Learning from 25 years of preventative interventions in Scotland

9. Housing First Pathfinder (HFP)

Scotland’s Housing First Pathfinder: Reducing Homelessness in Scotland

Scotland’s Housing First Pathfinder (HFP) programme provided independent (self-managed) tenancies and support for 579 individuals in five urban areas to prevent homelessness. The programme ran from 2019 to 2022. An independent evaluation found the programme was positively received and was highly successful in providing sustainable housing solutions for homeless people with complex needs. However, evidence of the wider impacts of the programme on outcomes associated with homelessness within the evaluation period was mixed and complicated due to the effects of COVID-19. Initial analysis suggests that Housing First has the potential to result in significant cost savings for the Scottish Government over time.

Introduction

Housing First is an upstream primary prevention intervention aimed at people who have multiple and complex needs and who may have a history of rough sleeping and repeat homelessness. The Housing First approach ensures those with high support needs are allocated settled accommodation with intensive support. It was not designed primarily as a ‘housing’ intervention, but rather a more holistic service within which rapid provision of settled housing is one (crucial) ingredient.*

Context

In 2017 homelessness, though relatively stable, remained a significant problem in Scotland's four main cities despite the very strong statutory safety net introduced by the Homelessness etc. (Scotland) Act 2003. ^[203] Between a third and a half of people experiencing homelessness had complex needs compounding their homelessness; housing outcomes (in terms of the security of tenancy achieved and sustained) were less favourable for those people than for other homeless applicants. The time homeless people were spending in temporary accommodation was increasing, and the significant costs to the public sector of homelessness had been highlighted. ^[204]

The experience of homelessness was heavily concentrated amongst men aged under 45. People who had grown up in poverty and/ or had experienced poor outcomes in early adulthood, such as drug use or school exclusion, were more likely to experience homelessness.^[205]

In 2017, six focus groups with representatives from stakeholder organisations were convened for research commissioned by Social Bite to develop an evidence base to support action on homelessness.¹ There was a sense that the visibility of rough sleeping had heightened in tandem with more overt begging in city centres; participants emphasised the need to make progress on rough sleeping. In doing so, it was seen as important to take particular account of refugees who had no recourse to public funds, of the role of addictions as a factor in homelessness, and of the need to recognise different patterns of temporary accommodation provision between Scottish cities.

Alongside access to affordable housing, participants emphasised a need for 'assertive', 'sticky' and 'flexible' trauma-informed services working with rough sleepers and other homeless people with complex needs. Key areas of need recognised included substance use and employability. There was strong support for the Housing First model of rapid rehousing into mainstream tenancies with wrap-around support.

A 2017 research publication¹ broadly estimated the costs of implementing Housing First in the four main Scottish cities was £2.7m gross in year 1 (but only about £1m net once cost offsets to the public sector are taken into account), rising to £5.5m gross (or £1.96m net) in year 2. This was based on 470 adults with complex needs being resettled annually across all four cities, ranging from 35 cases per annum in Dundee to nearly 300 per annum in Glasgow. After those first two years an overall (net) saving to the public purse was anticipated; previous modelling^[206] based on 80 cases in five other UK Housing First initiatives suggested savings of between £893 and £7,700 per head in the second year.

Response

The focus group research informed recommendations to develop a Scottish approach to Housing First from both the Scottish Parliament’s Local Government and Communities Committee (following a cross-party inquiry into the scale and nature of homelessness in 2018) and the Homelessness and Rough Sleeping Action Group (a national taskforce charged with assessing how to better address and solve homelessness).^[207]

In 2018, in response to these recommendations^[208] the Scottish Government announced funding to support more than 800 vulnerable people with complex needs through a Housing First approach over three years, recognising that ‘a safe and secure home is the best base for recovery’. ^[209] Housing First, therefore, was intended to accelerate access to permanent accommodation, to allow service users to engage with support on their own terms, and to better coordinate different forms of support.²

Intervention

The Housing First approach was developed in the United States and departs from orthodox ‘linear’ approaches to homelessness by placing homeless people with complex needs directly into independent tenancies without first insisting that they progress through transitional housing programmes, prove ‘tenancy readiness’ or undergo treatment. There are seven principles: ^[210]

• People have a right to a home
• Flexible support is provided for as long as an individual needs it
• Housing and support are separate
• Individuals have choice and control
• An active engagement approach is used
• A harm reduction approach is adopted
• The service is based on people’s strengths, goals, and aspirations

Compelling international evidence indicated the effectiveness of this approach in ending homelessness for people with co-occurring mental health and/or substance misuse issues.^[211] Between 2010 and 2013, Turning Point Scotland delivered the first pilot Housing First approach in the UK, providing housing and support to 22 individuals in Glasgow who were homeless and actively involved in substance misuse, with positive results. ^[212]

Funding for the Pathfinder was provided by the Scottish Government (£5.8 million), Social Bite (£2.16 million, including evaluation costs), and Merchants House of Glasgow (£150,000). Scotland’s HFP programme was implemented in five urban areas (Edinburgh, Glasgow, Aberdeen, Dundee and Stirling) to provide independent tenancies along with flexible, non-time-limited support in homes and communities. Housing providers made available up to 830 one-bedroom flats specifically for people experiencing rough sleeping and complex support needs. Social Bite helped fund dedicated support to accompany the tenancies, appointing the Corra Foundation and Homeless Network Scotland to design and manage a collaborative commissioning structure. The programme ran from April 2019 to March 2022.

Monitoring and Evaluation

An external process, economic and impact evaluation ^[213] of the three year Pathfinder was commissioned from academics at Heriot Watt University by Corra Foundation with funding from Social Bite. This adopted a mixed methods approach drawing on extensive interviews, programme administrative and expenditure data, holistic needs assessments and service user surveys. The primary outcome for the intervention was housing retention; key secondary outcomes of interest included wellbeing and engagement with the health and justice systems. The evaluation also aimed to capture value for money.

Since 2021 a monitoring framework has captured progress on the scaling up of Housing First across Scotland as well as information on all new Housing First tenancies since 1 April 2021. ^[214] The monitoring framework collects data on household characteristics; referral routes to Housing First; support provision; and tenancy sustainment, as well as positive outcomes such as reduced support requirements.

Key Findings

a) Improved and Sustained Housing Outcomes

The main success of Housing First was in providing sustainable housing solutions for homeless people with complex needs. 579 individuals were housed over the Pathfinder period (Figure 1), mostly male (68%), White British (99%) and aged 26-49 years (65%). The Pathfinder attained tenancy sustainment rates of 88% at 12-months and 80% at 24-months overall, commensurate with those recorded elsewhere internationally. Many interviewees were surprised at these outcomes given the challenges to service delivery caused by the COVID-19 pandemic during most of this period.

Source: Tracker monitoring data. Base 579, in Johnsen, S., Blenkinsopp, J. & Rayment, M. (2022) Scotland's Housing First Pathfinder Evaluation: Final Report

b) Support in Addressing People’s Wider Needs

Housing First is intended as a holistic intervention that not only addresses housing needs but also the complex wider needs associated with homelessness. The evaluation therefore sought to capture impacts in outcomes for health, substance misuse, engagement with the criminal justice system and social support networks. However, the COVID-19 pandemic brought a concurrent negative impact on both service provision (e.g. through heightened staff absence) and many aspects of wellbeing (particularly mental health), as well as limiting the scope for data gathering on non-housing outcomes.

Nevertheless, some positive changes were observed. There was some reduction in service use, with a shift from the use of emergency health services toward treatment-based services. Service users emphasised the value of Housing First in enabling a sustained escape from harms associated with rough sleeping and homeless hostels, and providing a stable home to do ‘normal’ things which restored dignity and fostered recovery. While Housing First improved tenants’ lives in many ways, it did not counteract entirely their pre-existing disproportionate risk of premature death.^[215] Six percent of individuals housed by the Pathfinder sadly passed away, with most deaths reported to be substance misuse related.

Service providers interviewed emphasised the time taken to establish relationships and the significance of ‘small steps’ or incremental changes for an individual’s recovery journey, which may not be captured by mainstream monitoring tools. Sustainable positive outcomes were felt likely to take some years to attain given the complexity of the challenges that service users faced; in the context of pandemic impacts on service provision, positive outcomes for many individuals were not necessarily seen as achievable within the Pathfinder timeframe.

c) Cost effectiveness

The combination of a small sample, the complexity of these tenants’ needs and the time frame for the evaluation meant the study could not assess value for money conclusively. Over the Pathfinder period, the average annual costs per person housed fell to £5,632 (comparable to other UK studies). The combined annual cost of homelessness, police, criminal justice and health services per client at baseline was estimated to average at least £23,000. Findings from a small quantitative sample and qualitative data indicated a strong potential for benefits to exceed costs over time.

Learning and Next Steps

In 2021, the Scottish Government’s long-term national housing strategy Housing to 2040 included a commitment to continue scaling up Housing First, with the aim for this ‘to be the default option for [homeless] people with multiple and complex needs’ (p35).^[216]

Rollout of the programme in collaboration with COSLA is ongoing.¹² This work is coordinated by Homeless Network Scotland, who provide coordination to monitor progress on systems change, support local authorities to design services,and collect data on the numbers of people supported. As of 31 September 2024,^[217] 27 Local Authorities were operating a Housing First programme. 1,206 tenancies have commenced since 1 April 2021 (ranging from 123 in Renfrewshire to less than 5 in Highland). With an 85% sustainment rate over 12 months, the programme demonstrates effective support and housing stability for participants. Out of the 1,003 active Housing First tenancies, 17 local authorities have 109 tenancies in which 190 children are resident, an increase of 172 children in 30 months. Twenty six Housing First participants are employed either full-time or part-time, and 10 participants are engaged in voluntary work.

Scotland has been heralded as an international pioneer in Housing First implementation in an international review of best practice, with the level of political commitment the approach has commanded and pace of scale-up being noted.^[218] The Scottish Drug Deaths Taskforce recommended in 2022 that the Scottish Government continue to support and expand delivery of Housing First and endorsed the application of some of its principles as best practice for other services.^[219]

The Pathfinder programme was seen to have acted as a sector ‘disruptor’: changing how services worked together to address complex needs, raising the priority accorded to Housing First in policy debate and catalysing wider adoption. Key lessons included that the time required to develop partnerships with key stakeholders across relevant sectors should not be underestimated. This was seen to underscore the need for broader systems change to overcome the systemic and structural barriers to access housing and treatment.¹¹

Despite its successes the programme has faced challenges, such as long waiting periods for tenancy placement and unmet support needs, particularly in mental health services. Changes in consortium composition and delivery in some areas during the third year – including increased caseloads or pressure to limit the duration of support – generated some concern that fidelity may have been weakened.¹¹

Homelessness as a policy area has a strong focus on upstream prevention, making it more complex to demonstrate causal attribution between policy and outcomes. Policies in areas including affordable housing, anti-poverty, education, justice etc. all contribute towards homelessness prevention, and cross-sectoral funding input has been called for so that responsibility for its ongoing delivery does not fall solely to the housing/homelessness sector.