Also available in: French

1.4. The Evidence for Housing First

1.4.1. Ending Homelessness for People with High Support Needs

Housing First services are very successful at ending homelessness for homeless people with high support needs. In most cases, European Housing First services end homelessness for at least eight out of every ten people((Pleace, N. and Bretherton, J. (2013) The Case for Housing First in the European Union: A Critical Evaluation of Concerns about Effectiveness European Journal of Homelessness, 7(2), 21-41

In 2013, the Housing First Europe project reported that 97% of the high-need homeless people using the Discus Housing First service in Amsterdam were still in their housing after 12 months in the service. In Copenhagen, the rate was 94% overall, with a similarly impressive level reported by the Turning Point Housing First service in Glasgow (92%). The Casas Primeiro Housing First service in Lisbon reported a rate of 79%((Busch-Geertsema, V. (2013) Housing First Europe: Final Report –

The French Un Chez-Soi d’abord Housing First programme reported interim results in late 2013, showing 80% of the 172 homeless people using Housing First services in the four city pilot sites had retained their housing for 13 months((

Initial results from the Spanish HÁBITAT Housing First programme indicated extremely high levels of housing sustainment in late 2015((

Finland has reported a fall in the absolute numbers of long-term homeless people following the adoption of a national strategy centred on using Housing First to end long-term homelessness. In 2008, 2,931 people were long-term homeless in the ten biggest cities. This number had dropped to 2,192 in late 2013, a reduction of 25%. Numbers of long-term homeless people fell from 45% to 36% of the total homeless population during the same period((Pleace, N., Culhane, D.P., Granfelt, R. and Knutagård, M. (2015) The Finnish Homelessness Strategy: An International Review Helsinki: Ministry of the Environment. –

In 2015, an observational evaluation of Housing First in England reported that, across five Housing First services, 74% of homeless people had retained their housing for at least 12 months((Bretherton, J. and Pleace, N; (2015) Housing First in England: An Evaluation of Nine Services – media/chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf)).

In 2015, the Housing First service in Vienna reported that, among all the service users worked with over a two-year period, 98% were still in their apartments((Neunerhaus (2015) Housing First Pilot Project Report – Neunerhaueser/Housing_First/20150925_HousingFirst_Report_english.pdf)).

Success rates in Europe parallel or exceed the results achieved in North America. US studies have reported rates of housing sustainment between 80% and 88%((Tsemberis, S. (2010) ‘Housing First: Ending Homelessness, Promoting Recovery and Reducing Costs’ in I. Gould Ellen and B. O’Flaherty (eds) How to House the Homeless Russell Sage Foundation: New York)). The recent evaluation of the Canadian At Home/Chez Soi programme reported that Housing First service users spent 73% of their time stably housed over two years, compared to 32% of those receiving other homelessness services((Goering, P., Veldhuizen, S., Watson, A., Adair, C., Kopp, B., Latimer, E., Nelson, G., MacNaughton, E., Streiner, D. and Aubry, T. (2014) National At Home/Chez Soi Final Report Calgary, AB: Mental Health Commission of Canada. – http://www. pdf)).

An international evidence review conducted in 2008 reported that between 40% and 60% of homeless people with high support needs were leaving or being ejected from staircase services before they were rehoused. This was in sharp contrast to Housing First services that were typically keeping 80% or more of their service users housed for at least one year((Pleace, N. (2008) Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from an International Review Edinburgh: Scottish Government –

As previously stated, Housing First is very successful at ending homelessness among homeless people with high support needs. However, there are some people, typically between 5-20% of service users, for whom Housing First is not able to provide a sustained exit from homelessness.

1.4.2. Health and Well-Being

Housing First can make a positive difference to the health and well-being of homeless people with high support needs:

  • In 2013, the Housing First Europe research project reported that 70% of Housing First service users in Amsterdam had reduced their drug use, with 89% reporting improvements in their quality of life and 70% reporting improvements in their mental health. Positive results were also produced by the Turning Point service in Glasgow, where drug/alcohol use was reported to have stabilised or reduced in most cases. In the Casas Primeiro service in Lisbon, 80% reported a lower level of stress. Danish Housing First services reported a more mixed picture, but 32% reported improvements in alcohol use, 25% an improvement in mental health and 28% in physical health((Busch-Geertsema, V. (2013) Housing First Europe: Final Report – uploads/2016/03/FinalReportHousingFirstEurope.pdf Some deterioration in health and well-being were also reported. Estecahandy P. A “Housing First” Trial in France –
  • In 2015, interim results reported from the French Un Chez-Soi d’abord Housing First programme((Tinland, A. and Psarra, C. (2015) Housing First: Lessons from France presentation at the IGH Homelessness in a Global Landscape conference, Chicago, June 2015)) showed that, in the six months prior to inclusion in Housing First, homeless people had spent an average of 18.3 nights in hospital. When they had been using Housing First for 12 months, the time spent in hospital in the last six months had fallen to 8.8 nights on average. Contacts with hospitals and the frequency of stays in hospital had fallen significantly.
  • The 2015 evaluation of Housing First in England found that 63% of service users self-reported improvements in physical health and 66% self-reported gains in mental health, with some smaller improvements around drug and alcohol use((Bretherton, J. and Pleace, N. (2015) Housing First in England: An Evaluation of Nine Services – media/chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf)).

Housing First, both in Europe and North America, has been shown to deliver improvements in health and well-being. Results can be variable – not all Housing First service users benefit from better health and well-being – but Housing First is able to deliver positive changes for many of the people using it((Pleace, N. and Quilgars, D. (2013) Improving Health and Social Integration through Housing First: A Review. Brussels: DIHAL/ FEANTSA integration_through_housing_first_a_review.pdf Johnson, G., Parkinson, S. and Parsell, C. (2012) Policy shift or program drift? Implementing Housing First in Australia AHURI Final Report No. 184 – Implementing_Housing_First_in_Australia.pdf)).

1.4.3. Social Integration

Social integration has three main elements:

  • Social support, which centres on someone feeling that they are valued by others, called esteem support; help in understanding and coping with life, called informational support; social companionship (spending time with others) and practical or instrumental support((Cohen, S. and Wills, T. (1985) Stress, Social Support and the Buffering Hypothesis Psychological Bulletin, 98, 310-357)).
  • Community integration, which can be tricky to define precisely, but which generally refers to positive, mutually beneficial relationships between Housing First service users and their neighbours. In a broader sense, community integration also refers to a homeless person not being stigmatised by the community((Pleace, N. and Quilgars, D. (2013) Improving Health and Social Integration through Housing First: A Review)). Housing First can help someone to adjust to new community roles, i.e. being a good neighbour.
  • Economic integration, which can mean paid work, but also socially productive or rewarding activities, ranging from participating in arts-based activities through to informal and formal education, training and job-seeking.

A key goal of Housing First (see Chapter 3 and Chapter 4) is to promote social integration in the community. Housing functions as the basis, or foundation, from which Housing First seeks to help a service user develop the social supports, community integration and economic integration that can improve their quality of life. Good quality social supports, living a life that involves positive engagement with the surrounding community and having a structured, purposeful existence, can all demonstrably enhance health and well-being((Ibid.)).

The Casas Primeiro Housing First service in Lisbon reported that almost half the Housing First service users had started to meet people in cafés to socialise, with 71% reporting they felt ‘at home’ in their neighbourhood and 56% reporting feeling part of a community((Ornelas, J., Martins, P., Zilhão, M.T. and Duarte, T. (2014) Housing First: An Ecological Approach to Promoting Community Integration European Journal of Homelessness (8.1), 29-56 – uploads/2016/03/Housing-First-An-Ecological-Approach.pdf)).

A recent evaluation of Housing First in England found that of 60 users of Housing First services, 25% had reported regular contact with their family prior to working with Housing First, rising to 50% once they were receiving Housing First support. Prior to working with Housing First, 78% of people were involved in nuisance behaviour, such as drinking alcohol on the street. This fell to 53% after they began working with Housing First((Bretherton, J. and Pleace, N. (2015) Housing First in England: An Evaluation of Nine Services chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf)).

There is qualitative research from both Europe and North America that shows that people using Housing First can have a greater sense of security and belonging in their lives than was the case before homelessness. This has been described as Housing First enhancing someone’s sense of security in their day-to-day life, or ontological security((Padgett, D. K. (2007). There’s no place like (a) home: Ontological security among persons with serious mental illness in the United States. Social science & medicine, 64(9), 1925-1936, p. 1934.)).

Evidence that Housing First has the capacity to help homeless people with high support needs into paid work is not extensive in Europe or North America, but it must be noted that the people using Housing First often face multiple barriers to employment. Housing First is designed to deliver improvements in health, well-being and social integration. Housing First is not presented, nor expected to be seen, as a ‘miracle cure’ or panacea that will rapidly end all the negative consequences of homelessness. Housing First successfully ends homelessness and that, in itself, creates a situation in marked contrast to the multiple risks to health, well-being and social integration that are associated with homelessness.