It’s a disarmingly simple idea: to fix homelessness, give homeless people a home. But does it work?
A decade ago the Rudd government launched a national campaign against homelessness, describing the problem in a country as wealthy as ours an “obscenity”.
Ten years later and we haven’t solved the problem, in fact we may be getting further away from a solution.
The Australian Bureau of Statistics says homelessness increased 14% between 2011 and 2016, with 116,000 Australians without a home, and an estimated 8,200 sleeping rough, on the streets or in makeshift shelter, on the night of the census.
In inner cities, the number of people sleeping in parks and sheltered nooks has become increasingly visible.
Meanwhile, the number of beds in hostels and dormitories for the homeless has been shrinking, explains Professor Olav Nielssen, a psychiatrist who has worked closely with the homeless over the course of his career.
He recently looked at the type of people who were coming through the mental health clinic he runs at in the Matthew Talbot hostel, as well as two other clinics in inner Sydney homeless shelters, and found that with the levels of mental illness and disability, past trauma and substance use, the current housing system was failing people.
People were coming out of psychiatric hospitals and prisons and falling through the cracks. Public housing was not working for many. We were approaching it all backwards.
Instead, he pointed to another idea that has been gaining traction in the field of homelessness, known as Housing First.
It’s a disarmingly simple idea: to fix homelessness, give homeless people a home.
It’s no secret that substance use disorders and mental health disorders are common among those sleeping on the streets or in precarious housing.
In Professor Nielssen’s study of 2400 individuals who came into the clinics over eight years, more than half were on the disability pension.Two out of every three had a substance use disorder and one in two had a psychotic illness, most often schizophrenia.
What Professor Nielssen found the most interesting when he looked through the history and medical records of these men were that one in five of them had actually already been in public housing and then been kicked off it or dropped out.
This was supposed to be the solution to homeless, he said. While Professor Nielssen praised the NSW housing department for prioritising people with mental illness and those who were currently homeless, supply wasn’t keeping up with demand. Nor was the available accommodation always suitable for this population.
These are often people who just can’t take advantage of the support that’s out there. In his study, many of the visitors had multiple disabilities.
Half said that they had experienced trauma as a child or an adult, and one in seven had an acquired brain injury.
So when it came to government housing, he said that many couldn’t keep it clean, couldn’t maintain rent, and so would eventually lose their tenancies.
Drinking and drug taking were both consequences and causes of homelessness.
It’s no great surprise that the stress and hardship of living on the street would make drugs more appealing, and when they are readily available and part of peer-pressure, it makes the problem worse.
At the same time, drinking and using drugs made it harder for these people to lock down secure long-term housing, both socially and financially, and in their ability to organise and maintain the house.
Homelessness, substance use and mental health problems are intermingled and acting on each other in complex ways. It is reasonable that governments, organisations and individuals have attempted to help people out of homelessness by helping with their substance use, or helping with their mental health problems.
Once those problems are sorted, people will be in a better spot to hold down a home and a job, the thinking goes.
But one Canadian town claims to have solved their homeless problem, and it wasn’t by doing either of those things, or funding new shelters. They simply gave homeless people homes.
In 2015, the town of Medicine Hat, Alberta, declared it had ended chronic homelessness.
In a deviation from many other approaches, they didn’t do it by offering more services for mental health conditions or substance use. Instead, they just gave any of the chronically homeless a home if they wanted it.
Individuals didn’t have to jump through any hoops or prove that they had participated in any programs, as the proponents argued that housing would come first and help them fix these other problems down the track.
Another feature of this Housing First model was that it zeroed-in on the long-term or chronically homeless, who are the most vulnerable population and the ones most likely to be using emergency services.
While specific numbers can be hard to come by, the majority of the homeless in Australia are not people living on the streets, but instead are sleeping in insecure or unsafe accommodation, such as couchsurfing, staying with friends or in boarding houses.
Most may only be homeless temporarily, but for the minority who are without a home for longer stretches the economic and wellbeing costs escalate.
In Medicine Hat and other places, the aim is to stop leaving people languishing in shelters for years and instead get them into secure housing as quickly as possible.
Medicine Hat and other regions that have taken this approach report that not only do they have high rates of people staying in the housing long-term, but that it does appear to help with mental health problems, people often report drinking less and doing fewer drugs, and there are heartwarming stories of people reconnecting with family and getting back into employment.
WHO IS GOING TO PAY?
Of course, it has been met with reservations. There is the aspect of worthiness, where the question is why do these people deserve the hand-out of an apartment with no strings attached. There’s also the question of who is going to pay for it.
As Professor Nielssen’s study showed, homeless people have complex needs.
One study from Melbourne last year put the cost of rough sleeping at $25,000 per person per year. People who are chronically homeless are more likely to use emergency services, costing the community in potentially avoidable emergency room visits, longer stays there, and more interactions with the criminal justice system through policing, jail time and court costs.
Internationally there is a growing body of research which indicates there are substantial cost-savings to be made by giving homes to the homeless. Australia’s better welfare net compared with countries such as the US means there are limitations to how translatable the findings are, however. So to test the economics out here, Associate Professor Cameron Parsell undertook an evaluation of one of Brisbane’s housing projects, known as Common Ground.
There are a number of Common Ground projects around major cities in the country, which essentially provide supportive housing to the chronically homeless, and are coupled with support and concierge services.
Professor Parsell, who runs a program on homelessness, health and wellbeing at Queensland University, found that if authorities committed to housing the chronically homeless, they could look to save around $13,000 per person a year.
Looking through data on emergency department presentations, ambulance use, in-patients stays, mental health visits, police arrests, custody, court appearances, prison, probation, parole time, victims reports and use of homeless accommodation services, Professor Parsell and his team estimated that each person who was chronically homeless in Queensland cost the government around $48,000 per year.
When people were invited into supportive housing, the costs were only $35,000, which included the $14,000 each year the costs of the housing and support itself.
What they also found was that once participants started to live in these apartments, other aspects of their lives tended to improve. Criminal offending, time in police custody, even being a victim of crime, all halved over the course of a year. People were using mental health services at only a third of the rate they were before.
So by putting the 41 tenants into housing, $832,000 was saved in healthcare costs, $123,000 in the criminal justice system and $169,000 in homelessness services.
Professor Parsell said that while there was an economic argument to be made for housing the homeless, that wasn’t the only one. “It’s very clear that for a certain minority, those in the chronically homeless category, it’s definitely cheaper to get them into housing,” he said.
“But for many, it’s possibly not cheaper. Just like it’s possibly not cheaper to send everyone to school to get a public education,” he added. “If we’re only doing it to save money, we’ll come unstuck.”
When people moved into housing, it gave them a sense of control over their lives, he said. People start being better able to manage their healthcare, to be able to cook healthy meals and to store and take their medications.
He said it was a myth that certain people weren’t “housing ready”.
“The idea that either they are not morally worthy, or not capable, of sustaining housing – the evidence now disputes that,” he said.
“Even if people continue to have an addiction, we don’t need to fix them first and house them second. The evidence is still that we house them first.”
Unlike Common Ground, where clients were clustered in high-density accommodation, Mission Australia trialled a slightly different approach, which had men scattered throughout different homes in the western Sydney suburb of Parramatta.
As well as helping individuals maintain their tenancies, the Michael’s Intensive Supported Housing Accord (MISHA) provided intensive care tailored to the individual’s needs and wishes and case workers going out to visit them.
This meant participants could choose when and how they accessed support, including medical, psychological, dental, social or vocational.
After two years, almost 90% of the men were still in their homes, mental health disorders had halved and substance use disorders dropped from 37% to 7%.
Echoing the findings of Brisbane Common Ground, they estimated that the program saved the government $8000 per person each year in health, justice and welfare costs, reducing it from $32,000 to $24,000.
One of the researchers on the project, Western Sydney University senior research fellow Dr Elizabeth Conroy, said that this study and others show the Housing First model is great at sustaining tenancies.
The high retention rates were even in the context of many having challenges typical of these types of programs, such as falling behind on the rent, nuisance complaints from neighbours and trouble maintaining the property.
This did mean that case managers had to spend quite a bit of time on tenancy issues, she explained. And there were also other issues that emerged over the two years.
Because MISHA launched around the time of the global financial crisis, Australia enjoyed a substantial injection of funds into the construction industry, meaning properties were available.
This isn’t necessarily going to be the case for future projects.
“To do Housing First, you need housing,” Dr Conroy said. “This is a significant investment, and Australia has quite a significant issue with housing affordability.”
Even then, there were still pockets of housing affordability that drove the decision of where to home people, and while services were available to help with community integration, isolation and loneliness were common issues.
An issue she commonly saw among people trying to avoid homelessness was that people would like to have the choice to live close to their friends, family and support network.
“But this isn’t always possible,” she said.
“They might have grown up in an area that was once low income, but the gentrification of that suburb means that as they mature they don’t necessarily have the option of staying in the same area.”
While they did see improvements when it came to hospitalisations and high cost health service usage, there wasn’t a tremendous change in terms of mental health symptoms.
Some missed the connections they had while they were homeless, Dr Conroy said. One client would head back to the city to a drop-in service to shower and eat, because that’s where their connections were.
So questions remained over whether putting people on their own was in the best interests of the client, Dr Conroy said, with some case managers reporting clients feeling alone and frightened in their own property.
One of the clients in MISHA wound up being evicted from their property because they had been stood over by a drug dealer who moved in and kicked them out.
“That person was then incredibly ashamed about what happened,” Dr Conroy said.
“But there is a vulnerability amongst clients with quite complex needs around their ability to assert themselves and to manage relationships and boundaries, and they can be preyed upon.”
So there was a tension between when an assertive personal agency approach needed to be balanced with a more direct-care provision, she said.
Overall though, men reported feeling safer in the accommodation. Although their paths were varied, it could take time, six months or more to open up and trust the case manager or psychologist working with them.
Thankfully a benefit of long-term housing, they have these longer time frames to work with.
The complicated needs and trauma many of the chronically homeless experience mean that simply putting a roof over their heads is unlikely to be the cure-all.
“If you have physical, mental and substance use health needs then you are much more likely to require treatment and more intensive support than if you just had one of those alone,” Dr Conroy said.
Any Housing First approach must therefore have a strong infrastructure to support it, she added.
“And if you’re going to use a watered-down version of Housing First, you can’t necessarily expect to have the same outcomes.”
Going forward, Dr Conroy said researchers and policymakers would need to understand which groups of homeless people this was best suited for in the Australian context compared with the other types of support systems we had in place.
Professor Parsell was also cautious about overpromising on Housing First, stressing that it wasn’t a panacea to fix a lifetime of exclusion or other problems causing or as a result of poverty.
And while he encouraged providing residents of housing with support, he also cautioned against too much of an interventionist approach, that could “trap them in a paternalistic support system”.
In the midst of all the talk of Housing First, experts are often quick to point to the pivotal role that housing affordability has on the issue.
Carolyn Whitzman, Professor of Urban Planning at the University of Melbourne, said the reason there was a 74% increase in people sleeping rough in Melbourne between 2014 and 2016 wasn’t down to a sudden huge increase in mental illness, for example.
“It’s because there is a lot less affordable housing than there used to be,” she said.
“Homelessness is a continuum, and homelessness is a function of a lack of affordable housing more than any other factor such as mental health et cetera.”
Contrary to what many would expect, this increase in homelessness wasn’t necessarily taking the form of older men with mental health issues, but younger people coming directly out of foster care and older women for example.
“Older women are the fastest growing group of people in severe housing stress, simply because the amount of affordable rental housing for low-income people bears no resemblance to either Commonwealth rental assistance or any kind of pension system for older people,” she said.
“So it’s not rocket science.”
