Homelessness is a growing problem in the EU, also due to the current crisis, and homeless population includes now new groups, such as young people, older people and migrants but also large families. Member States have the responsibility to tackle this phenomenon by applying different strategies which may space from staircase model to housing first led approaches or a mix of those. The second model is inspired by a programme developed in the United States and which seems to be more efficient, although there are some concerns regarding its applicability to the European contexts. This article has the purpose of presenting Housing First (HF) programme as designed for the US context and also how it was applied in some European countries, underlying the differences between this and the staircase model.
Housing First is a programme created by Dr. Sam Tsemberis which aims at providing homeless people immediate access to permanent supported housing. It was first applied in New York at the beginning of the 1990s and now is also being adopted in some European countries as a part of the national strategies to end homelessness. Housing-led approaches to tackling homelessness are now supported across Europe because of emerging evidence on their effectiveness if compared to other existing models. The traditional way of dealing with this problem is based on the staircase model which considers that homeless persons must first deal with the problems which led them to be homeless or have arisen as a result of homelessness, such as drug and alcohol misuse or mental health issues. They become ready for long term accommodation only if they succeed in recovering or demonstrate improvements. Before being eligible for access to housing the client has to undergo treatment. The candidate must demonstrate to have some basic living skills and also show commitment to continue/engage in treatment. Criticism to this strategy is that of losing clients between the different stages because people often do not succeed in passing through all the required steps before being considered ready for a permanent accommodation. Before arriving there they are offered shelters and hostels but these are only temporary solutions which do not give people the stability needed in order to face their other problems. A different approach is Housing First programme which is aimed at placing people into permanent housing and offers them the possibility to access other services without making them compulsory. It was firstly designed for chronically homeless people who showed a record of repeated and sustained street homelessness, high rates of problematic alcohol and drug consumption, severe mental illness and poor physical health. The leading principle is that of housing as a basic human right and it does not require participation in treatment and sobriety as a precondition for housing, although it offers support services for people such as drug and alcohol services and psychiatric services. Dr. Sam Tsemberis declared that they did not start with the idea of Housing First. They only went asking people what they wanted and the answer was: quick access to permanent housing. This is how they decided to radically change the approach by capsizing it: housing became the first step in tackling homelessness rather than an end goal. One thing which must be stressed is the fact that housing is offered along with support services which may consist in helping them reconnecting with their families, assuring them medical services and also a psychiatrist. Because of decoupling of housing and services, people can choose not to use the help and keep drinking and using drugs. One of the main challenges for social workers is that of trying to provide very attractive services if they want their clients to use them. The approach is always oriented towards harm reduction but this happens in the long term. Service providers look for a place where the person can live, help people with the deposit and furniture in order to assure them the effective possibility to move in and in the end they also assign a support worker on ground which helps these persons to go on. Support is the key success of the programme since it helps people to keep the house once they have obtained one. According to where HF is applied it may present some different features but there are three main versions: Pathway Hosing First, Communal Housing First and Housing First “light”. Pathway Housing First This is the original programme and has the characteristics described above. A fundamental element of this version is that they provide scattered site housing throughout the city and accommodation in independent apartments, along with separation of housing and services. It uses private rented housing, usually with the service being the “tenant” and the former homeless person having the sub tenancy. Consumers’ choice and self-determination are the core philosophy of this approach. Moving to a normal neighbourhood with a rental contact can help people recovering in a better way. The retention rate is very high, around 80-90% of people are still in housing at 12-18 months from the start, provided that they get the support they need. Therefore, mobile support services are available under the form of Assertive Community Treatment Team (ACT) composed by a team leader, part-time psychiatrist, a part time doctor or nurse practitioner and a full time nurse, a qualified social worker (mental health), specialists in supported employment, a drug and alcohol specialist, a ‘Peer specialist’ and sometimes a family specialist (reconnection) and ‘wellness management and recovery specialist’ (healthy lifestyle). Usually a ten person ACT team is responsible for around 70 people in scattered housing. In also include an Intensive Case Management Team (ICM) with a case management or service brokerage role connecting service users to mental health, drug and alcohol health and social work services alongside other services to meet other needs. ICM team staff are each assigned up to 20 service users in scattered housing.
Communal Housing First A first striking difference is that of providing communal accommodation and not independent scattered housing with the support staff on site or nearby but it can also offer self-contained apartments. CHF maintains the other characteristics of PHF such as separation between services and housing and also the harm reduction approach, therefore drinking and drug use is allowed and psychiatric services are not compulsory. In this model too both ACT and ICM teams are available. This version is widely used in Finland and USA. It has higher cost than PHF as it requires the use of entire buildings and a support team fully available. It may pose problems because of the presence of many people with complex problems in the same site with a potential negative impact on the service users. It seems that CHF can be the perfect solution for people who fear isolation and loneliness if collocated in scattered housing.
Housing First “Light” It is mostly used in the UK and provides low intensity mobile support workers to formerly and potentially homeless people living in their own homes. It also gives some direct support aimed at promoting housing stability. In some cases it can provide some type of care and health services directly but usually the approach is that of service brokerage with HFL acting as intermediary between the service user and the local service. An additional difference is that of time limit, while the two previous programmes are virtually endless, they last as long as the service user needs assistance. HFL enable access to health, social care and welfare systems for vulnerable homeless people who might not have using them before with an impact on total costs which may be higher although here again it depends on the welfare system present in the country where HFL is implemented.
Does Housing First really work? Studies showed that 85% of people who go in Housing First remain in the house, opposed to 30-45% of people involved in staircase model. There is evidence of stabilised and fall of the consumption of drugs and alcohol but this does not seem to necessarily lead to giving up their use. It seems also that well-being improves among service users, mainly due to the presence of a place to live. The impact is important, since having a house allows people to store food in a fridge and not spending all their money on food in fast foods like they do while living in the street. It also lowers the possibility of getting in trouble with the police. Furthermore it seems also to be cost effective, since it allows to save money with respect to other approaches but on this point there is not a common view since it depends on the welfare system of the country where implemented and also on the cost of support personnel which is needed in order to run the programme. Funding may come from the State, NGOs, or municipalities and the services might be covered by the Ministries of social and health care but this changes from country to country. In several countries, namely Denmark and Finland, this has become part of national strategies, in other countries there are some projects, for example in Netherlands there were around 15 projects, in France projects involved four cities, in Belgium five cities and also Portugal, Italy and Poland have adopted this programme, although with small projects in no more than two sites.
European Commission, DG for Employment, Social Affairs and Inclusion, funded a project called Housing First Europe (HFE) under the PROGRESS programme from August 2011 to July 2013. The aim was that of obtaining an evaluation and mutual learning between, local projects in ten European cities. HFE involved five test sites where the approach was evaluated (Amsterdam, Budapest, Copenhagen, Glasgow and Lisbon), and facilitated the exchange of information and experiences with five additional cities (Dublin, Gent, Gothenburg, Helsinki and Vienna) where Housing First projects were planned or elements of the approach were being implemented. The project was followed by a report by Busch-Geertsema in 2013 which analyses the outcome. Comparison between these projects resulted difficult, since they had different features, started in different moments and were inserted in different types of welfare systems. Considering these problems the document reports that after two years from the start the retention rate was 80% in Lisbon, 90% in Amsterdam, Copenhagen and Glasgow with no certain data for Budapest. Some of these projects included communal housing and in Copenhagen both models of housing were present and it was possible to measure the satisfaction in both the cases. The result was that of a higher degree of satisfaction of people living in scattered housing than the others. In Lisbon 96% of the participants declared to be satisfied with the accommodation in terms of privacy, comfort, tranquillity and empowerment. Life quality seemed improved for the 70% of participants. In 50% of the cases there was a drop or an interruption in the use of alcohol and drugs, mainly in Lisbon and Amsterdam and 67% of participants in Amsterdam were reconnected with their children. In Lisbon there has been a drop of 90% of access in jail and psychiatric emergency services. With the exception of Amsterdam, where there have been several complaints by the neighbours about the noise, there have been no problems with the other tenants. What about the costs of HFE? A comparison among the several projects is almost impossible because of the difference in costs of services among the locations. In Amsterdam a HF full user has a cost of 70 euros per day, which is lower than the cost of hosting a person in a shelter with 24 hours support. In Lisbon the daily cost per person was around 16.40 euros, far lesser than the daily recovery in a psychiatric hospital, which can reach 2500 euros. These findings seem to support HF as a cost effective solution but we should not forget that data obtained must always be contextualised. Local and national existing policies and services and their cost vary from place to place, therefore it is important to keep this in mind when trying to assess cost effectiveness. Now HFE has ended and there is a wide consensus in considering it a success. In occasion of the World Homeless Day on the 10th of October 2014 Commissioner Lazslo Andor declared that “For its part, the Commission has provided policy guidance as part of the February 2013 Social Investment Package, urging Member States to tackle homelessness through integrated, preventive and housing-led strategies and by revising current eviction practices. EU support for action by Member States is available from the European Social Fund, the Fund for European Aid to the Most Deprived and the European Regional Development Fund. Concrete action is long overdue to ensure that all EU citizens can live a dignified life.” While it is clear that the solution lies at national and local level, European projects may have a very positive impact, thanks to exchange of experience and best practices among different MS. Every version of HF may work for certain categories of persons with different needs but it certainly cannot cover all the homeless population. HF is not suitable for emergency accommodation, for migrant homelessness, groups with specific needs, such as women at risk of gender based violence and for people with low support needs. Furthermore, PHF works well on a small scale approach, CHF can work at a larger scale and FHL may be used together with other existing services. The ideal solution would be that of including housing led projects in the national strategies to tackle homelessness while continuing to offer shelter system and staircase services. HF may not represent the perfect solution but it remains one of the most interesting and challenging ways to tackle homelessness. We have to wait longer before assessing its success or failure, since it deals with complex issues which require a longer timeframe. Up to now concerns regarding its adapting capacities to new contexts seem to have been exaggerated. Further research regarding European projects is needed since most part of the literature on this issue regard projects in the US and Canada and it is not surprising since those are the first countries which have adopted it.
(Ana Daniela Sanda)
To know more:
-. Statement of Commissioner László Andor on World Homeless Day http://europa.eu/rapid/press-release
-. FEANTSA Homeless in Europe Magazine: Autumn 2014 http://www.feantsa.org/spip.php?article4037&lang=en