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

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

[email protected]

[email protected]

www.york.ac.uk/chp/

@CHPresearch

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

Business

Transcript of Recognising and Overcoming the Barriers to Housing First in the European Context: Case Studies from...