Recognising and Overcoming the Barriers to Housing First in the European Context: Case Studies from Ireland and England

EUROPEAN RESEARCH CONFERENCE
Housing First. What’s Second?
Berlin, 20th September 2013
Recognising and Overcoming the Barriers to Housing
First in the European Context
Case Studies from Ireland and England
Nicholas Pleace
Joanne Bretherton

Presentation Overview
 Exploration of critiques and concerns about
using Housing First in Europe.
 Draws on research projects assessing strategic
implementation and the service-level piloting of
Housing First during 2012/13.
 ‘Finding the Way Home’ housing-led strategy in
Ireland
 ‘Camden Housing First’ pilot evaluation in London
 Conclusions and implications

Critiques of Housing First
 High rates of housing sustainment, but
concerns:
 Model drift
 Does not work for all
 Cost effectiveness
 Mixed results around social integration, health and
well-being
 Is it really innovative?
 Behavioural modification advocates
 Too expensive

‘Finding the Way Home’: A Housing-Led
Strategy in Ireland
 Critical review of the Ireland homelessness strategy for
the Simon Communities of Ireland
 Examined how suitable ‘Housing First’ was for Ireland
from various perspectives
 Consultation with policymakers and service providers
 Representatives from eight major agencies
 High level consultative briefing with government and service
providers
 Consultation with service providers
 Simon Communities in Cork, Dublin, Dundalk, Letterkenny, Sligo
 Consultation with homeless people
 Focus groups with 27 people, 19% women, 81% men

Key findings from Irish research
 Housing-led and harm reduction philosophy
viewed positively by service providers and
homeless people
 But also as closely reflecting current practice
 Suitability for some people
 Affordable housing supply
 Joint working
 Concern about ‘watering down’

Positive views of Housing First
 Rapid housing and support
 Own front door/ontological security
I am an adult. I am capable of looking after
myself…you know, the idea of getting your own
key, closing your own front door Homeless Woman.
 But, key aspects were normal practice:
 Harm reduction, choice, some housing-led services

Positive views of Housing First
It’s more effective, the harm reduction, than being given an ultimatum,
which I’ve been given through me life and I just left like, just one day
you just leave and find yourself homeless again Homeless Man.
The dictatorial approach, it would just simply not work, people are
where they are at and there’s absolutely no progress unless that
person decides to progress themselves, but there is so much
dictatorship going on, and if the client makes a mistake and guess what
people make mistakes, then that’s it ‘goodbye’, that kind of dictatorial
approach does not work with people who have come through
homelessness, or even with any of us in the room, that type of
approach. Service Provider.

Suitability of Housing First
 A few homeless people said they preferred
communal services with on site support
 History of institutionalization
 Isolation, inactivity and boredom
 Drugs and alcohol issues
 Providers reported that Housing First should not
be only choice, might not be the best option for
some homeless people

Preference for communal services
I suppose it [Housing First] would be handy for
some people, but there are a number of people I
suppose would struggle…I suppose people would
feel on their own, like, you know. I’d say most
people would like to be independent but there’s a
few who’d be much happier in the [communal
service] Homeless Man.

Preference for communal services:
Isolation and Drug and Alcohol use
It is a problem like, because if you are a drinker, I’m a
drinker…if your hands are empty, you say ah I’ll go for one
and then you go for two, you know what I mean, it’s a trap
in that sense. Homeless Man.
Isolation is the thing, isolation is the key. If you’re in
isolation you don’t stand a chance, you’ve got to have
support, but it needs to be 24 hours a day, it’s no good
having a key-worker who visits ten minutes a day…
Homeless Man.

Housing First as not suitable for all
I think there will always be a need for supported housing,
because we have people who go into supported housing
who couldn’t then take up a housing-led style apartment or
place to live. I think it will depend on the individual, on the
assessment, on what they want from us. Service Provider.
There are people with more complex needs than others.
Like if you get someone whose been heavily entrenched in
homelessness for the last six years and put him into an
apartment somewhere and have a floating support worker,
it might not be enough for that individual, because they
might need more contact. Homeless Man.

Joint working
 All Housing First services rely on joint working to
provide packages of support
 Challenges in case management because
health, welfare and social care services were
being cut back
There’s an assumption like, and it’s quite prevalent, particularly in some
meetings that we go to…that structurally the services are there like and the gap
is with the individual as such like and with the problems of the individual, of
which there is many, but it’s an assumption through these models that
structurally everything is in place, it’s just a matter of organisation and
coordination, which it quite simply isn’t. Service Provider.

Affordable and adequate housing supply
 Insufficient supply of affordable, adequate housing
People on housing lists for years, who just haven’t been offered anything, and
there doesn’t seem to be direct answers or reasons as to why that’s happened.
And we would have a number of people who, you know would benefit [from
Housing First]…where they would move into a decent property and have the
floating service, but it’s often impossible to get that, it’s rare if ever. Service
Provider.
I’m renting at the moment, I’ve no house from the council or anything like that,
which is nearly €70 a week I’m paying, you know rent, that’s without ESB
[electricity], gas or putting something in the fridge. You know that’s a lot of
money when you’re on social welfare. Very difficult to get a council house in
[location]. What I’m looking for is a council house really, which is only €25, €30
a week and they look after you...Homeless Man.

Concerns about ‘watering down’
 Concerns that successful Housing First service models
would be ‘diluted’
 Worry among service providers that government wanted much
cheaper, low intensity services
 ‘Hiding’ expenditure cuts by presenting as ‘innovative Housing
First’ services
I think that the Pathways model as it’s employed in New York, Philadelphia and
wherever else is great, but I think that the danger in Ireland is that the support
side of it will be watered down...you have the mental health expert and the
drugs expert, where here, the goal seems to be to have one key-worker
support maybe 15 people, doing everything and what’s lost is the assertive
community treatment [ACT] teams which are so specialist…Service Provider.

Camden Housing First
 An intensive case management, scattered site Housing
First service
 The pilot had capacity for engagement with up to 10
people
 Unusual use of a Housing First approach
 Designed to work alongside an existing staircase
service system
 Focused on chronically homeless people who were
‘stuck’ in staircase system for three or more years,
because they were not judged to be ‘housing ready’

Camden Housing First
The Study
 18-month longitudinal study of a small scale Housing
First experiment in central London
 Independent study, supported by University of York and
SITRA
 Tracked outcomes using service user records
 Tracked progress of service with regular interviews with
frontline and management staff, plus discussions with
service commissioners
 Interviews with service users
 Reviewed costs

Key Findings: Camden Housing First
 Successful engagement with people who had not lived in housing
for many years or never lived independently.
 Could support people with very high needs
 Possible to overcome major restrictions in suitable housing supply
by using private rented sector
 Joint working could be effective
 Social integration was a slow process
 Possible to replicate successes of NY Pathways Housing First
using operational principles rather than exact duplication, raises
possibility of comparable cost Housing First models using intensive
case management (ICM) and scattered private rented sector
housing being used in the EU

Successful engagement
 Service users had very high needs
 13 in total, 6 women, 7 men, typically in 40s, ethnically and
culturally diverse
 Almost all had problematic drug/alcohol use
 Very high rates of severe mental illness and personality disorder
and poor physical health
 Long term workless
 Histories of anti-social behaviour
 At the point that the research stopped:
 7 people were still housed
 1 rehoused for six months, but lost the tenancy
 5 awaiting housing, all successfully engaged with by CAMHF

Ending chronic homelessness
 Many service users had never lived independently
 All had been in hostels in Camden for at least three years, often far
longer. They were defined as not housing ready by other services.
People are so institutionalised, all these things people don’t know how to do,
they’ve never even thought about, people can be like a kid, leaving home for
the first time,. you know, but these people are much older and have much less
confidence. But it’s an entirely different mind-set to living in a hostel with all the
rules that are being forced upon you, to being self-directed, that is a massive
shift, and that’s the ultimate dream for people to be in charge of themselves
and to manage themselves. CAMHF Team Member.
 However CAMHF had successfully engaged with and was
delivering housing sustainment for this group

Service user views of CAMHF
It’s been helpful… you know what I mean, got me into this place, away
from things I didn’t want around me, and trying to help me get back on
my feet…CAMHF Service User.
It’s been brilliant, yeah, very good, she’s [specialist floating support
worker] been brilliant, and she’s always, when she’s said she’s going
to be there, she’s been there, not let me down, you know? She came
with me every time to view the flats because we’ve viewed three, she
was there with me, she didn’t let me go on my own. And every now
and then she rings me and asks me how I am, how is my day going
and she’s going to be there for about a year, I’m liking that. CAMHF
Service User.

Staff views of CAMHF
So much of it is about treating an adult like an adult, getting
your message across, most of the time with humour, and
actually being there when they do change their minds
about things. CAMHF Team Member.
It’s not really for us to tell somebody what to change, we
can advise and give them their options or explain the
consequences, but without the nagging thing attached to it.
CAMHF Team Member.

Using private rented housing for CAMHF
 Very little social housing available
 March 2013, the Greater London Authority reported that
380,301 Londoners were on social housing waiting lists.
 This is a 56% increase in the level reported in 2003, equivalent
to 4.65% of a total population of 8.17 million people.
 However, major challenges in using the PRS:
 Victorian and older buildings, poor space standards, insulation,
sound proofing
 Welfare benefits pay maximum rents of up to £800-£1,000 a
month for a one-bedroom / studio apartment (€940-€1,178)
 Much private rented housing in central London has rents above
these levels

Using private rented housing
 Housing service users could take time (average of 75
days)
 Adequate and affordable PRS housing is scarce
 However, by forming relationships with PRS letting
agents, the support team were able to secure adequate,
central London housing within rent levels paid by
welfare system
The first thing he said was- “I don’t want any druggies, I don’t want any
junkies, I don’t want any ex-cons” and, of course, but we -spent what, an hour
and a half, two hours with him and it ended up with him- showing us properties
and in the end he’s housed our clients…and that’s all just because of building
the relationships, it’s not because of anyone coming forward saying ‘yeah, I
want to work with your clients’. CAMHF Team Member.

Joint / Inter-agency working
 Aside from issues accessing the PRS, CAMHF
were successful in working with other agencies.
 Working effectively with health and care
services
 Registration with General Practitioners (family doctors) who are
the main route of access to health services (all service users)
 Connection with drug and alcohol services and mental health
services. Evidence of some improvements in mental health and
drug and alcohol use

Economic and social integration
 Less progress around education, training and
employment, but this was a group very ‘distant’
from paid work
 Social integration outcomes vary. Interaction
with neighbours was sometimes a challenge,
but there was some evidence of integration
It’s a massive thing, for people who’ve been like completely socially excluded
from mainstream society to then actually be a part of it, you know they may not
be the most productive members of society, but they are still part of it…
CAMHF Team Member.

Replication of Housing First approach
 Slightly lower costs than Pathways Housing First (New York)
 CAMHF used two full-time case managers with a caseload of 5
each. It provides intensive case management
 CAMHF £90k per year, €106k, with caseload of 10, one person, for one
year, would be £9k, €10.6k.
 Mean cost for hostel/supported housing £10.6k, €12.6k per person, per
year
 But hostel/supported housing costs could range as high as £17.5k,
€20.6k per person, per year for specialist services
 These are care costs only, exclude rent/accommodation charges
 CAMHF suggests successful Housing First approach can be
replicated at slightly lower cost, following operational principles, but
not all details, of New York model

Conclusions
 Non-housing outcomes, yes, results can vary, but
housing sustainment improves situation (shown in other
research)
 Model drift, yes, but that can be a positive, effective ICM
based London service was relatively low cost
 Does not work for all, no it cannot, some may not be
suited, but London example shows very high need
groups can be successfully supported
 Cost effectiveness, yes, but emphasis on effectiveness,
not on being ‘cheaper’ and while slightly less expensive
than New York Pathways model, Camden Housing First
was not cheap, not ‘watered down’, it was an ICM model


Conclusions
 Clearly Housing First is different from what has been
done in Ireland and England before. London example
was able to engage with chronically homeless people
defined as ‘not housing ready’ by established services
 Behavioural modification as a more effective alternative
i.e. the staircase model – nothing to support that
conclusion from Irish or English work reported here.
 Findings in line with wider evidence base, lots of
reasons to continue with Housing First, but also to be
careful.

Thanks for Listening
 Nicholas.Pleace@york.ac.uk
 Joanne.Bretherton@york.ac.uk
 www.york.ac.uk/chp/
 @CHPresearch

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