Benchmark Cost Housing First 543 6.85 (£ per unit per annum) Emergency & Specialist Housing – 355 6.21 Housing First 12607 24 Hour Cover Emergency & Specialist Congregate Housing – 17523 Emergency & Specialist Housing – 561 5.05 24 Hour Cover Other Emergency & Specialist Congregate Housing – 9000 Housing-led – access to housing 3184 1.07 Other Total 19.18 Housing-led – access to housing 335 140 Housing First feasibility study for Liverpool City Region Appendices 141

implications, but the research would money provided by investment in Appendix 7: Potential for suggest in the short or medium term Housing First is to undertake a cost some of these would actually increase effectiveness exercise, rather than efficiencies: Value for money as a result of Housing First achieving a cost benefit exercise as such. This its secondary objectives of helping involves calculating the cost per people engage with services more successful outcome and comparing analysis effectively, and in particular address it to the cost per successful outcome their serious health problems more of the current set of homelessness effectively. In the short to medium- services. There are 2 main types of analyses that individuals – and will probably not all term, use of mental health and other demonstrate the value for money that accrue to the agencies shouldering planned health / social care services One of the key issues that has to be can be generated by a particular form the cost of the intervention. This are bound to increase if Housing First resolved is over what time frame the of service intervention. These are: potentially undermines the impact works as it should. Treatment costs cost effectiveness is assessed. Housing of the analysis. There is also the and engagement with substance First can be a long-term service as it is • Cost Effectiveness Analysis question as to whether the savings are misuse services will also probably intended to be open-ended, but for all • Cost Benefit Analysis “cashable” – will it actually result in increase in short term but then reduce. kinds of practical reasons it will tend other budgets actually being reduced to taper away over time. At the same A cost-effectiveness analysis looks or not increasing as much as they Some other costs such as the use of time, as the principal objective is the to calculate the cost of achieving would otherwise do. The number emergency services (A&E, ambulance ending of long-term homelessness a certain specified outcome e.g. of individuals involved generally service, etc) and criminal justice costs as measured by the successful effectively breaking the cycle of have to be pretty significant in order resulting from offences committed sustainment of a tenancy, this never homelessness. It returns the cost for this to be the case – unless the should, based on other research involves an absolute outcome for per successful outcome. It is really costs being saved are something like reduce in short-term as well as the individual – the tenancy clearly intended to compare different ways benefit savings where there is a direct long-term. could be sustained for 10 years of approaching the same objective relationship between the individual and then break down the next day. and thereby comparing the value and the money expended. Having completed cost benefit For pragmatic purposes, however for money of two (or more) different analyses elsewhere we would say effectiveness can only be judged by interventions aiming to achieve Most research on the costs of that the biggest costs long term that taking a fixed point in terms of elapsed this. The output is a relative cost homelessness indicate that the impact on the cost benefit calculation time from the tenancy start date and per successful outcome – it does main savings involved in reducing in relation to the public purse are time recording whether it is still in place at not take into account any potential homelessness are generally from the spent in psychiatric inpatient care or in that point. savings generated elsewhere by the homelessness services themselves custody. Other research would suggest intervention – although these can e.g. the research used subsequently that Housing First is more likely to For the illustrative exercise, we have be alluded to. It is importantly the – Better than Cure? Testing the case impact on the latter than the former undertaken we have taken this fixed case that the intervention that is most for Enhancing Prevention of Single – but again these are unlikely to be point to be after 2 years and therefore successful in achieving the desired Homelessness in England, Pleace and cashable savings. we have looked at the likely cost of the objective may not be the most cost Culhane, 2016, found that the cost of intervention over 2 years and similarly effective if it is the most expensive e.g. homelessness service itself constituted Generally, the evaluations done the likely cost of the alternative pattern if it is twice as effective in achieving 43 per cent of the total costs on Housing First in the UK and of services over the same period, and the objective but three times as identified for the 86 homeless people elsewhere to date have shown a assessed the chances that at the end expensive per head it will be seen to interviewed for the study, and that the significant success rate in helping of this period the individuals will be in be less cost effective. net savings across the consumption of people maintain a tenancy, but have their own settled housing. homelessness, NHS, criminal justice, been more mixed in terms of other A cost benefit analysis involves an mental health and drug and alcohol outcomes. But then as already stated, This is mostly because the evidence of attempt to compare the costs of services is actually less than the it is important to remember that the effectiveness of Housing First from the new service intervention to cost than the costs of homelessness the principal objective of a Housing evaluations undertaken in the UK and the costs of carrying on with the services alone. This just serves to First programme is ending long- elsewhere has generally been over an “business as usual” alternatives. And confirm that the cost effectiveness term homelessness, and tenancy equivalent time period. then comparing this to the value analysis illustrated here is by far the sustainment is the principal indicator of the benefits achieved or the dis- most effective way to demonstrate the against which the effectiveness of the It could be said that this may skew the benefits avoided to the extent to value for money of Housing First to programme should be judged. results as Housing First is a long-term which these can be monetised. These the state as a whole. service that in most cases is likely to benefits, and thereby the potential For these reasons in this instance go on consuming costs well beyond savings, can accrue to a range of A cost-benefit analysis would want it would seem that the best way 2 years, and that this calculation agencies or in some models to the to look at the wide range of cost to demonstrate the value for will therefore make the cost per 142 Housing First feasibility study for Liverpool City Region Appendices 143

successful outcome in effect much Using the analysis of Mainstay, we centre-type services on a sporadic In cost effectiveness terms Housing lower than it actually will be. On the found that out of 1,104 people who basis. The research by Pleace and First is shown to be 4.93 times as cost other hand the evidence suggests had a high level of need in relation Culhane, based on interviews with 86 effective as existing service provision, that the long-term homeless people to 2 out of 3 of the domains – homeless people, made an attempt as well as being 5.3 times as effective that Housing First is aiming at tend mental health, substance misuse to track this based on analysis of the in achieving the desired results. to spend a very long time in the and offending (a proxy for those that services that this sample of 86 had Importantly this conclusion has been system using the gamut of current Housing First is aimed at) that 170 consumed over a 90-day period. This based on defensible but conservative homelessness services on a cyclical people had been successfully resettled was then grossed up to produce an assumptions. In reality, it could be even basis. The Pleace and Culhane work into some form of mainstream annual cost of £14,808 per person. more cost-effective if the tenancy already quoted found for example that accommodation. This represents 15 retention rate for people successfully people had spent an average of over per cent of the caseload (rounded). This is potentially misleading however being resettled under the current 4 years as homeless and in receipt of because the hostel element of the system was taken into account. services (not continually however). On a very conservative basis we costs included the full rental payment This complements the conclusions Cost effectiveness is intended to will assume that all 15 per cent do and most Housing First clients will be reached in the previous section on show the relative value for money then successfully hold on to that equally dependent on benefits to meet financial modelling – a housing-led of interventions so in this instance a accommodation and therefore for this their rental payments (up to the LHA strategy built around Housing First 2-year timeframe does not feel too exercise 15 of the 100 other clients are level). In order therefore to ensure that can be delivered at no net cost and far unrealistic. still in settled housing at the end of the we can discount this element of the higher in terms of effectiveness and 2 years. rental from both sides of the equation cost-effectiveness. There are therefore 4 basic elements we have therefore deducted the LHA to the cost effectiveness calculation: Cost of Housing First rate of £90 per week for the estimated The calculated cost of Housing First, 60 per cent of users in the Pleace • The proportion of people receiving including the estimated subsidy to a and Culhane study who made use of the intervention who will achieve the Local Lettings Agency, is £12,607 a hostel during the set period. This specified outcome per year. reduces the estimated annual cost by • The proportion of people receiving £2.808, producing a total of £12,000. the comparator intervention who will For the purposes of this exercise we This will amount to £24,000 over achieve the specified outcome. therefore assume that the 80 clients 2 years. • The cost of the intervention being who are sustained successfully for the evaluated full 24 months will cost 2 x £12,607 = For 15 clients, however there is • The cost of the comparator £25,214. assumed to be no cost because for intervention this exercise they are assumed to be However, the costs of those who do housed at the beginning of the 2-year We look at each of these in turn. The not succeed in meeting the outcome period and remain so throughout calculation is based on a notional also need to be taken into account as (although in reality there will be other scenario of 100 clients receiving costs of the intervention. However, inputs to sustain them – so again this Housing First and 100 continuing to by definition this is not for the full 2 is a conservative assumption). receive services as of now. years. Elsewhere we have estimated that initial failures to maintain settled Putting these assumptions together Achieving the specified outcome with housing may take place on average we produce the following results: Housing First after 9 months, so we also assume Various Housing First evaluations have this here and therefore for each of the Housing First Existing Homelessness indicated that between 70 per cent clients who do not meet the outcome Services and 90 per cent of clients placed in the assumed costs are £12,607 x 0.75 housing were still in settled housing at = £9,455. Cost of Service (25,214 x 80) + 24,000 x 85 the end of the evaluation period, with (9,455 x 20) a tendency to be at the higher end of Costs of Existing Homelessness = £2,040,000 this scale. For this exercise, therefore Services = £2,206,225 we will take a conservative assumption This is complicated by the reality of and assume that 80 Housing First service usage. Almost by definition the Achieving sustained tenancy 80 15 clients were still in settled housing at cohort that Housing First is aimed at, the end of 2 years. dip in and out of services – sometimes Cost Per Successful £27,578 £136,000 living in hostels, sometimes living Outcome Achieving the specified outcome with on the streets or in other temporary existing homelessness services settings, while using outreach or day Crisis is the national charity for homeless people. We are committed to ending homelessness. Every day we see the devastating impact homelessness has on people’s lives. Every year we work side by side with thousands of people, to help them rebuild their lives and leave homelessness behind for good.

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