More Than a Roof: Holistic Outcomes of Housing First

More Than a Roof

Exploring the holistic outcomes of Housing First

More Than a Roof

Exploring the holistic outcomes of Housing First

Written by Sakinah Abdul Aziz and Sophie Boobis

Published January 2024

Acknowledgements

We are grateful to all the Housing First services, residents, peer researchers, and staff who took time out of their busy schedules to contribute to this research.

Executive summary

The trauma of long-term homelessness, poverty and social exclusion means there is a small but significant cohort of people whose needs consistently go unmet by traditional homelessness services. These individuals typically have significantly worse physical and mental health compared to not only the general public, but also other people experiencing homelessness. Their lives are often marked by cycles of rough sleeping, temporary accommodation, prison stays and hospital admissions as their health and social care needs worsen, and offending behaviour feeds survival needs. Housing First serves as a tailored programme to meet their needs, particularly for those who struggle with multiple issues ranging from chronic health issues, substance misuse and addiction, and those who have been in contact with the criminal justice system. Given the current context in the UK where rough sleeping is on the rise and the support needs of people on the streets are not only increasing but are becoming more complex, Housing First has never been more important.

Housing First has been backed with strong international evidence on its effectiveness and benefits,1 as well as in England. Nevertheless, despite the evidence of the effectiveness of Housing First there remains an evidence gap of the longer-term impact and outcomes. Therefore, the main aim of this research is to fill in this research gap and to further investigate how multi-year engagement with Housing First impacts on the wider outcomes such as physical and mental health, offending behaviour, substance use, social networks, employment and training, engagement with meaningful activities and more.

Our research methodology consists of four key strands:

i) survey

ii) analysis of individual outcomes data from services

iii) peer research with residents

iv) interviews with frontline workers

1 Pleace, N. (2016). Housing First Guide Europe. FEANTSA. https://www.feantsa.org/download/hfg_full_digital1907983494259831639.pdf

Key findings

Below are the topline findings from our survey, which detail the Housing First residents’ outcome trajectory over the course of a three-year period.

Physical health

• 28% of the residents represented by our survey have a known physical disability and more than half of them (58.9%) have physical health issues at the point of entry into the service.

• Given this, it is a positive start that more than a quarter of people (30.5%) have shown reduction in their overall physical health needs by the end of the first year (i.e. improvement in their general health). This is followed by 38.4% and 38.8% of people showing reduction in their health needs at the end of their second and third years respectively.

• A gradual increase in the reduction of physical health needs over these three years shows a promising trajectory for people’s general health in the formative years with Housing First and the importance of Housing First as an inclusion health intervention.

Mental health

• A high proportion of people (92.5%) represented by our survey have experienced mental health issues (whether diagnosed or identified by frontline workers), at the point of entry with Housing First.

• Given this, it is remarkable that half of people (50.4%) showed reduction in their mental health needs by the end of the first year, followed by 58.2% and 54.5% of people showing reduction in their mental health needs by the end of the second and third years respectively.

Access to healthcare services

• There is a significant increase in the engagement with GP services from the point of entry where only almost half of people (49.7%) were registered with a GP, to 81.4% of people engaging with GP by the end of their first year. This is followed by a stable engagement of GP services by the end of the second and third years (85.6% and 88.9% respectively).

• There is a notable increase in the engagement with dental services between the point of entry and the end of first year with Housing First (13.7% to 28.5%). The engagement with dental services gradually remains stable by the end of the second and third years (31.5% and 32.4% respectively).

• There is a sharp 20.0% decrease in the use of the A&E services between the six months prior to entry into Housing First until the end of their first year (59.1% to 39.1%). This is followed by a stable use of A&E services by the end of the second and the third years (36.2% and 38.2% respectively).

• There is a downward steady trend in the hospital admissions across the three years. 37.5% of people were admitted into hospitals six months prior to entry into Housing First, followed by 27.8%, 23.4% and 17.7% at the end of their first, second and third years with the service respectively.

• There is a notable increase in people’s engagement with mental health services between the point of entry until the end of the first year with Housing First (22.7% to 39.1%). This is followed by a plateau until the second year, before a small decline to 35.7% by the end of the third year. More research has to be conducted to ascertain whether this implies people’s recovery or whether they are generally less engaged with mental health services.

• Half of the people (50.2%) at the point of entry into Housing First, compared to 31.8% of people by the end of the third year, are presented with safeguarding concerns, reflecting a significant drop of 18.4%. There is a consistent trend of 41.9% and 42.6% of people exhibiting safeguarding concerns at the end of the first and the second year respectively, before the drop.

Substance misuse and addiction

• There is a clear downward trend in substance misuse across the three years. 90.7% of people were misusing substances at the point of entry, compared to 68.6% by the end of the third year, demonstrating a 22.4% overall reduction.

• There is a steady increase in the engagement with drug and alcohol services from the point of entry to the end of the second year (from 48.0%, to 58.2% to 61.5%). It then plateaus to 60.4% by the end of the third year. More research must be conducted to ascertain whether this plateau implies people are recovering or whether they are generally less engaged with drug and alcohol services.

Antisocial and offending behaviours

• There is a clear reduction in antisocial and offending behaviours across the three years. 84.3% of people were involved in antisocial and offending behaviours at the point of entry, compared to 44.8% by the end of the third year. There is a sharp 23.5% decrease particularly between the point of entry (84.3%) and the end of the first year (60.8%), followed by a steady decline until the end of the third year.

• There is also a clear reduction in the contact with the criminal justice system (CJS) across the three years. 71.3% of people had contact with the CJS at the point of entry, compared to 39.0% by the end of the third year. Likewise, the drop (of 16.6%) between the point of entry and the end of the first year is the largest, followed by a steady decrease until the end of the third year.

Tenancy sustainment

• There is some level of consistency in tenancy sustainment across the three years. Given that 92.0% of the people represented by this survey have had a history of rough sleeping previously, seeing more than two-thirds of them being able to manage their tenancies at these three-year points (specifically 67.7%, 69.0% and 66.2% respectively) shows a positive trajectory in tenancy sustainment.

• General upward trends are observed in the ability to manage finances (e.g., paying bills and avoiding accumulation of debt) and the ability to perform everyday tasks (e.g., cooking and cleaning) over the three years, which also indicate a positive trajectory for tenancy sustainment. There are notable sharp increases for both indicators between the point of entry and the end of the first year.

Meaningful use of time

• While only 9.0% of people represented in this survey engaged in hobbies and their interests at the point of entry, there is a significant increase in time spent on these activities by the end of the first and second years (27.7% and 38.2% respectively), followed by a steady 37.2% by the end of the third year.

• There is a general increase in positive social networks from the point of entry into Housing First until the end of their third year. There is a sharper increase between entry point (16.6%) to the end of the first year (26.6%), and to the second (34.1%), and a slower increase to 36.3% by the end of the third year.

Why does Housing First work?

We also summarised the key themes of the peer research and interviews with frontline workers on the elements which contribute to the success of Housing First and its delivery and operations.

The principle of granting people accommodation without the need to fulfil any conditions is essential for people with multiple disadvantage.

• Residents have the space to get their basic needs met, process any trauma they may have, think about what they want in life based on their own terms and start establishing boundaries.

• Owning a home is truly a springboard upon which other positive outcomes can emerge e.g., residents being able to think about budgeting, and not having to rely on shoplifting to meet their needs, which reduces their offending and criminal behaviour.

• Residents feel valued, respected and have a sense of belonging to wider society.

The principle of providing flexible and long-term support for as long as it is needed is befitting for people with chronic history of homelessness and with multiple support needs.

• Finding accommodation for residents, management of tenancy and everyday upkeep of the home, and adjustment to their new homes takes time and requires extra support.

• Residents have been let down from services previously, especially where there is a time limit to engage. In Housing First, without the time pressure frontline workers are able to provide flexible, sustained support to residents building the relationships and security needed.

Active engagement of workers gives the consistent support that residents need.

• Workers are allowed to ‘meet the residents where they are at’ which reflects a person-centered approach.

• Active engagement recognises that intervention and support in the initial phase are timely and urgent, and there is a need to respond accordingly to the needs of the client which ebbs and flows throughout their time with Housing First.

• Small caseload allows for workers to be proactive in their engagement with residents and allows them to focus on building relationships with the residents and serve more as a supportive presence for them.

Frontline workers are the heart of Housing First and lifeline for the residents. They serve as their greatest advocate and support in various ways.

• Having workers by their side as a strong advocate and be their voice when the need arise, instils in them hope and confidence that their lives can get better.

• Workers also serve as role models in many aspects in life, such as how to perform everyday tasks, how to communicate with others and set boundaries, and how to form safe, healthy, and trusting relationships.

Collaborative and joint working amongst professionals who are involved in supporting the residents have contributed to the success of Housing First.

• The perception that every professional whom residents have been referred to knows each other, can create a sense of feeling supported by a community of professionals and trusting that they do not have to repeat their history numerous times given that the professionals are communicating with each other.

• Joint working bridges expertise and intelligence e.g., support workers working with outreach teams when identifying residents who have gone back rough sleeping.

Barriers and challenges

Below are the key summaries and themes of the challenges faced by services and support workers in Housing First.

Unsustainable funding cycles

• Short-term funding cycles affect services’ ability to plan long-term operationally and logistically as well as impact their capacity to provide long-term and consistent support to the residents.

• The coming to the end of the funding cycle without any extension of contract takes away the lifeline support for residents who are most in need and in critical stages in the programme.

Shortage of affordable housing supply

• Residents can experience a long wait before acquiring a tenancy and this can affect the relationship the support workers have built with them.

• Lack of housing supply meant that residents cannot be housed nearby each other, which can affect workers’ commuting time and can limit their capacity to support their residents in a timely manner.

Dependency of residents on Housing First

• There is a challenge in finding the fine balance between supporting and letting residents achieve self-reliance and independence.

• Concerns have been raised about residents who only have a positive relationship with their support workers, without having a wider pool of network for support.

Lack of knowledge about people who are experiencing homelessness

• Concerns have been raised about how people experiencing homelessness have been perceived and treated by professionals whether in healthcare or by the police force.

Conclusion

This research shows a definite indication of positive long-term trajectory for many outcome indicators of Housing First, further adding on to the mounting evidence that Housing First is simply not just a response to homelessness and rough sleeping, but rather a whole systems solution towards ending multiple disadvantage. As it is a tailored and uniquely high-intensive intervention that fills a major gap in service delivery, it has become clear how great the need for Housing First is as part of our wider solutions to ending homelessness, as we face the challenge of increasingly complex support needs amongst those experiencing homelessness.

Recommendations

1 Develop a national standard for impact and outcomes data in Housing First services. There is an urgent need for more rigorous and consistent data collection across Housing First services, particularly data which will aid in measuring impact and benefits of Housing First i.e. measuring the ‘distance travelled’ for each resident in their journey in Housing First.

2 Embed fidelity to the core Housing First principles. In the mission to expand and upscale Housing First to other regions and to meet the demands of the programme, it is necessary to ensure that the fidelity to the core principles is properly adhered to and that they withstand over time.

3 Establish and strengthen cross-departmental response to end homelessness as a default. There is a need for greater joint working and the setting up of multi-disciplinary groups representing professionals and workers from diverse sectors to provide holistic, tailored, and intensive support for people with history of repeated homelessness.

4 Provide sustainable funding for long-term support. Sustainable funding and commissioning cycles for Housing First projects is vital to facilitate long-term support and impact. There is a need to review current funding practice and eradicate short-term contracts and allocate the estimated £150.3 million per annum required to fund Housing First at scale.

5 Commit to building adequate supply of social housing to upscale Housing First. There is an urgent need to engage and establish partnership with more housing providers to get involved to scale up the tenancy provision. The next Government should commit to build 90,000 social homes per year for the next 10 years and unfreeze Local Housing Allowance.

6 Strengthen service management and delivery Strengthen partnerships with civil society, local authorities, charities, and governmental organisations to facilitate positive networking amongst people experiencing homelessness. It is also recommended to actively shift away from assessments and tools which are deficit-based and to include people with lived experience, particularly in shaping service delivery, solutions to homelessness and policy development.

7 Increase awareness of impact of homelessness and trauma informed approaches. Develop and roll out a national trauma-informed training programme in England for Local Authorities and providers of commissioned homelessness services and an awareness raising programme for wider health, social care, and criminal justice organisations.

Chapter One Introduction

Chapter 1: Introduction

The trauma of long-term homelessness, poverty and social exclusion means there is a small but significant cohort of people whose needs consistently go unmet by traditional homelessness services.

These individuals typically have significantly worse physical and mental health compared to not only the general public but also other people experiencing homelessness. Their lives are often marked by cycles of rough sleeping, temporary accommodation, prison stays and hospital admissions as their health and social care needs worsen, and offending behaviour feeds survival needs. The strong base of evidence for success in Housing First has seen it adopted internationally and within the UK to support people experiencing multiple disadvantage.

What is Housing First?

Housing First is both a philosophy and a service model. The Housing First philosophy understands that everyone has a right to a home. The Housing First model is a distinct service design in which people with multiple, intersecting support needs are provided a secure tenancy and wrap-around support with fidelity to the seven principles of Housing First.

Housing First is tailored for people who struggle with multiple issues ranging from chronic health issues, substance misuse and addiction, and who have been in contact with the criminal justice system. Given the intensity of support required to address these needs, Housing First is often contrasted against the “linear” or “stairway” schemes, which can lack capacity to provide the necessary intensity of service support.2 Given the current context in England where rough sleeping is on the rise and the support needs of people on the streets are not only increasing but are becoming more complex, Housing First has never been more important.

2 Housing First: tackling homelessness for those with complex needs. https://researchbriefings.files.parliament.uk/documents/SN02007/CBP08368.pdf

Housing First Principles

There are seven key principles that are required to design and deliver Housing First in England. Below is a summary of the seven principles and what they mean based on Homeless Link’s guidance on the key Housing First principles.3

Principle 1: People have a right to a home

• Eligibility for housing is not contingent on any conditions other than willingness to maintain a tenancy.

Principle 2: Flexible support is provided as long as it is needed

• Providers commit to long-term offers of support which do not have a fixed end date; recovery takes time and varies by individual needs, characteristics, and experiences.

Principle 3: Housing and support are separated

• Support is available to help people maintain a tenancy and to address any other needs they identify.

• An individual’s housing is not conditional on them engaging with support.

Principle 4: Individuals have choice and control

• Individuals can choose the type of housing they have and its location within reason as defined by the context.

Principle 5: An active engagement is used

• Staff are responsible for proactively engaging their clients; making the service fit the individual instead of trying to make the individual fit the service.

• Caseloads are small allowing staff to be persistent and proactive in their approach, doing ‘whatever it takes’ and not giving up or closing the case when engagement is low.

3 Homeless Link. (2017). Housing First in England: The Principles. https://homelesslink-1b54.kxcdn.com/media/documents/The_Principles_for_Housing_First.pdf

Principle 6: The service is based on people’s strengths, goal and aspirations

• Services are underpinned by a philosophy that there is always a possibility for positive change and improved health and wellbeing, relationships, and community and/or economic integration.

• Individuals are supported to identify their strengths and goals.

Principle 7: A harm reduction approach is used

• Staff aim to support individuals to undertake practices that reduce harm and promote recovery in other areas of physical and mental health and wellbeing.

There has been strong international evidence on the effectiveness and benefits of Housing First.4 Impact and effectiveness of Housing First in the context of England has also been documented including through the evaluation of three Housing First pilots funded by Department for Levelling Up, Housing and Communities (DLUHC),5 as well as other small localised projects.6,7 Recent studies have set out both the scale of Housing First needs as well as cost analysis of delivering a national Housing First programme in England.8

Nevertheless, despite the evidence of the effectiveness of Housing First there remains an evidence gap of the longer-term impact and outcomes of Housing First. This research seeks to build the evidence base on non-housing related outcomes such as mental and physical health, employment and training, offending behaviour, social networks, and activities. We recognise that there are many Housing First services which have been operating for a substantial number of years, which offer the opportunities for us to understand the outcomes journey of Housing First residents and how Housing First can help those experiencing multiple disadvantage.

4 Pleace, N. (2016). Housing First Guide Europe. FEANTSA. https://www.feantsa.org/download/hfg_full_digital1907983494259831639.pdf

5 Department for Levelling Up, Housing, and Communities. (2022). Evaluation of the Housing First Pilots: Third Process Report. https://assets.publishing.service.gov.uk/ media/6311c6f88fa8f5578fbb84f5/Housing_First_Evaluation_Third_process_report.pdf

6 Mackie,P., Johnsen, S., & Wood, J. (2017) Ending rough sleeping: what works? An international evidence review. London: Crisis. https://www.crisis.org.uk/media/238368/ending_rough_ sleeping_what_works_2017.pdf

7 Jones, K., Gibbons, A. and Brown, P. (2019). Assessing the Impact of Housing First in Brighton and London. University of Salford and St Mungo’s. https://www.mungos.org/wp-content/ uploads/2023/10/Housing-First-in-Brighton-Westminster-Full-Report.pdf

8 Pleace, N., & Bretherton, J. (2019) The cost effectiveness of Housing First in England. University of York. https://eprints.whiterose.ac.uk/145440/1/The_cost_effectiveness_of_Housing_First_in_ England_March_2019.pdf

Methodology

This research seeks to evidence the long-term impact of Housing First, with a particular focus on the key outcomes of the intervention. To meet this research objective, a mixed methodology of both quantitative and qualitative approaches were used to not only understand the journey of people’s outcomes across time, but to also infuse these key trends with context and narratives from people’s lived experiences of either being a resident of Housing First or a frontline worker. This research consists of four key strands, which will be expanded on below.

1. Survey

Homeless Link designed a survey with the aim of capturing three key strands of information:

i) service information ii) insight into the residents supported by each service iii) outcomes journey of Housing First residents over three years.

The survey is intended for service managers, team leaders and project managers of Housing First to complete. The survey was designed on an online platform, Survey Monkey, and was first disseminated on 17 August 2023 to Housing First services across England. A second email was sent on 4 September 2023 and a third round was sent on 12 September 2023. 27 services completed the survey, representing 934 Housing First residents in total.

Length of time with Housing First

Services were asked to share information about the residents they are supporting, particularly the length of time they have been with them, and the myriad of support needs they present at the start of their time with Housing First. The breakdown of residents by length of time with Housing First is demonstrated in Table 1.1. below. Most of the residents from the survey (62.7%) have been with their respective Housing First services between two to four, followed by 31.0% of residents being with the services for less than two years. 5.4% of the residents represented by this survey have been with the services for between five to six years, followed by 0.9% of residents being with the services for seven to ten years. Given that the sample size of those who have been with the service for five years and beyond is small, this research will only be focusing on the outcomes of residents who have been with the service for up to three years.

Table 1.1. Number of residents by length of time with Housing First

Source: Homeless Link’s Housing First Longitudinal Survey, N = 855

Gender breakdown of residents

Chart 1.1 illustrates the gender breakdown of residents who are represented by the survey. Almost three-quarter (73.7%) of the residents represented by this survey are male and about a quarter (26.0%) are female. 0.1% are transgender men, while 0.2% are transgender women.

Age groups of residents

Source: Homeless Link’s Housing First Longitudinal Survey, N=934.

There is a diverse spread of residents across various age groups. As illustrated in Chart 1.2, about four out of ten (43.6%) people are between the ages of 35 – 44, a quarter (26.8%) are between the ages of 45 – 59, one-fifth (21.2%) are between the ages of 25 – 34, 4.4% are 60 and above, and 4.0% are between the ages of 19 – 24.

Chart 1.2. Age groups of residents in the survey

Source: Homeless Link’s Housing First Longitudinal Survey, N=934.

Ethnicity of residents

Most of the residents (89.0%) are White, 3.6% of residents are Asian, 3.6% are mixed race, and 3.4% of residents are Black.

Chart 1.3. Ethnicity of residents in the survey

Source: Homeless Link’s Housing First Longitudinal Survey, N=934.

Support needs of residents

Consistent with the intended profile of Housing First, our survey findings reveal the multiple support needs of the residents represented by the survey as seen in Chart 1.4. below. More than half of the residents (56.1%) have a history of adverse childhood experiences, and more than a quarter have a history of domestic abuse (28.9%), have a physical disability (28.5%), and were formally assessed for care needs (26.3%). At least a fifth of them have received support from Adult Social Care (22.2%), and have a learning disability (20.7%), and one in six of them have a history of being supported in the care system (16.5%).

Chart 1.4. Support needs of residents

Physical disability

Learning disability

History of being supported in the care system

History of adverse childhood experiences

History of domestic abuse

Formally assessed on care needs

Receipt of support from Adult Social Care

Source:

2. Individual

outcomes data

Homeless Link approached 13 Housing First services representing a diverse geographical spread of England, requesting for data sharing of the long-term outcomes of the residents they support. The rationale behind this method of data collection is to utilise data collected by services across many years previously. This was met with numerous challenges given the gap in data collection and the lack of standardised data being used across services.

Nonetheless, we received a large WEMWBS dataset (Warwick-Edinburgh Mental Wellbeing Scales), which is an assessment tool to measure service user’s mental health. This represented at least 400 individuals who were supported previously and are currently being support by Greater Manchester Housing First (GMHF). While WEMWBS typically contains a 14-item scale, GMHF only collected individual data based on seven items. Given this, we will not be able to measure the overall scores against the UK population norms. Instead, the analysis of this data will be used to depict the trend of mental health trajectory of Housing First residents across time. The analysis of this dataset will be further presented in Chapter 2 as a case study.

3. Peer research

Involving the voices of people with lived experiences is integral to understand the rich context that outcomes occur in, and this project is no exception to upholding this. Homeless Link commissioned Expert Link, a peer led organisation, to investigate how multi-year engagement with Housing First impacts on their physical and mental health, offending behaviour, substance misuse, social networks, and engagement with meaningful activities. Peer researchers with lived experience of homelessness and rough sleeping, designed the interview questions, and held the interviews either online via Zoom, phone, or face-to-face.

A total of 14 people were interviewed – four from Housing First services in North West England, five from a service in Yorkshire and the Humber, two from a service in London, and three from a service in South East England. One graduated service user was interviewed from a service in West Midlands. An additional of five people were involved in a focus group discussion with members from a Lived Experience Forum in a service in North West England. All Housing First residents involved in the peer research have been with the service between a few months to seven years.

In terms of sampling, Expert Link reached out to residents through their Housing First project leads, service managers and/or support workers. During some of the interviews, the residents were accompanied by their support workers. In some instances, the support workers assisted in clarifying the questions for them or prompted them. It is noted that Expert Link and Homeless Link are aware that the sampling of peer research may be biased towards those who are actively engaged in Housing First and those who have sufficient wellbeing to be contribute to this study. In addition to this,

residents who have expressed in the interviews about their intentions to ‘give back’ to the community, tend to have positive experiences in the service as well. Nonetheless, this bias has been mitigated through other strands of this research, such as the survey responses as well as findings from staff interview. The identities of everyone who took part in this study are anonymised.

4. Staff interviews

Last but not least, Homeless Link conducted interview with seven staff from across three Housing First services in North West England, Yorkshire and the Humber, and London. These services also took part in the peer research led by Expert Link and their peer researchers. The aim of the staff interviews is to understand from the perspective of frontline staff and service managers the outcomes journey of the residents, as well as unpacking the reasons why Housing First works and the challenges faced by services and staff. The interviews were conducted online over Zoom. The identities of all staff who took part in this study are anonymised.

Limitations

Although necessary measures have been put in place to ensure robustness of our research, we recognise the limitations of our survey. 27 Housing First services responded to this survey which is not a true representative picture of Housing First services across the country. The findings of our survey can therefore only show indicative trends of their outcomes journey over the three-year period. As demonstrated in Table 1.2 below not all the figures reflected in the survey are exact and data should be interpreted accordingly.

Table 1.2. Quality of data provided by respondents

Source: Homeless Link’s Housing First Longitudinal Survey N=27

Profile of services represented by survey

Respondents of the survey were asked to fill in basic service information, from the region in which they are based, to details of their service delivery such as number of staff and caseload, to the type of support model they adopt.

There is a good representation of services across the regions in England that responded to this survey, with the exception of the East Midlands and the North West, as seen in Figure 1.1. below. Nonetheless, there is representation from North West England in our qualitative research, particularly residents and frontline workers who took part in our peer research. Furthermore, we received a large dataset showcasing the mental health journey of each resident across time from Greater Manchester Housing First (GMHF). Data from GMHF has been taken as a case study to represent the North West of England.

Source: Homeless Link’s Housing First Longitudinal Survey, N=27.

Services were also asked which support model best described their approach. As seen in Table 1.3. more than half of respondents (55.6%) adopt the intensive case management (ICM) support model where residents are supported by an intensive support worker. About one in five respondents (22.2%) adopt ICM, with enhanced support from coordinated services. The same proportion of respondents adopted ‘other’ forms of support model which include a mixture of ICM and ICM+ and incorporating joint working with various agencies with ICM. However, there is no representation for services that adopt assertive community treatment (ACT).

Table 1.3. Support model of Housing First services

, with enhanced support from coordinated services (ICM+) – service operated within established multiple disadvantage networks (e.g., MEAM or Fulfilling Lives) and drawing upon this network to provide a wide range of support for residents

Source: Homeless Link’s Housing First Longitudinal Survey, N=27.

The services were also asked about the average caseload of their staff. As seen in Table 1.4. more than half of respondents (51.9%) reported that their staff hold an average caseload of four – six, 37.0% of respondents reported their staff hold an average caseload of seven – nine, 7.4% of them hold one –three caseload, and 3.7% of them hold more than ten caseload. According to the principles of Housing First caseloads should be small to ensure that flexible, wrap-around support can be provided.

Source: Homeless Link’s Housing First Longitudinal Survey, N=27.

Chapter Two

Impact and Outcomes of Housing First

Chapter 2: Impact and outcomes of Housing First

This chapter details the impact and outcomes of Housing First, showcasing our survey findings as well as anecdotes from our fieldwork with Housing First staff and residents across services in Yorkshire and the Humber, the North West, London and in South East England. It will unpack trends across a three-year period for various Housing First outcomes, namely physical and mental health, substance misuse, offending and antisocial behaviour, tenancy sustainment, meaningful use of time and positive social networks.

While we are presenting the trends of each outcome throughout this chapter individually, it is noteworthy to acknowledge that these outcomes in reality do not occur in isolation, but rather, they can occur consecutively, and/or they occur simultaneously as residents continue to receive the intensive, targeted support from Housing First. As the evidence is presented from one section to another, it becomes clearer of the impact one outcome has on another. For instance, we will see how crucial it is to provide homes first without needing to fulfil the condition of ‘housing-ready’ (as per the first principle of Housing First), as there is indicative evidence from our research of the outcomes that start to emerge over time once residents have a stable accommodation. Further research is needed to be conducted to understand the correlations between one outcome and another, however we cannot deny the interactions between different outcomes observed.

It is also important to bear in mind that the quantitative findings only reflect trends, and every resident’s outcome journey across time is unique, and they are never truly linear. Our qualitative research findings provide greater context for individuals and give detail to the reasons behind some of the outcomes observed.

Physical health

People experiencing homelessness are more likely to experience poorer health outcomes compared to the general population. In Homeless Link’s Unhealthy State of Homelessness research, 78% of homeless people reported having a physical health condition and 80% of these people reported having at least one comorbidity.10 The research also reveals that 63% of homeless people, compared to 22% of the general population, had a long-term illness or disability. Our survey findings are consistent with this general trend, revealing that more than half of the residents (58.9%) displayed physical health issues at the initial point of engagement with Housing First, and with over a quarter (28%) having a known physical disability.

There is some existing evidence on the vital role Housing First plays as a health intervention but lacking its long-term evidence.11 Our research sought to investigate whether there is any reduction in residents’ general physical health needs over a three-year period. One survey question required respondents to answer the proportion of the residents that show a reduction in their general health needs on a yearly basis. It is noteworthy to highlight that this question measures reduction in general health captured at the end of every year, which means that people who continue to show reduction through their first to second year for instance, will be included in the figures, and the figures do not measure new reductions yearly. This question also does not measure whether people are fully recovered from their health issues, nor does it measure any chronic illnesses which may persist amongst them.

As seen in Graph 2.1, nearly a third of people represented by this survey (30.5%) have shown reduction in their health by the end of the first year with Housing First. This is followed by 38.4% and 38.8% of people showing reduction in their health needs by the end of their second and third years respectively. A gradual increase in the reduction of physical health needs over these three years shows a promising trajectory for people’s general health in the formative years with Housing First and the importance of Housing First as an inclusion health intervention. It also reflects the important role of Housing First in providing the gateway for people to access the health interventions they urgently need.

End of 3rd year

of 2nd year

of 1st year

Source: Homeless Link’s Housing First Longitudinal Survey, N=27. Note that 27 Housing First services responded to the survey, representing a total of 934 Housing First residents.

10 Hertzberg, D., & Boobis, S. (2022). Unhealthy State of Homelessness 2022: Findings from the Health Needs Audit. Homeless Link. https://homelesslink-1b54.kxcdn.com/media/ documents/Homeless_Health_Needs_Audit_Report.pdf

11 Baxter, A. Tweed, E. Katikireddi, S.V. & Thomson, H. (2019). Effects of Housing First Approaches on Health and Wellbeing of Adults who are Homeless or at Risk of Homelessness: Systematic Review and Meta-Analysis of Randomised Control Trials. Journal of Epidemiology and Community Health.

Mental health

Like physical health, there has also been numerous research showcasing the impact of homelessness on people’s mental health.12,13 According to Homeless Link’s recent report on the Unhealthy State of Homelessness, 82% of homeless people reported to have a mental health diagnosis. Our survey shows that 92.5% of Housing First residents experienced mental health issues (whether diagnosed or identified by frontline workers) at the initial point of engagement with Housing First.

Similar to the previous section, we also measured the reduction of mental health needs over a threeyear period. As seen in Graph 2.2, by the end of the first year, half of people (50.4%) showed reduction in their mental health needs, followed by 58.2% and 54.5% of people showing reduction in their mental health needs by the end of the second and third years respectively. However, given that the proportion of the mental health reduction seems to hover around the 50th percentile suggest that more research is needed to understand the mental health journey of Housing First residents and the intensity and long-term nature of support needed to work as an effective intervention. Like the previous section on physical health, this question only measures reduction in general mental health captured at the end of every year and does not measure new reductions yearly. We also cannot eliminate the possibility of chronic mental health issues which may persist amongst people for years despite the general trajectory showing a reduction in mental ill health.

End of 3rd year

of 2nd year

12 McPhillips, M. (2017). The impact of housing problems on mental health. Shelter.

13 Leng, G. (2017). The impact of homelessness on health: A guide for local authorities. Local Government Association. https://www.local.gov.uk/sites/default/files/documents/22.7%20 HEALTH%20AND%20HOMELESSNESS_v08_WEB_0.PDF

Mental health case study: Greater Manchester Housing First

This case study looks at the average scores on mental health of Housing First residents across a four-year period. Greater Manchester Housing First (GMHF) uses the Warwick-Edinburgh Mental Wellbeing Scales (WEMWBS) to measure this at various timepoints for every resident. It is noted that this is a 14-item scale, however GMHF use a reduced WEMWBS scale only collecting data based on seven out of 14 items (as per the default scale). As such, we will not be able to measure the overall scores against the UK population norms. However, this analysis will help to understand the mental health trajectory of overall residents over time. The higher scores reflect a better score on one’s mental health. There was insufficient diversity in the sample to analyse this based on gender, ethnicity, and age.

The seven items on this scale are:

1) Feeling optimistic about the future

2) Feeling useful

3) Feeling relaxed

4) Dealing with problems well

5) Thinking clearly

6) Feeling close to other people

7) Able to make up my mind about things

Based on the average WEMWBS scores at six month intervals as seen in Chart 2.5, there is a slow and steady increase in residents’ mental health across time, which suggests that the longer people are with Housing First service, the more improvement that can be seen in their overall mental health. This chimes in the wider discourse on the importance of open-ended and long-term support provision of Housing First to see the benefits that emerge when time is given for mental health recovery and healing. As seen in Chart 2.3, there is a general upward trend between the entry point and by the end of three and half to four years. There is a slight decrease in scores between six months to one and half years, and there is a consistent score between one and half to two and a half years. This helps build the bigger picture when it comes to understanding the long-term impact of Housing First on mental health outcomes.

Chart 2.3. Average WEMWBS score over time

Source: Greater Manchester Housing First’s WEMWBS data for each resident. N=414 at entry, N=334 at 6 month-1 year, N=274 at 1-1.5 years, N=237 at 1.5-2 years, N=183 at 2-2.5 years, N=121 at 2.5-3 years, N=70 at 3-3.5 years, and N=32 at 3.5-4 years.

We also analysed the aggregated average variance in the earliest and most recent scores of individuals. Based on Chart 2.4. below, there is only a very slight difference between the average earliest and most recent scores of people in the first cohort (people who have been in the service for less than a year) and there is a reverse trend of that for people in the second cohort (those who have been in the service between one to two years). However, there is a notable gradual increase in the average variance between the two scores in the third cohort (those who have been with the service between two to three years), and an even greater variance between the two scores for the longest cohort in this case study (those who have been in the service between three to four years). This demonstrates that the impact of Housing First on mental health seems to emerge more significantly when people are engaged with the service beyond two years. This offers a promising trajectory for people who have been with Housing First for a longer period. Further research will need to be done to track whether this trend continues beyond four years. As we will continue to see in Chapter 3, there is a consistent theme of taking the time for residents to see benefits and outcomes emerging in their lives.

Chart 2.4. Average variance between the earliest and latest score by cohorts

Source: Greater Manchester Housing First’s WEMWBS data for each resident. N=112 for ‘<1 year’ cohort, N=104 for ‘1 – 2 years’ cohort, N=125 for ‘2 – 3 years’ cohort, and N=71 for ‘3 – 4 years’ cohort.

Access to healthcare services

Primary healthcare services i.e. GP and dental services

One factor that contributes to the health inequalities is poor access to healthcare services. The three most common barriers faced by the homeless population in accessing General Practitioners (GPs) and dentists are anxiety and/or depression, followed by feeling judged or stereotyped by healthcare professionals, and fear of diagnosis.14 It doesn’t help that there is a culture of declining patients without permanent addresses from registering with a GP,15 further increasing the barrier for people experiencing homelessness accessing primary healthcare services.

Experiences of homelessness can also significantly impact an individual’s oral health. It is well known how accessing dental services amongst the general population in England has been a challenge,16 which only means that access to dental services is even more out of reach for the homeless population. Dental problems are the second most reported physical health problem affecting people experiencing homelessness, however only 53% of people were registered with a dentist, a much lower figure than GP registrations.17 Groundswell’s peer-led health audit on oral health reveals that 90% of people had issues with their mouth, 60% experience pain from their mouths and 70% reported losing their teeth since they became homeless.18 This only reflects the scale and severity of poor access of the homeless population to dental services.

Our survey findings suggest that Housing First functions as the bridge through which residents can gain access to primary healthcare services such as GP and dental services. As reflected in Chart 2.5 below, there is a sharp increase (of 31.7%) from the point of entry where only almost half of people (49.7%) were registered with a GP, to 81.4% of people engaging with GP services by the end of their first year. This is followed by a stable engagement with GP services by the end of the second and third years (85.6% and 88.9% respectively).

A similar trend is reflected for the engagement with dental services across the three years as well. There is the highest increase between the point of entry to the end of first year with Housing First; from 13.7% of people being registered with dental services at the point of entry, to 28.5% of people engaging with the services (although this is not as sharp as the increase seen in the engagement with GP services). The proportion of engagement with the dental services gradually remains stable by the end of the second and third years (31.5% and 32.4% respectively).

14 Healthwatch Nottingham & Nottinghamshire. (2020). Homelessness and Barriers to Primary Healthcare. https://hwnn.co.uk/wp-content/uploads/2020/10/Homelessness-and-Barriersto-Primary-Healthcare.pdf

15 Murison-Bowie, K. (2023, 19 June). Two-thirds of GPs refuse to register homelessness patients. Health Service Journal. https://www.hsj.co.uk/primary-care/two-thirds-of-gps-refuse-toregister-homeless-patients/7035028.article

16 Kay, L. (2022, 8 August). This is why it’s so difficult to get an NHS dentist. The Independent. https://www.independent.co.uk/voices/dentist-nhs-waiting-list-teeth-pulling-b2140691.html

17 Hertzberg, D., & Boobis, S. (2022). Unhealthy State of Homelessness 2022: Findings from the Health Needs Audit. Homeless Link. https://homelesslink-1b54.kxcdn.com/media/ documents/Homeless_Health_Needs_Audit_Report.pdf

18 Groundswell. (2017). Healthy Mouths: A peer-led health audit on the oral health of people experiencing homelessness. https://groundswell.org.uk/wp-content/uploads/2017/10/ Groundswell-Healthy-Mouths-Report-Final.pdf

Chart 2.5. Average proportion of peoples’ engagement with GP and dental services over time

Engagement with GP services

Engagement with dental services

Entry Endof1styear Endof 3rdyear Endof 2ndyear

Source: Homeless Link’s Housing First Longitudinal Survey, N=27. Note that 27 Housing First services responded to the survey, representing a total of 934 Housing First residents.

People’s consistent engagement with their primary healthcare may not always mean that they have ongoing health needs, but rather it is possible that they are being encouraged by the services to attend routine and regular medical check-ups. If this is the case, this speaks to the consistent and person-centered approach of the support given in Housing First, in helping residents navigate access to treatment services (which will be further elaborated in Chapter 3). More importantly, this continued engagement with their primary healthcare services can be incredibly beneficial given its proactive and preventative approach in addressing health-related issues.

Contact with emergency services

The use of accident and emergency (A&E) services and hospital admissions have seen a spike across the years amongst the homeless population. According to recent research by The Salvation Army, there is a 33% rise in A&E attendance as of 2021/2022 since 2017, compared to 2.5% rise for the general population, and a 60% rise in hospital admissions, a stark contrast to the 4% decline amongst the general population in the same period.19 This is estimated to translate into a cost to the NHS of £9.5 million and £41 million respectively.20 People experiencing homelessness are also more likely to use A&E services for primary healthcare purposes, such as getting a prescription or getting a dressing changed, as they do not have access to a GP.21 Given the disproportionately high use of emergency healthcare services amongst the homeless population, the importance of proactive measures to

19 Bushnell, J. (2023). Homelessness and the NHS: A briefing on a freedom of information request with NHS Trusts. The Salvation Army. 20 Ibid.

21 Gorton, S., Manero, E., & Cochrane, C. (2018). Listening to Homeless People: involving homeless people in evaluating health services. London: Groundswell. https://groundswell.org.uk/ wp-content/uploads/2018/10/Groundswell-Health-Link-Listening_to_Homeless_People.pdf

prevent constraints on these services and delivering a more upstream approach in getting people registered with the necessary primary healthcare services is key to ensuring people are accessing timely and appropriate preventative healthcare.

The impact of the consistent engagement with primary healthcare seen in the previous section (at least in the first three years), can be seen through the reduced reliance on A&E services and reduced incidences of hospitalisation, as reflected in Chart 2.6. below. There is a sharp 20.0% decrease in the use of the A&E services between the six months prior to entry into Housing First (59.1%), to the end of their first year (39.1%). This is followed by a stable use of A&E services by the end of the second and the third years (36.2% and 38.2% respectively). The marked decrease in the use of A&E services within the first year in Housing First coincides with the sharp increase in the engagement with GP services in the same period seen previously, which further suggests that engagement with primary healthcare is highly associated with less reliance and pressure on the A&E services. There is also a downward trend in the hospital admissions across the three years. 37.5% of people were admitted into hospitals six months prior to entry into Housing First, followed by 27.8%, 23.4% and 17.7% at the end of their first, second and third years into the service respectively.

Chart 2.6. Average proportion of people’ use of A&E services and number of hospitalisations over time

Use of A&E services No. of hospital admissions

6mthspriortoentry Endof1styear Endof2ndyear Endof3rdyear

“Last time I was in the hospital was like, four years ago. So that’s quite a long time now I haven’t been in hospital.”

Resident of 3.5 years

South East England

This serves as crucial evidence of Housing First programme being a preventative intervention to ending repeated homelessness, particularly when there are proactive efforts in monitoring residents’ health whilst in the programme, which can reduce costs and burden on A&E services. A resident shared that their last appointment with the hospital has been years ago, which implies their general progress in their physical health whilst in Housing First.

Engagement with mental health services

As seen in the previous sub-section when it comes to access to GP, there are similar barriers to accessing mental health services. Nevertheless, it is positive to see that there is an increase in people’s engagement with mental health services from the point of entry (22.7%) until the end of the first year with Housing First (39.1%) based on Chart 2.7. below. This is then followed by a consistent engagement with mental health services by the end of the second year (39.0%) and a small decline to 35.7% by the end of the third year.

This significant increase in their engagement with mental health services within the first year since the point of entry suggests the scale of the mental health support needs of Housing First residents. Moreover, this also reiterates the aforementioned point that Housing First serves as a gateway to other services. It is not clear whether the plateau from the end of the first to the third year shows an improvement in people’s mental health or if people are generally less engaged with mental health services. Further research has to be conducted as to whether this is due to reduced need or if there are any continued barriers or accessibility issues in accessing services.

Chart 2.7. Average proportion of people’s engagement with mental health service and safeguarding concerns over time

Engagement with mental health services

Safeguarding concerns

Source: Homeless Link’s Housing First Longitudinal Survey, N=27. Note that 27 Housing First services responded to the survey, representing a total of 934 Housing First residents.

“I’ve got bad anxiety. So a lot of my thing about appointments is getting there… It means I don’t have to worry as much about going there. In terms of mental health, they’ve helped me a lot.”

Resident of 5 years Yorkshire and the Humber

As shown in Chart 2.7. there is a significant drop of 18.4% between the point of entry until the end of the third year in Housing First when it comes to safeguarding concerns. Safeguarding concerns here refer to any self-harming tendencies and suicidal ideation, amongst others. This translates to a decrease from about half of Housing First residents (50.2%) to under a third (31.8%) by the end of the third year. The findings on engagement with mental health services show almost a mirror image of the findings on safeguarding concerns being raised during the same period, which meant that the more engagement with the mental health services, the more concerns can be raised and in turn, addressed. This also applies in the opposite direction as well.

This finding similarly suggests that Housing First serves as a protective factor for residents, and the consistent support from their support workers helps with identify any potential safeguarding concerns exhibited by them. A resident shared the support they received which helped their mental health overall:

“Things are working out for me on a personal basis quite well at the moment, you know, mental health support. There’s more people getting involved with my mental health support. And, you know, all the financial stuff as well… I’m in the right frame of mind, and the support helps me stay in that positive frame of mind.”

Resident of 3.5 years, South East England

Substance misuse and addiction

Substance misuse and addiction disproportionately impacts people experiencing homelessness. In Homeless Link’s Unhealthy State of Homelessness research, 38% of the survey respondents have, or are in recovery from a drug problem, while 29% of them have, or are in recovery from an alcohol problem.22

Substance use can increase one’s risk to homelessness, while at the same time, the experience of homelessness can lead to substance abuse. People experiencing homelessness may turn to drugs or alcohol for various reasons, including to self-medicate as a means of coping with their unmet mental health needs.23 There has been some evidence showing that Housing First has been effective in reducing drug and alcohol use amongst residents.24 Our survey findings further reiterate this. As illustrated in Chart 2.8. below, there is a general positive trajectory when it comes to substance misuse activity across the three years.

22 Hertzberg, D., & Boobis, S. (2022). Unhealthy State of Homelessness 2022: Findings from the Health Needs Audit. Homeless Link. https://homelesslink-1b54.kxcdn.com/media/ documents/Homeless_Health_Needs_Audit_Report.pdf

23 Ibid.

24 Bretherton, J. & Pleace, N. (2015). Housing First in England: An Evaluation of Nine Services. University of York. https://eprints.whiterose.ac.uk/83966/1/Housing_First_England_Report_ February_2015.pdf

Chart 2.8. Average proportion of people’s substance misuse activity, and engagement with drug and alcohol services over time

Misuse of substances

Engagement with drug and alcohol services

Entrypoint Endof1styear Endof2ndyear Endof3rdyear

Source: Homeless Link’s Housing First Longitudinal Survey, N=27. Note that 27 Housing First services responded to the survey, representing a total of 934 Housing First residents.

90.7% of people were misusing substances at the point of entry, compared to 68.6% by the end of the third year, demonstrating a 22.4% reduction overall. It is also interesting that there is a concurrent steady increase in the engagement with drug and alcohol services from the point of entry to the end of the second year (from 48.0%, to 58.2% to 61.5%). It then plateaus to 60.4% by the end of the third year. This trend of seeing noticeable increase in the formative years when it comes to engagement with services and treatment is consistent with the earlier trends we see when it comes to engagement with physical and mental health services. This further affirms the importance of Housing First as the window to specialist services to meet the needs of the residents.

Anecdotes from our fieldwork further tell some of the drivers of reduction in substance misuse. Not surprisingly, this comes hand in hand with being accommodated through Housing First where they are able to establish some form of routine and receive the necessary support from their workers and specialist services. Moreover, managing a tenancy makes them accountable, and therefore motivates them to stay away from substances so as not to jeopardise their home.

“I’ve had women say to me, ‘I really want to be able to make this feel like home and I want to stay here forever, I don’t want to do anything to jeopardize this. So I want to reduce my use or I want to detox.’ [..] Once they’re in the flats and they have this place that’s theirs and they’re safe and they’re warm and they can start shifting to thinking about other things. And I think substance use is definitely a big one. And women are a lot more willing to engage in that kind of support.”

Support worker, London

“When I first, like, got me flat. I was there. I was a raging crackhead. Basically, I was shoplifting everyday burgling, you know, injecting myself and, you know what I mean? And then when they got me flat, I, within a couple of months, I stopped using needles. And later, I stopped the drug.”

Resident for 2 years, North West England

“And I think that substance use is a really big one that I’ve seen for our women that are in Housing First flats now. Just because being somewhere stable where they can be on a script with a regular pharmacy that they go to every day and have that sense of routine. And then also I think having this home environment and a flat to look after, you know.”

Support worker, London

“The help just wasn’t there back then, they put you in a hostel, then move you to another hostel, because my lifestyle was manic then, I was addicted to drugs, I haven’t taken them for 5 years now with Housing First, that’s when I first started to stop and change my life.”

Resident for 5 years, London,

The physical relocation from the streets to safe accommodation has an impact on people’s social networks, as they are then presented with opportunities to be acquainted with a different set of peers within a different community. Their support workers serve as a crucial helpline for them, which can help them achieve reduction in substance use.

“I’m a full blast alcoholic. I’ve got it under control now, I still drink. But the first time I recall meeting [Worker], I was on the streets living homeless and [Worker] approached me. I’d never met [Worker] before. I’ve got on with him straight away. He offered me some help which I desperately, desperately needed.”

Housing First Graduate, West Midlands

“I was a heroin addict before I moved in here. I’ve been clean, 3 or 4 years with me methadone. It’s the support I’ve had that’s kept me away from that.”

Resident for 5-6 years

Yorkshire and the Humber

Antisocial and offending behaviours

Homelessness and the criminal justice system are deeply intertwined. Experiences of homelessness can increase one’s risk of committing offences, particularly when driven by the need to survive and fulfil one’s basic needs. According to a study, close to 30% of people admitted that they committed a minor crime so that they are being taken into custody to resolve their housing problems.25 On the other hand, spending time in prison can also increase one’s risk of homelessness, especially when prison leavers have no safe spaces to go to upon release. According to a Ministry of Justice report in 2021, 15% of people in England and Wales had experience of homelessness prior to being in prison, but around 50% of people who are released from prison without any safe abode are more likely to re-offend.26 This perpetual cycle of criminality and homelessness can be difficult to break.

There has been evidence of reduced criminal activity amongst Housing First residents,27 and we were interested to explore whether this is the case in our survey. The survey findings show that there is a positive trajectory when it comes to offending and antisocial behaviours and involvement in the criminal justice system across the three years. Contact with the criminal justice system in our survey meant being known to the probation and prison service, getting arrested, being warned by the police, and having upcoming court cases. As seen in Chart 2.9., there is a downward trend in both instances. There is a clear reduction in antisocial and offending behaviours between the point of entry (84.3%) and the end of the third year (44.8%).

Chart 2.9. Average proportion of residents’ involvement in antisocial and offending behaviours, and contact with criminal justice system over time

Involvement in antisocial and offending behaviour

Contact with criminal justice system

Source: Homeless Link’s Housing First Longitudinal Survey, N=27. Note that 27 Housing First services responded to the survey, representing a total of 934 Housing First residents.

25 Bubb-McGhee, M., & Rhodes, L. (2016). Homelessness and the Criminal Justice System: Guidance for Practitioners. The Queen’s Nursing Institute. https://www.qni.org.uk/wp-content/ uploads/2016/09/homelessness_criminal_justice.pdf

26 Crisis. (2023). Expert Review Panel on Homelessness Briefing for Meeting 8: Criminal Justice and Homelessness. https://www.crisis.org.uk/media/avsdwwkv/meeting-8-briefing.pdf

27 Woodhall-Melnik, J.R., & Dunn, J.R. (2015). A systematic review of outcomes associated with participation in Housing First programs. Institute for Public Policy and Social Research College of Social Science.

There is also a clear reduction in the contact with the criminal justice system between the point of entry (71.3%) and the end of the third year (39.0%). Likewise, the drop between the point of entry and the end of the first year is the largest, by 16.6%, followed by a steady decrease until the end of the third year.

Findings from our qualitative fieldwork also tell a similar story. A reduction in offending behaviour seems to also coincide with positive outcomes that emerge since residents have been engaged with Housing First, such as time spent on meaningful and positive activities which they enjoy (which will be discussed more in the next section), as well as sustaining and maintaining their tenancies. Having a tenancy meant that there is more for residents to lose, and the motivation to stay away from crime partly seems to stem from the desire to maintain their tenancies.

“I found better ways to entertain myself now. Go out clubbing, football a lot nowadays. I actually have reasons to not want to get locked up. Well, before I had nothing to stop me before, when were younger, no consequences. If I got locked up, because my life was already at the bottom of the heap. Well, now I’ve came so far that if I was so get locked up again, I’d have to come and start from the bottom again. And nobody got time for that.”

Resident for 5 years, Yorkshire and the Humber

“I’ve just got a new stereo, ... two years, no ASBs. So I went downstairs [to see the neighbour] and said ‘I just bought a new stereo’ and he said, ‘Well, I didn’t hear it.’ ‘So come outside and go back in there. Now here’s my number. Just ring me and just tell me if it’s too loud or not.’ House properly shaking, ASBs here I come! [Things will be OK though] ‘cause I’ve already spoke to the neighbour. Just ring me if it gets too loud.”

Resident, North West England

Another crucial point raised by a frontline worker was regarding the relationship between basic needs and offending behaviour. A few support workers have mentioned that theft occurrences stemmed from residents needing to fulfil their basic needs. Having access to support through Housing First, as seen in the case below, also meant having their basic needs met, and also having extra cash and other essential items.

“We are very lucky we have the [organisation name] that I don’t know what the grand number is, but they give us a grand which is to spend on the women each year. You know, I can buy £15 Tesco voucher for them, things like that, or we can refer them to food banks if you know, like essential items, clothes, things like that. We can help them especially when they are still on the street or still vulnerably housed. And that I think automatically takes away the risk of offending behaviour. Most of their offending behaviours in the women is to do shoplifting, which got a direct correlation with not having like basic items.”

Support worker, London

Tenancy sustainment

Despite the need to explore Housing First outcomes beyond housing impact, tenancy sustainment is of course still a vital outcome to measure. There has been strong evidence of high tenancy sustainment rates, between 60 – 90% housing retention internationally, which typically tends to coalesce around 80%.28 In the context of England, an evaluation of nine Housing First services conducted in 2015 also show clear evidence of housing sustainment, at least in the first year,29 while the city region Housing First pilots had shown 88% tenancy sustainment by September 2020.30

Three questions in our survey sought to measure tenancy sustainment. The first question was a straightforward assessment of people’s ability to manage their tenancies over time, which included measuring their risks of getting evicted or losing their property. The other two questions sought to capture i) people’s ability to manage their finances such as paying bills on time and preventing debts from accumulating, and ii) whether they can perform everyday tasks in their homes such as cleaning, cooking, and the general ability to look after themselves well. These are some of the indicators which also reflect people’s overall ability to manage their tenancy, apart from not getting evicted.

92.0% of the people represented by this survey have had a history of rough sleeping at the baseline level. Given this, seeing that more than two-thirds of them being able to hold their tenancies at these three-year points (67.7%, followed by 69.0% and 66.2% respectively) as seen in Chart 2.10. below, is commendable. The tenancy sustainment across the three years reflects some form of consistency as they all tend to hover around the 60th percentile.

Chart 2.10. Average proportion of peoples’ ability to manage tenancy over time

Source: Homeless Link’s Housing First Longitudinal Survey, N=27. Note that 27 Housing First services responded to the survey, representing a total of 934 Housing First residents. Endof1styear Endof2ndyear

28 Mackie,P., Johnsen, S., & Wood, J. (2017) Ending rough sleeping: what works? An international evidence review. London: Crisis. https://www.crisis.org.uk/media/238368/ending_rough_ sleeping_what_works_2017.pdf

29 Bretherton, J. & Pleace, N. (2015). Housing First in England: An Evaluation of Nine Services. University of York. https://eprints.whiterose.ac.uk/83966/1/Housing_First_England_Report_ February_2015.pdf

30 The Centre for Social Justice (2021). Close to home: Delivering a national Housing First programme in England. https://www.centreforsocialjustice.org.uk/wp-content/uploads/2021/02/ CSJ-Close-to-Home-2021.pdf

The ability to manage their tenancy from this survey seems consistent with the housing retention rates evidenced in previous studies.31 There is a slight dip between the end of second to third year (from 69.0% to 66.2%). It is however worth noting that not being able to manage their tenancy on their own does not necessarily mean a resident has lost that tenancy, as support from their Housing First worker to sustain tenancy will have continued despite difficulty in managing their tenancy independently

Furthermore, the journey of housing sustainment is not particularly linear, as alluded by frontline workers from our staff interviews mentioning how it takes time just to accommodate the residents, and that it is not always a clear-cut easy process for some of the residents. Some are susceptible to being victims of getting their homes ‘cuckoo-ed’, as seen through the anecdote below (the taking over of one’s home to engage in exploitative activity such as drug dealing, storing and consumptions). Nevertheless, more research has to be conducted to understand the challenges facing residents in maintaining their tenancy, as well as understanding the trajectory of tenancy sustainment beyond the third year.

“Many of them are so pleased to have their own property. They invite their associates who also have their own multiple and complex needs. So they end up, what we call cuckoo-ing the property, taking over, coming there to use their substances, come in there to commit anti-social behaviour and bring problems for our tenant.”

Support Worker, Yorkshire and the Humber

We also note that 26.0% of all the Housing First residents represented in this survey have been formally assessed for care needs, and 22.0% of them have received support from Adult Social Care (ASC). ASC refers to support provided by agencies and individuals to help those in need to maintain their independence and well-being.32 The support provided is wide-ranging, which can include managing daily tasks such as household chores, errands, and finances, to personal care, and to helping people engage in social and community activities.

Our survey sought to understand whether residents are able to manage their finances and everyday tasks such as cooking and cleaning, as these are important indicators to show that one is able to manage a tenancy and an indication that Housing First is supporting individuals with wider ASC related needs. Given the figures above on the support care needs of the residents, they show a positive trajectory in these two aspects, as illustrated in Chart 2.11. below. Our survey findings reflect a general upward trend in both indicators since the time of entry until the end of the third year with Housing First service. There is an increase for both indicators between the point of entry to the end of the first year – an increase of 21.8% on their ability to manage finances (from 23.7% to 45.5%) and an increase of 25.1% on their ability to perform everyday tasks (from 13.8% to 38.9%) respectively.

31 Mackie,P., Johnsen, S., & Wood, J. (2017) Ending rough sleeping: what works? An international evidence review. London: Crisis. https://www.crisis.org.uk/media/238368/ending_rough_ sleeping_what_works_2017.pdf

32 Newham London. (n.d.). What is adult social care? Retrieved 18 December, 2023 from https://www.newham.gov.uk/health-adult-social-care/adult-social-care

Chart 2.11. Average proportion of peoples’ ability to manage their finances and everyday tasks over time

Ability to perform everyday tasks

Ability to manage finances

Source: Homeless Link’s Housing First Longitudinal Survey, N=27. Note that 27 Housing First services responded to the survey, representing a total of 934 Housing First residents.

“It’s

a lot better because now I am in my own property, I am not out being homeless. Now I care, its different because I do care because I have got my property.”

Resident for 5 years London

The findings from our fieldwork with residents and frontline staff also concur with these trends. The notion that there is a lot more to lose after being granted property has been articulated by residents and frontline workers through the fieldwork, which may well be their main motivation to sustain their tenancies.

Some anecdotes further tell the complex story of the move from the streets to safe accommodation for people with a history of repeated homelessness, rough sleeping and multiple disadvantage. It is important to recognise the challenges experienced during this transition period, and that this journey of tenancy sustainment differs from one resident to another, depending on individual circumstances and support needs. There is also a consistent narrative of how it takes time to see this transition happening successfully.

“Because I spent a long time on the streets, so I have got some trauma. It took me a year to go into a room. I have a bed on the floor, I sleep on the floor because that is how I was sleeping. I don’t really sleep at night.”

Resident for 3 years, London

“It’s a lot better than what I had before. Yeah, it’s a big step. Being on the street for 12 years, I had to adjust, and things that have happened to me in the past.”

Resident for 3.5 years, South East England

“Many of our clients start off with emergency accommodation and they come off the streets. There they can be placed in emergency accommodation through Yorkshire and the Humber housing options or through the homeless outreach partnership. And then they’re referred to us. So we try our best to you know, advise the clients to comply with the house rules, wherever they’re staying so that they may be able to move on to more permanent settings because it does happen in stages. It’s very rare we find someone from street homeless straight into their own home. But it can happen.”

Support Worker, Yorkshire and the Humber

The management of tenancy is not always an easy task, as it involves learning or re-learning life skills such as cooking, cleaning and managing bills which requires time to develop. One resident shared how they went from nothing to having what they needed in their accommodation in less than three years with the support of Housing First, and another shared how managing these everyday tasks such as personal upkeep and maintaining personal hygiene are only possible with the support of the frontline worker in Housing First. The importance of the presence of support worker in residents’ journey, giving flexible and proactive support will be further elaborated in Chapter 3.

“Was seven or eight grand in debt. Now I’m not getting help managing my money. I still find it hard, but it’s a lot easier.”

Resident for 5 - 6 years

“Well, we arrived here with absolutely nothing because it was unfurnished, but I think we got a grant with Housing First and we just went to like B&M and just got the basics. But I think I’m most proud of the fact that […] we had absolutely nothing. But now I’ve got more or less everything that I want in like less than three years, so I think I’ve done quite well.”

Resident for 3 years, North West England

“You see, personal care improves as well, their personal hygiene, that you see an improvement there. Because they have a place to shower, they can have clean clothes. And even then, we can still support them while they’re waiting for like, say a washing machine. We can support them with laundry. They are more settled.”

Support Worker, Yorkshire and the Humber

Meaningful use of time

As demonstrated in the previous sections, there is something to be said about the relationship between how people are spending their time and their involvement in antisocial activities. Given the circumstances of rough sleeping and homelessness, criminal and antisocial activity and substance misuse do not just occur in a vacuum. When a programme seeks to reduce antisocial activities from a resident’s routine, there needs to be a replacement of that time with more positive and meaningful ones. It is therefore important to understand how people are being engaged on an everyday basis.

Chart 2.12. Average proportion of residents who are NEET and having hobbies and interests over time

Not in education, employment or training

Having hobbies and interests

Source: Homeless Link’s Housing First Longitudinal Survey, N=27. Note that 27 Housing First services responded to the survey, representing a total of 934 Housing First residents.

Based on Chart 2.12, our findings have shown that the general proportion of people who are not in education, employment, and training (NEET) over the course of three-year period remained relatively consistent, apart from the slight decrease of 6.1% from the point of entry (71.8%) to the end of the first year (65.7%). While the changes seem rather minimal in terms of their how they are ‘formally’ spending their time (such as that in education or employment) between the first and third year, our further findings on their engagement in hobbies and interests depict a more positive picture.

While only 9.0% of people represented in this survey engaged in hobbies and their interests at the point of entry, it is remarkable to see a significant increase in time spent on these activities by the end of the first and second years (27.7% and 38.2% respectively), followed by a steady 37.2% by the end of the third year. It is noted that the end of second and third years show a plateau, therefore, further research has to be conducted to have a better understanding of how the time spent on hobbies and interests can be sustained and meaningfully engaged beyond three years. Nonetheless,

it is interesting to note that the uptake of hobbies and interests is reflected the most in the first two years of their time in Housing First. This chimes with findings in the previous sections in terms of the benefits that emerge just by being engaged with Housing First services and support workers being the point of contact and referral point to a myriad of support services and activities. This finding offers a potentially positive trajectory in one’s meaningful use of time in Housing First, and how this can only serve as a protective buffer against slipping back (or further) into the world of antisocial and criminal activities.

While reduction in NEET statuses amongst people in Housing First is an indicator of a positive outcome, how they spend time fruitfully outside of ‘formal’ vocation is equally important. Anecdotes from our fieldwork further validate this survey finding. A frontline worker shared how impactful it has been for a resident to be involved in any kind of activity, even if it is unpaid work.

“He’s actually doing something when he’s like, so he’s now getting more involved with his family and getting more involved in doing little jobs. Nothing major, you don’t get paid or anything. It’s just all about being involved in something.”

Support Worker, North West England

Similar to this sentiment, another resident also echoes how spending his time at a farm despite it being an unpaid work, still kept him occupied and engaged.

“Helping out on a farm. It’s not paid, but it keeps me busy.”

Resident for 5-6 years, Yorkshire and the Humber

How Housing First residents have been meaningfully spending their time came up a lot in the peer research. They engage in a range of activities, from sports to the arts, involvement in nature such as gardening, and volunteering and giving back to communities. The anecdotes from the peer research below will reflect this range of activities they have been engaged in during their time with Housing First.

“Table tennis. I watch people play table tennis and play sometimes. And listen to music.”

Resident for 5 years, London

“I got back into my cooking. I got back into my poetry, got back into my art and things like that, so I never get bored.”

Focus Group participant, North West England

“Do you know what, I never had plants before, it was [name of Housing First service] who got me my first one and then I thought I want another one, and I want another one, and another one so now I have got loads.”

Resident for 5 years, London

“I’ve done peer support training in psychology, but it’s helped me to work on myself as well because of the low self-esteem. So yeah, it’s been fun to be able to help other people, and that’s what my goal is.”

Focus Group participant, North West England

“A bit of everything. I wash the plates when they needed it doing, … I wash the tables before we start. We help prepare the food. Serve it…. This one lady that comes in, she’s quite traumatised. Most days, I would sit down and have a chat, not just owning favoritism, but all the clients down there, have a chat with them. If I see someone in distress, I’ll go and I’ll try and intermingle, you know, to try and break the bubble that they’re in. And it does work, you know…”

Resident for 10 months, Yorkshire and the Humber

Frontline workers also highlighted how they see some of the residents being forward looking and wanting to engage in positive causes in the future and in their goal-setting exercises:

“And a lot of our women will talk about becoming like peer mentors in the future or being able to work with other women who’ve experienced homelessness and abuse. The woman that I work with who’s in a really high-risk relationship you know, she often will say to me, because she’s still very young. She’s in her early 20s and she will say to me, ‘You know, I really hope one day that I can do what you do and I can like work with women who are experiencing what I’m experiencing’”

Support worker, London

Positive and supportive networks

Research has shown that relationship breakdown is a common precedent to experiences of homelessness, and that people withdraw from potential sources of support due to stigma attached to homelessness.33 Based on Chart 2.13. below, our survey findings indicate an increase in positive social networks from the point of entry into Housing First until the end of their third year. There is a sharper increase between entry point (16.6%) to the end of the first year (26.6%), and to the second (34.1%), and a slower increase to 36.3% by the end of the third year. This trend should be examined in conjunction with the emergence of the positive outcomes demonstrated in the earlier sections. Being accommodated into a safe home meant a novel exposure to the local area in which they live, and being acquainted to new communities. As also seen in the previous section, being involved in various activities organised by their services or referral through their support workers meant that they have newer platforms and settings through which they can establish positive peer relationships.

Chart 2.13. Average proportion of residents having positive social networks to rely on over time

Source: Homeless Link’s Housing First Longitudinal Survey, N=27. Note that 27 Housing First services responded to the survey, representing a total of 934 Housing First residents.

An anecdote from peer research illustrates building positive networks from their local area and community:

“I know almost everybody in the block. Everybody’s really friendly. A lot of them have got animals as well, and I take the cat out, so I’ll just talk to them a lot, but I’ve got quite a new, quite a few new friends just in the area anyway and that I’ve made like since I’ve been living here.”

Resident for 3 years, North West England

33 Rea, J. (2023). Social relationships, stigma, and wellbeing through experiences of homelessness in the United Kingdom. Journal of Social Issues, 79(1), 465-493.

Some residents shared about how getting their tenancy through Housing First is a way for them to stay away from negative peers who may have a negative influence on them e.g., misusing drugs, further reiterating the argument mentioned in the previous section about the importance of Housing First functioning as the springboard upon which other positive outcomes can emerge.

“I think that’s another reason why I like being where I am because I’m not close to the town centre, I’m right on the outskirts. So the only way I’ll be around them people now is if I purposely put myself there. So I’ve just got used to like avoiding them situations okay. And because I’m not … and like people are on drugs and stuff and [do not] just turn up at my house randomly like, …. So I can invite like, normal friends…”

Resident for 5 years, Yorkshire and the Humber

“Was born in [PLACE] so I’m quite happy with the area I’ve got. I’ve got a lot of associates that I would never go back near again, you know what I mean? But I’ve got a handful of friends that I’ve known for like over 10 years, over 20 years some of them, and I have been able to rely on them and they’ve been able to rely on me.”

Focus Group participant, North West England

Another important narrative is how being engaged with Housing First has facilitated some residents in reconnecting with their family members, which have made positive impact in their lives.

“I don’t think I spoke to my family in 10, 11 years. Till I started working with these. I mean, I think my mum was talking to [NAME], my worker, before she was even talking to me.”

Resident for 4 -5 years, Yorkshire and the Humber

“Yeah, mum comes up all the time. She comes up all the time.”

Resident for 4 – 5 years, Yorkshire and the Humber

“Family back, now that’s amazing. Breaking the ice with my dad. Brother not so stubborn, warming to the new [NAME] that everyone is seeing.”

Resident for 10 months, Yorkshire and the Humber

Within a service in North West England, there is a co-production panel which involved Housing First residents. A focus group discussion was held to understand how members’ experiences have been in this group. It also appears that providing this space has helped them to connect with and relate to each other through their shared experiences. This has served as a protective factor for them, as one person articulated how they are coming together to learn from one another, instead of engaging in activities such as drinking and taking drugs.

“It’s a passion of mine and it’s nice to meet people who have different views, not just drink, drugs and homelessness, but different areas and meet different people to learn off each other, because that’s [a] very important experience to me. Cause that’s where the answers are mainly.”

Resident, North West England

“We talk to each other at night time as well… It does get hard to go home and you’re not alone. Now if you feel alone, you’re going to go home and you’re going to have a cry because no one’s checking in but the difference with [this] is we check in on each other and you know what that means a lot. It’s very powerful. Just a few minutes of each other’s time, you know, I mean, it just gives you that pick up knowing somebody cares because we’ve all been through the same.”

Resident, North West England

Through engaging in positive activities, whether it is engaging in their hobbies, or being part of a local community group, they are presented with new avenues they can establish positive networks and peers.

Chapter Three

Why does Housing First work?

Chapter 3.

Why does Housing First work?

As demonstrated in the previous chapter, there are clear indications of positive outcomes from Housing First. This chapter seeks to interrogate the factors which pave the way to the emergence of these positive outcomes presented in Chapter 2, and why Housing First has been responsive to the complex needs of residents with chronic rough sleeping and with multiple disadvantage. This section is based on the qualitative findings from interviews with frontline staff as well as peer research in London, North West England, Yorkshire and the Humber and South East England.

Accommodation first: the springboard upon which other outcomes can follow

The crucial reason why Housing First works lies in the name in and of itself. Housing First’s success will not happen without its fundamental principle of affording anyone the basic right to a home, without a need to fulfil any prior conditions or to be ‘housing-ready’.34

“Saying, ‘Would you have to come off this substance before we’ll house you? Or ‘You have to, you know, get your act together before we’ll look for a property for you?’ No, that can’t work. People need somewhere to live”.

Support Worker, Yorkshire and the Humber

34 Keenan, C., et al. (2020). Accommodation-based programmes for individuals experiencing or at risk of homelessness: a systematic review and network meta-analysis. Queen’s University Belfast. https://uploads-ssl.webflow.com/59f07e67422cdf0001904c14/5f99a8ab2504f7fa7f905ba4_CHI%20Accommodation%20SR%202020.pdf

This principle of granting people a home they can call their own, is particularly essential for people with multiple disadvantage who not only require a lot of treatment but consistent intervention and tailored support. When people are rough sleeping or without a safe and secure home, they are in a perpetual state of survival where they have to navigate risk and uncertainty about their safety.35 The physical move from the streets to safe accommodation means that there will be a shift from a survival mentality to one that can finally focus on their support needs, and beyond such as living and thriving in life.

“When you are trying to only meet your basic needs, trying to make sure that you’re going to stay warm and you’ve got something to eat, you don’t really think about processing trauma and what’s happened to you. Whereas when they have the space of their own, they begin to process some of the things and it gives them that space to do that safely. And then, some of them have decided to engage with mental health services or talking services, or drug and alcohol services for the first time”

Support Worker, London

“Their lives becomes more than just surviving. They they’re able to do things that they enjoy and get up everyday and be happy and not just think about if they can survive that day and getting their basic needs met.”

Support worker, North West England

“Gives that choice, gives that freedom and gives that safety so that when all of your basic needs are met, you can actually start to think about what is it that I want in life, you know, what kind of people do I want in my life? How do I feel in my mental and physical self, and what kind of changes do I want to make? Whereas when you’re on the street or in a hostel, it’s most of the time just survival.”

Support worker, London

An anecdote from a frontline worker captured a sentiment from a resident who struggled to get things done as requested by other services due to his physical health issues. This is incredibly powerful to demonstrate the importance of Housing First in not putting the pressure for people to be ‘housingready’ just to acquire a property.

“’Well, I struggle doing what they want me to do is because of my legs, my legs, I’ve got so many ulcers and I can’t physically do things.’ And I say right, ‘Do you know what we’re going to do? We’re going to sort the housing out, yes. But alongside that. I’m going to get your legs treated’. So I literally booked in the street nurse.”

Support worker, North West England

35 Sanders, B., & Albanese, F. (2016). It’s no life at all: Rough sleepers’ experiences of violence and abuse on the streets of England and Wales. Crisis. https://www.crisis.org.uk/media/20502/ crisis_its_no_life_at_all2016.pdf

Both residents and staff have expressed how owning a home is truly the springboard upon which many other positive outcomes can follow.

“It’s a massive improvement and I’ve seen how many people it’s affected and how it’s changed things. Just the whole the whole philosophy with housing you give them home first and then you work on all the others here. And yeah it won’t work for everyone but I guarantee most people like me that want that chance you know, it will work for them.”

Resident for 1.5 years, South East England

“..offending and criminal behaviour for a lot of the women when they are on the street is things like shoplifting and you know, things that are them trying to sustain themselves. So, when they move into their flats and their benefits are in place, and they’re better able to think about budgeting, the offending kind of disappears because there’s other things in place. They don’t feel like they have to do that anymore.”

Support worker, London

A tenancy is empowering

What comes with affording people a basic right to a home, is how this translates into treating people with dignity and respect. Some frontline workers have shared how certain accommodation may not be suitable for the residents, such as shared spaces like hostels or other transient spaces. Involving them in conversation regarding where they would like to live not only affords them agency, but also evens the unequal playing field and empowers them to be accountable over the maintenance of their tenancies.

“Whereas with Housing First at least you can identify somewhere, someone would like to live at least an area and that’s pretty suitable for them. They’ll feel more comfortable in that. Then you can work around that person in that flat. Then you can bring in services to that person and what the needs are”

Support worker, North West England

“If you look at a property and you don’t like it, you don’t have to take it…”

Resident for 5 years London

An anecdote from a support worker below speaks to the flexibility of Housing First which fills in what appears to be a gap in terms of the person-centered support offered. In this case, the resident’s relocation helped to foster a better relationship with her mother just by living close by and essentially boosted her accessibility to a source of social support.

“She did actually want to live near her mum. The relationship was difficult because the mum needed help and she couldn’t always get there. So we’ve got her a flat round the corner from her mum, and that relationship has just flourished from then. They’re helping each other, and she’s sort of got that community. And that’s the difference with Housing First. If any other service, if someone said, you know, ‘I want to live on this street or this street or this street’, it’d be like there’s no chance, you’ve just got to take what you can. But with her, we were able to say to the Housing Association, you know, she can live in this small area. It’s going to massively positively impact her life, and it has.”

Support worker, North West England

Offering a home as a basic right also gives people a sense of feeling valued, respected and being part of wider society. They now have access to homes, just like everyone else.

“I think they just feel more respected, like having your own home and sort of paying your Council tax. People say to me, ‘I feel like part of society and people don’t just not want me around.’ So just their general outlook on life really is a lot better.”

Support worker, North West England

Frontline workers in a women specialist Housing First service in London have articulated this sense of empowerment and ownership amongst women with lived experiences of domestic and sexual abuse. A safe accommodation that now belongs to them, gives them the sense of freedom and agency to think about how they want live based on their own terms. This is a major shift from the spaces where they are often exploited and remained at the margins, such as navigating the power dynamics in their relationships as well as at work (i.e., sex work). Having the sense of ownership over their own homes then gives them the safety and freedom to process their relationships, think about setting boundaries around them and also around their sex working (for those which this applies).

“They’ve had conversations with me around how they’re very careful about who they let into their life, who they let into their flat because it’s important[..]that we talk about the flat being their home, their safe space. You know, completely up to them who they let inside of it. And I really do think that the women realise that. I actually think it’s really liberating for them to have somewhere that they’re like, ‘actually it’s completely up to me who I decide gets to come into this, who I decide gets to be here because it’s my tenancy’.

Support Worker, London

“I’d probably say sex working becomes safer when they have their own place. It’s something that we are constantly safety planning around and talking about.”

Support Worker, London

“’I’m in this safe space and I know that nobody’s going to encroach on it unless it’s a choice that I make, I feel that I can open up a lot more about the things that happened in my past and the things that got me here’. So I think it’s a really great environment for encouraging that because it’s made very clear these are lifetime tenancies. [..] I think then they just have the space to think more freely about what kind of relationships they want.”

Support Worker, London

Slowly but surely: the long-term, flexible support of Housing First

Another crucial aspect of Housing First which makes it unique and fills a big gap in terms of the service provision in the homelessness sector is the open-ended and flexible nature of its support. This consists of the second principle of Housing First, which is to provide flexible support as long as it is needed, where the support is given without any fixed end date and each support is tailored to every individual’s pace and progress.36

A common theme which emerged through the fieldwork, and is supported by the survey data, is the long-term nature of the support of Housing First, which is befitting for people with chronic history of homelessness and rough sleeping. A frontline worker stated that certain outcomes take time, and it is not reasonable to expect certain outcomes such as widening support networks, and reconnecting with family and friends to happen immediately after the residents have been housed. This is important evidence that speaks to the need of longer-term intervention to address homelessness, such as Housing First.

“Getting them out and about a little bit more, widening their support network, things like that. But this is somebody who’s probably been in their flat for probably under a year, whereas the person who is now reconnecting with friends and family has been in their flat for a couple of years.”

Support Worker, London

36

It is therefore essential that there is a homelessness intervention such as Housing First which considers the time needed for people to adjust from sleeping on the streets to a very different life to what they may have been living for years. Moving into their own home is a significant life event which can bring a range of positive experiences, but also challenging experiences such as isolation, claustrophobia, depression, and the surfacing of their traumas in the initial period of adjustment.37 This experience can be daunting and challenging, therefore the expectation on them to quickly respond to and engage with services, and to begin living a life that resembles ‘normality’ within a short period of time is unrealistic. A frontline worker articulated how it is important to not overcomplicate things and ensure to make the transition as manageable as possible for the residents.

“When someone’s at a chaotic point at the very beginning, you really do have to spend time and consistency [..] When you plan something, you don’t overdo it, don’t over complicate things. You sort of make things a little bit more manageable right? Just identify and prioritise certain things and slowly but surely, start going through it. And I think what you do is you need to take the person with you.”

Support Worker, North West England

Some workers also mentioned how it takes a long time to even engage potential residents in the first place prior to getting them housed. Further to that, the process of helping them settle in their homes and guiding them to manage their everyday upkeep of the homes requires time. They highlighted how many things that seem normal and easy to majority of people, such as paying the bills, attending appointments, cleaning and cooking, are not necessarily easy or comes naturally for the residents. It takes some re-wiring, modelling and a lot of help and support to get their residents to maintain these everyday tasks. The absence of time-limit in Housing First helps for people to take as long as they needed to adjust and settle in.

“The women who are in the flats have said to me before, ‘If I’ve moved into the flat and just been left to it without the support, I probably wouldn’t have stayed here, like I probably would have gone back on the street’. Because it’s so overwhelming for them to move into somewhere and have to deal with, you know, bills and furniture and making a house a home, you know, living independently, cooking, everything like that. So, the fact that Housing First doesn’t have a time limit on it and you’re there for the women as long as they want you to be there, it’s incredible. [..] You’ve got as long as it takes them, as long as the service will be there for them.”

Support Worker, London

37 Homeless Link. (2019). Exploring patterns of Housing First support: Resident Journeys. https://homelesslink-1b54.kxcdn.com/media/documents/Exploring_patterns_of_Housing_First_ support_2019.pdf

“The longer they are with us, the more what we call, normal stuff. What is normal stuff becomes normal to the person. Like keeping doctor’s appointment, going to supermarket, keeping the house, getting along with the neighbours.”

Support Worker, Yorkshire and the Humber

In fact, support workers have expressed the importance of taking their time with the residents as many services they have been engaged with previously have let them down which led to their mistrust towards services. Due to these services being unable to meet their complex needs, they had to go back to the streets and having to access help and support from the beginning all over again. This makes it challenging especially the risk of experiencing trauma and re-traumatisation which can happen in the retelling of their story with multiple services.

“This stuff, like, I don’t know, mental health and blah blah blah and, I don’t know, like some people just didn’t want to deal with me. They think I was, like, too complex for them.”

Resident for 3 years, London

“A lot of the clients will have negative feelings towards staff and services because they feel like they’ve been let down. So it is a long process. I might spend 6 months just meeting someone for a coffee, or a McDonald’s and just getting them to trust me, really. The end goal is to get them their own independent accommodation, and then we sort of put in wrap-around support after that.”

Support Worker, North West England

Support workers also discussed the importance of the open-ended nature of Housing First, particularly when this is not always the case for other support model and services. Some anecdotes below fully capture this, particularly residents’ sentiments of being ‘penalised’ when they miss their window period to engage with a mainstream service, thereby losing the support and assistance they need at that time and having to restart the process all over again. Housing First allows support workers to meet individuals where they are at, and pick up from where they had left off.

“If someone engages with a service and they usually have to go into real depth about their life and be really vulnerable with a stranger and tell them everything, answer every question they ask. Say they go through all of that information, then the next appointment they miss for some reason - they’ve had the phone stolen, sleeping on the street. When they go back to that service, ‘Sorry you can’t come here, you didn’t engage’. You’ve got to start again and go through that process again and it just. You just can’t build a relationship that way with people.”

Support Worker, North West England

“It’s normally if they don’t engage, so they’ll be given sort of two chances. So if you miss one appointment, you’ll be given one more chance. If you miss that, you’re off the service. And for our people, that’s just impossible. It’s an impossible standard to hold them to. And also another thing, I think Housing First is really good at is getting them in the window of opportunity. So when the time comes around and they think do you know what I do want to change, we’re there. And if they ring, we’re able to meet their needs. It’s not on other services. It would be like, OK, I’ve got an appointment two weeks on Tuesday, but two weeks on Tuesday comes by and that window’s gone completely. Whereas with Housing First, we can sort of jump when they want us.”

Support Worker, North West England

Housing First offers a unique service, without the time pressure and also without the typical work hours, which gives support workers the time to build rapport and trust with those who need this service the most.

“I think Housing First is so special as well because there’s no time limit on how long you can work with somebody. And in previous roles I’ve had like 3-month windows where you’re then supposed to close the client. And you know it takes 3 months with the women that we work with, sometimes for them even to say hello to us when they see us. So having that time, for as long as they need the service, it’s just amazing.”

Support Worker, London

A frontline worker shared how this flexible support is especially crucial for Housing First residents, especially in the case presented below when a resident was being held in a custody and expressed anxiety whether their support will still be continued.

“So yeah, it’s been really interesting having somebody in custody. When I first managed to speak to her, it took a few weeks to be able to get her on the phone. She said to me, ‘Am I going to lose your support?’ And when I said, ‘no, no, well, we’re going to keep supporting you. And you know, we’ll be here when you get out’, she and she just burst into tears straight away on the phone. She was just like, ‘Thank you so much. You know, I’ve never had anybody waiting for me when I get out of here’. So that’s why Housing First is so amazing in its flexibility and the way that we bend with the clients and we do whatever it is that they need.”

Support worker, London

Active engagement of workers: meeting the residents where they are at

Tightly linked to the previous theme of open-ended, flexible, and long-term support, is the active engagement of frontline workers whilst supporting the residents, and their relationship. This consists of the fifth principle of Housing First, which is to ensure active engagement is used to make the service fit the individual instead of trying to make the individual fit the service. The workers are the heart of Housing First, and their relationship with the residents and their ongoing support seems to act as a lifeline for residents to keep going in their tenancies.

“If I didn’t have people look after me, like [name of worker], I wouldn’t be here actually because I have been so badly affected. Everyone has got different background and stories, but the street really affects you and 6 years is long, you know? Many bad things have been happening. When you get accommodation, it is very important to have a system around you because it is very noisy. You need help.”

Resident, London

Given the long-term nature of the support of Housing First, frontline workers can engage the residents actively. They have expressed the need to ‘meet them where they are at’ as they recognise their individual pace and response to the programme, which reflects the person-centered approach of their practice. A few support workers went on to explain how important it is to be ready to support the residents more intensively, particularly during the initial stage of their time with Housing First in the wake of the chaos they experienced. They highlighted that they may not have anywhere else to go to, may have nobody else to turn to during the most difficult of times, and how things could have gone far worse if the support was provided much later on. Active engagement also meant intervention and support is timely and urgent.

“She spent years trying to get support and she was supported by different services, but they just weren’t able to meet her needs and give her the intensive support that she needed to get some stability back. And it’s not all, it doesn’t have to be intensive for that long, but in that initial period when someone’s coming out of all the chaos it needs to be sort of. I always think of it like, you or I or you know, most of us are lucky enough that if something in our lives goes really wrong, we’ve got family or people we can go to. And in that moment, I feel like we have to mimic that relationship to them. And if they want to call 10 times a day, they can and yeah, just to feel like they’ve got that backup really.”

Support worker, North West England

“So, the inevitable thing would have happened, then things would have started to break down. Support would have been around, yeah, but it would come through more later than it would initially, and then too late.”

Support worker, North West England

An aspect of active engagement that has been raised is also the involvement of residents in the conversation on how they would want their support to look like, reiterating the importance of meeting them where they are at and tailoring support accordingly to each individual, instead of trying to make the individual fit the service.

“So we have active engagement. So we’ll really try and engage people, but it’s also knowing what they want at that time. So like I said before, with building the relationship, some people, if I’m ringing them and texting them every day and can I meet that might be overwhelming. So it’s sort of asking them what do you want from me? How do you want this to look? And some people will say, you know, can we meet once a week, but I’ll text you every day if there’s anything wrong? And then I’ve got other people who, yeah, I must speak to at least for three hours every single day. And it’s just whatever works for them, really.”

Support worker, North West England

An important narrative raised by frontline workers is how this active engagement could also be very non-linear given the various seasons and phases the residents are experiencing. As mentioned previously, residents’ lives may be challenging and chaotic, and some workers have raised instances where some of the residents disappear suddenly, arrive late for appointments or experience mishaps such as losing their phones which made them uncontactable. For instance, a frontline worker shared how a resident has gone silent for a few weeks, and she was responding to them with compassion and grace, allowing them to pick up from where they had previously left off. She related how important it is to have a service which adheres to this principle of active engagement which allows her to continue engaging with the residents.

“They know that they can just call us and we’ll be there. And I had one person - he’d go missing for sort of weeks at time. And every time he’d call me, he’d be like, ‘I’m really, really sorry’. And I was just like, ‘It’s fine. Ok, let’s pick up where we left off.’ And he was like, oh, really like surprised that I wasn’t sort of angry or I was just like, no, that’s fine. Like, you’re ready now. Do you want to meet today? So that’s what they need really. When they need you, when they want the support, they need you to just be there, sort of ready, which I understand all the services haven’t got the capacity to do.”

Support Worker, North West England

Small caseload

A low and small caseload in Housing First has allowed frontline workers the time they need to proactively engage the residents and give the quality time needed to every individual. The small caseload allows Housing First services to develop a work culture that prioritises relationship-building as fundamental for frontline workers and gives the logistical and operational support required for workers to work flexibly to meet the needs of the residents.38 Building relationships not only takes work, but most importantly cannot be rushed.

“The idea is to focus on and give support. And to do that, it’s nicer to have smaller caseload and it’s beneficial for the person that you support. It’s also good for yourself because, I don’t think you’ll be able to do it. It wouldn’t make sense if it was lots more.”

Support Worker, North West England

“Our managers are also never really putting any of these time pressures and constraints on us, so I’m able to build these really genuine connections with the women, just like laugh and have nice conversations and talk about, you know? They’ll talk about like their family and funny memories and things like that and because you don’t have this expectation on them that they need to get things done. You can be the person that just becomes a bit more of just a supportive kind of presence.”

Support worker, London

“Some of my clients sort of function until later in the day. So if I’m saying right, I’ll meet you at 10 AM tomorrow, that’s an impossible standard for them to do. But because of Housing First of how flexible it is, I can say to my manager, do you know what? So and so likes to meet at 6 PM, so I’m going to start later today and work later, and that would be completely fine. Whereas other job that’s 9 - 5, if they don’t come for the appointment at 10 AM, they’ve not engaged”

Support Worker, North West England

Most importantly, with the wealth of time, frontline workers can give residents the consistent support they need. One support worker particularly shared how active engagement for her also meant going the extra mile to get to know the neighbours in the local area to mitigate risks or anticipate any issues the resident she’s supporting may face.

“What I’ve always done for a long, long number of years is got to know the neighbours. [..]. And I always think, if you get on your neighbours’ side, you’re halfway there.”

Support worker, Yorkshire and the Humber

38 Homeless Link. (2017). Housing First in England: The principles. https://homelesslink-1b54.kxcdn.com/media/documents/The_Principles_for_Housing_First.pdf

“To give that consistency and the time to someone, I think makes a massive difference. Because they’re in their head, everyone else has just let them down and sort of walked away. Whereas with us, sort of within reason they can do whatever and we’ll still be like hi, we’re still here. Like we’re here when you’re ready. So yes, it’s like the unconditional positive regard as well, no judgement.

Support Worker, North West England

Walking alongside them: workers as advocates and role models

A theme which comes up is the role of the worker as the residents’ greatest advocate and supporter in many ways. As mentioned previously with regards to their lack of trust towards services and a sense in which they felt let down, it is incredibly important to have a worker who journeys alongside them as a strong advocate and who can also be their voice when the need arise. Having workers by their side instils in them hope and confidence that their lives can get better. A few anecdotes below demonstrate the importance of workers accompanying their residents for appointments and meetings with other professionals, and navigating support systems which can be daunting and complicated for them.

“I’ve got one client who is really fearful of any kind of professional. So she wants me in those appointments. She feels especially in medical appointments in the past, she’s been sort of her needs have been ignored because of the stereotype around a drug user. So having me there, she feels she gets heard more and taken more seriously. So I go to every single appointment with her.”

Support worker, North West England

“For a lot of women, you know, healthcare environments can be really triggering, there can be a lot of shame and stigma involved with the kinds of things that they might want to see a doctor about. So I’ve had women who’ve been a lot more comfortable going to those kinds of appointments if their support workers going with them just because you’ve developed that relationship where they know that they’re not going to feel any judgment from you and they trust you, you’re more able to then kind of encourage them to trust other people, including like medical professionals and things like that. Same kind of thing with mental health is once they’ve developed that trust with you and they feel that you’re not going to judge them. They kind of trust your instincts a little bit more, so have been more open to engaging with counselling and psychotherapy and things like that.”

Support Worker, London

“[Worker] was like my big sister, you know? I mean, she took, she made sure I went to [appointments]. Because when I left, the homeless thing, I had like 13 big ulcers on my legs, you know what I mean? And she used to, she [helped me to the] appointment, you know, made sure I went to them al. Like I said, she was a big sister.

Resident of 2 years, North West England

“You’re more like them an advocate. So you’re sort of like the go-between that person. We can work with these guys because someone else is now informing us of the difficulties and keeping us informed and letting us know what’s going on.”

Support worker North West England

Seeing their workers as advocates also slowly built their trust in them, which meant their workers serve as positive role models in various aspects including how to perform everyday tasks, to how they communicate to others and set boundaries, and how to form safe, healthy and trusting relationships. This is particularly relevant for residents with traumatic and challenging early experiences.

“You go to places with them and I was going with him and we’re making sure he was there on time, making sure I was there on time.[…]I pointed out at certain places you could go to for getting certain things like his mobile phone sorted out or the bank even, you know, going to the bank.”

Support worker, North West England

“Especially for women that have experienced abuse since they were a child. We talk a lot about modelling behaviour, so if for example if the client is being quite abusive towards me, I’ll say, ‘You know I’m not gonna speak to you like that when you’re like this. I’m gonna give you some time to calm down and I’ll call you back’. And you know, if someone has grown up in a household where there is a lot of abuse going on and that continues with them being an adult, they may not have been able to ever see someone set a boundary like that. And I think it is, and we talk a lot about setting boundaries and certain boundaries, I think that model of Housing First and you’ve been close to your key worker and your key worker have been trained in trauma-informed practice and a certain boundaries of modelling behaviour is really important for the women.”

Support worker, London

“But slow change into opening up to you and trusting you and feeling like they can have this relationship that’s, you know, not going to be something that’s going to be negative for them. It’s not somebody who’s taking advantage of them, which so often is the relationships that they experience on the street.”

Support Worker, London

Another frontline worker shared as a professional with lived experience of substance misuse herself, being in this role mirrors to the residents that it is possible to achieve what she has achieved:

“Because most of us, the team in Housing First, we’ve had firsthand experience, you know, lived experience of misuse in substances and maybe homelessness ourselves. So we can identify with them, they can identify with us. And they can see the change that’s happened in us. You know, we’ve had dreams, we’ve had aspirations and along the way we’ve overcome with some of the challenges of the addictions. We’ve pressed on toward our goal. And now we’re in this situation as like, peer mentors for them and they can see, well, you know, we’ve come through voluntary work, to give back to community. Especially with treatment recovery or even within Housing First. Cause I myself started volunteering here first, before I became an employee. Yes, so they can see by our own personal experience and testimony, lived experience, that it’s doable, it’s achievable.”

Support worker, Yorkshire and the Humber

Funding gives the freedom to provide person -centered support

It is undeniable how crucial the role of funding is in ensuring the long-term support given to Housing First residents. Frontline workers from services in the North West have shared how important it is for them to receive “personalisation budget” in helping them set up the essential things required for settling in their new homes, such as buying furniture, but also in spending on other basic needs. Having the budget to do this enables residents to feel empowered by being involved in making choices on what they can purchase, but also makes a difference in how they feel about their homes and themselves. As seen through the anecdotes below, just having that extra financial support improves their sense of self-esteem and gives them a sense of being part of the wider society

“I think as well because we have the personalisation budget just being able to buy some fresh clothes and have a haircut. For some people walking into that coffee shop when you’ve got your new clothes on and you’ve had your haircut, you don’t feel like people are looking. Cos when you’re rough sleeping, people feel like they get looked down on a lot. They’ll get told to leave shops even though they’re not doing anything because of how they appear. So I think they just feel more confident that they’re going to be accepted in society.”

Support worker, North West England

“Just making a house at home. Because a lot of the time people will get a property, but when there’s no furniture, no carpets, it just feels like a shell. And I’ve had a client say to me before, ‘You know, it’s just a concrete tent, my situation is no different.’ So yeah, it’s really just to make them feel like it’s a place they want to stay and want to be in. […] It’s within reason they can get what they want really. We’ve got one client who’s just bought wallpaper and a lamp shades and she’s just got a dog as well. So she wants to go to puppy lessons. So once the flat is sort of set up, if there’s money left over, it’s really their choice what they spend it on. I’ve got another client that wants driving lessons, so yeah, it’s quite individual within reason.”

Support worker, North West England

It takes a village: the importance of joint working

Another important aspect which contributed to the success of Housing First thus far is the collaborative working between professionals in the housing, health and social care, drug and alcohol, and criminal justice sectors particularly in the context of the outcomes achieved across all these sectors. Evidence from the UK and internationally shows that working in partnership and collaboration is key to providing person-centered support to those experiencing homelessness.39 The anecdotes below demonstrate the extent support workers in Housing First have worked in collaboration with many professionals.

“I think also the networking between us as professionals. The input from the general practitioners. Some of them have Hepatitis C and they can have that addressed and treated. Some with the ulcers, as I said, you know, the wound and treatment and regular changing up of their bandages, etc. Mental health input also. Maybe with probation and supporting them to remain, away from committing crimes and things like that, coaching them, encouraging them. The treatment recovery practitioners also - their input and helping them to try and reduce their substance misuse, keeping them on their methadone scripts, even helping with rehab if the client is ready for a rehabilitation. Finding the local or nearby rehabilitation centres and organising that for them and helping them to reduce, preparing them for rehab. I think it’s just the multidisciplinary team that they can rely and they can turn to for different aspects of their holistic wellbeing, I could say.”

Support worker, Yorkshire and the Humber

“We work together. If there’s a crisis with our client, we’ll call a multidisciplinary meeting to discuss the way forward, and then best interest for our client.”

Support worker, Yorkshire and the Humber

39 Williams, M. (2021). From enforcement to ending homelessness: How police forces, local authorities and the voluntary sector can best work together. London: Crisis. https://www.crisis. org.uk/media/245310/from-enforcement-to-ending-homelessness-full-guide.pdf

“And you know we’re really fortunate to say, we’ve got a list of housing partners. You’re on top of the list. We’ll take you to a flat. You can view it. If you don’t like it, it’s fine. You can take another one, you can have that one. And that opportunity I think is just so good for them because the council housing system you can wait for years. A lot of them have been through it already. And it’s really complicated and lots of different people, lots of waiting around in the offices. [..] It is really nice and it also the housing associations that we work with offer really lovely properties. And they can change and decorate how they want.”

Support worker, London

There are numerous benefits of joint working articulated by frontline staff, all which will have direct or indirect impact on residents. Some key benefits that will directly impact residents is the perception they have that every professional whom they have been referred to actually know each other, creating a sense of feeling supported by a community of people, as well as knowing that they do not have to repeat their history all over again knowing that these professionals are communicating with each other. Joint working not only fosters trauma-informed care for the residents, but it also bridges expertise and intelligence among a diverse group of professionals to best support them.

“So it’s this really great network and we can check in with them every week and kind of put our heads together and think about actions that we can come up with to keep her safe, update each other, things like that. It’s really nice there’s so many great people working in this sector that you can just pick up the phone and chat to them, you know. It’s having those professional relationships, it’s great. And I also think it’s really nice for the woman to see that everybody knows each other, you know, everybody’s aware of their situation, they don’t have to keep retelling their story over and over again because they see that the services are interlinked and they work together, which is really nice.”

Support Worker, London

“We can work with these guys because someone else is now informing us of the difficulties and keeping us informed and letting us know what’s going on. And they’re also there to help” (referring to housing workers)

Support Worker, North West England

“If you have a woman who’s not got a clear sleep spot who you’re trying to find- going with outreach teams and hostel key workers is amazing like, it just means that you’re doubling the knowledge and doubling the amount of people who are looking out for them.”

Support Worker, London

Frontline workers also highlighted the benefits that joint working has on them, particularly how it frees more time to focus on their key role in supporting residents in their day-to-day living, helping them to live better lives and setting goals with them, and just being a supportive presence in their lives. This eventually has an impact on the residents and enables them to receive the intensive care and support they may need.

“They might have a substance use worker, their hostel key worker, a counsellor and then you. So that leaves you more open to exploring, you know, talking like I said, about like future plans and goal setting. And then obviously more practical stuff like benefits and bills and things like that, but it just means that our role - we have a lot more freedom with what it is that we want to do with the women, you know.”

Support worker, London

The anecdote below illustrates the importance of collaborative working and partnership with other professionals, through a gendered lens. This support worker from a women’s specialist Housing First service related how crucial it is to work with male colleagues from the outreach them, particularly in locating female residents who would be found rough sleeping with their perpetrators.

“We really closely work with the outreach teams in the borough. They are so useful for us because when we have someone on target. It’s really good that we can email them saying, ‘I’ve been looking for this lady, she looks like this - have you seen her?’ And then they’ll be like, ‘Yeah, we actually have seen her’ because they go out every day. And they do obviously they’re walking around large areas and we can’t, just like capacity wise. It’s really important having that relationship with them and they’re really helpful for us. Passing all messages or letting us know where they are, coming out with us, especially when our client rough sleeping with the perpetrator. It’s really good to be able to get out of the outreach team. And we’re all-women team. So when there’s a male perpetrator there, it’s quite nice to have a male colleague to work with and that partnership working is good.”

Support worker, London

Barriers and Challenges Chapter Four

Chapter 4.

Barriers and challenges

As there are numerous drivers of why Housing First works seen in the previous chapter, there are also barriers and challenges impeding the operational delivery of Housing First services.

Unsustainable funding cycle: an impediment to long-term planning

Another prominent challenge faced by Housing First services is the unsustainable nature of where they receive their funding. Based on the Picture of Housing First research which explores funding sources across Housing First provision 66% of services were funded through their Local Authority, which can be impacted by local authority funding structures and mechanisms. For example, the Rough Sleeping Initiative (RSI) is used to fund Housing First projects, but between 2019 and 2021 this was allocated on an annual basis, and the current grant is a three-year programme undermining needed commitments to long-term funding. Based on Homeless Link’s Picture of Housing First research, only 5% of services have indefinite funding, and very few receive local authority funding from adult social care (9%) or public health (6%),40 which speaks to the urgent need to diversify funding sources, particularly from sectors beyond homelessness. Nevertheless, there has been some investments going towards Housing First in efforts to move away from unstable 12-month cycles such as the national pilot projects.

Short-term funding cycles still affect the services that took part in our research and these can severely impact service delivery, particularly in the ability for services to plan long-term operationally and logistically. There is also the uncertainty around the capacity to provide long-term and consistent support to the residents, which is most needed for the group Housing First seeks to support.

“Housing First is meant to be open-ended. But we know with how our funding system works, that’s not possible for us to promise. So we do also have a responsibility to get them in a place where everything’s not going to crumble when we walk away”

Support worker, North West England

40 Ibid.

The coming to the end of the funding cycle with no extension of contract means that this can reverse all the good work that’s been done during the resident’s time with Housing First. This takes away lifeline support for most residents in Housing First, particularly those who are in most need and in critical stage in the programme. This not only cause anxiety amongst residents, but also with frontline staff who can have little job security.

“It is really, really difficult. First of all, there are different people affected. The staffthere’s loss of employment and then loss of this work that they’ve been doing, that they really enjoy doing. And then what do you say to the women? I mean, these are vulnerable people where things have just ended for. These are people who in their life things have come up and ended abruptly. And they’ve been abandoned, they’ve been rejected. I mean and you’re telling them now the service is not going to be not funded anymore? So we are going to have to close. I mean that’s another rejection. So it’s a big thing. So you have to prepare them for the ending, but usually like you’re not even given enough time to prepare for the ending, you know. I went through that myself in [a location] and where I had to hand over the clients to the local authority. The support they give them is not the same.”

Service Manager, London

“We had like 3 months extension on our contracts and then we had a 1-month extension. And you know you’re thinking for yourself, ‘Am I gonna be paid in 2 months?’ And it also thinking to a client like, ‘Am I gonna have to start getting you ready, not just me not being here, but the whole service not being here?’ And they’ve got really high support needs, there’s not another service in the borough that can look after them in the way that we can. So I think funding security in terms of like for the staff, for the project is really important like across the charity sector. That in particular so this group of, or any multiple disadvantage services, because the handovers that we do are going to be very long.”

Support worker, London

“I would say we it would be nice to have like the funding increased so that this staff can earn fairly better than they are now. I know we’re a charity, but with the cost of living, I mean, it’s such a struggle. That’s why sometimes there’s very high turnover [..] They (the workers) always up and about like running you know and like I just wish that we could be paid better.”

Service Manager, London

Due to a lack of funding, a frontline worker articulated the tricky situation services find themselves in where their caseload remains static, therefore they are unable to take in more residents in their services as their current residents are still relying on their services. This meant that workers have to find ways to gradually prepare residents for graduation or at least, having limited dependency on the service.

“I know I think they’re starting to run training now to start having those conversations (about graduating) because it has been brought up that staff don’t feel that equipped and to where to start with it. Yeah. And I do think that will be quite tricky for some people. But as well it’s not realistic for people, for us, to keep getting the funding if we’re not taking extra people on, and we can only take extra people on if some people are graduating. So yeah, it’s a difficult situation.”

Support Worker, North West England

Shortage of housing supply

Constraints and shortages of housing supply in England have been a cause for concern over the years, and these challenges have also been impacting the success of Housing First delivery across the country. Government figures reveal a net loss of 165,000 social homes in England in the last decade (between 2012/13 – 2021/22), with disproportionate selling and demolition of homes more than the construction of social homes.41 In 2023, 1.2 million households in England, a rise of 5% since 2021,42 are currently on waiting lists for social homes,42 which inadvertently affect the supply of homes for Housing First residents.

Unsurprisingly, the lack of housing supply to accommodate Housing First residents has been prominently cited from our interviews with frontline staff. The consequence of this is that residents who have been engaged with their workers may experience a long wait before acquiring a tenancy. As one of the workers aptly shared below, this challenge can affect their relationship with the residents and this can feed into their sentiments of disappointment and mistrust towards services, as previously mentioned in the last chapter.

“But as I’m sure you know there’s a housing crisis at the moment, so we haven’t had loads of flats available and it’s been a bit kind of difficult that that side of things.”

Support worker, London

41 https://england.shelter.org.uk/media/press_release/14000_social_homes_lost_last_year_as_over_a_million_households_sit_on_waiting_lists

42 Ibid.

“I think the housing stock and just the lack of affordable and appropriate housing. And that was the same in Liverpool and London. There’s no 1-bed properties that people can afford. So that is a barrier because we can have people on the programme for a long time before they get offered a property and that really affects the relationship we have with them because they think, well, ‘I thought you were coming to help me with a house’. And sort of six months in, there’s still no house.”

Support worker, North West England

A challenge faced by workers due to the lack of housing supply particularly in the same local area, is housing residents in various locations which are not necessarily nearby each other. This affects workers as they need to commute long distances to support the residents, which can limit their capacity to physically support them in a timely manner or be as reactive as they would like to be.

“The thing I would say is a hindrance is the availability of housing within the borough. Like my clients are from Hackney to Tooting, to Brent. So, like a huge amount of my time is on TFL (Transport for London). Like we’re very used to, we’re all very capable now of researching the support within the borough and you know, working pan-London. Your client might be moved to a borough that you’ve never worked in before and you have to kind of navigate that. But that’s part of our job and we are used to it, but I think that physical distance becomes harder for us especially when you work so much on emotional support and sometimes people call you upset and you want to be there, but you’re working on the other side of London.”

Support worker, London

Allocation and distribution of caseloads

Another challenge faced by frontline workers is that given the physical nature of the support they are expected to provide for the residents, there is little control in the location in which they are eventually accommodated. So in reality, they may hold a caseload of residents who are spread out in various places, and the redistribution of cases can be challenging as it may disrupt the relationships residents have with the current staff member.

“I think sometimes the area that you cover. I drive now, but when I first came to [an area in North West], I use public transport and I would take a while to get places which affects how sort of reactive you can be [..] It’s hard because we want to be consistent with the caseload. We don’t want to be swapping people from worker to worker. But it would help to have people in areas you know. You’ve got six clients, they’re all in this small area. But I don’t know if that’s realistic because you get your caseload and then they get housed.“

Support Worker, North West England

There is also the challenge of some workers having to provide a lot more support than other workers, as some of them may have a few high-intensive cases, while some have more stable cases. This further proves that redistribution is vital to manage the capacity of workers and prevent experiencing burnout.

“So I do feel like there’s a role in a team where one person could sort of hold a higher caseload for the clients who are a bit more stable and a bit more independent. To try and keep it consistent, really because you’ll speak to some staff members and if they’ve got four people in crisis that week or four people about to get evicted or any anything like that, it’s way too much.”

Support Worker, North West England

Dependency on Housing First: how flexible should it be?

Housing First has been criticised for ‘encouraging dependency’ and there has been numerous conversations on what it means to promote independence and develop resources and resilience for residents beyond the service, as well as what it means to manage dormancy and close cases.43 This has similarly been articulated by workers from our interviews and the challenge lies in finding the fine line between supporting and letting residents achieve self-reliance. There is the concern about the risk of residents who are more dependent on the service potentially losing support in the face of funding issues.

“I think it is nice because it does mimic that relationship that you’d have with maybe a parent or a partner, but again, it’s not realistic that we’re going to be around forever. And are we setting them up to fail if they are that dependent on us? I know I’ve been concerned in the past about, you know, starting the conversations about endings, because we’re only funded till the March after, so another 18 months. Hopefully the funding will get extended, but if not, how do we start having those conversations with the people that are really dependent on us? And make sure with Housing First, if it is taken away, the last thing we want is for all those tenancies to sort of end or become difficult for people to manage. So yeah, I do think that can be an issue. But I think the reassurance that it gives to people is massive, that there’s sort of no rush and we’re going to be here for a long time. Yeah, it’s hard, I can see the difficulties with it as well.”

Support Worker, North West England 43

As mentioned by one of the frontline workers, it could be that the Housing First support mimics the kind of support residents needed, in the same way that any ‘normal’ person needs support from their close family and friends or significant others. Hence, their reliance on the service should not be seen as a ‘failure’ but rather an expression of the human nature and needs. This however meant that their supportive networks must be extended beyond the services, and this can be challenging for some residents as they may require longer time to build those supportive networks.

Reflections and observations from peer researchers who held conversations with the residents in the research also raised similar concerns about residents who only have a positive relationship with their support workers instead of having a wider pool of network for support. This chimes in some of the learning from past evidence to provide support more sustainably which includes commissioning Housing First alongside a wider network of services and developing other offers within the service such as peer mentoring that allows for step-down and step-up.44 Housing First should not operate as an island, and this remains to be a challenge in practice and more conversations should be held to discuss ways to ensure sustainable and realistic support provided for residents.

Lack of knowledge about people experiencing homelessness

People experiencing homelessness not only face a multitude of health challenges but also social challenges in the form of stigma, discrimination, and social exclusion. While there have been some improvements in the public perception of people experiencing homelessness,45 there remains some structural discrimination they face such as barriers to healthcare,46 as well as not getting the appropriate and trauma-informed support from the police force.47 These have been articulated by the frontline staff in our interviews, where they identify a lack of informed knowledge on the part of professionals when it comes to understanding the issues faced by people experiencing homelessness. According to an anecdote below, people experiencing homelessness face discrimination even in spaces like hospitals, where they are meant to be treated with respect, dignity and compassion.

“The behaviour of the society towards marginalised, these women who are terribly marginalised. Yeah, sometimes I find it really frustrating that we who work in the sector, we doing our best, our best we can do and there are people who are just there to undo the work we do. The stigmatising them [..[ a lot of our women don’t really get accepted in places where they should be only accepted, like even in hospitals. I have had experiences in hospitals with women. And like the way they’re treated is not great at all.”

Staff, London

44 Ibid.

45 Ipsos. (2023). Understanding public perceptions of homelessness in the UK. The Royal Foundation. https://homewards.org.uk/wp-content/uploads/2023/08/Public-Perceptions-Key-Findings. pdf

46 https://www.birmingham.ac.uk/news-archive/2019/homeless-people-are-denied-basic-health-care-research-finds-1

47 Sanders, B. and Albanese, F. (2017) An examination of the scale and impact of enforcement interventions on street homeless people in England and Wales. London: Crisis. https://www. crisis.org.uk/media/237532/an_examination_of_the_scale_and_impact_of_enforcement_2017.pdf

Another worker also articulated the difficulties working with the police because of the lack of understanding about domestic violence and the lack of trauma informed care.

“Tricky relationships with the police sometimes [..] You know, like these mirrors, and if you look at it from one angle, you look like really funny. If you look at another angle, you look normal. I sometimes describe my relationship with the police like looking into that mirror. Like we’re both looking at the same thing, doing completely different things. I think it is well known especially in London that a lack of understanding about domestic violence and towards women. That’s a wider issue. Which I’m sure is about by majority of women. No, not through that. It comes from the car, but yeah, we’ve worked with a huge variety of people.“

Support Worker, London

Conclusion

This research shows a definite indication of positive long-term trajectory for many outcome indicators of Housing First, further adding on to the mounting evidence that Housing First is simply not just a response to homelessness and rough sleeping, but rather a whole systems solution towards ending multiple disadvantage. This research continues to reiterate the importance of granting homes without prior fulfilment of conditions to those who experience some of the most extreme forms of homelessness. Housing First serves as the first point of contact, the window through which people can receive the right amount of support, care, and intervention, and have their support needs properly attended to. This is especially important considering that the majority of services cannot match the level of intensity, length, and depth of the support of that which Housing First can provide. As it is a tailored and uniquely high-intensive intervention that fills a major gap in service delivery, it has become clear how great the need for Housing First is as part of our wider solutions to ending homelessness, as we face the challenge of increasingly complex support needs amongst those experiencing homelessness.

The demand for Housing First is high, yet the capacity to meet these demands is getting more challenging. There is an urgent need to remove the impediments and barriers to the continued operations and service delivery of Housing First, such as short-term funding cycles and shortages of housing supply. There is a need to shift the notion that homelessness is a short-term need, clearly reflected by the unsustainable funding cycles on which majority of Housing First services operate. These all can lead to further challenges in meeting its core principle of providing long-term, flexible support for as long as it is needed for the residents, and difficulties in addressing questions surrounding moving people beyond Housing First. The answer to multiple disadvantage is not one which is easily solved through simplistic solutions. As evidenced through this research, it is one which requires collaboration between sectors from the systemic and structural level, to the practice on the ground.

With increasing evidence on the effectiveness of Housing First to reduce pressure on emergency services, upscaling Housing First in England has to be a policy priority, and adequate funds need to be channelled into this project from multiple governmental departments with sustainability as its end goal. It has become clear that now is the time to invest in Housing First. There is on the horizon the potential to help people with multiple disadvantage in making the shift from surviving, to living and thriving, which can only be tackled by cross-departmental commitment.

Recommendations

1 Develop a national standard for impact and outcomes data in Housing First services. There is an urgent need for more rigorous and consistent data collection across Housing First services, particularly data which will aid in measuring impact and benefits of Housing First i.e. measuring the ‘distance travelled’ for each resident in their journey in Housing First. It is necessary to agree upon the same data services are seeking to collect and agree to standardise the ways to measure this data and the frequency of collecting this data (e.g., every quarter, every year etc.). This will assist with both ongoing understanding of individual journey in Housing First, as well as understanding broader impact and facilitate the ease of future evaluation and research activity across services being able to make the case for further upscaling of Housing First across the country.

2 Embed fidelity to the core Housing First principles. In the mission to expand and upscale Housing First to other regions and to meet the demands of the programme, it is necessary to ensure that the fidelity to the core principles is properly adhered to and that they withstand over time.

3 Establish and strengthen cross-departmental response to end homelessness as a default. Our findings only continue to reiterate that a siloed, isolated response from the housing sector to meet the complex needs of people facing homelessness is inadequate, and therefore must be multi-faceted. Likewise, our findings have evidenced that Housing First does not operate as an island, given its impact which fall under the remit of other governmental departments overseeing areas of health and social care, criminal justice, and substance misuse. There is a need to call for greater joint working and the setting up of multi-disciplinary groups representing professionals and workers from diverse sectors to provide holistic, tailored, and intensive support for people with history of repeated homelessness. The commissioning of Housing First alongside a wider network of services can facilitate step-down and step-up support as and when needed for residents who are fully reliant on just Housing First.

4 Provide sustainable funding for long-term support. Our findings strongly evidence that benefits and positive outcomes emerge when ample time is given. Funding and commissioning cycles for Housing First projects need to facilitate sustainable long-term support to ensure impact. There is also a need for more funding into Housing First as a preventive, proactive and cost-effective intervention to reduce burden on emergency services and public funds across sectors. There is a need to review current funding practice and eradicate short-term contracts and allocate the estimated £150.3 million per annum required to fund Housing First at scale.

5 Commit to building adequate supply of social housing to upscale Housing First. There continues to be a shortage of housing supply to meet the increased demands of Housing First. There is an urgent need to engage and establish partnership with more housing providers to get involved to scale up the tenancy provision. The next Government should commit to build 90,000 social homes per year for the next 10 years and unfreeze Local Housing Allowance.

6 Strengthen service management and delivery. Our findings indicate the possibility of outcomes of Housing First being mutually reinforcing to each other, which evidenced the importance of strength-based approaches. For instance, a reduction in substance misuse and criminal and antisocial activities amongst people experiencing homelessness, is also tied to their engagement in positive activities, how they occupy their time and opportunities to build positive networks. There is a need to strengthen partnerships with civil society, local authorities, charities, and governmental organisations to provide more avenues and infrastructures and to develop programmes to facilitate positive networking amongst people experiencing homelessness. It is also recommended to actively shift away from assessments and tools which are deficit-based and instead, focus and tap into individual’s strengths. It is recommended for programmes, services, and intervention to include people with lived experience, particularly in shaping service delivery, solutions to homelessness and policy development.

7 Increase awareness of impact of homelessness and trauma informed approaches. Negative experiences and stigma impact on engagement with necessary health, social care and criminal justice services and organisations. Raising awareness of how trauma impacts on behaviours and trauma informed approaches that can be taken is needed across relevant sectors. In order to do this there is a need to develop and roll out a national trauma-informed training programme in England for Local Authorities and providers of commissioned homelessness services and an awareness raising programme for wider health, social care, and criminal justice organisations.

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