Transcript for episode 5, ‘Housing First: Are we one step closer to ending homelessness?’.
Zina Smith
Welcome to the latest episode of CT Brief Honest conversations. This complements our latest CT brief, which is now live on our website and focuses primarily on health care and support issues. Today we’re really pleased to have seated directors Liz Zacharias, who leads on our health care and support work, and Catherine Little, whose work includes governance, regulation and risk.
Here to discuss housing first and CT’s work evaluating two of the government’s national pilots. Liz and Catherine, consider some of the interesting findings from our local evaluations for West Midlands Combined Authority and Liverpool City region combined authority, as well as what some of the main hurdles are to housing first being adopted at a national level. We hope you find it a useful and interesting discussion.
Catherine Little
Liz, what are some of the key findings and lessons we could take away from the local evaluations that CT carried out?
Liz Zacharias
Quite a lot of findings, actually. I mean, I think some of them are around the way that the support workers worked with the individuals who were part of the housing first pilot. Lots of stuff around multi agency working housing provision, graduation rates, graduation, I. E. Meaning that people step down from housing first. So, for example, one of the most interesting findings was, which was a kind of unintended consequence, really, in that for all the housing first pilots, access to housing and availability of housing has been a real, real challenge because we’re living in the middle of a housing crisis. So once people got signed up for the service, there was a waiting period before they got housed. And for some of that period, maybe people were actually in hostels or were still rough sleeping. And one of the things that happened was that the workers to put time into engaging with people, so giving practical kind of support during that period, so purchasing people phones so that they’d be able to maintain contact with them, giving them food, helping them with any kind of issues that they had while they were still in this kind of temporary or rough sleeping phase before going into the housing first period. And that wasn’t actually part of the project, but that period was really helpful in terms of building up that relationship between the worker and the person.
Catherine Little
Did that start to build more formally into the process?
Liz Zacharias
Not really, because in a way, I think what we recommended was that that period should be seen as part of the housing first sort of process. But actually, we didn’t want to kind of recommend that that happened per se, because the only reason it happened was because there wasn’t enough housing. And if there was a kind of cab rank or pipeline of housing for people to go into, then that relationship building would have had to be done in situ during the sort of process of getting somebody into the housing and things like that. And I mean, I think the other thing that helped there was that people had personal budgets, so once they were allocated a flat or whatever, then they had a personal budget which helped with things like furnishings and getting the sort of property to look how they wanted it to look, which was really kind of helpful. And it meant the money was just there quickly. There wasn’t a need to sort of apply through, I don’t know, universal credit or apply to charities or whatever. Although some people did that, there was a pool of money there that could help that, and that helped people to sort of settle in and to actually commit to the housing that they’d been allocated.
I think I talked earlier about the way that staff worked with people, so I think some of that was around persistence, really being persistent and being willing to try again. You try something, it doesn’t work, you try something else that doesn’t work, you try something else. And that kind of stickability and the ability to sort of just stay with it and just try any different way you could to sort of resolve that person’s issues or to kind of get things kind of sorted or get them to a point where they’re a bit more kind of stable in their housing and engaging with other services that they needed to engage with. That was a really key part of the way that the staff worked. I think the other part of it that came through to us was that the multi-agency working bit is absolutely essential. And actually, housing first isn’t just a housing solution, it’s a system solution. And that different parts of the system, whether that’s health, social care, substance misuse, mental health services, whatever, all of those different parts of the system had to be kind of committed to playing their part strategically and operationally.
And where sometimes you got one but not the other, it just didn’t work whichever way round it was. So the people at the top might be strategically committed to it, but the people who are actually on the ground doing the work in those different systems, right, if they didn’t understand what it was, who it was for, what role they had to play in it, then it didn’t work. And sometimes you maybe got really good, committed people on the ground, but because there wasn’t the strategic buy in, it was kind of just one good social worker or one good health worker or something, or one good service, rather than a kind of whole systemic thing that was sort of saying, actually this is a group that’s been failed and failed again, and now is an opportunity to maybe try and change some of that.
Catherine Little
I think what you’re saying really fits with my kind of step back understanding of housing first, in that it just seems like a win-win approach in terms of outcomes for people who’ve experienced homelessness through to you’re talking, the evaluation around housing first is more expensive, but the outcomes are so much better that I think it was 2.5 times as effective in terms of every pound you spend. And presumably that runs across that network of partners that you were talking about. Social care, housing, criminal justice.
Liz Zacharias
Yeah, I think one of the things that we found, actually, and you do find with these kinds of services, but with housing first, people don’t cost very much because they’re not engaging with services. So once you get them into housing first, they do become quite expensive because they are now engaging with services that they haven’t engaged with before. But actually, over time, as that settles, then they’re using services in a planned way. So they’re going to the GP rather than turning up at A and E, for example, or they’re not getting custodial sentences because they’ve got that kind of stability and other things are sort of happening for. There’s. One of the things we weren’t able to do was look at cost avoidance in much detail. So, I think there’s still some work to do around that. And actually, in the Liverpool city region, there was another bit of work that was commissioned by them that looked at individual kind of customer journeys and was able to kind of model some of that more individualised cost avoidance. What we could do was actually look at it on a system wide sort of basis. But one of the things we did find was that, for example, in the Liverpool city region, I think there was about 1415 people that had undiagnosed learning disabilities that were actually.
They were assessed and they were able to have that need addressed, or that support issue addressed where it hadn’t been sort of picked up before. So that engagement.
Catherine Little
So it strikes me you’ve talked quite a lot about the role of the staff there in terms of being really person centred, really tenacious, not giving up and kind of following up on people rather than giving up on them. And also, I suppose, understanding the systems out there that you need to navigate. So learning difficulty, diagnosis, mental health, perhaps. And I suppose I just wonder how difficult it was. Did that come up in the evaluation? How difficult was it to find the right people and to train them and to provide that kind of, perhaps, peer support? Because it must be a challenging role, very rewarding. But challenging as well, I think probably.
Liz Zacharias
In terms of recruitment and retention of staff. I think there’s a big issue across the board. I think some of the housing first roles appeal to people that have got a kind of track record within the world of rough sleeping. It’s a pilot, it’s something new. There’s quite a lot of resource being put into the pilot. So, in some senses, it’s actually an attractive sort of role for someone who’s got that kind of commitment and sort of career progression and commitment to sort of really making a change in terms of rough sleeping. And I think the other thing that was helpful was that the pilots, there was kind of clinical supervision and there was psychology sort of input in terms of supporting workers with difficult cases that they’ve got people that they’re working with who have got quite a lot of challenges. There was some of that kind of backup in built, and there was also kind of peer learning and that kind of additional sort of support that was available, which I think was really valued.
Catherine Little
That makes sense. And I suppose, having read that, the evaluations, they really seem to make the case in terms of longer-term cost savings, as we said, as well as outcomes for individuals. But I wonder what some of the main hurdles are in housing first being adopted at national level and how, as a sector, might we try and overcome those?
Liz Zacharias
Yeah, I mean, I think the biggest hurdle actually is access to housing, because we’re in the middle of a housing crisis. The access to social housing in the right location is really critical. And actually, the fact that the pilots took time to ramp up to sort of full capacity, and that was because of the availability of suitable units. And I also think that because it was a pilot, the funding was time limited, although it’s kind of been extended a little bit, but it was time limited. And so there was a lot of kind of nervousness on the part, particularly of housing associations, to engage with it. Some of them really sort of could see it and really went for it, but others were much more kind of risk averse in that way. And I think that certainly one of the things that was happening in the West Midlands was that they developed a kind of protocol around how it was all going to work and the housing providers were brought into the fold of the service, if you like. And there were discussions about, and I think the same with the Liverpool city region, but I think the access to housing is critical.
There was very little use of private rented sector. We thought there was possibly a bit more that could be done on that score. But again, I think that would require things you’d need to have quite a lot of good sort of risk sharing. I know one of the housing first services in the West Midlands, one of the things they were exploring was about paying for insurance for landlords to cover sort of damage and things like that. So I think that way of working and risk sharing is really important if you’re going to overcome this kind of lack of housing and landlords have got other options, less risky options, possibly. So needing to look at, de-risking it, I think, is very important as far as you can. So that’s that. I think the other thing to note is that it is actually expensive. Caseloads are low. It’s only like between one to five and one to seven, as opposed to maybe most floating support services, where it could be anything from, I don’t know, one to 15 to one to 50 and beyond. So that’s expensive. And I think the other thing is to remember that it doesn’t work for everybody.
There were instances of people being cuckooed, and so as part of the housing first programme, there needs to be a kind of partnership and a way of working with that, and a way of actually assessing the risks of that and working with people to sort of look at how they can reduce their own risks in relation to that, but also that the partnerships are there. And if there is an issue that people can jump in very quickly to try and sort of mitigate that or move people, I think a much more flexible, kind of managed moves approach is really important as well.
Catherine Little
That already makes sense. So, essentially having enough properties, having the right funding and having the right partnerships, where people are really set up to succeed with the support right across the board of whatever it is they need. And I suppose I was thinking about this question of how we crack this nationally and add another couple of thoughts. Liz, the first was something you’ve mentioned around understanding of housing first, and perhaps housing first as part of a housing led system, rather than just a bolt on to a kind of rationed, pathway-based approach to homelessness. And that feels like a big shift is needed in our understanding of homelessness and how we resolve. Well, we hopefully resolve it. The other thing is political will. And it just strikes me that these are three city regions, each with their own mayor, who is kind of a figurehead, I suppose. And, you know, Andy Burnham in Manchester kind of comes to mind, in particular because of the pledges he’d made. But all three of the city regions that have done, the pilots, have got this mayor in position. It just makes me wonder how that works across the counties with district authorities in place, with the kind of dual layer local government, particularly where you’ve got different political parties, perhaps, and how you get that kind of long term joined up political ambition to work together to end homelessness.
Putting aside political differences almost, I suppose, I wonder what role the integrated care systems might have in moving some of that forward. But perhaps we’re not quite there yet. What do you think?
Liz Zacharias
I think the overarching thing is the kind of partnerships at a local level and the commitment to sort of drive it through. And I think the mayors signing up to it was obviously really key and there was a real sort of driver for it. But I think the other thing that was really because you could have had that two-tier kind of conflict if it hadn’t worked very well, because you still had local authorities that are responsible locally for rough sleeping and homelessness. And it was the quality of the kind of work that went on the regional level with the mayor’s area level as well as the local level, and the quality of those partnerships that was really important. I think in terms of looking at it from district and county, that partnership dynamic would still. It’s just on a different scale. And I think you can’t do it. It shouldn’t be a stopper, but you can’t do it effectively without both parts of that relationship being signed up. I think in terms of integrated commissioning arrangements, personally, I think they do have a role to play. I don’t think they have played a role.
They were just coming in last year and I think they’ve still got a long way to go until they get kind of bedded in and sort of are working effectively. But I think what’s really interesting is, like, for example, the nice guidance on working with homelessness and rough sleeping, and since COVID the acknowledgement of inclusion health issues and how, yes, there are cohorts of people that have got kind of health issues that haven’t been part of the kind of health system before. So I think that’s the way in, if you like. It is through the kind of inclusion health element of that, and the fact that people do haven’t been getting the kind of health service that maybe they should have had. And there’s a lot of kind of obviously cumulative physical mental health issues. So I think housing first has to be seen within that kind of health context as well. One of the biggest issues is access to mental health services, actually, and how flexible or not those systems are to this sort of group of people who are very sort of marginalised.
Catherine Little
And I suppose coming back almost to where we started, to me that’s the biggest finding from this, is just that although the cost to some of those services are bigger to begin with, the outcomes and actually the costs longer term really make the case very strongly.
Liz Zacharias
So, Catherine, I know you were involved in homes for Kathy. I’m just wondering what that was about in terms of and any kind of links around housing first in relation to that.
Catherine Little
Yeah, there’s definitely links, Liz. So Homes for Cassie is a coalition of housing organisations and really it started off with the housing associations from the 60s, from the Kathy come Home era, the Ken Loach film, and recognising that years later, unfortunately not much had changed and kind of reaffirming, I suppose, the commitment to the reason those housing associations were established and that was important, I think, for a few reasons. One is quite often you go to a housing conference and it’s all housing providers, you go to a homelessness conference and it’s all homelessness organisations, and sometimes you kind of think, well, never the twain shall meet, and how silly, when they should be working in partnership. So, I think that’s been really powerful through homes for Cathy. The other thing is what they did was produce nine commitments and asked housing associations to sign up to them. And the reason that’s really important is the regulation of housing associations is such that allocations have to be fair, they have to make best use of available stock, and they do have to support local authorities in discharging their homelessness duties. But this is not a very active requirement if housing is the solution for homelessness, with whatever level of support, and housing first being one of those, I think that the case that the Homes for Cathy campaign has made is really, it ought to be considered within the regulatory framework and housing providers should be held to account around evictions, around tenancy sustainment and also around access to housing, because, as you mentioned, in terms of housing first, there needs to be something alongside perhaps the core purpose and mission of a housing association that encourages a bit of risk in terms of letting homes and that’s not consistent, I would say.
Liz Zacharias
No, I agree. In fact, I think, if anything, it’s got a bit worse.
Catherine Little
I’ve certainly heard that a bit from some local authorities I’ve worked with, and I think it does vary enormously. But if it’s not kind of on the top of the list, if it’s not on the radar, as consumer regulations coming up and a lot of changes are happening, kind of what’s going to focus the mind and what’s going to make us look at? Well, how are we making sure people get a home and can stay in their home and have the right level of support to do so? So, we talked about some of the barriers to upscaling international level and we know there’s a lot of smaller housing first work going on around the country. It just strikes me that kind of joining up, that learning is really key so that organisations can see how they do de-risk it, how do they make it person focused and how do they learn lessons that you’ve covered in the evaluations in the two of the three pilots.
Zina Smith
Thanks Catherine and Liz for that insightful discussion. You can find out more about these housing first evaluations and the CT brief on our website and in links with this episode. If you have any questions, comments, or insights you’d like to share, send us a message via our social media or email us on comms@campbelltickell.com
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To discuss the issues raised in episode 5, contact Catherine Little on catherine.little@campbelltickell.com 0r Liz Zacharias on liz.zacharias@campbelltickell.com
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