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Housing First - Provincie West-Vlaanderen

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AcknowledgementsThe author would like to thank Marie Gaffet at DIHAL forcoordinating the drafting and production of this report, aswell as Ruth Owen, Policy Officer at Feantsa for her help withthis review and her comments. Responsibility for any errorslies with the author.


<strong>Housing</strong> <strong>First</strong>Table of ContentsSummary..................................................................................................................................................3What is <strong>Housing</strong> <strong>First</strong>? ............................................................................................................................................................................................................3Pathways <strong>Housing</strong> <strong>First</strong> (PHF)...........................................................................................................................................................................................................3Communal <strong>Housing</strong> <strong>First</strong> (CHF)..........................................................................................................................................................................................................4<strong>Housing</strong> <strong>First</strong> ‘Light’ (HFL).......................................................................................................................................................................................................................4Evidence in favour of <strong>Housing</strong> <strong>First</strong>................................................................................................................................................................................5The Global Influence of <strong>Housing</strong> <strong>First</strong>............................................................................................................................................................................6The Case for <strong>Housing</strong> <strong>First</strong>...................................................................................................................................................................................................61. Introduction........................................................................................................................................ 7About this Report...........................................................................................................................................................................................................................7The Structure of the Report.................................................................................................................................................................................................82. Pathways <strong>Housing</strong> <strong>First</strong> (PHF).......................................................................................................... 9Introduction..........................................................................................................................................................................................................................................9Origins......................................................................................................................................................................................................................................................9Problems with ‘staircase’ services..................................................................................................................................................................................................9What is Pathways <strong>Housing</strong> <strong>First</strong>? ................................................................................................................................................................................10The PHF Philosophy..................................................................................................................................................................................................................................11Delivering a Pathways <strong>Housing</strong> <strong>First</strong> Service .....................................................................................................................................................14Which groups of homeless people is PHF designed to help?.................................................................................................................................14What are the aims of a PHF service?........................................................................................................................................................................................14How is the PHF service accessed? ...........................................................................................................................................................................................15How is the PHF service delivered?..............................................................................................................................................................................................15What does PHF cost?.............................................................................................................................................................................................................................17Risk management........................................................................................................................................................................................................................................17Summary of PHF service delivery...............................................................................................................................................................................................18Evidence of effectiveness.......................................................................................................................................................................................................18<strong>Housing</strong> Stability...........................................................................................................................................................................................................................................18Changes in Drug and Alcohol Use...............................................................................................................................................................................................18Changes in Mental Health....................................................................................................................................................................................................................19Social Inclusion.............................................................................................................................................................................................................................................20Economic Inclusion...................................................................................................................................................................................................................................20Cost Effectiveness......................................................................................................................................................................................................................................213. Communal <strong>Housing</strong> <strong>First</strong> Services...............................................................................................................23Introduction......................................................................................................................................................................................................................................23Origins..................................................................................................................................................................................................................................................23What is Communal <strong>Housing</strong> <strong>First</strong>? .............................................................................................................................................................................23CHF Philosophy ...........................................................................................................................................................................................................................241


The <strong>Housing</strong> <strong>First</strong> philosophy and CHF services in Finland...................................................................................................................................25Delivering a Communal <strong>Housing</strong> <strong>First</strong> Service...................................................................................................................................................26Which groups of homeless people is a CHF service designed to help?......................................................................................................26What are the aims of a CHF service? ....................................................................................................................................................................................27How is a CHF service accessed?.................................................................................................................................................................................................27How is a CHF service delivered? ................................................................................................................................................................................................27What does a CHF service cost?...................................................................................................................................................................................................28Risk management.......................................................................................................................................................................................................................................29Summary of CHF service delivery..............................................................................................................................................................................................29Evidence on effectiveness...................................................................................................................................................................................................29<strong>Housing</strong> stability...........................................................................................................................................................................................................................................29Changes in Drug and Alcohol Use.............................................................................................................................................................................................30Changes in mental health......................................................................................................................................................................................................................31Social and economic inclusion..........................................................................................................................................................................................................31Cost effectiveness.......................................................................................................................................................................................................................................314. <strong>Housing</strong> <strong>First</strong> ‘Light’ Services........................................................................................................................32Introduction......................................................................................................................................................................................................................................32Origins..................................................................................................................................................................................................................................................32What are HFL services?......................................................................................................................................................................................................32HFL philosophy.............................................................................................................................................................................................................................34Delivering a <strong>Housing</strong> <strong>First</strong> Light Service.................................................................................................................................................................35Which groups of homeless people is a CHF service designed to help? .....................................................................................................35What are the aims of a HFL service? ....................................................................................................................................................................................35How is an HFL service accessed?..............................................................................................................................................................................................36How is an HFL service delivered? .............................................................................................................................................................................................36What does an HFL service cost? ...............................................................................................................................................................................................37Risk Management......................................................................................................................................................................................................................................38Summary of the HFL service model..........................................................................................................................................................................38Evidence on effectiveness...................................................................................................................................................................................................39<strong>Housing</strong> stability...........................................................................................................................................................................................................................................39Changes in drug and alcohol use.................................................................................................................................................................................................39Changes in mental health.....................................................................................................................................................................................................................39Social and economic inclusion.........................................................................................................................................................................................................40Cost effectiveness......................................................................................................................................................................................................................................405. <strong>Housing</strong> <strong>First</strong> in France...................................................................................................................................41Introduction........................................................................................................................................................................................................................................41The Global Influence of <strong>Housing</strong> <strong>First</strong>..........................................................................................................................................................................41Questions about Using a <strong>Housing</strong> <strong>First</strong> Approach in France.................................................................................................................42The Limits of <strong>Housing</strong> <strong>First</strong>................................................................................................................................................................................................................42<strong>Housing</strong> <strong>First</strong> is “not designed” for France............................................................................................................................................................................43<strong>Housing</strong> <strong>First</strong> cannot address all forms of homelessness in France..............................................................................................................44Why use <strong>Housing</strong> <strong>First</strong> in France?..............................................................................................................................................................................452


<strong>Housing</strong> <strong>First</strong>SummaryWhat is <strong>Housing</strong> <strong>First</strong>?<strong>Housing</strong> <strong>First</strong> differs from other homelessnessservices because it immediately provides homelesspeople with either secure independent or communalhousing. This means that <strong>Housing</strong> <strong>First</strong> giveshomeless people ‘housing first’ before it doesanything else. <strong>Housing</strong> <strong>First</strong> ‘separates’ housingand support. This ‘separation’ means that homelesspeople are immediately given secure housing withoutbeing required to enter psychiatric treatment orbecoming abstinent from drugs and alcohol. Inaddition, homeless people can remain in the securehousing provided by a <strong>Housing</strong> <strong>First</strong> service withoutthere being any expectation that they comply withpsychiatric treatment or stop drinking alcohol orusing drugs. <strong>Housing</strong> <strong>First</strong> services use a ‘harmreduction’ approach that attempts to stabilise andreduce mental health problems, problematic drugand alcohol use. <strong>Housing</strong> <strong>First</strong> services also have‘recovery orientation’ that aims to encouragehomeless people away from behaviour that iscausing them harm.<strong>Housing</strong> <strong>First</strong> was originally developed by theorganisation Pathways in New York. Sincethe Pathways <strong>Housing</strong> <strong>First</strong> service was firstestablished, several different forms of <strong>Housing</strong> <strong>First</strong>service have appeared in the USA and in a numberof EU member states including Denmark, Finland,Ireland, France, Hungary, the Netherlands, Portugal,Austria and the UK. These services all share asimilar philosophy but can work in quite differentways. The three main groups of <strong>Housing</strong> <strong>First</strong>service are:❱❱Pathways <strong>Housing</strong> <strong>First</strong> (PHF),❱❱Communal <strong>Housing</strong> <strong>First</strong> (CHF)❱❱<strong>Housing</strong> <strong>First</strong> ‘Light’ services (HFL) 1Pathways <strong>Housing</strong> <strong>First</strong> (PHF)❱❱PHF works with ‘chronically homeless people’ 2who are characterised by severe mental illness,problematic drug and alcohol use, nuisancebehaviour, low-level criminality, sustainedworklessness and long periods living inhomelessness shelters and on the street.❱❱PHF provides independent housing with securityof tenure immediately or as soon as possible to achronically homeless person.❱❱PHF provides low-level support designed topromote housing stability, service brokerage (toconnect chronically homeless people to essentialservices) and also directly provides psychiatric,drug and alcohol, social work, medical and otherservices. The team providing these services ismobile and visits people using the service in theirhomes or at other agreed locations.❱❱PHF services give considerable choice andcontrol to chronically homeless people byfollowing a harm reduction model which allowsthem to continue drinking alcohol and usingdrugs. Chronically homeless people can chosenot to use the psychiatric and drug and alcoholservices that are made available by PHF whilstremaining in the housing provided by PHF. Thisis called a ‘separation’ of housing and support.1 Please note that the acronyms PHF, CHF and HFL are used consistently within this report hereafter2 The US Federal government defines a chronically homeless person as either an unaccompanied homeless individualwith a disabling condition who has been continuously homeless for a year or more; or an unaccompanied individual witha disabling condition who has had at least four episodesof homelessness in the past three years. The term is used moreand more frequently in European contexts to describe long-term homeless people with more complex needs.3


<strong>Housing</strong> <strong>First</strong>Table S.1 : Broad Types of <strong>Housing</strong> <strong>First</strong> ServicesService offeredPathways<strong>Housing</strong> <strong>First</strong>Communal<strong>Housing</strong><strong>First</strong><strong>Housing</strong><strong>First</strong> Light<strong>Housing</strong> with security of tenure in private rented sector or in socialhousing provided immediately or as soon as possibleYes No YesOffers communal housing (single rooms or apartments) with securityof tenure provided immediately in a building only lived in by homelesspeople using the serviceNo Yes NoHomeless people have to stop using drugs No No NoHomeless people have to stop drinking alcohol No No NoHomeless people have to use mental health services No No NoHarm reduction approach Yes Yes YesUses mobile teams to provide services Yes No YesDirectly provides drug and alcohol services Yes Yes NoDirectly provides psychiatric and medical services Yes Yes NoUses service brokerage Yes Yes YesProvides support to promote housing stability Yes No YesEvidence in favour of <strong>Housing</strong> <strong>First</strong>The bulk of evidence about <strong>Housing</strong> <strong>First</strong> isAmerican. There is also some evidence from Europeand in particular from Finland. Large scale testingof the <strong>Housing</strong> <strong>First</strong> model is occurring across theEuropean Union and within France. For example,<strong>Housing</strong> <strong>First</strong> Europe 3 is a Social Experimentationproject funded in the framework of the PROGRESSprogramme of the European Commission. It willevaluate and provide mutual learning on 10 <strong>Housing</strong><strong>First</strong> projects in European cities and deliverconclusions in 2013. France is implementing a majorsocial experimentation called “Un Chez-soi d’abord” 4to test the effectiveness of <strong>Housing</strong> <strong>First</strong> servicesfor homeless people with mental illness.There is very strong evidence from the USA thatPHF services provide stable housing for chronicallyhomeless people with very high support needs and along history of homelessness. There is more limitedevidence on CHF and HFL services that also showsuccess in providing stable housing for homelesspeople. There is some evidence that by promotinghousing stability and following a harm reductionapproach, <strong>Housing</strong> <strong>First</strong> services can stabilise andin some cases reduce mental health problems andproblematic use of drugs and alcohol.PHF has shown far more success in providinghousing stability for ‘chronically homeless’ peoplethan ‘staircase services’. Staircase services requirehomeless people to move through a series of ‘steps’before they are given access to housing. They oftenrequire abstinence from alcohol and drugs. There isstrong evidence that the ‘staircase’ approach fails toprovide stable housing for the majority of chronicallyhomeless people who use staircase services.3 http://www.servicestyrelsen.dk/housingfirsteurope4 http://www.developpement-durable.gouv.fr/Programme-Chez-Soi-d-abord.html5


The Global Influence of <strong>Housing</strong><strong>First</strong><strong>Housing</strong> <strong>First</strong> has become globally important becauseof the unparalleled success that it has shown inproviding stable housing and accommodation forchronically homeless people. <strong>Housing</strong> <strong>First</strong> hasbeen central to the Federal homelessness strategyin the United States under both the Bush andObama administrations. <strong>Housing</strong> <strong>First</strong> services havebeen integrated into the homelessness strategies ofFrance, Denmark, Finland, Ireland, the Netherlandsand Sweden and are being widely tested in pilotprogrammes across many EU Member States. TheJury for the European Consensus Conference onHomelessness, held in Brussels in December 2010,recommended that ‘housing-led’ approaches werethe most effective solution to homelessness and thatthe different forms of <strong>Housing</strong> <strong>First</strong> service weregood examples of these ‘housing-led’ services.The Case for <strong>Housing</strong> <strong>First</strong>There are three main reasons to consider using<strong>Housing</strong> <strong>First</strong> services in France.❱❱The core philosophy of <strong>Housing</strong> <strong>First</strong> is thereason for the success that has been achievedin delivering stable housing and accommodationfor formerly chronically homeless people. The<strong>Housing</strong> <strong>First</strong> philosophy can be drawn uponwithout copying the detailed operation of <strong>Housing</strong><strong>First</strong> services working in the USA. The ideas of<strong>Housing</strong> <strong>First</strong> can be used to design services thatcan be used to reduce long-term homelessnessin different countries with different welfaresystems. An example of this has been the useof the <strong>Housing</strong> <strong>First</strong> philosophy to effectivelyredesign homelessness services in Finland.❱❱<strong>Housing</strong> <strong>First</strong> is highly flexible. The corephilosophy has been adapted from the PHF modeland employed in CHF and HFL services that canbe focused on both chronic homelessness andon other forms of homelessness.❱ ❱ <strong>Housing</strong> <strong>First</strong> services can support othertypes of homelessness services, for example,by stopping very long stays in emergencyaccommodation beds by chronically homelesspeople. It is important to note that <strong>Housing</strong> <strong>First</strong> isnot designed to replace all existing homelessnessservices and has been used as one part of amixture of services to respond to homelessness.By supporting the work of other homelessnessservices, <strong>Housing</strong> <strong>First</strong> services can potentiallyenhance their capacity to respond to issues suchas migrant homelessness and homelessnessamong families with low support needs in France.6


The Structure of the ReportThe rest of the report is structured as follows:❱❱Chapter 2 focuses on Pathways <strong>Housing</strong> <strong>First</strong>.The chapter begins by describing the PHFmodel and then reviews the evidence on theeffectiveness of PHF.❱❱Chapter 3 looks at ‘Communal <strong>Housing</strong> <strong>First</strong>’and follows the same structure as Chapter2, describing how CHF services work andreviewing the evidence on the effectiveness ofthe CHF approach.❱❱Chapter 4 looks at <strong>Housing</strong> <strong>First</strong> ‘Light’ servicesand again follows the same structure as chapters2 and 3, describing HFL services and reviewingthe evidence.❱ ❱ Chapter 5 discusses the use of <strong>Housing</strong> <strong>First</strong>services in France, looking at why <strong>Housing</strong><strong>First</strong> has become globally influential, exploringsome of the questions that have been raisedabout whether or not <strong>Housing</strong> <strong>First</strong> is suitablefor France and finally summarises the case forconsidering using <strong>Housing</strong> <strong>First</strong> in France.8


<strong>Housing</strong> <strong>First</strong>2. Pathways <strong>Housing</strong> <strong>First</strong> (PHF)IntroductionThis chapter looks at the original <strong>Housing</strong> <strong>First</strong>service model which was developed by Pathwaysin New York City. The chapter begins by looking atthe origins of the Pathways service and then moveson to discuss its philosophy and operation. Finally,the evidence base for Pathways <strong>Housing</strong> <strong>First</strong> isdiscussed.OriginsProblems with ‘staircase’ servicesThe ‘staircase’ model is widely used in the USA 6and in several European countries 7 to try to endenduring ‘chronic’ homelessness among peoplewho have high rates of severe mental illness andproblematic use of drugs and alcohol. Each staircaseservice has a series of steps that are designed tomake a chronically homeless person increasingly‘ready’ for housing. Chronically homeless peopleare expected to achieve goals that a staircaseservice sets for them in order to progress fromone step to the next. These ‘steps’ involve movingbetween accommodation, with each step allowing achronically homeless person more independenceuntil they finish the process with access to theirown home. At the end of the ‘staircase’ a chronicallyhomeless person is supposed to be able to liveindependently in their own home and to no longerhave problems related to severe mental illness anddrug and alcohol use 8 .Staircase services have strictrules about behaviour, compliance with psychiatrictreatment and also the use of drugs and alcohol.During the 1990s a series of evaluations in the USAreported that staircase services were expensive tooperate and failed to end the homelessness of mostof the chronically homeless people they workedwith 9 . Chronically homeless people quite oftenbecame ‘stuck’ in staircase services, unable to ‘climb’to the next ‘step’. In addition, chronically homelesspeople were also frequently abandoning staircaseservices 10 because of harsh rules requiring totalabstinence from drugs and alcohol 11 . Conditionswithin some staircase services in the US werealso criticised as being inhuman because of theirextensive and strictly enforced rules and becausestaff had a hostile and judgemental attitude towardshomeless people 12 . Only a minority of chronically6 Collins, S.E.; Clifasefi, S.L.; Dana, E.A. et al (2011) ‘Where harm reduction meets <strong>Housing</strong> <strong>First</strong>: Exploring alcohol’s role ina Communal <strong>Housing</strong> <strong>First</strong> setting’ International Journal of Drug Policy doi: 10.1016/j.drugpo.2011.07.0107 Sahlin, I. (2005) ‘The staircase of transition: Survival through failure’ Innovation 18, 2, pp.115-136; Busch-Geertsema, V.and Sahlin, I. (2007) ‘The Role of Hostels and Temporary Accommodation’ European Journal of Homelessness 1 pp.67-93; Johnsen, S. and Teixeira, L. (2010) Staircases, Elevators and Cycles of Change: <strong>Housing</strong> <strong>First</strong> and Other <strong>Housing</strong>Models for People with Complex Support Needs London: Crisis.8 Ridgway, P. and A. M. Zipple (1990) ‘The paradigm shift in residential services: From the linear continuum to supportedhousing approaches’ Psychosocial Rehabilitation Journal 13, pp. 11-31.9 Gulcur, L., A. Stefancic, et al. (2003). ‘<strong>Housing</strong>, hospitalization and cost outcomes for homeless individuals with psychiatricdisabilities participating in Continuum of Care and housing first programmes’Journal of Community and Applied SocialPsychology 13, 2, pp. 171-186.10 Bebout, R. R.; Drake, R.E. et al.(1997) ‘<strong>Housing</strong> status among formerly homeless dually diagnosed adults’ PsychiatricServices 48, 7, pp. 936-41;11 Dordick, G. A. (2002) ‘Recovering from Homelessness: Determining the «Quality of Sobriety» in a Transitional <strong>Housing</strong>Program’ Qualitative Sociology 25, 1, pp. 7-32; Carr, E. S. (2006).«’Secrets keep you sick’: Metalinguistic labor in a drug treatment program for homeless women.» Language in Society35, 5, pp. 631-653.12 Dordick, G. A. (2002) op cit; Lyon-Callo, V. (2000) ‘Medicalizing Homelessness: The Production of Self-Blame and Self-Governing within Homeless Shelters’ Medical Anthropology Quarterly 14, 3, pp. 328-345.9


homeless people were being helped by expensivestaircase services that took quite a long time toachieve results 13 . Research in Europe has reportedvery similar problems with staircase services incountries that include Sweden 14 . The experienceof homeless people using staircase services canbe one of a series of disruptions or ‘ruptures’ asthey move between ‘steps’ in a programme andhave to readjust to a new living environment withnew rules several times before they are eventuallyable to have a settled home. This can mean thathomeless people never feel secure while they arein the staircase, because each step except the laststep (if they progress that far) is not a permanenthome, i.e. they are unable to settle because theyknow each step is temporary.There is a view that homeless people are maintainedin an insecurity regarding their accommodation aswell as their social network by staircase services.The whole system of support bases progression upthe staircase on the individual effort that the personmakes. The person must “earn” housing throughbehaviour, conformity, and engagement with care. Insystems of care in collective shelter/accommodation,people develop skills for group living. But once theyeventually reach independent housing, it will beindividual and personal skills that they require 15 . Ifunsuccessful in the progression up the staircase,the person feels individually responsible for failingto maintain their efforts. In this view of the staircasesystem, it is not the nature of the support that isbeing questioned but the failure of the person.All observations show that one of the constantsamongst homeless people is a severing of all socialties. The staircase system causes ruptures with theneighbourhood, social workers etc at each step,contributing to instability.What is Pathways <strong>Housing</strong> <strong>First</strong>?The Pathways <strong>Housing</strong> <strong>First</strong> service, founded byDr Sam Tsemberis, first appeared in New Yorkin 1992 16 Pathways <strong>Housing</strong> <strong>First</strong> (PHF) has thefollowing key characteristics 17 :❱❱provides independent housing with security oftenure immediately or as soon as possible to achronically homeless person.❱❱provides support designed to promote housingstability and service brokerage to connectchronically homeless people to essential services❱❱directly provides psychiatric, drug and alcohol,social work and medical services. The teamproviding this support is mobile and visits peopleusing the service in their homes or at otheragreed locations.❱❱gives considerable choice and control tochronically homeless people by following a harmreduction model. Chronically homeless peoplecan chose not to use the psychiatric and drugand alcohol services that are made available byPHF and can still remain in the housing providedby PHF. This is called a ‘separation’ of housingand support.1013 Devine, J. A., Brody, C.J. et al (1997) ‘Evaluating an alcohol and drug treatment program for the homeless: Aneconometric approach’ Evaluation and Program Planning 20, 2, pp. 205-215; Pleace, N. (2008) Effective Servicesfor Substance Misuse and Homelessness in Scotland: Evidence from an international review Edinburgh: ScottishGovernment.14 Sahlin, I. (2005) op cit.; Busch-Geertsema, V. and Sahlin, I. (2007) op cit.15 Tsemberis, S. and Stefancic, A. (2007) ‘<strong>Housing</strong> <strong>First</strong> for Long-Term Shelter Dwellers with Psychiatric Disabilities in aSuburban County: A Four- Year Study of <strong>Housing</strong> Access and Retention’ American Journal of Public Health 28, pp.265-279.16 Ridgway, P. and Zipple, A.M (1990) Ibid; Tsemberis, S. (2010a) <strong>Housing</strong> <strong>First</strong>: The Pathways Model to End Homelessnessfor People with Mental Illness and Addiction Center City, Minnesota: Hazelden.17 Tsemberis, S. (2010b) ‘<strong>Housing</strong> <strong>First</strong>: Ending Homelessness, Promoting Recovery and Reducing Costs’ in I. Gould Ellen andB. O’Flaherty (eds) How to House the Homeless Russell Sage Foundation: New York.


<strong>Housing</strong> <strong>First</strong>The PHF PhilosophyThe Pathways organisation takes the view thatPHF is not simply a different way of deliveringservices to chronically homeless people. InsteadPathways believes that PHF represents a shift in thephilosophy of service delivery to homeless peoplewhich is in part a reaction against the approach thathas been taken by staircase services. The founderof <strong>Housing</strong> <strong>First</strong> has often been critical of whathe sees as the failure of staircase services in theUSA, criticising both their operational effectivenessand how the staff in staircase services regardchronically homeless people 18 . The PHF philosophyis described as following these principles::❱❱<strong>Housing</strong> as a basic human right.❱❱Respect, warmth and compassion for all clients(a ‘client’ is a chronically homeless person usingthe PHF service).❱❱A commitment to working with clients for as longas they need.❱❱Scattered site housing, independent apartments(that clients should live in the community inordinary apartments, not in a single apartmentblock).❱❱Separation of housing and services.❱❱Consumer choice and self-determination.❱❱A recovery orientation.❱❱Harm reduction.<strong>Housing</strong> <strong>First</strong>: <strong>Housing</strong> as a ‘Basic Human Right’PHF is ‘housing first’ because the service works byimmediately providing chronically homeless peoplewith an apartment, or providing an apartment asquickly as possible 19 . Unlike staircase services, thereis no requirement that the chronically homelessperson completes a training programme to be made‘housing ready’ before they move into an apartment.In New York, apartments are provided throughan arrangement with a private landlord. In manycases, the PHF signs a lease or tenancy agreementwith the landlord and asks the service user to sign asub-tenancy or sub-lease with PHF. This is intendedto guarantee the housing rights of the service userwhile providing reassurance to the private landlord.PHF avoids concentrating the people using its servicewithin single apartment blocks 20 . The reason forthis policy is that PHF seeks to reintegrate formerlyhomeless people into mainstream community life,something that would be difficult if all PHF serviceusers were concentrated in one or two apartmentbuildings.It is made clear by PHF that, unlike in a staircaseservice, housing is not provided as an incentive tostop using alcohol and drugs or as an incentive tocomply with psychiatric or detoxification treatment.Instead housing is provided as a ‘basic human right’.This means housing is provided to someone using aPHF service on the following basis::❱❱There is no requirement to stop or reducealcohol or drug consumption in order to receiveand to remain in housing provided via PHF.❱❱There is no requirement to comply with treatmentfor mental health problems or with detoxificationtreatments in order to receive and remain withinhousing provided via PHF.Respect, Warmth and Compassion for ClientsPHF places particular emphasis on showingrespect, warmth and compassion to the chronicallyhomeless people using its services. The terms‘respect’, ‘warmth’ and ‘compassion’ are used in thegeneral sense. As noted, Pathways argue that thismakes their service philosophy different from that ofstaircase services because of evidence that staff insome US staircase services can have judgementalattitudes towards homeless people 21 .18 Tsemberis, S. (2010a) <strong>Housing</strong> <strong>First</strong>: The Pathways Model to End Homelessness for People with Mental Illness andAddiction Hazelden: Minnesota, p. 18.19 Immediately where possible; sometimes there may be a short wait in temporary accommodation but this is not supposedto exceed four weeks.20 Ibid.21 Dordick, G. (2002) op cit.11


A Commitment to Working with Clients as Longas They NeedThe PHF model is designed to provide support foras long as is needed. There may be a point at whichservices are reduced because someone is copingwell on their own and services might eventuallybe withdrawn because an individual becomes fullyindependent. PHF does not stop supporting aformerly chronically homeless person if they losethe housing they have been provided with by thePHF service (for example, for breaking the termsof the tenancy agreement). While the PHF servicewill not keep rehousing a service user again andagain, the PHF service will give an individual whohas lost the housing they were provided with two,three or more chances depending on their needs.PHF services will also stay in contact with someoneif they return to homelessness, are imprisoned forshort periods or have to enter hospital (includingpsychiatric care) 22 .Scattered Site <strong>Housing</strong>, Independent ApartmentsThe use of ordinary housing is one of the keyfeatures of PHF. In the context of New York, there isvery little social rented housing available and thereare not the resources available to buy or develophousing because of the costs that would be involved,so private renting is the only option. There aresome areas of New York where PHF cannot affordthe rent for housing, which means the PHF projectis not active throughout the city. Within the financiallimitations of the PHF service, homeless people areallowed some choice about which area they livein and what sort of housing they have. The PHFapproach is summarised in the guidance:This scattered site feature of the housingmodel helps ensure that people with psychiatricdisabilities are not all housed together in onebuilding but are integrated into the buildingsand into their communities. In this model, clients[people using the PHF service] don’t move intoa ready-made unit of a housing program –they move into their own apartments in theirneighbourhood of choice 23 .A key goal of this approach is to promote socialinclusion. PHF operates on the assumption that inliving alongside other citizens and being within anordinary neighbourhood in ordinary housing, theformerly chronically homeless people using PHF arebrought back into contact with ‘normal’ life. Supportis also provided to enable service users to establishand maintain new friendships and relationships andto get back in contact with their family if they haveone.In addition, PHF seeks to reconnect formerlychronically homeless people with paid work,through the provision of support services that aredesigned to enable access to training and educationand help with getting into employment. Through thisrehousing in the community, the fostering of positivesocial and family relationships and help to becomeeconomically active in paid work, PHF seeks to‘resettle’ formerly chronically homeless people backinto society.Separation of <strong>Housing</strong> and ServicesA person using PHF does not have to receivesupport related to severe mental illness andproblematic use of drugs and alcohol if they chosenot to. Their housing will not be affected if theyrefuse to use drugs and alcohol services or tocomply with psychiatric treatment. This is describedas the ‘separation’ of housing from support, becausebeing given and being allowed to stay in housing isnot dependent on accepting treatment and supportservices.This ‘separation’ of housing and services is not total.PHF service users have to agree to a weekly visitfrom PHF staff to check on their well-being and toensure there are no problems with the apartment 24 .Consumer Choice and Self-DeterminationConsumer choice and self determination refer tothe emphasis within the PHF on enabling chronicallyhomeless people to make their own decisionsabout where and how they live their lives and, toa considerable extent, what services and support1222 Tsemberis, S. (2010a) op cit.23 Tsemberis, S. (2010a) op citp. 22.24 Tsemberis (2010a) op citp. 48.


<strong>Housing</strong> <strong>First</strong>they use. This means that the people receivingPHF services can act as (to use the Americanterminology) as ‘consumers’ and exercise ‘selfdetermination’.In practice, this means that the people receiving aPHF service can decide what their own goals are(this is what is meant by self-determination), forexample to drink less alcohol, to cease drinkingalcohol and, because this flexibility exists within thePHF model, not to set themselves any goals abouthow much alcohol they drink. The PHF model is builtaround an assumption that chronically homelesspeople will generally not, when given access tohousing and support, opt to refuse all support andchoose courses of action that are harmful to theirown well-being.As noted, the consumer choice and selfdeterminationoffered by PHF are not limitless.Alongside the compulsory weekly support visit,someone using a PHF service must comply withthe terms of their lease, just the same as any othertenant. However, the level of control given to peopleusing PHF services is sufficient to mean that theycan and do get into difficulty:Honouring client [people using PHF services] selfdeterminationis especially important in times ofdifficulty, such as when clients deplete their financialresources, when a landlord threatens eviction, orwhen a client has relapsed into addiction. In thesesituations, staff must resist the impulses to controlor resolve a chaotic situation. Instead, staff mustmake every effort to help clients explore theiroptions during a crisis 25 .A Recovery OrientationThe ‘recovery orientation’ of PHF refers to a focuson encouraging people using PHF services in theright direction. This is not viewed as contradictingthe emphasis on ‘consumer choice’ in the PHF model.Staff are expected to encourage people using PHFservices to believe that they can permanently ceaseto be homeless, can stop using drugs and alcoholand get treatment that will help with their mentalhealth problems.The recovery orientation in PHF services isdesigned to also encourage a greater degree ofself-reliance among the people using PHF services.Over time, staff are expected to maximise the extentto which people using PHF services do things forthemselves, encouraging and reinforcing their abilityto live independently.Harm ReductionHarm reduction is an approach to stopping peoplemaking heavy or dangerous use of drugs andalcohol that does not require abstinence from drugsand alcohol. Harm Reduction is also a means ofreducing the harmful consequences of mental healthproblems. The emphasis is on minimising the risksassociated with problematic behaviour and/or drugand alcohol use and trying to reduce, with the hopeof eventually ending, those behaviours that harm anindividual.The PHF harm reduction approach works byemphasising to an individual the aspects of their lifethat are being harmed by their behaviour. Extensivesupport is made available - if a chronically homelessperson decides to use it -to help them end behaviourthat causes them harm.From the Pathways perspective, harm reductionshould not be viewed as an ‘alternative’ approach totreatment; the ultimate goal of harm reduction is thesame as for services trying to enforce abstinenceand compliance with treatment, to engage peoplewith severe mental illness with psychiatric servicesand to end problematic drug and alcohol use 26 .However, harm reduction is centred on respectingan individual’s current wishes and behaviour, withthe aim of encouraging an individual to use servicesrather than ‘requiring’ an individual to use servicesor stop using drugs and alcohol.25 Tsemberis (2010a) op citp. 27.26 Tsemberis (2010a) op citp. 30.13


Delivering a Pathways <strong>Housing</strong><strong>First</strong> ServiceThere is extensive guidance on the delivery of aPHF service in the ‘manual’ written by the founderof PHF, Sam Tsemberis, which is entitled <strong>Housing</strong><strong>First</strong>: The Pathways Model to End Homelessnessfor People with Mental Illness and Addiction 27 . Inaddition, guidance is available on the Pathwayswebsite 28 .This section provides a summary overview ofthe operation of PHF, including information on thefollowing areas:❱❱Which groups of homeless people is a PHFservice designed to help?❱❱What are the aims of a PHF service?❱❱How is the service accessed?❱❱How is a PHF service delivered?❱❱What does a PHF service cost?❱❱Risk managementWhich groups of homeless people isPHF designed to help?PHF is targeted only at chronically homeless people.The needs, characteristics and experiences ofchronically homeless people can include:❱❱A disrupted childhood and/or experience of thechild care system.❱❱Problematic/addictive use of drugs, includingillegal drugs❱❱Problematic drinking of alcohol (i.e. unhealthy ordangerous levels of consumption).❱❱Severe mental illness, i.e. psychiatric conditionsthat are severe enough to impede capacity tolive independently, secure and sustain work andwhich in some instances might represent a riskto an individual or to those around them.❱❱Low level criminality, including ‘survival’ crime tofeed and clothe themselves and also crime tosustain problematic drinking and/or drug use.❱❱Nuisance behaviour, sometimes linked to lowself esteem, poor mental health and to drug andalcohol use.❱❱Poor physical health, linked to poor diet, alcoholand drug consumption, poor physical environment(i.e. living on the street and in emergencyaccommodation for sustained periods).❱❱Sustained worklessness, linked to low educationalattainment, health and support needs.❱❱Alienation from mainstream society linked to poorself-image and low self-esteem and sustainedexclusion from ordinary social and economic life.❱❱Repeated and sustained homelessness.What are the aims of a PHF service?PHF is ‘housing first’ but it is not ‘housing only’.Through a harm reduction led philosophy thatemphasises choice and control for the people usingthe PHF service, a series of goals are pursued:❱❱<strong>Housing</strong> stability, including developing the capacityof formerly chronically homeless people to livelargely or wholly independently over time.❱❱Reductions and where possible cessation ofproblematic drug and alcohol use.❱❱Reductions in criminal behaviour (if present).❱❱Reductions in severe mental illness and othermental health problems among service users.❱❱Improvements in physical health by emphasizingwell-being and ensuring contact with medicalservices where necessary.❱❱Reengagement with normal social and communitylife, developing friendships, re-establishing familyties where possible and developing and sustainingsuccessful personal relationships.1427 Tsemberis, S. (2010a) op cit.28 www.pathwaystohousing.org


<strong>Housing</strong> <strong>First</strong>❱❱Engagement with work related activity, includingproductive activity that is similar to work,education and training as well as securing paidwork where this is possible and practical.PHF is a service intended to deal with theconsequences of repeated and sustainedhomelessness among people with high supportneeds in a number of ways. Alongside tacklinghomelessness through the provision of stablehousing, PHF is also intended to promote positiveoutcomes in terms of social and economic inclusionand in terms of health and well-being, using a harmreduction framework that separates housing andsupport and which emphasizes choice for peopleusing the PHF service.How is the PHF service accessed?The PHF service in New York takes referrals fromhomelessness services. There can also be referralsfrom psychiatric services and prisons, either whensomeone has been referred to those services from asituation of homelessness or seems likely to becomehomeless on leaving. There is also the capacity totake self-referrals from chronically homeless peoplewho decide they need help 29 . Each individual who isreferred to PHF is assessed individually.The process of ‘engagement’ with service users isnot something that PHF expects to be completedvery quickly. According to the PHF manual, trusthas to be established with service users who havesometimes become used to being promised suitablehousing by staircase services, only to find a greatmany conditions and requirements being placedupon them once they started using a staircaseservice. PHF therefore aims to emphasize serviceusers’ choice and control, seeking to give theservice user confidence in the service and adoptingan approach that is focused on asking service usershow PHF can help, rather than behaving like astaircase service which ‘tells’ people using serviceswhat to do 30 . For this reason, the initial meetingwith a potential service user is at a venue theychoose (within safety constraints) and there is arequirement to allow the service user to control thepace at which their engagement with PHF moves.Locating an apartment centres on taking intoaccount a service user’s preferences before makingan offer of an apartment. Service users are shownthe apartment, to check that it is acceptable to them,before they are asked to sign a lease. In the case ofthe New York PHF service, the process of securingsuitable private rented housing usually takes placewithin two to four weeks.PHF offers a full property management serviceto private rented landlords, meaning all aspects ofhousing management are handled by PHF, includingrent collection 31 . As noted, this enables access toprivate rented apartments because the lease ortenancy is often signed by PHF, not by the personusing the service and any issues with rent collectionor other housing management issues are handledby PHF. This means a private landlord need donothing but collect the rent.How is the PHF service delivered?PHF is not a very complex service. Essentially PHFimmediately places chronically homeless people inordinary rented apartments and provides themwith services that are delivered by a mobile teamof workers and professionals who visit them intheir apartments or another venue which they havechosen.PHF service users must accept a weekly visit,devote 30% of their income to paying rent, and signa lease or sub-lease agreement for their apartment.The three requirements of the PHF service are asfollows:❱❱A weekly home visit from PHF staff❱❱Signing a lease or sub-lease, which gives theservice user some housing rights alongsideresponsibilities for the apartment they live in.❱❱Signing rental agreements guaranteeing 30% ofavailable income be devoted to payment of rent.The core components of a PHF service are:❱❱Ordinary apartments. In the USA these areusually found in the private rented sector, but29 Tsemberis, (2010a) op cit.30 Tsemberis, (2010a) op cit, p. 41.31 Tsemberis, (2010a) op cit.15


PHF could also use social housing. Apartmentsare furnished by the PHF project. A housingspecialist within the PHF team arranges accessto suitable housing. Chronically homeless peopleusing PHF must usually be in receipt of welfarebenefit payments linked to severe mental illnessin order to make a contribution to the rentalcosts of their apartment.❱❱Support with maintaining housing stability andliving an independent life. This might includeassistance with claiming welfare benefit paymentsto which a service user is entitled, help in gettingused to living independently and learning abouttheir neighbourhood, help managing relationshipswith the private landlord, maintaining their home,budgeting and shopping. The main mechanismfor this is the weekly home visit to each serviceuser in the apartment by a PHF staff member.❱❱An Assertive Community Treatment (ACT)team of mobile support workers. This part ofthe service is closely modelled on the ACT teamsdeveloped in mental health services in the US.A PHF ACT team includes a Team Leader whocoordinates the services provided, along witha part-time psychiatrist, a part time provider ofprimary medical care (either a doctor or nursepractitioner32 ) and a full time nurse. In addition,the ACT team will include a qualified social worker,usually with specialist knowledge of mental health,and specialists in supported employment, a drugand alcohol specialist and an administrativeassistant. The ACT team must also include a‘peer specialist’. This is an individual qualifiedto provide support who has been through theexperience of chronic homelessness themselves.Alongside providing practical support, the ‘peerspecialist’ is also seen as a ‘living illustration’that ‘recovery’ 33 from chronic homelessness ispossible. 34 An ACT team may also include whatis termed a ‘family specialist’; this is essentiallya worker whose role centres on positivereconnection between a formerly chronicallyhomeless person and their family. In addition,an ACT team may also include a ‘wellnessmanagement and recovery specialist’, a rolethat centres on helping a formerly chronicallyhomeless person develop and manage positivepersonal relationships and which encouragesa generally healthy lifestyle. 35 The ACT teamprovides intensive support. A ten person ACTteam would be responsible for around 70formerly chronically homeless people, a ratio ofone staff member for each seven service users.The ACT team works with service users with thefollowing characteristics:〉〉Severe mental illness (e.g. manic depression,bi-polar disorder) without problematic drug oralcohol use.〉〉Severe mental illness and low use of drugsand/or alcohol.〉〉Severe mental illness and heavy use of drugsand/or alcohol.❱❱An Intensive Case Management (ICM) team.The ICM is also based on a service model usedfor people with mental health problems in theUS. The ICM team has a service brokeragerole. This means that the ICM connects aservice user with services they need that arenot directly provided by PHF, this can includesupport services, medical services and welfarebenefit payments that can be accessed by anyUS citizen but can also include specialist services,such as support with problematic drug use. TheICM refers service users to external servicesand supports them in accessing those services.The ICM team also provides some direct supportitself. ICM team staff are each assigned up to 20service users. The ICM team works with serviceusers with the following characteristics:1632 A nurse practitioner has some of the training used for doctors and is qualified to a higher level than an ordinary nurse,though their training is less extensive than for a doctor. A nurse practitioner can prescribe some drugs.33 Recovery’ is a term used by PHF to describe the process by which someone ceases to be a chronically homeless person.34 Tsemberis, S. (2010a) op cit.35 Ibid.


<strong>Housing</strong> <strong>First</strong>〉〉Mental health problems (e.g. depression)without problematic drug or alcohol use.〉〉Mental health problems with low use of drugsand/or alcohol.〉〉Mental health problems with heavy use ofdrugs and alcohol.What does PHF cost?While it is more economical than the staircaseapproach (see discussion under Evidence ofEffectiveness), the PHF service is not a low costservice. PHF provides an extensive range ofsupport services. A sample budget provided in themanual on PHF produced by Pathways suggeststhat a PHF scheme can be developed and run forone year at a cost of $1.5 million (approx. €1.23million) 36 . It is difficult to exactly cost the servicefor France because the salaries, housing costs andother operating costs will not be the same as is thecase for New York. There are important differencesin context. These centre on the amount of welfarepayments available to chronically homeless people,which will be significantly higher in France andalso the fact that social housing is available to usein France. Using US costs, a PHF team handling70-80 chronically homeless people would costapproximately €482,500 in direct salary costs forone year of operation.To these costs must be added: benefits foremployees, transport for the mobile workers,furniture purchase, medical supplies, movingexpenses, apartment maintenance (on behalf ofprivate landlords) and costs for transport. The PHFsample budget adds another €270,000 to coverthese costs, another €57,000 for administrative andsupervisory costs and a further €287,000 for anoffice in which the team are based, taking the totalbudget to about €1.23 million.A French PHF service would probably have lowerdirect costs. There are several reasons for this.Direct salary costs may be less because Francehas extensive healthcare provision that wouldbe accessible to service users, i.e. it might not benecessary to directly employ as many medicalprofessionals in a French PHF service. If a FrenchPHF service were able to mobilise the socialhousing stock to implement PHF, there might beless reliance on housing specialists. In addition, ifa PHF service was operated by a medium or largesize French NGO, many administrative tasks couldbe handled by existing bureaucracy, rather thanrequiring dedicated staffing. Some of the additionalcosts of the PHF service might be less in France,for example public transport is much more widelyavailable and cheaper than in the USA.Risk managementDelivering a service by using mobile support that isprovided to people in their own homes presents anumber of risks that are not present in a communalservice. The evidence base on how PHF managesrisk is not extensive, although there is somedescriptive information in the PHF manual 37 . Thekey risks that could potentially arise centre onsomeone using the PHF service becoming seriouslyill, or overdosing, and the possibility that a serviceuser might harm themselves or (less likely) harmsomeone else, including one or more staff from themobile support services. The techniques used tomanage risk are:❱❱Assessment of needs on referral to theservice. PHF would not refuse to engage with achronically homeless person because they wereseriously ill, very likely to overdose or presenteda potential risk to themselves or others. However,judgements are made about how practical it isfor PHF to support each individual.❱❱Twenty-four availability of one member of theACT or ICM team by mobile telephone.36 Tsemberis, S. (2010a) op cit p. 219-222.37 Tsemberis, S. (2010a) op cit.17


❱❱Keys to apartments are held by the ACT/ICMteam and by the housing staff as well as by theservice user.❱❱Checks on service users by the PHF staff,including the weekly visit.Summary of PHF service delivery❱❱PHF works with ‘chronically homeless people’who are characterised by severe mental illness,problematic drug and alcohol use, nuisancebehaviour, low-level criminality, sustainedworklessness and long periods living inhomelessness shelters and on the street.❱❱PHF provides independent housing with securityof tenure immediately or as soon as possible to achronically homeless person.❱❱PHF provides low-level support designed topromote housing stability, service brokerage (toconnect chronically homeless people to essentialservices) and also directly provides psychiatric,drug and alcohol, social work, medical and otherservices. The team providing these services ismobile and visits people using the service in theirhomes or at other agreed locations.❱❱PHF services give considerable choice andcontrol to chronically homeless people byfollowing a harm reduction model which allowsthem to continue drinking alcohol and usingdrugs. Chronically homeless people can chosenot to use the psychiatric and drug and alcoholservices that are made available by PHF but canremain in the housing provided by PHF. This iscalled a ‘separation’ of housing and support.Evidence of effectiveness<strong>Housing</strong> StabilityThere is very strong evidence that PHF producesa high level of housing stability among chronicallyhomeless people in the US. Beyond the evidencefrom the studies of the PHF in New York, thereis also strong evidence from a number of otherAmerican cities where PHF models have beenimplemented. 38PHF has delivered unprecedented levels of housingstability among chronically homeless people, oftenmore than doubling the success rates reported bystaircase services. In 2004, a study on PHF inNew York reported that 80% of PHF service userswere stably housed after two years. Over time,the success rates reported by PHF have increased,with housing stability rates of 88% being reported 39 .By contrast, research on staircase servicesreported that, at best, housing stability was beingproduced for 30-40% of the chronically homelesspeople using staircase services 40 .The founder of thePHF service in New York has described the mainsuccess of PHF in very simple terms:<strong>Housing</strong> <strong>First</strong> ends homelessness. It’s thatsimple. 41<strong>Housing</strong> <strong>First</strong> has become globally important inhomelessness policy because of what PHF hasachieved in delivering housing stability for chronicallyhomeless people (see final chapter).Changes in Drug and Alcohol UseThere is evidence that PHF achieves the goal ofharm reduction in drug and alcohol use amongformerly chronically homeless people. Alcohol use1838 Pleace, N. (2008) Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from aninternational review Edinburgh: Scottish Government; Johnsen, S. and Teixeira, L. (2010) op cit.39 Tsemberis, S. (2010b) op cit.40 Bebout, R.R.; Drake, R.R. et al (1997) op cit; Pleace, N. (2008) op cit; Tsemberis, S. (2010b).41 Tsemberis, S. (2010a) op cit p. 4.


<strong>Housing</strong> <strong>First</strong>and drug use tend to stabilise and also fall amongpeople using PHF services and there is no evidencethat PHF services produce any increase in drug oralcohol use 42 .Some US academics have raised concerns thatPHF does not produce large enough improvementsin problematic drug and alcohol use 43 . There arearguments about whether it is better to deliver totalabstinence for a minority of chronically homelesspeople, which is what ‘staircase’ services try todeliver, or harm reduction for a greater number(with only relatively few becoming abstinent), whichis what PHF delivers 44 . There have also beencriticisms that PHF does not work with the veryheaviest users of drugs and alcohol at the samerate as staircase services do 45 .The counter argument is that PHF tends to reducealcohol and drug use among many of the peopleusing it, most of whom remain with the PHF service.By contrast, while a US staircase service mighteventually produce an end to drug and alcoholuse for some of the chronically homeless peopleusing it, such staircase services tend to eject, orbe abandoned by, between 60-70% of chronicallyhomeless people before an end to drug or alcoholuse has been achieved 46 . Pathways has acceptedthat it is not always possible for PHF to engagewith people making extremely heavy use of drugsand alcohol, but also reports that it is working witha group of chronically homeless people who veryoften have problematic use of drugs and alcohol 47 .To set the findings of the research on PHF (andstaircase) services in context, it is important to notethat problematic drug and alcohol use are generallyquite difficult to treat. Service outcomes for peoplewith problematic drug use who are not homelessmay be little or no better than for service outcomesfor homeless people with drug problems 48 .Changes in Mental HealthThere is evidence that housing conditions andhousing stability have direct impacts on mentalhealth and that the wrong housing in the wrongneighbourhood can be ‘toxic’ to mental health. Thismeans there may be particular benefits to mentalhealth when someone is given some choice aboutwhere they live 49 . While these are difficult conceptsto measure, it seems a sense of safety, securityand privacy at home promotes good mental health.Homelessness disrupts or removes all that isassociated with feeling ‘at home’ 50 .Some research in the US by Padgett has arguedthat PHF gives service users the dignity and controlof having one’s own home and home life. Padgetthas argued that in providing chronically homelesspeople with their own ‘home’ in which they can maketheir own choices, PHF creates a stable platformfrom which a recovery from mental health problemscan begin 51 .More generally there is some evidence fromevaluative research showing that mental health tends42 Kertsez, S.G.; Crouch, K.; Milby. J.B.; Cusimano, R.E. and Schumacher, J.E. (2009) ‘<strong>Housing</strong> <strong>First</strong> for Homeless Personswith Active Addiction: Are we overreaching?’ The Milbank Quarterly 87, 2, pp. 495-534; Tsai, J.; Mares, A.S. andRosenheck, R.A. (2010) ‘A Multisite Comparison of Supported <strong>Housing</strong> for Chronically Homeless Adults: “<strong>Housing</strong> <strong>First</strong>”Versus “Residential Treatment <strong>First</strong>”’ Psychological Services 7, 4, pp. 219-232.; Padgett, D.K.; Stanhope, V.; Henwood,B.F. and Stefanic, A. (2011) ‘Substance Use Outcomes Among Homeless Clients with Serious Mental Illness: Comparing<strong>Housing</strong> <strong>First</strong> with Treatment <strong>First</strong> Programmes’ Community Mental Health 47 pp. 227-232.43 Lipton, F. R., Siegel, C. et al (2000) ‘Tenure in supportive housing for homeless persons with severe mental illness’Psychiatric Services 51,4, pp. 479-86; Tsai et al (2010) op cit44 Collins, S.E. (2011) op cit.45 Tsai et al (2010) op cit; Padgett et al (2011) op cit.46 Pearson, C. et al (2007) op cit.47 Tsemberis, S. (2010b) op cit.48 McKeganey, N., Bloor, M., Robertson, M., Neale, J. and MacDougall, J. (2006) ‘Abstinence and drug abuse treatment:Results from the Drug Outcome Research is Scotland study’, Drugs: education, prevention and policy 13, 6, pp. 537-550.49 Srebnik, D.; Livingston, J.; Gordon, L.; King, D (1995) ‘<strong>Housing</strong> Choice and Community Success for Individuals with Seriousand Persistent Mental Illness’ Community Mental Health Journal, 31, 2, pp. 139-152.50 Padgett, D. (2007) ‘There’s no place like (a) home: Ontological security among persons with a serious mental illness in theUnited States’ Social Science and Medicine 64, pp. 1925-193651 Ibid.19


to improve among users of PHF services. Scoreson short questionnaires designed to assess mentalhealth 52 also tended to improve 53 . However, there is noexpectation that formerly chronically homeless peopleusing PHF services should comply with psychiatrictreatment, which means that access to treatment forsevere mental illness or mental health problems maynot occur for people using PHF services 54 .Criticism of the extent to which PHF can deliverimprovements to mental health takes two mainforms. <strong>First</strong>, there are the arguments that becausethere is no requirement that chronically homelesspeople using PHF services comply with psychiatrictreatment, mental health problems can go untreated.The second criticism centres on what PHF servicesare able to deliver in terms of housing choices.Some researchers have the view that necessarycompromises resulting from limited funds forPHF can mean that neither the housing nor theneighbourhoods where the housing is located arebeneficial to mental health 55 .Social InclusionPHF is intended to improve the social inclusionof chronically homeless people by housingthem as independently as possible in ordinaryneighbourhoods and communities. PHF is basedon an assumption that social inclusion is beinggenerated because chronically homeless people areliving in the community alongside other citizens andare not physically separated from other people in aseparate service or apartment block.Evidence on whether or not social inclusion is beingpromoted by PHF is not extensive. There has beensome work that suggests that users of PHF ‘feel’more included in society than was the case whenthey were homeless, 56 but a sense of social inclusioncan vary according to individual perception. Thereis research suggesting that intolerance and hostilitytowards people with support needs, or even simplytowards people on lower incomes, can be an issuein socially and economically mixed neighbourhoods 57and this may sometimes be an issue for peopleusing PHF services.Economic InclusionPHF seeks to promote economic inclusion, which inthe context of the US means access to education,training and paid employment. There is evidencethat securing work can improve self-esteem,promote social inclusion and generate benefits inmental and physical health for formerly homelesspeople. However, these benefits are associated withwork that offers fair pay and is rewarding 58 .There is no real evidence that PHF has been ableconsistently to secure access to education, training orpaid employment. In part, this is because this aspectof <strong>Housing</strong> <strong>First</strong> services has not been systematicallyinvestigated. There is evidence that it is relativelydifficult to secure access to paid employment forhomeless people, particularly those with a criminalrecord or history of drug use 59 , because employersare reluctant to employ this group of people, evenduring times of relative economic prosperity.2052 A short series of questions that are used to test mental well-being which are ‘validated’ measures that are repeatedlytested to ensure that results are consistent and they are a good indicator of mental health. The example used in someevaluations of PHF was the Colorado Symptom Index (CSI).53 Greenwood, R.M.; Schaefer-McDaniel, N.J.; Winkel, G. and Tsemberis, S. (2005) ‘Decreasing Psychiatric Symptoms byIncreasing Choice in Services for Adults with Histories of Homelessness’ American Journal of Community Psychology36, 3/4, pp. 223-238.54 Tsemberis, S. (2010a) op cit.; Gilmer, T.P.; Stefanic, M.A.; Ettner, S.L.; Manning, W.G. and Tsemberis, S. (2010) ‘Effect ofFull-Service Partnership on Homelessness, Use and Costs of Mental Health Services and Quality of Life among Adultswith Serious Mental Illness’ Archive of General Psychiatry 67,6, pp. 645-652.55 Tabol, C.; Drebing, C. and Rosenheck, R. (2009) ‘Studies of “supported” and “supportive” housing: A comprehensive reviewof model descriptions and measurement’ Evaluation and Program Planning 33 pp. 446-45656 Yanos, P.T.; Barrow, S.M. and Tsemberis, S. (2004) ‘Community Integration in the Early Phase of <strong>Housing</strong> AmongHomeless Persons Diagnosed with Severe Mental Illness: Successes and Challenges’ Community Mental Health Journal40, 2, p.133- 15057 Bretherton, J. and Pleace, N. (2011) ‘A Difficult Mix: Issues in achieving socioeconomic diversity in deprived UKneighbourhoods’ Urban Studies, Volume 48 Issue 16, pp. 3429 - 3443.58 Rio, J., Ware, L., Tucker, P., Martinez, J. (2008) Ending Chronic Homelessness through Employment and <strong>Housing</strong>: AProgram and Policy Handbook for Successfully Linking Supportive <strong>Housing</strong> and Employment Services for ChronicallyHomeless Adults New York: Corporation for Supportive <strong>Housing</strong> and Advocates for Human Potential.


<strong>Housing</strong> <strong>First</strong>Cost EffectivenessIn the US, PHF is seen as cost effective becauseit significantly reduces the amount of time thatchronically homeless people spend outside a settledhome. Producing housing stability among formerlychronically homeless people has four main potentialcost-saving effects 60 :❱❱Reductions in the use of emergency homelessshelters by chronically homeless people whooften make repeated and sustained use ofemergency homeless shelters (this has beendemonstrated). Some estimates are that the10% of the US homeless population who arechronically homeless may use up to 50% ofthe bed spaces that emergency shelters haveavailable during the course of one year 61 , becausethey occupy beds for such long periods of time.❱❱Reductions in the use of emergency medicaland psychiatric services as chronicallyhomeless people using PHF have direct accessto psychiatric and medical services and mayexperience improvements in health and wellbeing(this has been demonstrated). Studies inthe US have suggested that there is reduceduse of emergency psychiatric treatment and thatnet savings have been produced ranging from$4,000 to $8,880 a year for each formerlychronically homeless person using a PHF service(€2,900 to €6,400) 62 .❱❱Reductions in arrests and imprisonment forchronically homeless people using PHF services,producing savings in expenditure on criminaljustice services (this has been demonstrated).❱❱If PHF were to demonstrate effectiveness ingetting formerly chronically homeless people intopaid work, meaning they were no longer relianton welfare benefit payments, there would be acost saving (this has yet to be demonstrated).Pathways has estimated the relative costs of itsservices on a per-night basis and drawn a broadcomparison with other services. The comparison isbroad, because chronically homeless people wouldnot tend to stay in the most expensive places forvery long periods (Table 2.1).Tableau 2.1 : Relative costs of PHF compared to alternatives in the USA according to PathwaysService Cost per night ($) Cost per night (€)PHF $57 $42Emergency homeless shelter $73 $54Jail $164 $120Hospital ER $519 $381Psychiatric hospital $1 185 $869Source: Pathways 6359 Kemp, P. and Neale, J. (2005) ‘Employability and problem drug users’, Critical Social Policy 25, 1, pp. 28-46.60 Culhane, D.P. (2008) ‘The Cost of Homelessness: A Perspective from the United States’ European Journal ofHomelessness 2, pp. 97-114; Culhane, D.P.; Gross, K.S.; Parker, W.D. et al (2008) ‘Accountability, Cost-Effectiveness, andProgram Performance: Progress Since 1998’ National Symposium on Homelessness Research http://works.bepress.com/dennis_culhane/2261 Kuhn, R. and Culhane, D.P. (1998) ‘Applying cluster analysis to test a typology of homelessness by pattern of public shelterutilization’ American Journal of Community Psychology 26, 2, pp. 207-232.62 Tsemberis, S. (2010a) op cit, p. 187-188.63 http://www.pathwaystohousing.org/content/our_model21


A large scale study in New York found that 95%of the costs of providing PHF were covered by thesavings to health, criminal justice and other servicesthat PHF generated. The study looked at 4,679homeless people placed in PHF type housing in NewYork and compared utilization of public shelters,public and private hospitals, and correctionalfacilities with a matched control group. Each unit ofpermanent supportive housing saved $16,282 peryear in public costs for shelter, health care, mentalhealth, and criminal justice. These savings offsetnearly all of the $17,277 cost of implementing thePHF package of housing and support. Almost all thecosts of providing a PHF service were effectivelymet by saving money that would otherwise havebeen spent elsewhere 64 .A recent review of PHF and other <strong>Housing</strong> <strong>First</strong>costs in the US identified a potential limitation to thecost effectiveness of PHF and other <strong>Housing</strong> <strong>First</strong>services 65 . This limitation is that the cost offsetsare greatest when PHF services are used withchronically homeless people with the highest levelsof need. When people using PHF and other <strong>Housing</strong><strong>First</strong> services have slightly lower levels of need, thefinancial benefits of PHF and other <strong>Housing</strong> <strong>First</strong>services can be less clear 66 . Some commentators inthe US have responded to this criticism by arguingthat purely economic evaluation of PHF and other<strong>Housing</strong> <strong>First</strong> services is not the basis on whichpolicy decisions should be made 67 .2264 Culhane, D.P., Metraux, S. & Hadley, T. (2002). ‘Public service reductions associated with placement of homeless personswith severe mental illness in supportive housing’ <strong>Housing</strong> Policy Debate, 13, 107-163.65 Culhane, D.P. (2010) Ending Chronic Homelessness: Cost-Effective Opportunities for Interagency Collaboration WhitePaper Commissioned for New York State Office of Mental Health and NYC Department of Homelessness Services http://works.bepress.com/dennis_culhane/9466 Kertesez, S.G. and Weiner, S.J. (2009) ‘<strong>Housing</strong> the Chronically Homeless: High Hopes, Complex Realities’ Journal of theAmerican Medical Association 301, 17, p. 1823.67 Culhane, D.P. (2008) op citp. 109.


<strong>Housing</strong> <strong>First</strong>3. Communal <strong>Housing</strong> <strong>First</strong> ServicesIntroductionThe PHF philosophy has become very influential.However, different NGOs and governments havetaken some of the ideas on which PHF is based andhave altered those ideas to create their own versionsof ‘<strong>Housing</strong> <strong>First</strong>’. There are now many differentexamples of <strong>Housing</strong> <strong>First</strong> service and one groupof services can be broadly defined as ‘Communal’<strong>Housing</strong> <strong>First</strong> services. This chapter describesthe origin of this group of services, explores thedifferences in how they operate compared to PHF,looks at the evidence on the effectiveness of CHFservices and finally provides a description of howCHF services are delivered.It is important to note that this chapter describesa range of services that operate in broadly similarways, rather than providing a description of a single,specific type of service.OriginsAs the influence of PHF spread across the US,some NGOs took some of the elements of the PHFphilosophy and applied them to staircase services.These services retained the physical structure of astaircase service, but the way in which the servicewas delivered was very different 68 . Some newCommunal <strong>Housing</strong> <strong>First</strong> services have also beendeveloped.Communal <strong>Housing</strong> <strong>First</strong> (CHF) was the result ofapplying <strong>Housing</strong> <strong>First</strong> principles to communalhomelessness services. CHF services giveconsiderable choice and control to service users,including choices over the range of support theyreceive and whether or not to stop using drugsand alcohol. CHF offers communal housing (singlerooms or apartments) with security of tenureprovided immediately in a building only lived in byhomeless people using the CHF service. <strong>Housing</strong>is also provided on a permanent or long-termbasis, there is no expectation that service userswill move out, which means there is no programmeto create ‘housing readiness’ or any ‘steps’ toclimb. 69 These forms of ‘<strong>Housing</strong> <strong>First</strong>’ service havestarted to sometimes be described as ‘Project-Based <strong>Housing</strong> <strong>First</strong>’ (PBHF) services in the US 70 ,though it is perhaps clearer to describe them asCommunal <strong>Housing</strong> <strong>First</strong> services, in which groupsof chronically homeless people and support staffare all within one building.What is Communal <strong>Housing</strong> <strong>First</strong>?CHF services are not all the same. Some serviceshave been developed as new services, others aremodifications of staircase services. All draw on theideas developed for PHF services, but different CHFservices do not all reflect the philosophy of PHF tothe same extent. CHF services do however sharesome basic characteristics. The basic features ofCHF services are: 71 :❱❱<strong>Housing</strong> in a building that is only for chronicallyhomeless people using the service (largerservices might employ several buildings). Thetype of housing on offer varies between CHFservices, some have small self-containedapartments, some have single rooms and somehave only semi-private spaces in communal livingareas 72 . All offer some security of tenure. Thevariety of living arrangements offered by CHFservices is considerable, and some would notbe considered by many commentators to behousing in the true sense.68 A studio apartment contains a living area, kitchen and sleeping space, sometimes in one room and a bathroom.69 Pearson, C.; Locke, G. et al (2007) The Applicability of <strong>Housing</strong> <strong>First</strong> Models to Homeless Persons with Serious MentalIllness Washington DC: HUD70 Collins, S.Eet al (2011) op cit;Pearson, C. et al (2007) op cit; Larimer, M.E.; Malone, D.K.; Garner, M.D. et al (2009) ‘HealthCare and Public Service Use and Costs Before and After Provision of <strong>Housing</strong> for Chronically Homeless Persons withSevere Alcohol Problems’ Journal of the American Medical Association 301, 13, pp. 1349-1357.71 Pearson, C. et al (2007) op cit.72 Collins, S.E. et al (2011) op cit.23


❱❱Support is provided on site, with the staffdelivering the support being based within thebuilding (or nearby if more than one buildingis used). The range of support on offer variesbetween services. Some mirror the extensiveservice provision of PHF services, includingmental health and drug and alcohol services,other CHF services might have less extensivesupport services and make more use of servicebrokerage (arranging access to externallyprovided services).❱❱<strong>Housing</strong> is either long-term or permanent; thereis no pressure or expectation on service usersto move out of the CHF service, though thosewishing to move on may be supported to do so.❱❱Service users have choices over whether or notto use support services and have a role in settingtheir own goals.❱❱CHF service users have the option to continuedrinking and using drugs, they can also refuseto work with psychiatric services, and this doesnot impact on their right to stay, i.e. people canstay in the housing provided by the service andcontinue to drink and use drugs, or chose not toengage with mental health services.❱❱CHF services follow a harm reduction andrecovery orientation model.CHF PhilosophyCHF services do not always operate in the same wayas one another. This makes a detailed discussion ofCHF philosophy difficult, because CHF services arenot consistent. However, it is possible to comparethe basic CHF philosophy with the PHF philosophy:❱❱<strong>Housing</strong> as a basic human right. Those CHFservices that offer a single room or a semiprivatespace in a shared environment couldbe said to provide accommodation but are notproviding housing. In the case of CHF servicesthat offer self-contained studio apartments withsecure tenures it could be argued that ‘housing’ isbeing provided. Not everyone would necessarilyshare that view because concentrating formerlyhomeless people in one place may segregatethem and limit their social integration 73 .❱❱Respect, warmth and compassion for all clients(service users).A CHF service does adopt a nonjudgementalattitude, with staff treating chronicallyhomeless people as individuals worthy of respect,warmth and compassion.❱❱A commitment to working with clients as longas they need. A CHF service does make an openended commitment to working with homelesspeople for as long as they might need the service.Some CHF services will encourage and supportpeople to move on, but they are designed to offerpermanent accommodation.❱❱Scattered site housing, independentapartments. A studio apartment in a CHFaccommodation block does give someone theirown front door, but it is a front door within ablock in which the staff support team and otherservice users are the only neighbours. Thesingle rooms and the ‘semi-private’ living spacesoffered in some CHF schemes cannot offerthe privacy or independence of an apartment.Chronically homeless people using CHF servicesare also physically isolated from other citizens,rather than living among them in the way thatPHF service users do. CHF therefore does notoffer scattered site housing and independentapartments.❱❱Separation of housing and services. PHFseparates housing and services because itgives chronically homeless people ‘housing first’without expecting them to accept drug, alcoholand mental health services. A CHF service doesnot expect homeless people to be ‘housing ready’.CHF services will not force service-users to2473 Tsemberis, S. (2011) op cit.


<strong>Housing</strong> <strong>First</strong>move out if they do not use the drug, alcohol ormental health services which are offered to them.Whether this is comparable to PHF is debatable,because it is sometimes only accommodation –or just one type of housing in a block with otherservice users – that is being offered by the CHFservice.❱❱Consumer choice and self-determination. Thechoices offered by PHF are not limitless: serviceusers have to accept a weekly visit from asupport worker, have to follow the terms of theirlease or tenancy agreement and have only somechoices about where to live set by the availablebudget. However, the PHF model offers morechoice and control than a CHF model becauseit is designed to provide service users with arange of options about where and how they willlive. In addition, service users in a PHF modelare physically separated from the mobile supportservices that are on offer to them, whereas theusers of CHF are generally on the same siteas the support services. CHF services offer farmore ‘consumer choice’ than a staircase service,because they allow chronically homeless peoplechoices about which services to use and whetheror not to drink and use drugs, but they do notallow chronically homeless people any choiceabout where to live.❱❱A recovery orientation and harm reduction 74 .CHF services do follow the recovery orientationand the harm reduction approach which togetherform the seventh and eighth elements of the PHFphilosophy.In summary, a CHF service shares many aspectsof the PHF philosophy, but it differs in oneimportant respect, in that some CHF services offer‘accommodation’ or a single housing option first,rather than genuine community-based ‘housing’ first.Such services may offer some security of tenureand may even be a self-contained apartment, but itwill be an apartment in an apartment block that isdesigned only for chronically homeless people. Thisis not the same as the ordinary apartments that arescattered across a community which are used byPHF services.The <strong>Housing</strong> <strong>First</strong> philosophy and CHFservices in FinlandIn February 2008, the Finnish governmentintroduced a strategy that was intended to halvelong term (i.e. chronic) homelessness. Finlanddecided on an approach that involved extensiveuse of a CHF service model 75 in the context oftheir strategy to reduce long-term homelessness.A key part of the strategy was to redesign andmodify what were defined as ‘residential homes’ (i.e.institutional communal accommodation with on siteservices) to make them into ‘residential units’ thatwould be supported using services that followed a<strong>Housing</strong> <strong>First</strong> philosophy. The main goals were 76 :❱❱to provide secure permanent housing with atenancy agreement to long-term (chronically)homeless people;❱❱to reduce the use of conventional homelessnessshelters/emergency accommodation by changingthese services into blocks of supported, rentedapartments;❱❱the prevention of eviction by means of housingadvice services and financial support;❱❱drafting plans for individual rehabilitation andservices (i.e. involving chronically homelesspeople in planning and choosing their ownsupport services);❱❱provide guidance in the use of normal socialwelfare and health services (i.e. provide servicebrokerage services), and❱❱promote social inclusion for formerly homelesspeople.74 Tsemberis, S. (2010a) op cit, p. 18.75 Busch-Geertsema, V. (2010) The Finnish National Programme to Reduce Long-Term Homelessness: Discussion PaperPeer Review: Finnish national programme to reduce long term homelessness http://www.peer-review-social-inclusion.eu/peer-reviews/2010/the-finnish-national-programme-to-reduce-long-term-homelessness76 Luomanen, R. (2010) Long term homelessness reduction programme 2008-2011 Peer Review: Finnish nationalprogramme to reduce long term homelessness http://www.peer-review-social-inclusion.eu/peer-reviews/2010/the-finnishnational-programme-to-reduce-long-term-homelessness25


The second goal of the Finnish strategy was veryclose to the goals of CHF services in the USA 78 .Finland sought to alter the way in which existingcommunal homelessness services worked by usingthe PHF philosophy as a reference point. However,while some US service providers sought only tomodify the operation of existing staircase services,Finland embarked on an extensive programme ofrefurbishment and new building that was designedto deliver one person apartments for chronicallyhomeless people. There has been some policywithin debate in Finland as to how far an approachlargely based on a CHF model can fully reflect thephilosophy of PHF 77 .Delivering a Communal <strong>Housing</strong><strong>First</strong> ServiceUnlike PHF, there is no standardised or agreed setof guidance on how to deliver a CHF service. Thisis because CHF services vary in the detail of theiroperation.This section looks at the operation of CHF in sixrespects:❱❱Which groups of homeless people is a CHFservice designed to help?❱❱What are the aims of a CHF service?❱❱How is the service accessed?❱❱How is a CHF service delivered?❱❱What does a CHF service cost?❱❱Risk managementWhich groups of homeless people isa CHF service designed to help?Like PHF services, CHF services in the USA aredesigned primarily to help chronically homelesspeople (see Chapter 2). In Finland, the term ‘longtermhomeless’ is used to describe the group ofhomeless people that CHF services are designedto help, but this group is defined in a very similarway to ‘chronically homeless people’ i.e.people withmental health problems, problematic alcohol/drugconsumption and other complex support needswhich mean they could not access housing withoutsupport 79 .Sometimes, as in Finland, the main target group forCHF services are chronically homeless people whohave been in the homelessness shelter system fora long time. CHF services may also be targeted onindividuals who are judged to be at risk of chronichomelessness, such as people with a history ofhomelessness who have high support needs andwho are about to leave psychiatric hospital or theprison system without any home of their own to goto. Some CHF services in the USA are focused onchronically homeless people with the very highestsupport needs only. In practice this means that CHFservices are designed for:❱❱Chronically homeless people who have beenusing homelessness services for a long time.❱❱Chronically homeless people with high levels ofneed associated with mental health problems andproblematic alcohol and drug consumption.❱❱People thought to be at risk of chronichomelessness because of their history and/ortheir characteristics.What are the aims of a CHF service?The key aim of a CHF service is to provide stablehousing that will reduce the harm that chronichomelessness has caused to an individual. Alongsideproviding a stable and secure place in which to live,CHF services are intended to help minimise and wherepossible reduce mental health problems and the useof drugs and alcohol that are strongly associatedwith chronic homelessness. In the USA and Finland,services are being used as a replacement forstaircase and emergency accommodation servicesthat were found not to be effective in ending thehomelessness of most of the people who used them.In both countries, CHF services are primarily used2677 Larimer, M.E. et al (2009) op cit.78 Social Innovation Europe interview with JuhaKaakinen 2011 http://www.socialinnovationeurope.eu/magazine/localdevelopment-and-communities/interviews/ending-homelessness-finland79 Busch-Geertsema (2010) op cit.


❱❱The separation of tenancy and support, meaningthat chronically homeless people can stay evenif they choose not to use the mental health, drugand alcohol services that are made available.❱❱Security of tenure.❱❱An emphasis on non-judgemental approachesto homelessness and homeless people, which ispart of providing support within a framework ofharm reduction.Alongside providing accommodation, a CHF servicewill also offer:❱❱Support workers who are available on site,sometimes on a 24-hour basis. These workersmay help access outside services that are notprovided on site, they may also provide low levelsupport, answering questions and providinginformation as well as listening and talking toservice users.❱❱Drug and alcohol support services that followa harm reduction philosophy and which areavailable on site.❱❱Mental health services that follow a harmreduction philosophy and which are available onsite.❱❱There may be provision of services thatare designed to enable social and economicintegration; however, the available evidenceon CHF services does not suggest these areprovided by any service that has been evaluated 81 .What does a CHF service cost?The costs of a CHF service will vary considerably.Some services take an existing staircase serviceand extensively modify its philosophy and approach,changing how the service operates and sometimesthe range of supports it offers. What this means infinancial terms is difficult to quantify because it willvary between services. Some staircase serviceshave extensive drug, alcohol and mental healthservices which require an alteration in philosophy,but which may not require any more expenditure,in order to create a CHF service. In other cases,where existing buildings are modified to create a CHFservice, or an entirely new building is constructed,the development costs to provide a CHF service canbe considerable.As noted above, while precise or typical costsare not available because CHF services varyconsiderably, the Finnish programme has created1,250 units of CHF accommodation and someother housing at a cost of some €201.1 million 82 .In the USA, a CHF service for which a purposebuilt building was developed cost some $12 millionin building and setting up costs, with an estimatedadditional typical daily cost of $37 (€28) per day forproviding services to each service user 83 .As is the case with PHF services, CHF is notnecessarily cheaper than existing homelessnessservices (see further discussion under Evidenceof Effectiveness). CHF services can be relativelyexpensive to develop and to deliver. While there isevidence that CHF either cost no more than theexisting expenditure on chronic homelessness byhealth and criminal justice services and may in somecases (particularly when working with people withparticularly high support needs) cost less overall,CHF services are not a ‘low cost’ homelessnessservice.Risk managementCHF services differ from PHF services in how theyare able to manage risk and in the nature of the risksthey face. One difference is that unlike PHF services,a CHF service can continually monitor the well-beingand behaviour of a formerly chronically homelessperson because the support services are either inthe same building or are very close by. This maybe more of a challenge for PHF services, which canbe some distance away from a formerly chronicallyhomeless person who is living in an apartment inan ordinary neighbourhood. This might mean thatthe management of risks associated with formerlychronically homeless people with very high support2881 Social Innovation Europe interview with JuhaKaakinen 2011 http://www.socialinnovationeurope.eu/magazine/localdevelopment-and-communities/interviews/ending-homelessness-finland82 Luomanen, R. (2010) op cit83 Larimer, M.E. et al (2009) op cit.


<strong>Housing</strong> <strong>First</strong>needs may be less challenging for a CHF servicethan is the case for a PHF service. However, riskmanagement is not a part of CHF service deliverywhich has been evaluated systematically or whichhas been directly compared with PHF services.Although it may be easier to monitor chronicallyhomeless people in a CHF service and forservices to reach them very quickly if a problemor emergency occurs, the communal nature ofCHF services can also present challenges for riskmanagement. The challenges centre on several ormany formerly chronically homeless people sharingcommunal living areas or living next to each otherin self-contained apartments. In Finland, thereare some concerns that the disruptive behaviourof some individuals, or the disruptive behaviour ofgroups of chronically homeless people associatingwith one another, may be having a detrimentaleffect on the effectiveness of CHF services 84 . Theperceived risk in Finland has two aspects. <strong>First</strong>,there is a concern that exposure to other drug andalcohol users may make the process of reducingharm associated with drug and alcohol consumptionmore difficult in CHF services and second, somechronically homeless people might find some CHFservices rather distressing environments in whichto live.Summary of CHF service deliveryThe CHF service model can be summarised asfollows:❱❱CHF services are focused on chronicallyhomeless people. These services are deliveredin communal buildings that are only lived in bypeople using the CHF service. This can be singlerooms with shared living areas or individual selfcontainedapartments in an apartment block.The accommodation has often been modified,or designed, to provide a service for chronicallyhomeless people. Support and medical servicesare situated in the same building or are verynearby.❱❱CHF provides communal housing in a sharedbuilding with security of tenure immediately to achronically homeless person.❱❱CHF directly provides psychiatric, drug andalcohol services and medical services and mayalso use service brokerage to arrange access toother services.❱❱CHF services give considerable choice andcontrol to chronically homeless people as part offollowing a harm reduction model. If chronicallyhomeless people opt not to use the services thatare on offer, or choose not to stop drinking andusing drugs, this does not place their housing inthe CHF service under threat.Evidence on effectiveness<strong>Housing</strong> stabilitySome CHF services do not deliver true ‘housing’stability because they do not offer self-containedhousing. CHF services may provide a single roomor semi-private area in a shared block that isaccommodation rather than “ordinary” housing. Theevidence on CHF services in the USA shows thatthese services do create a stable living situation, inthat most of the service users do not often returnto homelessness 85 . CHF services can end sustainedstreet homelessness and also sustained use ofemergency beds in homeless shelters, but while thechronically homeless people using these servicesare accommodated, it is sometimes difficult to seethem as being ‘housed’ in the sense that an ordinarycitizen in their own apartment is ‘housed’.The extent to which CHF services are providing‘housing’ when they offer self contained apartmentsthat are available only to chronically homelesspeople using the CHF service is debatable. By somecriteria, CHF services like some of those in Finlandare offering ‘housing’ because people using theservice are provided with their own apartment andhave some security of tenure. Yet these services84 Kettunen,M. and Granfelt, R. (2011) op cit.85 Larimer, M.E. et al (2009) op cit; Hanratty, M. (2011) ‘Impact of Heading Home Hennepin’s <strong>Housing</strong> <strong>First</strong> programs forlong-term homeless adults’ <strong>Housing</strong> Policy Debate 21,3, pp. 405-419.29


do not offer any choice about where to live, the‘housing’ is only accessible to people using theservice and is physically separated from the rest ofthe community because it is in one or more purposebuilt or converted buildings. Staff providing serviceswill also often be on site. From some perspectives,these services are delivering ‘housing’ stability, fromothers, such as that of Sam Tsemberis, the founderof PHF, these services are not actually offering whatmost ordinary citizens would recognise as ‘housing’and therefore only delivering ‘accommodation’stability 86 .In Finland, success has been reported in creatinggreater stability in housing or accommodation forlong term homeless people. Again, it is importantto note that Finnish services that follow a CHFmodel may offer long term, secure, tenure that isnot always intended to be permanent. There can beencouragement for some service users to move onto fully independent apartments in the community.Since the introduction of a ‘<strong>Housing</strong> <strong>First</strong>’ strategyin Finland, overall levels of long-term homelessnesshave either been reduced, or been halved, in theparticipating municipalities 87 . However, it has alsobeen noted that some of the reports of higher ratesof stability are anecdotal and that there are not asyet extensive data showing sustained stability inaccommodation or housing 88 .Changes in Drug and Alcohol UseThe research available on CHF services in theUS suggests a pattern of stabilisation and at leastsome reduction in drug and alcohol use, which issimilar to the results reported for PHF. Two studiesfound that CHF services that allowed chronicallyhomeless people to drink alcohol in their rooms sawthis pattern, but again, did not report that alcoholconsumption had actually stopped among mostservice users. 89Evidence on the Finnish experience is mixed. Somereports suggest that there has been a reductionin alcohol consumption in some CHF servicesin Finland 90 . Other research has indicated thatmanagement of high levels of drug and alcoholuse among some residents of CHF services hassometimes been problematic, in that tolerance of highlevels of drug and alcohol use in what is communalhousing has sometimes been difficult to manage.There are some concerns about high rates of drugand alcohol use in blocks of CHF apartments and it isbeing suggested that more provision should be madeto enable people to move away from CHF servicesand into their own independent apartments 91 . Thesearguments are linked to a possible limitation of CHFservices in respect of drug and alcohol use, theevidence that exposure to high levels of use (andtherefore to various sources of supply) can makereduction and recovery from problematic alcoholand drug use more difficult for some people 92 .Changes in mental healthUS research does not suggest that CHF servicesdeliver significant improvements in mental health,although there is no evidence to suggest that mental3086 Tsemberis, S. (2011) Observations and Recommendations on Finland’s “Name on the DoorProject” From a <strong>Housing</strong><strong>First</strong> Perspective <strong>Housing</strong> <strong>First</strong> Finland http://www.asuntoensin.fi/files/1242/Tsemberis_2011_-_Observations_and_Recommendations.pdf87 Kettunen,M. and Granfelt, R. (2011) Observations from the first year of the Finnish Name on the door project –recommendations for the long-term homelessness reduction programme for years 2012-2015 http://www.housingfirst.fi/en/housing_first/reading_room/general_reading/observations_and_conclusions/ Note: While the programme has had aspecific effect in reducing long-term homelessness, overall homelessness levels in Finland have not yet fallen.88 Busch-Geertsema, V. (2010) op cit.89 Larimer, M.E. et al (2009) op cit; Collins, S.E. et al (2011) op cit.90 Luomanen, R. (2010) op cit, p. 31.91 Kettunen,M. and Granfelt, R. (2011) op cit.92 Pleace, N. (2008) op cit.


<strong>Housing</strong> <strong>First</strong>health deteriorates as a consequence of using CHFservices 93 . There is also some evidence showingthat use of emergency mental health services issignificantly reduced among chronically homelesspeople using some CHF services 94 .There has not been a detailed evaluation of theimpacts of the Finnish <strong>Housing</strong> <strong>First</strong> programmeusing CHF services on mental health. As alreadynoted, there are some emerging concerns aboutwhether CHF services containing a number of longterm homeless people with high support needs arealways suitable places in which to recover frommental health problems, as well as from problematicdrug and alcohol use 95 .Social and economic inclusionThere is no clear evidence that CHF modelspromote either social or economic inclusion. Thechronically homeless people using CHF services areaccommodated in physically separate blocks, whichin at least some cases are architecturally distinctfrom surrounding buildings and houses. Promotingeconomic inclusion, in the sense of enabling peopleinto work related activity, education, training orpaid employment can present a challenge for anyservice providing support to chronically homelesspeople, though dedicated employment programmeshave achieved some positive outcomes 96 . In Finland,there has been some discussion of how to sociallyand economically include people living within CHFservices 97 .Cost effectivenessThere is evidence from the US and from Finland thatCHF services can generate significant ‘cost offsets’.These ‘cost offsets’ are reductions in expenditureon emergency medical services, including drugand alcohol and mental health services as wellas hospital emergency facilities, and the resultof less contact with criminal justice systems bychronically homeless people. When in stable andsecure accommodation, chronically homelesspeople generally have less contact with emergencyservices, with the police and also make muchless use of emergency homelessness shelters 98 .Development and running costs for some US andFinnish CHF services tend to be quite high, witha US study indicating savings of some $12 million(€9.1 million) from a new CHF service that had cost$11 million to develop (€8.3 million) 99 and the Finnishprogramme providing 1,250 units of CHF and otherhousing at a cost of some €201.1 million 100 .93 Sadowski, L.S.; Kee, R.A.; Vanderweele, T.J. et al.(2009) ‘Effect of a <strong>Housing</strong> and Service brokerage Program onEmergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults: A Randomised Trial’ Journalof the American Medical Association 301, 17, pp. 1771-1778.94 Larimer, M.E. et al (2009) op cit.95 Kettunen,M. and Granfelt, R. (2011) op cit.96 Burt, M.R. (2007) Evaluation of LA’s HOPE: Ending Chronic Homelessness through Employment and <strong>Housing</strong> FinalReport Los Angeles: City of Los Angeles Community Development Department97 Social Innovation Europe interview with JuhaKaakinen 2011 http://www.socialinnovationeurope.eu/magazine/localdevelopment-and-communities/interviews/ending-homelessness-finland98 Culhane, D.P. et al (2008) op cit.99 Larimer, M.E. et al (2009) op cit.100 Luomanen, R. (2010) op cit.31


4. <strong>Housing</strong> <strong>First</strong> ‘Light’ ServicesIntroductionIn both Europe and in the USA, there are low-intensityhomelessness services that use mobile workers tosupport formerly and potentially homeless peopleliving in independent apartments. These serviceswere sometimes developed at the same time as thePHF service but there are also some services thatwere operating before PHF existed. This groupof services has either adopted parts of the PHFphilosophy or have independently developed aphilosophy that is similar to the ideas of <strong>Housing</strong><strong>First</strong>. This chapter describes the origins of what itterms ‘<strong>Housing</strong> <strong>First</strong> Light’ (HFL) services, exploresthe differences between HFL and PHF services,provides a description of how HFL services aredelivered and finally looks at the evidence on theeffectiveness of HFL services.It is important to note that this chapter describesa range of services that operate in broadly similarways, rather than providing a description of a single,specific type of service.OriginsHFL services immediately provide housing withsecurity of tenure to homeless people and supportthem in their own housing by using low-intensitymobile support services. In the UK, low intensitymobile services were first developed to resettlepeople who had been long-term residents of largedormitory homelessness services 101 .These serviceswere then used by social housing providers tostop housing management problems including rentarrears, nuisance behaviour and abandonmentof housing by ‘vulnerable’ homeless people 102 .HFL services then began to replace the use ofemergency accommodation for homeless peoplewith high needs, using immediate access to housingwith low intensity mobile support. Eventually theseservices extended beyond the social housing sectorand began using both social and private rentedhousing, becoming the single most common form ofhomelessness service in the UK 103 . In the USA, HFLservices have been used in experiments looking atalternatives to the staircase services that failed toend the majority of chronic homelessness 104 .What are HFL services?HFL services are not a single type of service.These services have sometimes been developedwith reference to the PHF philosophy and havesometimes been developed wholly independentlywithout reference to the ideas of <strong>Housing</strong> <strong>First</strong>.The term ‘<strong>Housing</strong> <strong>First</strong> Light’ is used to refer tothis group of services in this document, but in thecountries in which these services operate theyare known as ‘supported housing’ services, as‘resettlement services’ as ‘tenancy sustainment’ andas ‘homelessness support services’ and sometimesreferred to using other terminology 105 . All servicesof this type share a number of broad characteristics:❱❱Like PHF and CHF services, these services provide‘housing first’, meaning that homeless people areplaced immediately (or as quickly as possible) intoindependent housing without any requirement thatthey are ‘housing ready’. Sometimes this housing32101 Dant, T and Deacon, A (1989) Hostels to Homes? The Rehousing of Single Homeless People Aldershot: Avebury102 ‘Vulnerable’ homeless people had priority access to social housing under the terms of the 1977/1978 homelessnesslaws (this group included many chronically homeless people) see Pleace, N. (1995) <strong>Housing</strong> Single Vulnerable HomelessPeople York: University of York http://www.york.ac.uk/inst/chp/publications/PDF/pleace.pdf103 Pleace, N. and Quilgars, D. (2003) Supporting People: Guide to Accommodation and Support Options for HomelessHouseholds London: Homelessness Directorate; Johnsen. S. and Teixeira, L. (2010) op cit.104 Tabol, C.; Drebing, C. and Rosenheck, R. (2009) ‘Studies of “supported” and “supportive” housing: A comprehensive reviewof model descriptions and measurement’ Evaluation and Program Planning 33 pp. 446-456;Caton, C.L.M; Wilkins, C. andAnderson, J (2007) ‘People who Experience Long Term Homelessness: Characteristics and Interventions’ Paper given atthe National Symposium on Homelessness Research and accessed on 6th September 2010 at http://aspe.hhs.gov/hsp/homelessness/symposium07/caton/index.htm105 Tabol, C. et al (2009) op cit.


<strong>Housing</strong> <strong>First</strong>is scattered throughout a municipality, city orregion, sometimes it is concentrated in specificapartment blocks. HFL services provide access tohousing in several ways〉〉An HFL service might be provided directlyby a social housing provider and use its ownsocial housing stock.〉〉An HFL service may function independentlyand work in cooperation with social housingproviders and private rented housing providersto provide homeless people with housing.〉〉An HFL service may not have direct access toany housing, instead it will provide support toa homeless person or household so that theyare able to access private rented or socialhousing.❱❱<strong>Housing</strong> is separated from support, meaningthat access to housing and security of tenure isnot linked to whether or not a homeless personaccepts the support services that are offered,including mental health and drug and alcoholservices.❱❱There is no requirement for abstinence fromdrug and alcohol use.❱❱HFL services use a service brokerage model, i.e.support workers enable access to mainstreamhealth and welfare services for homeless people,ensuring they receive all the support they areentitled to. Support workers might also arrangeaccess to specialist services, such as drug andalcohol detoxification or psychiatric services 106 .HFL services might also facilitate access toeducation, work-related and employment relatedservices, as well as services designed to promotesocial inclusion.❱❱HFL services use low intensity support, centringon service brokerage and on limited supportwith housing-related needs. Alongside arrangingaccess to welfare and health services, an HFLworker might also provide advice and assistancewith dealing with electricity bills, ensuring therent is paid and ensuring a homeless personis eating healthily. A worker might only see ahomeless person using an HFL service oncea week, or less, and HFL services are oftendesigned to gradually withdraw support as ahomeless person becomes better equipped tolive independently.❱❱An HFL service can be used for homeless peoplewith a range of support needs. This meansthat an HFL service may support chronicallyhomeless people but that it may also supporthomeless people with lower levels of supportneed.❱❱An HFL service can be focused partially orlargely on homelessness prevention, suchas some UK ‘tenancy sustainment services’,targeting people who have been identified as atrisk of homelessness who have not actually everbeen homeless.Services following this basic model operate in anumber of EU member states 107 . However, theextent of these services is difficult to map because,with the exception of France, 108 , and a few othercountries, databases of homelessness services areoften not available at the national level. As noted,services of the HFL type are the most commonform of homelessness service provided in the UK 109 ,but these services are less common than staircaseservices in the USA and may be less common thanCHF services 110 .106 Goldfinger, S. M., R. K. Schutt, et al (1999) ‘<strong>Housing</strong> placement and subsequent days homeless among formerly homelessadults with mental illness’ Psychiatric Services 50, 5 pp. 674-9; Hickert, A.O. and Taylor, M.J. (2011) ‘Supportive <strong>Housing</strong>for Addicted, Incarcerated Homeless Adults’ Journal of Social Service Research 37, pp. 136-151.107 Busch-Geertsema, V. (2005). «Does re-housing lead to reintegration? Follow-up studies of re-housed homeless people.»Innovation 18, 2, pp. 202-226.108 Marpsat, M. (2007) 149 Documents de travail Services for the Homeless in France: Description, official statistics, clientrecording of information INED109 Centre for <strong>Housing</strong> Research (2010) Supporting People Client Records and Outcomes: Annual Report 2009-2010 (StAndrews: University of St Andrews).110 Tabol, C. et al (2009) op cit.33


HFL philosophyHFL services vary in how they operate and inthe range of support that they provide 111 . As notedabove, it is important to remember that although theterm ‘<strong>Housing</strong> <strong>First</strong> Light’ is used in this document,there are services of this type that were developedindependently of the ideas of <strong>Housing</strong> <strong>First</strong> and,while they reflect the philosophy of <strong>Housing</strong> <strong>First</strong>,were operating before ‘<strong>Housing</strong> <strong>First</strong>’ servicesappeared. This makes a detailed discussion of HFLphilosophy difficult, because HFL services are notconsistent, but it is possible to compare a broad‘HFL’ philosophy with the PHF philosophy:❱❱<strong>Housing</strong> as a basic human right. HFL serviceswork by immediately providing or arranginghousing for homeless people. These services mayoperate by providing mobile support services toa single apartment block, but HFL services canuse apartments or houses scattered throughouta municipality or city.❱❱Respect, warmth and compassion for all clients(service users). An HFL service does adopt thesame non-judgemental attitude as PHF, with stafftreating homeless people as individuals worthy ofrespect, warmth and compassion.❱❱A commitment to working with clients aslong as they need. An HFL service can makean open ended commitment to working withhomeless people for as long as they might needthe service. HFL services will often encourageand support people to live independently andmay be designed with the intention that supportlevels are reduced over time. Some HFL servicesoperate with time limits, providing support for aset period of six or nine months. This use ofset time periods of support has sometimesbeen discouraged, as the needs of homelesspeople are not predictable, with more flexiblearrangements being encouraged 112 . For example,arrangements by which support can be quicklyredeployed in the case of a crisis.❱❱Scattered site housing, independentapartments. Many HFL services do providescattered, independent apartments. The extentto which they offer choice about where to livemay vary. Some services primarily make useof private rented housing, while others maybe more reliant on social housing, which canlimit the range of housing options available tohomeless people. Some HFL services may grouphomeless people together in neighbourhoods orin apartment blocks, which does not reflect thePHF philosophy.❱❱Separation of housing and services. An HFLservice provides access to housing with securityof tenure without a requirement that service usersuse drug and alcohol services or mental healthservices. Unlike PHF services, HFL servicesrely primarily on service brokerage, rather thanusing a mixture of directly provided health andsupport services and service brokerage.❱❱Consumer choice and self-determination. Asis the case for PHF services, HFL services donot offer limitless housing choices. There willbe a requirement to agree to the terms of alease for their housing and there may also be arequirement to agree to a minimum number ofvisits by a support worker.❱❱A recovery orientation and harm reduction.HFL services do follow the recovery orientationand the harm reduction approach, whichtogether form the seventh and eighth elementsof the PHF philosophy.In summary, an HFL service shares many aspectsof the PHF philosophy. However, HFL servicesmay not fully adopt all eight key aspects of thePHF philosophy, compromising on issues such asthe duration for which support is provided or theextent to which apartments are scattered. As isthe case with CHF services, a less than completeadoption of the PHF philosophy would not been seenby Pathways as meaning that a service could truly34111 Tabol, C. et al (2009) op cit; Pleace, N. and Quilgars, D. (2003) op cit; Jones and Pleace (2010) op cit; Busch-Geertsemaet al (2010) op cit.112 Pleace, N. and Quilgars, D. (2003) op cit.


<strong>Housing</strong> <strong>First</strong>be a form of ‘<strong>Housing</strong> <strong>First</strong>’ 113 . The point at whicha service becomes, or ceases to be, <strong>Housing</strong> <strong>First</strong>is debatable. However, HFL services are ‘housingfirst’ in the sense that they separate housing andsupport, do provide ‘housing first’ and adopt a nonjudgementalharm reduction led approach. Forthese reasons, HFL services can be viewed asfollowing much of the PHF philosophy.Delivering a <strong>Housing</strong> <strong>First</strong>Light ServiceThis section looks at the operation of HFL servicesin six respects:❱❱Which groups of homeless people is a HFLservice designed to help?❱❱What are the aims of a HFL service?❱❱How is the service accessed?❱❱How is a HFL service delivered?❱❱What does a HFL service cost?❱❱Risk managementWhich groups of homeless people isa CHF service designed to help?HFL services can be used to support chronicallyhomeless people. HFL services are also employedto support other groups of homeless people withvarying levels of need. These other groups ofhomeless people can include:❱❱Individuals and households assessed as beingat risk of homelessness but who have notactually become homeless. This might includepeople whose support needs have placed theirhousing stability at risk, for example because theyhave not paid rent or created a nuisance due tomental health problems or problematic drinkingof alcohol. Some HFL services can be largely orentirely focused on this form of homelessnessprevention.❱❱Groups of homeless people with particularneeds. For example HFL services might befocused on young homeless people, homeless andpotentially homeless people with mental healthproblems or homeless families and use workerswho are specifically trained for that group ofhomeless people. An HFL service for homelessfamilies might, for example, include workers whowere familiar with providing parental support,education and social services for children.In the USA, the Homelessness Prevention and RapidRe-housing Program (HPRP) uses what can bebroadly defined as an HFL model alongside directfinancial support of families and other householdswho are at risk of becoming homeless. Workersare provided for a period of up to 18 months forhouseholds at risk of becoming homeless andprovide service brokerage that is focused onensuring housing stability for the household atrisk of becoming homeless 114 . In the UK, there areexamples of HFL services that are focused onspecific groups, such as HFL services for homelessfamilies containing someone with high supportneeds and HFL homelessness prevention servicesfor people who are at risk of homelessness becausenuisance behaviour means they are threatened witheviction 115 .What are the aims of a HFL service?The primary aim of a HFL service is to ensurehousing stability. HFL services are designed toeither prevent a return to homelessness for peoplewho have already been homeless, or to preventa potentially homeless person or household frombecoming homeless.A HFL service may have a number of secondaryaims, which may be specific to the particular groupsof homeless people and potentially homeless peopleit is designed to assist. For example, an HFL serviceworking with chronically homeless people will havethe goal to minimise the risks to housing stabilityfrom severe mental illness and problematic drug and113 Tsemberis, S. (2011) op cit.114 http://www.hudhre.info/index.cfm?do=viewHprpProgram115 Jones, A. et al (2002) Firm Foundations: An evaluation of the Shelter Homeless to Home service, London: Shelter;Jones, A. et al (2006) Addressing Antisocial Behaviour: An independent evaluation of the Shelter Inclusion Project,London. Shelter.35


alcohol use through the use of service brokerageto arrange the necessary mental health and drugand alcohol services. By contrast, an HFL servicefor young homeless people might concern itselfparticularly with the social and economic exclusionof the young people it is working with, focusing onaccess to education, training and employment aswell as promoting housing stability.The aims of an HFL service can include:❱❱Promoting housing stability.❱❱Reductions and where possible cessation ofproblematic drug and alcohol use (if present).❱❱Reductions in criminal behaviour (if present).❱❱Reduction and where possible an end to severemental illness and mental health problems amongservice users (if present).❱❱Improve physical health by emphasizing wellbeingand ensuring contact with medical serviceswhere necessary.❱❱Reengagement with normal social and communitylife, developing friendships, re-establishing familyties where possible and developing and sustainingsuccessful personal relationships.❱❱Engagement with work related activity, includingproductive activity that is similar to work,education and training as well as securing paidwork where this is possible and practical.How is an HFL service accessed?As the operation, focus and nature of HFL servicesis subject to variation, there is no set mechanismby which referrals are made to HFL services.Some HFL services may accept referrals fromhomelessness services including emergencyshelters; daycentres or soup kitchens and HFLservices may also work in cooperation with mentalhealth and social work services. Some HFL servicesare operated by social housing providers and maybe accessed primarily by new tenants who havebeen homeless and existing tenants who may be atrisk of homelessness. It is possible that individualsmay be able to self refer to some services, butthis will depend on the specific arrangements andwhich groups of homeless people an HFL service isworking with.How is an HFL service delivered?HFL services use a combination of mobile supportworkers and ordinary housing. An HFL servicemoves homeless people into housing immediatelyor as soon as possible, and/or seeks to stabilisethe situation of a potentially homeless person whois at risk of losing their existing home when it hasa homelessness prevention role. As noted, HFLservices are primarily low intensity support servicesthat rely heavily on service brokerage. The mobilesupport workers employed by an HFL service willprovide:❱❱Low intensity support with the domesticmanagement of a home, this might include:〉〉Advice and support in claiming welfare benefits〉〉Advice and support on cooking healthy meals〉〉Advice and support on managing householdbills〉〉Advice and support on managing any existingdebt〉〉Support in securing furniture, kitchenappliances such as cookers and fridges forunfurnished housing (some services mayprovide furnished apartments).❱❱Service brokerage, which can include helpingservice users to access health care, psychiatricservices, drug and alcohol services, social worksupport, legal advice, education, training, debtand money management advice and education,training and employment related services.❱❱Low intensity support with issues such as isolationand boredom, though this will not necessarily beoffered by all HFL services.An HFL service will not directly provide any of thefollowing services, though, as noted, an HFL servicewill seek to arrange access to these services viaservice brokerage, when these forms of supportare required:36


<strong>Housing</strong> <strong>First</strong>❱❱Psychiatric services❱❱Health care❱❱Drug and alcohol services❱❱Social work support❱❱Education, training and employment relatedservices❱❱More intensive support with social isolationOne large American research review suggestssome core components that are a necessary partof any HFL service 116 :❱❱Settled housing should be provided immediately.Homeless people have a right to housing andwithout housing in place successful and sustainedexits from homelessness will not be possible.❱❱<strong>Housing</strong> provided should be affordable, adequateand located in a suitable neighbourhood.❱❱No requirements or conditions about staying inhousing.❱❱<strong>Housing</strong> and mobile support services areseparate.❱❱Support staff are a mobile team, they arephysically separate from where service userslive.❱❱Choice in housing options for service users.❱❱<strong>Housing</strong> provided should be integrated withhousing for non-service users (i.e. it is scatteredacross a community and not within oneapartment block, this is not an approach followedby all HFL services).❱❱<strong>Housing</strong> is long term or permanent.❱❱Normal tenancy agreements are used.❱❱<strong>Housing</strong> does not look any different from housingaround it (appearance fits with neighbourhood).❱❱Service users have privacy (own front door).❱❱Individualised and flexible social support.❱❱24/7 crisis cover.❱❱Services are nearby.❱❱Shared decision making, i.e. person-centredplanning and person-centred delivery of services,which involves homeless people in the choicesmade about the services they are offered andprovided with.This list of minimum requirements does not list theduration of the service, which in the case of PHFand CHF models is not fixed. Alongside the otherelements necessary to deliver an HFL service,setting no limit on the time for which formerlychronically homeless people can have support mightalso be included as an essential part of an HFLservice.What does an HFL service cost?HFL services do not exist in one form and havenot been subject to extensive systematic evaluation,which means that it is difficult to be precise aboutcosts 117 . The direct cost of providing an HFL servicecan be quite low, as the service provision centreson a mobile team of support workers, which meansthat an office base, salary costs, administrativesupport and a travel budget are the main formsof expenditure. Unlike a PHF service, HFL doesnot directly employ highly qualified staff such aspsychiatrists or nurse practitioners and unlike aCHF service, there is no expenditure on developingor renovating a specially designed building in whichto house homeless people and support services.An HLF service will however also generate additionalcosts for other services. Service brokerage byHFL services enhances access to health, socialwork, drug and alcohol services and a widerange of other service provision for homeless andpotentially homeless people, raising the expenditurefor those services. There is the potential that anHFL service may still reduce total expenditure byother services, because service brokerage is beingused, rather than expensive emergency provision.For example, it is cheaper for health services foran HFL service to enable access to a family doctorfor a homeless person through service brokeringthan to have a homeless person seek treatment in116 Tabol, C. et al (2010) p.448 op cit. This work reported a concern that HFL services in the USA were not consistent andsought to describe what were thought to be the key components of a successful service.117 Tabol, C. et al (2010) op cit37


the emergency facilities in a hospital. The promotionof housing stability may also improve mental health,help stabilize drug and alcohol consumption andreduce contact with the criminal justice system inmuch the same way as for PHF services.Risk ManagementThere are a number of risk management issuesthat are present when supporting vulnerable peoplewith complex needs in the community. These issuescentre on the potential that someone might overdose,commit harm to themselves or to others or becomeseriously ill and not be able to summon assistance.Some HFL services will seek to manage theserisks through the assessment process, not allowinghomeless people who are judged to represent a riskthat cannot be properly monitored or managed byan HFL service.In some cases, HFL services supporting people withdifferent levels of need will provide relatively moresupport to people judged to represent a higher riskand relatively less support to those who are judgedto be low risk. The mobile support workers will alsomaintain contact and check on the well-being ofpeople using the service on a regular basis. A wellrun HFL service should use service brokerage toensure that were risks are present the homeless orpotentially homeless person concerned has specificsupport in place. For example, if someone has risksassociated with severe mental illness, HFL workersshould ensure that person is being monitored andcared for by appropriate psychiatric services. Thetechniques used to manage risk in HFL services canbe summarised as:❱❱Using assessment processes to ensure thatindividuals or households who represent a riskthat is difficult to manage are referred to moreappropriate services.❱❱Using service brokerage to ensure that, wererisks linked to health or support needs arepresent, appropriate external services are inplace to monitor and manage those risks.Summary of the HFL servicemodelThe HFL service model can be summarised asfollows:❱❱HFL is delivered by using ordinary private rentedor social housing and a team of mobile supportworkers.❱❱HFL provides housing with security of tenureimmediately or as soon as possible to a homelessperson.❱❱HFL may be used to help prevent homelessnesswhere an individual or household who has neverbeen homeless is assessed as being at risk ofhomelessness.❱❱HFL provides low-level mobile support servicesdesigned to help promote housing stability.❱❱HFL uses service brokerage to arrange accessto psychiatric, drug and alcohol services andmedical services where these are required andmay also use service brokerage to arrangeaccess to education, training and other serviceswhere these are needed.❱❱HFL services do not directly provide medical,psychiatric or drug and alcohol services.❱❱HFL can support chronically homeless people butmay also be used for other groups of homelesspeople, including homeless people with lowersupport needs. The other groups that mightbe targeted by HFL services can include younghomeless people and homeless families.❱ ❱ HFL services give considerable choice andcontrol to homeless people as part of followinga harm reduction model. If homeless people donot use the medical and support services whichcan be arranged, or choose to continue drinkingalcohol and using drugs, this does not place theirhousing under threat.❱❱Monitoring of the well-being of service usersthrough contacts and visits by mobile supportworkers.38


statistics are not based on tested measures ofsocial or economic inclusion and cannot be assumedto be robust; the indicators used are also veryrestricted. What evidence there is suggests limitedgains in social inclusion but no effect on economicinclusion 124 . There is no systematic evidence on theextent to which HFL services may influence socialand economic inclusion.Cost effectivenessHFL services have not often been subject to detailedcost analysis 125 . The total costs are difficult tocalculate because of the reliance of HFL serviceson service brokerage. While the costs of deliveringan HFL service can be calculated, the HFL willcreate costs elsewhere as it connects homeless andpotentially homeless people to health, social careand welfare services, as well as to other supportservices. In addition, HFL services are also usedas a homelessness prevention service for peoplewho are at risk of homelessness, but who have notactually been homeless. Cost effectiveness can bedifficult to assess because it involves projection ofthe costs of homelessness that was thought to be atrisk of occurring, but which did not actually occur.There is the potential for HFL services to reduceoverall costs on the same basis as for PHF andCHF services, simply creating housing stabilityappears to reduce the use of emergency medicalservices and reduce the rate of contact that somehomeless people have with the criminal justicesystem. However, PHF and CHF have their costeffectiveness assessed on the basis of working withchronically homeless people, individuals who tend tohave a high financial cost for emergency services.HFL services would seem likely to generate similarsavings if working with chronically homeless people,but, as is the case with PHF services, the savingsmay be less obvious if the homeless people withwhom a HFL service is working have lower supportneeds. This is because homeless people withlower support needs may make much less use ofemergency health services and have less or littlecontact with the criminal justice system, so deliveringhousing stability for this group may generate lessof a financial saving. As noted above, there arestrong humanitarian reasons for not assessingthe effectiveness of HFL and other <strong>Housing</strong> <strong>First</strong>services in simply financial terms 126 .40124 Centre for <strong>Housing</strong> Research (2010) op cit.125 Tabol, C. et al (2009) op cit; Hickert, A.O. and Taylor, M.J. (2011) op cit.126 Culhane, D.P. (2008) op cit


<strong>Housing</strong> <strong>First</strong>5. <strong>Housing</strong> <strong>First</strong> in FranceIntroductionThis final chapter considers the applicability of the<strong>Housing</strong> <strong>First</strong> service model to France. The chapterbegins by looking at the global influence of <strong>Housing</strong><strong>First</strong>. The second part of the chapter considerssome of the questions about the applicability of the<strong>Housing</strong> <strong>First</strong> approach to France. The chapterconcludes by listing three reasons why it is worthconsidering using <strong>Housing</strong> <strong>First</strong> services in France.The Global Influence of <strong>Housing</strong><strong>First</strong>During the 1980s, enduring street homelessness andsustained use of shelter beds among a small groupof people with very high support needs appearedin many societies with advanced welfare systems 127 .This ‘chronic homelessness’ was a difficult problemto solve. Policy failure occurred at four levels:❱❱Chronically homeless people sometimes becamesemi-permanently resident in staircase servicesor other supported housing which failed to rehousethem.❱❱Chronically homeless people often becamecaught in a ‘revolving door’, repeatedly returningto homelessness after making use of services,such as staircase services, that, while theytemporarily stopped street homelessness, did notprovide a lasting solution.❱❱A small number of chronically homeless peoplewere not reached by any services or abandonedstaircase services because of their strict regimesand requirement for abstinence from drugs andalcohol. This group remained in the emergencybeds in homelessness shelters for very longperiods, restricting the capacity of homelessnessshelters.❱❱Public expenditure on attempts to counteractchronic homelessness was often considerablebut was – at best - only partially effective.In New York in the 1990s, Pathways <strong>Housing</strong> <strong>First</strong>achieved something that had not been achievedbefore. The PHF service targeted chronicallyhomeless people and produced lasting housingstability for the majority of this group of veryvulnerable people, using a mix of ordinary privaterented apartments and mobile support services.As variations of the <strong>Housing</strong> <strong>First</strong> model wereintroduced elsewhere in the USA, includingCommunal <strong>Housing</strong> <strong>First</strong> and <strong>Housing</strong> <strong>First</strong> Lightmodels, similar successes in achieving housingstability were reported.The level of success that <strong>Housing</strong> <strong>First</strong> serviceshave shown in delivering housing stability forchronically homeless people has never been seenbefore. It is this success that has led to <strong>Housing</strong><strong>First</strong> being incorporated in homelessness strategiesin Denmark, Finland, Portugal, the Netherlands andIreland, as well as within France.<strong>Housing</strong> <strong>First</strong> has become very influential becauseit is the first homelessness service that can clearlydemonstrate that it provides an enduring solutionthat provides housing stability for the majority ofchronically homeless people. There is strongevidence that <strong>Housing</strong> <strong>First</strong> does what no otherhomelessness service has managed to achieve,providing lasting solutions to the most extreme formof homelessness.The Jury for the European Consensus Conferenceon Homelessness held in Brussels in December2010 recommended that ‘housing-led’ approacheswere the most effective solution to homelessnessand that the different forms of <strong>Housing</strong> <strong>First</strong> servicewere examples of these services 128 . The Juryidentified as ‘housing-led’ all those approaches tohomelessness which focus on:❱❱Access to permanent housing as the primaryresponse to all forms of homelessness.❱❱Prevention of loss of housing.❱❱Provision of adequate mobile support services onthe basis of need.127 Daly, G.P. (1996) Homeless: policies, strategies, and lives on the street London: Routledge.128 European Consensus Conference on Homelessness: Policy Recommendations of the Jury http://ec.europa.eu/social/main.jsp?catId=88&langId=en&eventsId=315&furtherEvents=yes41


Questions about Using a <strong>Housing</strong><strong>First</strong> Approach in France<strong>Housing</strong> <strong>First</strong> services can deliver housing oraccommodation stability for most chronicallyhomeless people, something that has not beenachieved by other homelessness services. Thisachievement makes the <strong>Housing</strong> <strong>First</strong> model worthyof consideration in France.The other arguments in favour of <strong>Housing</strong> <strong>First</strong>centre on two sets of benefits:❱❱Some evidence that housing stability has a positiveeffect on the well-being of chronically homelesspeople, including improvements in mental health,stabilisation and some reductions in problematicdrug and alcohol use.❱❱Evidence that, whilst improving outcomes forhomeless people, <strong>Housing</strong> <strong>First</strong> services cangenerate significant cost savings for otherservices, in particular by reducing the use madeof emergency medical services, homelessnessshelters and the level of contact betweenchronically homeless people and criminal justicesystems.The idea of <strong>Housing</strong> <strong>First</strong> has met some resistancein France 129 . There are several reasons to becautious about the introduction of the <strong>Housing</strong> <strong>First</strong>model in France and these include 130 :❱❱The limits of <strong>Housing</strong> <strong>First</strong>: While the evidencethat <strong>Housing</strong> <strong>First</strong> can deliver housing stability formost chronically homeless people is very strong,some critics have suggested that some models of<strong>Housing</strong> <strong>First</strong> service cannot always work withpeople who present a high risk. There are alsouncertainties about how far some <strong>Housing</strong> <strong>First</strong>services are able to bring an end to problematicuse of drugs and alcohol and the extent to which<strong>Housing</strong> <strong>First</strong> services are able to improve socialinclusion for homeless people.❱❱<strong>Housing</strong> <strong>First</strong> “is not designed” for France:<strong>Housing</strong> <strong>First</strong> is not a French innovation.<strong>Housing</strong> <strong>First</strong> was developed in the USA, acountry with a radically different and far morerestricted welfare system than exists in France.The concern here is that foreign service designcannot simply be ‘imported’ into France andexpected to work well 131 .❱❱<strong>Housing</strong> <strong>First</strong> cannot address all forms ofhomelessness: <strong>Housing</strong> <strong>First</strong> has shown thegreatest success in working with chronicallyhomeless people. This group may not exist inquite the same form or to the same extent inFrance, not least because its welfare system isvery different from that in the USA. In addition,France has forms of homelessness, such ashomelessness amongst migrants with precariouslegal or administrative status, which <strong>Housing</strong> <strong>First</strong>services are not explicitly designed for.The remainder of this chapter will discuss each ofthese reasons for caution before concluding that<strong>Housing</strong> <strong>First</strong> has much to offer in the Frenchcontext, albeit taking account of a certain number ofrisks and preconditions.The Limits of <strong>Housing</strong> <strong>First</strong><strong>Housing</strong> <strong>First</strong> may not be able to deliver an endto problematic drinking and alcohol use for allchronically homeless people or meet all other needsof the chronically homeless people that use theseservices. The founder of PHF, Sam Tsemberis, hashimself noted there are limitations and acceptedthat PHF cannot always work with individuals whorepresent a serious risk or have extremely highneeds 132 .The counterargument is simple. No homelessnessservice can deal with all aspects of homelessness ormeet all the needs of all homeless people. To claimthat <strong>Housing</strong> <strong>First</strong>, that any homelessness service,can ‘solve’ all the problems of all homeless peoplewould not be realistic 133 . The advocates of <strong>Housing</strong>42129 Houard, N. (2011) ‘The French Homelessness Strategy: Reforming Temporary Accommodation, and Access to <strong>Housing</strong> todeliver ‘<strong>Housing</strong> <strong>First</strong>’: Continuum or Clean Break?’ European Journal of Homelessness 5, 2, pp. 83-98.130 Pleace, N. (2011) ‘The Ambiguities, Limits and Risks of <strong>Housing</strong> <strong>First</strong> from a European Perspective’ European Journal ofHomelessness 5, 2, pp. 113-127.131 Johnsen, S. and Teixeira, L. (2010) op cit.132 Tsemberis, S. (2010a) op cit.133 Busch-Geertsema, V. (2005) op cit.


<strong>Housing</strong> <strong>First</strong><strong>First</strong> do not argue it is the solution to every aspectof homelessness, but there is very strong evidencethat it is an answer to the most distressing anddamaging part of chronic homelessness. <strong>Housing</strong><strong>First</strong> stops the physical homelessness of chronicallyhomeless people and it stops most of them frombecoming homeless again. Having a stable homeimmediately improves the situation and well-beingof chronically homeless people. <strong>Housing</strong> <strong>First</strong> maynot answer all their needs, but the majority ofchronically homeless people are in a much bettersituation than they were before they had contactwith a <strong>Housing</strong> <strong>First</strong> service.<strong>Housing</strong> <strong>First</strong> is “not designed” forFranceThe second reason for caution is that <strong>Housing</strong> <strong>First</strong>is not a French innovation; it is an ‘import’ from theUSA. It is certainly the case that a model like the NewYork PHF model could not simply be transferred toFrench cities without adaptation. There are aspectsof the operation of PHF in New York that makelittle sense in the French context. The focus ononly private rented housing, for example, makes lesssense in France which has both social and ‘very’social housing available. France also possesses afar more extensive welfare and healthcare system,meaning that the direct provision of services such aspsychiatrists and nurse practitioners in PHF mightalso make less sense, particularly when servicebrokerage could enable chronically homeless peopleto access the extensive health and welfare servicesthat exist.However, the core aspects of the <strong>Housing</strong> <strong>First</strong>philosophy are not closely linked to any one societyor welfare system and can be adopted in a widerange of situations. Importantly, the evidence showsthat the success of <strong>Housing</strong> <strong>First</strong> stems not fromthose parts of the design that are specifically linkedto a particular welfare regime but from the generalphilosophy of:❱❱Providing housing immediately or as soon aspossible.❱❱Promoting choice and control for homelesspeople and treating them with compassion andrespect.❱❱Following a harm reduction approach andseparating housing and support services. Thismeans allowing homeless people to continuedrinking alcohol and using drugs - and to choosenot to use the psychiatric and drug and alcoholservices that are made available – while at thesame time allowing homeless people to remain inthe housing or accommodation provided.The core ideas of <strong>Housing</strong> <strong>First</strong> have already beenadapted and used in flexible ways. The combinationof secure housing and mobile support servicescan be used to respond to the needs of a widerange of homeless people, including those groupswho need only limited short term assistance, thosewith high needs and specific groups, such as younghomeless people or homeless families. The Finnishimplementation of <strong>Housing</strong> <strong>First</strong> has involved thedevelopment of a Finnish service for a Finnishcontext; it has not involved a simple ‘copying’ ofAmerican services.Much of the evidence drawn upon in this reporthas been American. This is because it is the USAwhere <strong>Housing</strong> <strong>First</strong> services are most developedand where the most research has been done.Evidence on <strong>Housing</strong> <strong>First</strong> is however developing atEuropean level as well as at national and local levelwithin Member States. As mentioned previously, theEuropean Consensus Conference on Homelessnessdevoted much attention to housing-led and <strong>Housing</strong><strong>First</strong> approaches. <strong>Housing</strong> <strong>First</strong> Europe 134 is aSocial Experimentation project funded in theframework of the PROGRESS programme of theEuropean Commission. It will evaluate and providemutual learning on <strong>Housing</strong> <strong>First</strong> in 10 Europeancities. The project was launched in August 2011andwill report in 2013. Its outcomes will give a moredetailed insight into the operation of <strong>Housing</strong> <strong>First</strong>services in Europe than is possible at present. Thiswill inform greater clarity on the potentials and limitsof the approach and its impact on homeless people’slives.In France, a major social experimentation called “UnChez-soi d’abord” is being carried out to test theeffectiveness of <strong>Housing</strong> <strong>First</strong> services for homelesspeople with mental illness 135 . A randomized controltrial over four sites (Paris, Lille, Marseille, Toulouse)will evaluate a Pathways-type service for this target134 http://www.servicestyrelsen.dk/housingfirsteurope135 http://www.developpement-durable.gouv.fr/Programme-Chez-Soi-d-abord.html43


population. The total study population will be 800people. Half of this population will be randomlyallocated to the experimental programme and theother half will continue to receive the conventionalservice offer available to them. The evaluation willcompare both the outcomes for beneficiaries andcost effectiveness of these services. The results willprovide a more detailed insight into the effectivenessof the approach and the key elements for success inthe French context.<strong>Housing</strong> <strong>First</strong> cannot address allforms of homelessness in FranceThe third reason for caution centres on thedifferences that may exist between the nature ofhomelessness in France and homelessness in theUSA. There is almost certainly a significantly higherrate of general homelessness and a higher rateof ‘chronic’ homelessness in the USA. However,survey evidence shows that the French homelesspopulation does appear to include a small groupof chronically homeless people, including homelessindividuals who have difficulty accessing welfareservices 136 . This means it is likely that there is agroup of chronically homeless people who couldbenefit from <strong>Housing</strong> <strong>First</strong> services in France.However, there are other groups of homelesspeople in France, including families and migrantswith precarious legal or administrative status.In considering this question, it is vitally importantto note that <strong>Housing</strong> <strong>First</strong> is not the only part ofthe homelessness strategy in the USA. Federalpolicy in the USA assumes that there are threegroups of homeless people, which are chronicallyhomeless people, episodically homeless people andtransitionally (temporarily) homeless people. Thefirst two groups have high support needs, withchronically homeless people having the highestneeds, and people who experience episodichomelessness (i.e. they keep becoming homelessagain after a few weeks or months away from thestreet or homelessness shelters) also having highneeds. The third group, of temporarily homelesspeople, is by far the largest group and also tendsto have low needs compared to other homelesspeople. This group includes individuals, couples andfamilies with children, all of whom are similar incharacteristics to poor people who are housed. Thisthird group is targeted by extensive preventativeservices including the ‘Homelessness Preventionand Rapid Re-<strong>Housing</strong> Program’ (HPRP), whichprovides assistance with rent and some low levelsupport services that can be classified as <strong>Housing</strong><strong>First</strong> Light (HFL) services.The USA recognises multiple forms of homelessnessand uses a mixture of preventative, low level and<strong>Housing</strong> <strong>First</strong> services to counteract these differentforms of homelessness. Beyond this, the USAalso employs not just one form of <strong>Housing</strong> <strong>First</strong>service but what are in reality multiple forms of<strong>Housing</strong> <strong>First</strong> following the Pathways <strong>Housing</strong><strong>First</strong> (PHF), Communal <strong>Housing</strong> <strong>First</strong> (CHF) or<strong>Housing</strong> <strong>First</strong> Light (HFL) approaches outlined inthis report. <strong>Housing</strong> <strong>First</strong> is therefore not seen asthe ‘only’ solution to homelessness in the USA. Thechronically homeless group which is addressedby most <strong>Housing</strong> <strong>First</strong> services is clearly not theonly target of homelessness policy. Other formsof homelessness exist and other services, besides<strong>Housing</strong> <strong>First</strong>, are in place to try to deal withthose forms of homelessness. Finland, too, doesnot confine its homelessness strategy or servicessimply to <strong>Housing</strong> <strong>First</strong>.There are particular issues with migranthomelessness in France. A high proportion of theplaces in homelessness services in Paris have beenreported as being taken up by Eastern Europeanand African migrants, both with documents andwithout documents 137 . An argument that has beenpresented against <strong>Housing</strong> <strong>First</strong> is that it wouldundermine the capacity of homelessness servicesto support those service users who due to theiradministrative or legal status face specific barriersto accessing permanent housing. <strong>Housing</strong> <strong>First</strong>44136 Brousse, C. (2009) ‘The Homeless Support Network: A segmented world’ in F2009/06 Economie et Statistique: SpecialIssue on the Homeless (English Version) INSEE: Paris, pp. 17-42137 Horréard, J. P. (2007) Migration and Homelessness in Paris, Homeless in Europe Autumn 2007: Social DemographicChange and Homelessness(Brussels: FEANTSA).


<strong>Housing</strong> <strong>First</strong>in this sense has been presented as a threat tounconditional shelter in France that could lead toincreases in homelessness in Paris and other cities.However, this argument assumes that <strong>Housing</strong> <strong>First</strong>would ‘replace’ all other forms of homelessnessservice. This would not be the case if something likethe American or Finnish approach to <strong>Housing</strong> <strong>First</strong>were followed in France, where <strong>Housing</strong> <strong>First</strong> isjust one type of the several forms of homelessnessservices, including homelessness prevention, whichare used.It is also worth noting that <strong>Housing</strong> <strong>First</strong> could havea beneficial effect in increasing the capacity ofhomelessness shelters and daycentres in France.Adopting a <strong>Housing</strong> <strong>First</strong> approach does not meanabandoning existing services where there is a needfor them. In the USA, a key argument for <strong>Housing</strong><strong>First</strong> has been that it reduces the use of homelessnessshelters significantly. This was because it was foundthat chronically homeless people, while representingperhaps 10% of all homeless people, stayed inshelters for so long that they used 50% of the bedsthat were available during the course of a year (i.e.each chronically homeless person used a bed inhomeless shelter many times, meaning it could notbe used by other homeless people). As <strong>Housing</strong> <strong>First</strong>services took chronically homeless people out of theshelter system, those beds became available again.Over time, it is true that it was hoped that somereductions on spending on shelters could occur inthe USA, as fewer beds would be needed overalldue to <strong>Housing</strong> <strong>First</strong>. In France, <strong>Housing</strong> <strong>First</strong> mightbe used to allow shelters to better meet the needs ofthose who are homeless and are unable to accesshousing immediately, such as migrants that facebarriers due to their legal or administrative status.Why use <strong>Housing</strong> <strong>First</strong>in France?There are three main reasons to consider using<strong>Housing</strong> <strong>First</strong> services in France.❱❱The core philosophy of <strong>Housing</strong> <strong>First</strong> is thereason for the success that has been achievedin delivering stable housing and accommodationfor formerly chronically homeless people. The<strong>Housing</strong> <strong>First</strong> philosophy can be drawn uponwithout copying the detailed operation of <strong>Housing</strong><strong>First</strong> services working in the USA. The ideas of<strong>Housing</strong> <strong>First</strong> can be used to design services thatcan be used to reduce chronic and other formshomelessness in different countries with differentwelfare systems. An example of this has been theuse of the <strong>Housing</strong> <strong>First</strong> philosophy to effectivelyredesign homelessness services in Finland.❱❱<strong>Housing</strong> <strong>First</strong> is highly flexible. The corephilosophy has been adapted from the Pathways<strong>Housing</strong> <strong>First</strong> (PHF) model and employed inCommunal <strong>Housing</strong> <strong>First</strong> (CHF) and <strong>Housing</strong><strong>First</strong> Light (HFL) services that can be focused onboth chronic homelessness and on other formsof homelessness.❱❱<strong>Housing</strong> <strong>First</strong> services can support other types ofhomelessness services, for example by stoppingvery long stays in emergency accommodationbeds by homeless people that could accesspermanent housing. It is important to note that<strong>Housing</strong> <strong>First</strong> is not designed to replace allexisting homelessness services and has beenused as one part of a mixture of services torespond to homelessness in the USA and Finland.By supporting the work of other homelessnessservices, <strong>Housing</strong> <strong>First</strong> services can potentiallyenhance the capacity of the overall homelessservice provision and ensure that the needs ofdiverse groups within the homeless populationare met.It is important to end this discussion with a noteof caution. <strong>Housing</strong> <strong>First</strong> services are effective ifthey follow the harm reduction approach and othercore elements of the <strong>Housing</strong> <strong>First</strong> philosophy. Aservice is not ‘<strong>Housing</strong> <strong>First</strong>’ if it adopts some ofthe core elements of this philosophy and not others.For example a service that gives immediate accessto housing and uses mobile support services, butwhich requires abstinence from drugs and alcoholis not a <strong>Housing</strong> <strong>First</strong> service. Similarly, a servicethat requires chronically homeless people or otherhomeless people to complete one or more steps in aprogramme to make them ‘ready for housing’, beforegranting access to secure housing is still followinga staircase model, it is not <strong>Housing</strong> <strong>First</strong>. Adoptionof the core philosophy of <strong>Housing</strong> <strong>First</strong> cannot bepartial. Although there is some scope for flexibility,immediate access to housing, the separationof housing and support and a harm reductionapproach are crucial elements of the <strong>Housing</strong> <strong>First</strong>philosophy and of the effectiveness of the approach.This core philosophy can be adapted to a range ofoperational contexts and service delivery models butthe key principals must be addressed in order toend situations of homelessness.45


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Printed on 100% recycled paper stock using bio vegetable based inks. Design: www.beelzepub.comPremier MinistreMinistère de l’Écologie,du Développement durable,des Transports et du Logementwww.developpement-durable.gouv.frwww.feantsa.org

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