Housing First is probably the single most important innovation in homelessness service design in the last 30 years. Developed by Dr. Sam Tsemberis in New York, the Housing First model has proven very successful in ending homelessness among people with high support needs in the USA and Canada and in several European countries.

Housing First is designed for people who need significant levels of help to enable them to leave homelessness. Among the groups who Housing First services can help are people who are homeless with severe mental illnesses or mental health problems, homeless people with problematic drug and alcohol use, and homeless people with poor physical health, limiting illness and disabilities. Housing First services have also proven effective with people who are experiencing long-term or repeated homelessness who, in addition to other support needs, often lack social supports, i.e. help from friends or family and are not part of a community. In the United States and Canada, Housing First programmes are also used with homeless families and young people.

Housing First uses housing as a starting point rather than an end goal. Providing housing is what a Housing First service does before it does anything else, which is why it is called ‘Housing First’. A Housing First service is able to focus immediately on enabling someone to successfully live in their own home as part of a community. Housing First is also focused on improving the health, well-being and social support networks of the homeless people it works with. This is very different from homelessness services that try make homeless people with high support needs ‘housing ready’ before they are rehoused. Some existing models of homelessness services require someone to show sobriety and, engagement with treatment and to be trained in living independently before housing is provided for them. In these types of homelessness service, housing happens ‘last’.

Housing First is designed to ensure homeless people have a high degree of choice and control. Housing First service users are actively encouraged to minimise harm from drugs and alcohol and to use treatment; they are not required to do so. Other homelessness services, such as staircase services, often require homeless people to use treatment and to abstain from drugs and alcohol, before they are allowed access to housing and may also remove someone from housing if they do not comply with treatment or do not show abstinence from drugs and alcohol.

In the USA, Canada and in Europe, research shows that Housing First generally ends homelessness for at least eight out of every ten people ((Based on a review of existing evidence, see: 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 http://housingfirstguide.eu/website/the-case-for-housing-first-in-the-european-union-a-critical-evaluation-of-concernsabout-effectiveness/.The figure refers to formerly homeless people housed for at least one year by a Housing First service (see later in this chapter for more details on the evidence for Housing First).  )). Success has also been reported with diverse groups of homeless people. Housing First has worked very well for people who are not well integrated in society after long-term or repeated homelessness, homeless people with severe mental illness and/or problematic drug and alcohol use and homeless people with poor physical health.

Housing First in Europe can be described as following eight core principles. These core principles are very closely based on those developed by Dr. Sam Tsemberis, who created the first Housing First service in New York in the early 1990s ((Tsemberis, S.J. (2010) Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction Minneapolis: Hazelden.)). These principles were defined in consultation with Dr. Tsemberis and the advisory board for this Guide.

Housing First was developed by Dr. Sam Tsemberis, at Pathways to Housing in New York, in the early 1990s ((Tsemberis, S.J. (2010) Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction Minneapolis: Hazelden.)). Housing First was originally developed to help people with mental health problems who were living on the streets; many of whom experienced frequent stays in psychiatric hospitals. The target populations entering Housing First later grew to include people making long stays in homelessness shelters and those at risk of homelessness who were discharged from psychiatric hospitals, or released from prison. With some modification to the support services, Housing First services are now also used with families and young people who are homeless in North America.

Before Housing First, permanent housing with support was only offered to homeless people in North America after they had graduated from a series of steps that began with treatment and sobriety. Each step on this ‘staircase’ was designed to prepare someone for living independently in their own home. When all the steps were complete, a formerly homeless person with mental health problems was meant to be ‘housing ready’ because they had been ‘trained’ to live independently. These types of services are sometimes called ‘staircase’, ‘linear residential treatment’ or ‘treatment-led approaches’.

These ‘staircase’ services and the ‘housing readiness’ culture had originally arisen from practice in North American psychiatric hospitals, where individuals with a diagnosis of severe mental illness were initially considered incapable of functioning in all areas of life and needed around-the-clock supervision and support. By the 1980s, North American mental health professionals were raising serious questions about the effectiveness of services based on these assumptions about severe mental illness ((Ridgway, P. and Zipple, A. M. (1990) The paradigm shift in residential services: From the linear continuum to supported housing approaches. Psychosocial Rehabilitation Journal 13, 11-31.)). However, a staircase approach became firmly established as the model for helping homeless people with high needs in North America.

European use of Housing First has been encouraged by the North American research results. Initially, the inspiration came from the original service developed in New York((Padgett, D.K.; Heywood, B.F. and Tsemberis, S.J. (2015) Housing First: Ending Homelessness, Transforming Systems and Changing Lives Oxford: Oxford University Press.)), then from other US Housing First services((Pearson, C.L., Locke, G., Montgomery, A.E. and Buron, L. (2007) The Applicability of Housing First Models to Homeless Persons with a Severe Mental Illness US Department of Housing and Urban Development: Washington DC. https://www.huduser.gov/portal/publications/hsgfirst.pdf)). More recently, some very successful results from the Canadian At Home/ Chez Soi Housing First programme, a randomised control trial (RCT) involving 2,200 homeless people comparing Housing First with existing homelessness services, have become influential in European debates((Goering, P., Veldhuizen, S., Watson, A., Adair, C., Kopp, B., Latimer, E., Nelson, G., McNaughton. E., Streiner, D. and Aubry,
T. (2014) National At Home/Chez Soi Final Report Calgary, AB: Mental Health Commission of Canada. – http://www.mentalhealthcommission.ca/English/system/files/private/document/mhcc_at_home_report_national_cross-site_eng_2.pdf)) (see Chapter 5).

Within Europe, the results of the Housing First Europe research project, led by Volker Busch-Geertsema, were among the first to confirm that Housing First could be successful in European countries((Busch-Geertsema, V. (2013) Housing First Europe: Final Report – http://housingfirstguide.eu/website/wp-content/uploads/2016/03/FinalReportHousingFirstEurope.pdf)) . A large-scale randomised control trial as part of the French Un Chez-Soi d’abord Housing First programme, being conducted by DIHAL, will provide systematic data on Housing First effectiveness across four cities in France, in 2016((Tinland, A., Fortanier, C., Girard, V.,Laval, C., Videau, B., Rhenter, P., Greacen, T., Falissard, B., Apostolidis, T., Lancon, C., Boyer, L. and Auquier, P. (2013) Evaluation of the Housing First program in patients with severe mental disorders in France: study protocol for a randomized controlled trial Trials, 14, p. 309)). A number of observational studies, that look at Housing First but do not compare it with other homelessness services, have also reported very positive results from Denmark((Benjaminsen, L. (2013). Policy Review Up-date: Results from the Housing First-based Danish Homelessness Strategy. European Journal of Homelessness, 7(2), 109-131 – http://housingfirstguide.eu/website/?p=4906)), Finland((Pleace, N., Culhane, D.P., Granfelt, R. and Knutagård, M. (2015) The Finnish Homelessness Strategy: An International Review Helsinki: Ministry of the Environment – https://helda.helsinki.fi/handle/10138/153258)), the Netherlands((Wewerinke, D., Al Shamma, S. and Wolf, J. (2013) Housing First Europe. Local Evaluation Report Amsterdam http://housingfirstguide.eu/website/housing-first-europe-local-evaluation-report-amsterdam)), Portugal((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 – http://housingfirstguide.eu/website/housing-first-anecological-approach-to-promoting-community-integration/)), Spain((https://www.raisfundacion.org/sites/default/files/rais/noticias/infografia_habitat_DEF_A3.pdf https://raisfundacion.org/es/informate/noticias_y_eventos/jornada-internacional-h-bitat https://issuu.com/rais_fundacion/docs/presentaciones_habitathf_web?e=5650917/30872088)) and the UK((Bretherton, J. and Pleace, N. (2015) Housing First in England: An Evaluation of Nine Services – https://www.york.ac.uk/media/chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf)). Collectively, these findings show that:

In Europe, Housing First is generally more effective than staircase services in ending homelessness among people with high support needs, including people experiencing long-term or repeated homelessness.

Housing First can be more cost-effective than staircase services because it is able to end homelessness more efficiently. Housing First may also generate cost offsets for (reduce the costly use of) other services. For example, Housing First may reduce frequent use of emergency medical and psychiatric services, prevent long and unproductive stays in other forms of homelessness service and lessen rates of contact with the criminal justice system.

Housing First addresses the ethical and humanitarian concerns raised about the operation of some staircase services((Sahlin, I. and Busch-Geertsema, V (2005) The Role of Hostels and Temporary Accommodation.Vid supra)).

In 2016, Housing First was becoming increasingly important in Europe. In some cases, Housing First was integral to comprehensive homelessness strategies, in others, experiments were still underway. The countries where Housing First was being used include:

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 http://housingfirstguide.eu/website/the-case-for-housing-first-in-the-european-union-a-critical-evaluation-ofconcerns-about-effectiveness/)).

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 – http://housingfirstguide.eu/website/wp-content/uploads/2016/03/FinalReportHousingFirstEurope.pdf)).

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((http://hf.aeips.pt/wp-content/uploads/2013/10/Pascale.pdf)).

Initial results from the Spanish HÁBITAT Housing First programme indicated extremely high levels of housing sustainment in late 2015((https://www.raisfundacion.org/sites/default/files/rais/noticias/infografia_habitat_DEF_A3.pdf)).

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. – https://helda.helsinki.fi/handle/10138/153258)).

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 – https://www.york.ac.uk/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 – http://www.neunerhaus.at/fileadmin/Bibliothek/Neue_Website/Neunerhaueser/Housing_First/20150925_HousingFirst_Report_english.pdf)).