Housing First in Europe Nicholas Pleace Joanne Bretherton

Overview The European context Europe prior to Housing First European interpretations of Housing First Some examples Key lessons

The European Union (EU) A group of countries participating in a series of treaties that are designed to facilitate free trade and common interest in areas related to free trade, EU is primarily an economic union. It has an elected parliament (The European Parliament) and a civil service (European Commission, EC) and a shared currency (Euro) and, of course, a flag 28 countries (known as member states), 24 official languages, 18 countries have Euro as their currency

The European Union EU GDP now exceeds that of the USA, collectively the World’s biggest single economy Germany, France and the UK are, respectively, the World’s 4th, 5th and 6th largest economies EU covers over 4 million km² and has 503 million inhabitants, World’s third largest population after China and India

European Union

European Context Severe Material deprivation rate, 2011 and 2012, Source: Eurostat

European Context Variations in relative prosperity Northern Europe is relatively more affluent than the South and the East Northern Europe also tends to spend more on social protection – health, welfare, social services, social housing/housing subsidies for poorer populations EU does concern itself with poverty, which is seen as a threat to economic stability, the 2020 goal to lift 20 million people out poverty and Social Investment Package are designed as an EU wide strategy to reduce poverty within a framework of increasing economic competitiveness

European Context Homelessness is a key priority in the Europe 2020 strategy, the European Commission has defined homelessness as an extreme form of poverty and deprivation, the reduction of which should be a key goal. In 2010, Fédération Européenne d'Associations Nationales Travaillant avec les Sans-Abri (FEANTSA), the EU federation of homelessness service providers organised a Consensus Conference on homelessness policy and FEANTSA has been actively campaigning for: A common definition of homelessness, to allow trends across the EU to be explored and mapped statistically, by the development and promotion of ETHOS (European Typology of Homelessness and Housing Exclusion) as a common standard A pan-EU homelessness strategy within wider strategic objectives to reduce poverty and exclusion

European Context But… Homelessness policy is ultimately determined at national, regional and local level in the EU, EU countries entirely control their own responses to homelessness Degree to which homelessness is seen as a strategic priority by national governments varies considerably, there are devoted, well-resourced national strategies, there are countries without any national homelessness policy and which devote few if any resources to homelessness

European Context Source: "On the Way Home": FEANTSA Monitoring Report on Homelessness and Homeless Policies in Europe 2012 http://www.feantsa.org/spip.php?article854&lang=en

Europe Prior to Housing First In Northern EU, extensive welfare, social services, social housing and health systems often included a wide range of homelessness services Homelessness was a ‘residual’ social problem (Meert, 2005; Busch- Geertsema et al, 2010) experienced by a fraction of the population Much ‘structural’ homelessness, i.e. caused largely or solely by income poverty appears to have been effectively prevented by welfare systems Child and family homelessness, for example, were comparatively rare because extensive safety nets existed for households, including lone women with children, who might otherwise have become homeless Elsewhere, there appeared to be more homelessness associated with poverty and lack of welfare safety nets, but situation was uncertain, countries with less money and less welfare spending have less and sometimes little or no, data on homelessness Homelessness can sometimes manifest in different ways in South and East, in contexts where there are few or limited welfare safety nets, some homeless people build shanties, almost unknown in North

Europe Prior to Housing First What was apparent was that almost every country (where there was some data) had populations of long-term and recurrently homeless people who had high support needs Severe mental illness and problematic drug/alcohol use, poor physical health, not socially integrated Interestingly, this population seemed to exist in radically different contexts, in terms of economic prosperity, welfare, health and social housing expenditure Chronically homeless people, in other words

Europe Prior to Housing First By the late 1990s and into the 2000s, some of the ideas that were underpinning the Housing First movement were also to be found in some European services There were services moving long-term and recurrently homeless people into ordinary housing and seeking to sustain that housing using mobile support workers And services working to a model that gave increased choice and control to homeless people And a shift to harm reduction had occurred

Europe Prior to Housing First The UK was running ‘resettlement’ and ‘tenancy sustainment’ services using social housing, which gave long-term vulnerable homeless people full tenancies and provided mobile workers who functioned as case managers in early 1990s Researched by Pleace in 1994… Into the 2000s, a cutting edge service, like the Tenancy Sustainment Teams used towards the end of the Rough Sleepers Initiative in London, were very close to a Housing First model, but developed without reference to Housing First. Finnish national strategy also developed initially without reference to Housing First, later realised the similarities in approach and built links to North America But a lot of Northern Europe was running what can be described as Linear Residential Treatment, Continuum or, what were termed ‘Staircase models’

Europe Prior to Housing First Evidence that “Housing Ready” behavioural modification models that required treatment compliance and abstinence, and which stepped long term and recurrently homeless people with high support needs towards re- housing were often not working People could not complete the steps, got ‘stuck’ People ran away Lack of dignity, privacy Humanitarian concerns, human rights Possibly increasing long term homelessness by causing pooling in systems that were not resettling people And were expensive… And you all know where this is heading already

Europe Prior to Housing First Although homeless people might need to prepare for future regular housing, there is no reason why this should take place in a hostel. Learning how to dwell in an institution does not facilitate independent living, conversely, it might entail opposite results: institutionalisation, secondary adaptation and stigmatisation. Successful strategies to provide “housing first ” cast additional doubts over the idea that housing requires exercise, preparation and support somewhere else than in a permanent dwelling. In addition, there is no reason why social support could not be just as well (or better) provided if homeless individuals have self-contained dwellings. In general, support works better if recipients want or at least accept it, and when it is detached from force and control. Busch-Geertsema and Sahlin (2007) European Journal of Homelessness http://www.feantsaresearch.all2all.org/IMG/pdf/ejh_vol1_article3.pdf

Europe Prior to Housing First The arguments in favour of treatment-first, abstinence based services that made people housing ready were the same as deployed elsewhere They ‘achieved more’ when they were successful They were able to cope with the highest needs, whereas mobile support using ordinary housing could not guarantee to manage risk effectively Staircases were not properly resourced, or could not move people on because of housing supply problems But there was evidence of a long-term homeless population circulating around in these services for years, sometimes decades, e.g. in Finland, in Ireland and in the UK

Housing First in Europe A similar set of issues Northern EU has populations of long-term and recurrently homeless people with high support needs Existing, treatment-led, behavioural modification models centred on making this population ‘housing-ready’ were only partially effective

Housing First in Europe North American evidence base and adoption of Housing First approach by Federal Government in USA attracts attention in EU EU academics begin discussing and reporting on Housing First, considering use in EU context 2010 EU Consensus Conference, organised by FEANTSA, concludes by recommending that housing-led and Housing First approaches need to be part of homeless strategies European Commission advocates use of Housing First approach

But there is variation in how Housing First is operationalised European Variations There is little variation in what Housing First is interpreted as being in the philosophical sense Enabling choice (client-led/personalisation) Providing intensive support (low case load for workers) Open ended support (not time-limited) Targeted on long-term/recurrently homeless people with high support needs Separation of housing and support (housing not conditional on service use, agreeing to care plan) But there is variation in how Housing First is operationalised

The European Variations The nature of support provided, centring on the extent to which there is reliance on case management using external services and the extent to which an in-house (dedicated) multidisciplinary team is directly provided by a Housing First service What form of housing is used, centring on whether or not that housing is congregate/communal or scattered

European Variations Case management Dedicated multidisciplinary teams (e.g. ACT model) Communal and congregate models Scattered housing models Variations pivot around whether or not scattered housing is used And the extent and nature of support that is directly provided But NOT in terms of underlying philosophy

Scattered Housing, ACT (France) France is running a control trial Three year evaluation of Housing First projects in Lille, Paris, Toulouse and Marseille 606 participants, 303 receiving Chez- Soi (Housing First) Final report 2016, initial findings suggest excellent results (80% housed @ 13 months) Close resemblance to Canadian approaches

ACT-Based, Mixed Housing (Denmark) Danish National Homelessness Strategy established an ACT-based Housing First service Used a mixture of scattered and congregate housing (social rented) Perception that some of long-term and recurrently homeless people with high needs would not manage on their own @ 1 year, 94% housed, but 68% of those in communal housing in original home, compared to 85% of those in original housing

Congregate Housing/ICM (Finland) No use of scattered housing Took existing homelessness services and converted them into apartment blocks (and some other buildings) Close adherence to core elements of Housing First philosophy Long-term and recurrent homelessness dropped to an estimated 1,070 people in 2013 , some 64% less than the 2008 level of 2,931 long-term homeless people.

Case Management, Scattered housing (Portugal) Recovery focus, with emphasis on community integration ‘Southern’ models of Housing First with more emphasis on using community as source of support 83% housing sustainment @ 1 year

Case Management, social scattered housing (The Netherlands) Scattered housing in social rented sector Discus project Amsterdam One visit a week, financial management Own tenancy Strength-based model of support, focus on capacity, skills, knowledge, connections and potential in individuals 77% housed at 5½ years

Camden Housing First (London) Integrated a Housing First response into a staircase/linear residential treatment model Used Housing First to target population ‘stuck’ in hostel system designed to make long-term homeless people “housing ready” Low resources, two workers, providing case management and sourcing private rented housing Seven people housed @ 1 year, all had spent at least 3 years in hostel system, people in their 40s, who had never lived independently, successfully housed Service expanded

Case management (UK) Camden Housing First was first of multiple experiments which are on-going Some using case managers in a double role as providing support and finding/securing housing, Often high reliance on private rented housing, though some have access to social rented sector Some make extensive use of experts by experience, formerly long-term homeless people employed as frontline workers

More examples… A service closely modelled on the original New York project in Dublin, also generating successful results And a Housing First programme in Belgium And in Sweden, gains in self-respect, social integration, motivation for using services alongside housing retention reported… Elsewhere there are some homelessness services that are not consistent with core Housing First philosophy, but which still call themselves ‘Housing First’ but these appear to be unusual, most examples of Housing First in Europe follow the core ideas

Key lessons While basic differences can be described in terms of where and how support is provided by different European models of Housing First There is a more complex reality when one looks at the details of how Housing First services operate Variations by Degree of peer support, from none through to all front-line staff being ‘experts by experience’ Extent to which community is seen as a resource, the idea of the neighbourhood as a supportive environment for formerly homeless people is much stronger in Southern Europe Housing tenure (implications for affordability, security of tenancy, availability)

Adherence to core philosophy Key Lessons Adherence to core philosophy Enabling choice Providing intensive support Targeting on long-term, recurrent, high need homeless people Harm reduction Open-ended support Separation of housing and care …appears fundamentally important to delivering housing sustainment

Key Lessons – the argument for Housing First in Europe This article has asserted that two of the key arguments underpinning criticism of the wider use of Housing First in the EU do not stand up to serious scrutiny. The first argument is that model drift makes Housing First services vary to the extent that there is a danger of inconsistent results and building strategies around a service model that is not clearly defined. The current evidence is that adherence to shared operational principles is sufficient for Housing First services to achieve consistently high success rates in ending chronic homelessness. The second argument is that Housing First should be treated with caution, because it is not as effective as claimed, because there is selectively, bias and gaps in the evidence used to support it. However, there is now simply too much evidence that Housing First services, with shared operating principles, are effective in a range of contexts across different countries for this critique to really be taken seriously. Pleace and Bretherton, 2013 The Case for Housing First in the European Union: A Critical Review of Concerns about Effectiveness European Journal of Homelessness http://www.feantsaresearch.org/IMG/pdf/np_and_jb.pdf

Key Lessons: Viva Diversity One of the most encouraging things about European work is how quickly and relatively cheaply a Housing First service can be deployed Here British examples are useful, essentially a couple of workers, a caseload of 10 or 4 workers with a caseload of 20 delivering an entire support service through case management, sourcing housing themselves That this sort of approach works well, even stands up to direct comparison to a fully loaded ACT model with specially provided social housing supply, is a very interesting finding from EU research But we need to be very careful that Housing First is not presented as a low cost option, the British models are still high intensity support services and they have considerable total costs, because case management creates connections to all the services vulnerable long-term homeless people were not necessarily using, total costs can go up because someone is connected to mental health, drug/alcohol and other services where they were not before Need to be careful too not to read too much into EU research, most Housing First services are young, and with some exceptions (Denmark and France) evaluations do not meet clinical standard of evidence

Key Lessons: Different Models are Effective The deviations from the pioneer “model” in terms of organising housing and support confirm arguments that a certain amount of “programme drift” and adjustment is inevitable if an approach is transferred to different local conditions. Volker Busch-Geertsema, Housing First Europe evaluation http://www.socialstyrelsen.dk/housingfirsteurope Everything that follows a Housing First philosophy appears to be effective at ending long-term and recurrent homelessness associated with high support needs for 8 or 9 out of every 10 people As a philosophy, Housing First enhances effectiveness in ending homelessness across a wide range of service models

Key Lessons: Housing Supply Affordable housing supply is restricted in much of Europe High pressure on social rented housing which tends to offer better standards at lower cost, with more security of tenure Suitable private rented can be expensive, relatively insecure in some countries (e.g. UK) and hard to find Landlord attitudes can be a barrier, both social and private rented Where is the housing? An important question

Key Lessons: Housing Supply Finland confronted this situation The resolution, in terms of finding enough housing quickly enough was to convert homelessness services into housing Hostels and emergency shelters became apartment blocks, people had their ‘name on the door’ Highly effective, though financial costs were high, less than trying to buy, build and find enough affordable housing in other ways

Key Lessons: Housing First, What’s Second? The title of the 2013 European Observatory research conference held in Berlin Essentially, if we can now re-house most of the vulnerable people experiencing long-term and recurrent homelessness, what happens then? Long term questions about Health and well-being Social integration Nuisance and anti-social behaviour Political and community participation Social supports (family, friends) Economic integration

Key Lessons: Housing First, What’s Second? Questions around health and social integration are still seen as not entirely resolved There is some positive evidence But there are questions about what is realistic, how far Housing First services can deliver improvements, how much they should be expected to deliver And here, particularly with regard to social integration, debates and questions about use of scattered versus communal/congregate housing are still live, can single-site facilitate social integration, can we really presume that scattered housing will deliver social integration?

Key Lessons: Not the Renaissance While the EU has been characterised, through French and German influence, with socio-democratic norms, that is not a direct reflection of wider political reality There are extreme right wing political parties, opposed to the ongoing existence of the EU, e.g. in France, the UK and they will not have much concern about, or sympathy towards homeless populations And in terms of Housing First, there is some direct political opposition

Key Lessons: Not the Renaissance Housing First is becoming widespread in some contexts, dominating debates about long-term and recurrent homelessness in Denmark, Finland, the Netherlands But is happening more slowly in other contexts And staircase, linear-residential treatment and lower intensity hostel-based models designed to make people ‘housing ready’ often predominate In the South and East, formalised, specialist homelessness services are less common, more emergency, basic services, often faith-based

Key Lessons: Not the Renaissance For homelessness sector, Housing First can sometimes be seen as a danger, a ‘smoke-screen’ to allow homelessness services to be cut away and replaced by cheaper, inadequate services which are described as innovative “Housing First” but which are in fact a low intensity, under-resourced model of case management – a concern in France and Ireland There is also resistance to the idea, the view that long-term homelessness can only be solved through treatment, abstinence and behaviour modification has not gone away

Key Lessons: Not the Renaissance Resources are a key concern, EU is still reeling from the financial crisis, while major economies like the UK have seen massive cuts to expenditure on social policy, talked about questions of where the housing will come from, but often it is a question of where the money will come from Political objections to Housing First are not unknown, referred to as ‘bottle first’ in Finland, idea that people exhibiting problematic drug and alcohol use should be offered secure housing, in context where affordable housing supply is restricted, still a hard sell

Key Lessons: Costs Never underestimate political appetite for services that achieve the same, or more, but which cost a lot less Herein lies a potential risk for Housing First in Europe There is an expectation that Housing First will save money Understanding of the costs of homelessness in the EU, all of the EU, is in its infancy, and Housing First has only started to be looked at from a cost perspective Yet economic evaluation of social and health policy is very well developed, e.g. the health economics that governs how the UK National Health Service spends money

Key Lessons: Costs Arguments that Housing First costs ‘less per day’ than a psychiatric ward hospital bed, intensive supported housing or prison, and produces cost offsets will be hard to sell in Europe, you’re not in prison or a psychiatric ward all the time… So what if, for example, Housing First reduces long-term homeless person use of Accident and Emergency (Emergency Room) by 78%, long-term homeless people constitute 0.14% of patient activity, cannot reduce costs on that basis, same logic with mental health, criminal justice etc. Yes, they are expensive, but there aren’t many of them Can address this by arguing Housing First reduces lifetime costs, e.g. someone might cost society €200,000 more over their life course if not housed and socially integrated by Housing First, but again, not that simple, case management by Housing First can put costs up, connecting long term homeless people to expensive services Could be a challenge for Housing First when costs are really looked at

Key lessons A lot to be positive about Key finding (so far) is that Housing First can be delivered in many ways and will remain effective if the core philosophy is adhered to Some questions too, all Housing First is high intensity, but the most intensive, expensive services do not appear to be more effective in terms of housing sustainment (mirroring some findings about outcomes for ACT/ICM in Canada) But some questions still to be answered and still many rivers to cross…

More (all free to download) 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. http://www.feantsaresearch.org/IMG/pdf/np_and_jb.pdf Pleace, N. and Bretherton, J. (2013) Camden Housing First: A ‘Housing First’ Experiment in London York: University of York. http://www.shp.org.uk/sites/default/files/user/downloads/camden_housing_first_final_ report.pdf Pleace, N. and Quilgars, D. (2013) Improving Health and Social Integration through Housing First: A Review DIHAL http://www.york.ac.uk/media/chp/documents/2013/improving_health_and_social_inte gration_through_housing_first_a_review.pdf Busch-Geertsema, V. (2013) Housing First Europe: Final Report http://www.socialstyrelsen.dk/housingfirsteurope European Observatory on Homelessness 2013 Eighth European Research Conference on Homelessness (Berlin) Housing First, What’s Second? http://feantsaresearch.org/spip.php?article181&lang=en New research on Housing First England, by Joanne Bretherton and Nicholas Pleace is forthcoming in early 2015, see http://www.york.ac.uk/chp

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