Tamsin Stirling reflects on seeing a Housing First service in practice in Lille.
In October 2016, I joined a CIH South East Branch study tour to Lille in north east France. The trip was hosted by ABEJ (Baptist Association for Mutual Aid and Youth), a third sector organisation that specialises in working with homeless people with mental health and other challenges. ABEJ provides a wide range of services in Lille, including a Housing First project.
Since 2011, a government-led trial of Housing First (the Un Chez-Soi d’abord programme) has been taking place in four French cities – Paris, Marseilles, Toulouse and Lille – initially for three years but since extended to 2016. A randomised control trial approach is being used, with eligible individuals either allocated to Housing First or existing services. The trial aimed to:
‘Provide and evaluate new solutions for access and retention in housing, access to health care, human rights and citizenship of homeless people with severe mental disorders and high needs.’
A significant budget was allocated from both the Ministry of Housing and the Ministry of Health and there is a national co-ordinator across the four cities. The trial is also supported by academic research which has tracked more than 700 participants in both groups – Housing First and existing services.
The approach to Housing First in France draws strongly on the Canadian Chez Soi programme. In each city, a management committee involving all participating organisations, including health and social care, is in place. At an operational level, Housing First comprises:
- rapid access to self-contained housing units with security of tenure (with no pre-conditions such as a requirement to receive treatment)
- priority given to user choice, respect and empathy
- recovery orientation and harm reduction approaches
- a flexible, open ended offer of floating support
- a client-centred approach and individual support plan
- high degree of staff availability to users, with each member of staff working with no more than 10 clients
- multi-disciplinary teams.
In Lille, housing is provided by private sector landlords, with ABEJ sourcing properties and holding the legal agreement with the landlord (and guaranteeing rent) until the client is ready to ‘take over the keys and rent’. If a particular individual is not able to keep a flat due to anti-social behaviour or other issues, then ABEJ will find another. An example was given of a client who was in his seventh flat.
The nature of the multi-disciplinary team providing Housing First was central: social worker, nurse, psychologist, psychiatrist and peer support worker, with health staff paid for by health budgets. There are four nurses in a team of 22 staff providing services for up to 100 clients. All members of the team carry out the same range of tasks based on the principle of recovery and focused on supporting people to ‘find their place in the city again’. The work of the team was described as ‘helping people to live normal and happy lives, to understand their mental illness and live with it’. A client said to us: ‘I am someone – I am respected – I can live my life’.
The social workers in the team, who we might refer to as support workers, are all professionally qualified. They have 3-year diplomas during which they specialised either in child protection, or working with marginalised people.
The team at ABEJ noted that the four cities in the trial are very different in many ways, including geography, access to housing and the organisation of psychiatric services. Lille has a good range of mental health services both in institutions and in the community and ABEJ has a track record of effectively integrating health into its services.
After we returned from the study tour, Vincent Morival at ABEJ let us know that the Housing First trials in the four cities are to be made into a permanent project and Housing First extended to a further 20 cities between 2018 and 2023. Full results of the trial will be shared at an event to be held on 6 April 2017 in Paris.
Summary findings are that participants in the Housing First group showed a very important decrease in the length of hospitalisations, but no decrease in the number of visits to A&E, GPs or imprisonment. However, real stability in housing, improvement in overall health and quality of life were experienced by participants in the Housing First group. No predictive criteria were identified regarding the capacity of an individual to live in independent accommodation, supporting the notion that Housing First should be tried first. The programme also managed to break down some barriers between social, medical and housing services. The cost of the project is estimated at €14,000 a year and the ‘avoided costs’ €18,000 a year.
The challenges faced during the trial sound familiar – access to affordable housing, the poverty of clients affecting their ability to take over tenancies, the stigma faced by clients in accessing employment and segmentation of housing, health and social care services. The national co-ordinator noted resistance to change from various stakeholders, with Housing First seen as competing for money and ideology of service provision. What was less familiar, certainly to me, was observing the degree of integration of health services and practitioners within Housing First in Lille, something that still seems a long way from much practice in the UK.
Tamsin Stirling can be contacted on tamsin.stirling@dial.pipex.com, @TamsinStirling