Prof Sarah Johnsen and Dr Janice Blenkinsopp reflect on key learning from Scotland’s Housing First Pathfinder following publication of the evaluation’s final report.
Scotland’s Housing First Pathfinder programme ran for three years from April 2019 and provided independent tenancies and support for 579 individuals across five areas: Aberdeen/Aberdeenshire, Dundee, Edinburgh, Glasgow, and Stirling. It served as a litmus test regarding the opportunities and challenges involved in scaling up Housing First as it moves toward becoming the default response for homeless people with complex needs across Scotland. Core messages from an independent evaluation, conducted by I-SPHERE in partnership with ICF, may be distilled as follows.
1. Housing First is just as effective in Scotland as elsewhere … even in the context of a pandemic
The Pathfinder attained tenancy sustainment rates commensurate with those recorded elsewhere internationally, these being 88% at 12-months and 80% at 24-months overall. Other individual-level outcomes (regarding health, substance misuse, and engagement with the criminal justice system for example) were mixed but positive on balance, which also aligns with existing evidence. Service user experiences varied but were very positive overall, with some describing the effects of Housing First as transformational. Significantly, these outcomes were achieved in the context of the COVID-19 pandemic which has had a profoundly negative effect on homelessness, health and social care services and the mental health and wellbeing of society more generally. The pandemic also contributed to lengthy hiatuses in property allocations and severely constrained opportunities for combating social isolation and facilitating community integration.
2. Stakeholder attitudes are changing for the better … but there is still a long way to go
In demonstrating the ‘art of the possible’ with Housing First’s target population, the Pathfinder induced some of Scotland’s homelessness service providers to adopt more flexible and/or less conditional forms of support and, furthermore, persuaded a cohort of housing providers to revise their procedures to cater more effectively for Housing First clientele. A great deal of progress was made in improving understanding of what Housing First is (and isn’t), and the needs of the target population, amongst stakeholders in housing and allied health and social care sectors. There nevertheless remains some way to go to redress stigmatised attitudes (especially but not solely amongst individuals in frontline roles) regarding what Housing First clients ‘deserve’ and/or are capable of, and further promote trauma-informed ways of working.
3. Housing First is effective in preventing repeat homelessness … but other benefits won’t be realised fully until barriers to healthcare are addressed
The limited availability and inflexibility of many of the (statutory) health and social care services that Housing First projects work in conjunction with have restricted the extent to which its potential benefits can be fully realised. The Pathfinder helped service users navigate what are often complex systems, but gaps in provision and barriers to access remain, with difficulties accessing mental healthcare being especially acute. This impeded the distance travelled on many individuals’ recovery journeys. The integration of health professionals into Housing First teams via secondment or other arrangements might be a prudent interim measure until such time as these systemic barriers have been eradicated (see also below).
4. Housing First improves lives … but does not vitiate disproportionate risk of early mortality
Housing First targets a population in extremely poor health and much more likely than other people to die young. A total of 6% of individuals housed by the Pathfinder sadly passed away, a proportion consistent with Housing First programme records elsewhere (e.g. in England and France). Most deaths were reported to be substance misuse related and occurred in the context of an acknowledged ‘drug deaths crisis’ in Scotland. The risks were noted to have been exacerbated by the pandemic given its impact on drugs markets and catalytic effect on increased and riskier patterns of substance misuse internationally. Stakeholders reported that the number of deaths attenuated to a degree when restrictions on social contact reduced, and it is also notable that the Scottish Drug Deaths Taskforce recently endorsed Housing First. It seems that while Housing First improves tenants’ lives in many ways, it does not counteract entirely their pre-existing disproportionate risk of premature death.
5. Implementational ‘sticking points’ are to be expected … and will shift over time
Strong political commitment at the highest level has been as a key factor facilitating the operationalisation of Housing First in Scotland. Even so, Pathfinder experiences indicate that barriers or ‘sticking points’ will almost certainly be encountered when Housing First projects are initially developed and/or scaled up. The location and nature of these vary depending on factors such as provider configuration or consortium size, the degree and nature of involvement of statutory bodies (most notably Health and Social Care Partnerships), and local housing market conditions. Stakeholders should expect the nature and location of sticking points to shift over time as Housing First projects become embedded and mature.
6. Joint working goes a long way … but is too often reliant on personal relationships and goodwill
Collective problem-solving overcame many operational challenges, but the resolution of issues often hinged on personal relationships between and/or the goodwill of individual stakeholders. This underscores the need for broader systems change to overcome the systemic and structural barriers to access housing and treatment that the target population faces. On a related point, there is a very strong call for cross-sector investment in Housing First given the benefits for service users and substantial potential for public cost offsets. In making a case for this, stakeholders should recall the origins of the Housing First approach, noting that it was not intended to be a ‘housing’ intervention, but rather a holistic service promoting the recovery of some of society’s most vulnerable members within which rapid provision of settled housing is but one (crucial) ingredient. On this, careful consideration should be given to where Housing First might ideally fit with respect to the proposed National Care Service in Scotland.
7. Fidelity to the core principles of Housing First is achievable … but also fragile
Most of the Pathfinder projects succeeded in operationalising the majority, if not all, of the seven principles of Housing First to a relatively high degree in the first two years of operation, albeit that deviations were evident in some areas (e.g. use of conditional tenancies for a few clients or higher than intended caseloads resulting from staff shortages). Changes in consortium composition and delivery in some areas during the third and final ‘transition’ year – including increased caseloads or pressure to limit the duration of support provided amongst others – generated concern that fidelity may have been weakened during the mainstreaming process. This is worrying given the potential negative influence on the likelihood of some individuals being accepted into Housing First and the adequacy (particularly intensity, flexibility, and duration) of the support received. There is a very strong call for fidelity to Housing First principles to be monitored closely going forward for these reasons.
8. Housing First staff have a tough gig … and should be supported (and ideally paid) accordingly
The success of Housing First hinges, in large part, on the relationship between frontline staff and individuals being supported. The support worker’s role is a difficult one given the challenging behaviours they often encounter, intensity of support required by many tenants, and barriers frequently encountered when brokering external support. The Pathfinder highlighted the critical importance of providing adequate levels of supervisory support and opportunities for reflective practice. Provision for clinical supervision, whilst only offered in some Pathfinder areas, was also regarded as good practice given the very real risk of staff exposure to vicarious trauma and/or potential burnout. Many stakeholders are calling for better remuneration for Housing First staff given the challenges of and specialist expertise required in the role so as to maximise providers’ prospects of recruiting and retaining high calibre staff.
9. Housing First works for most people it targets … but we still need solutions for others
Further reflection is needed regarding responses for people experiencing homelessness and multiple disadvantage but for whom Housing First is not an option because they either: a) lack capacity (due to cognitive impairment for example), b) have healthcare needs which exceed what can realistically be catered for, or c) do not want Housing First. Alternative 24/7 intensive support interventions are needed for the first two of these groups given that they require a care-led rather than housing-led solution. Further thinking and evidence are required to identify appropriate interventions for the third group, as well as for the minority of individuals who have been unable to sustain tenancies even with Housing First support. Devising solutions for them must remain a key priority for policy and research communities internationally going forward.
In conclusion, many valuable lessons were learned during the Pathfinder period, most notably that Housing First delivery in the Scottish context may well be difficult, but is achievable, and is very definitely worthwhile given the immense benefits for individuals who are poorly served by mainstream services, coupled with strong potential for public cost offsets to boot. Scotland has been heralded as an international pioneer in Housing First implementation given the level of political commitment the approach has commanded and recent pace of scale-up. Looking forward, we must hope that this level of commitment is maintained, and fidelity to the core principles of Housing First preserved, given the pivotal role that the approach can play in ending homelessness and promoting recovery for people experiencing multiple disadvantage.