Integrated Housing and Support: A Research Perspective Nicholas Pleace

The Research Perspective Definitions What we know Strengthening the evidence base

Definitions What is integrated housing and support? Several parameters “Welfare system in miniature” through to “case management” Low wage and relatively untrained workers through to staff who are trained social workers, medical professionals Purpose built through to ordinary, scattered housing with mobile support teams

Many forms of integrated housing and support Definitions Many forms of integrated housing and support People with mental health problems, disabled people, people with learning disabilities Older people with support needs Stigmatised/marginalised groups Offenders Drug users Young people Chronically homeless or long term/recurrently homeless people

Definitions Three main models Long term or permanent integrated housing and support. Designed to maximise independence in populations who are viewed as not able to live entirely independent lives. Short or medium stay supported housing. Designed to train people to live independently and modify behaviour that might threaten independent living. AKA as “Staircase” models. Housing Led and Housing First approaches

Housing-led, mobile support using ordinary, scattered/communal housing Definitions Housing-led, mobile support using ordinary, scattered/communal housing Housing First Consumer choice/personalisation Intensive support (ICM/ACT) Targeted on recurrent, long term/chronic homelessness Harm reduction Open ended Separation of housing and support Scattered Housing First (SHF) and Communal Housing First (CHF)

Can often still have these characteristics What we know For a long time, attempts at integrated housing and support resembled institutions in several respects Communal or congregate On site staffing (case management/tiny welfare state) Monitoring and rules Requirements on behaviour and for behavioural modification Can often still have these characteristics But there are longstanding trends that are changing integrated housing and support

Greater trends to more housing-like conditions Smaller services What we know Greater trends to more housing-like conditions Smaller services Use of scattered/core and cluster housing Use of ordinary housing Separations of housing and support, housing is not conditional on receiving support, can be kept as needs fall or cease altogether Greater emphasis on normalisation of living situation and on social integration Consumer choice and personalisation

What we know Communal/congregate can deliver successes Can provide long-stay and permanent integrated housing and support that people not only opt to stay in, but actively choose e.g. some forms of sheltered/supported housing for older people Well-run communal and congregate schemes may provide a sense of community, deliver informal support, also connect with the external community Some people may prefer short and medium stay communal/congregate models, including those requiring abstinence or other forms of behavioural modification, to learn to be ‘housing ready’

What we know Although designed to counteract the problems, costs, limitations and dehumanising effects of the institutional care of older people, disabled adults, people with learning difficulties, people with mental health problems and homeless people… …both the initial and also some current designs of integrated housing and support are physically separate and sometimes architecturally distinct communal/congregate housing that can replicate some of the problems of institutional care Ineffectiveness, at multiple levels, can be the result, including high rates of attrition (failure to complete programmes designed to resettle groups)

What we know Models that are housing-led and/or which follow Housing First approach tend to have very high rates of retention, i.e. people housed by these services tend to stay housed, including high needs groups Success rates in sustaining housing for homeless people via Housing First are (largely) unprecedented for high need groups, also positive evidence around similar services for people with severe mental illness and other groups ‘Own front door’, treated as an adult, respected, personalisation approach enabling ‘designing own support’ tends to make these services often very popular

What we know Short-term and/or low intensity support models may meet with lower levels of success, particularly with high needs groups There may be issues of isolation, boredom, lack of meaningful or productive activity There is an element of “magic” in the idea that being in “scattered housing” generates community and social integration. But it is not clear that just being in a specific type of housing somehow automatically generates social integration (Johnson et al, Australia). Potential issues around risk management

What we know All integrated housing and support, including those services that provide a “welfare state in miniature” are at least partially dependent on effective joint working/networking with wider welfare and health systems. Some forms of integrated housing and support are effectively case management services that are highly dependent on relationships with other services Integrated housing and support is something of a misnomer, services and their costs are not wholly self contained.

What we know There is the potential and some actual evidence that integrated housing and support can reduce financial costs Preventative effect, i.e. improvement of health and well-being through having decent housing and access to necessary support “Short stay” effect, i.e. people may be able to leave hospital, institutions more quickly if good quality integrated housing and support is in place But as said, understanding costs is not simply a matter of what the running costs are…

Improving the evidence base Why? If health commissioners and policy makers are to spend serious money on integrated housing and support, they will often require a clinical standard of proof The most effective models of integrated housing and support, as preferred by service users, may have economic benefits, but they are not cheap Gaps in evidence

Improving the evidence base Cost effectiveness – a major gap, particularly in Europe, but also globally, though Australians, Canadians and Americans do have some data and research Social integration – not clear how well this works and therefore how best to achieve it, must counter isolation, boredom, stigmatisation and worklessness to really improve quality of life Health and well-being – arguably we know how to settle someone into housing and keep them there in most cases, this helps health and well-being and has (to an extent) been recorded as having positive effects. Might be at the limits of what an integrated housing and support model can do with Housing First services. Wider issues of health, well-being and social integration may require new approaches, new policies.

More information Forthcoming report from OECD on integrated housing and support in OECD member states (contributing author) Pleace, N. and Bretherton, J. (2013) ‘The Case for Housing First in the European Union: A Critical Evaluation of Concerns about Effectiveness’ European Journal of Homelessness 7.2, pp. 21-41. Pleace, N. and Quilgars, D. (2013) Improving Health and Social Integration through Housing First: A Review DIHAL. Pleace, N. (2013) Measuring the Impact of Supporting People: A Scoping Review Cardiff: Welsh Government. Pleace, N. (2012) The Costs and benefits of Preventative Support Services for Older People Edinburgh: Scottish Government Pleace, N. with Wallace, A. (2011) Demonstrating the Effectiveness of Housing Support Services for People with Mental Health Problems: A Review London: National Housing Federation. Pleace, N. (2008) Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from an international review Edinburgh: Scottish Government.

Thanks for listening nicholas.pleace@york.ac.uk www.york.ac.uk/chp @CHPresearch www.feantsaresearch.org/ www.womenshomelessness.org/