CPD module: evaluating the impact of Housing First in the UK

Housing First is an approach to supporting those who have experienced chronic homelessness. Both a philosophy and a specific intervention, it has been used to enhance and strengthen responses for individuals with long histories of homelessness.

In some countries, the evidence base for the approach is strong. In others, including the UK, the picture is less clear. This CPD article considers the Housing First approach and its evidence base. It outlines the origins
of the model, the reasons behind its widespread adoption, and what is currently known – and unknown – about its impact.

The Housing First model was pioneered in the US in the 1990s and represented a fundamental shift in supporting those experiencing chronic homelessness – defined in the US as long-term homelessness alongside mental illness or substance misuse issues.

It challenged the traditional, treatment-first approach, in which individuals were expected to meet certain conditions, such as sustained sobriety or mental health stability, before being provided with permanent housing.

Instead, the Housing First model involves immediate access to stable housing without preconditions. It is grounded in the belief that housing is a basic human right and a necessary foundation for recovery and personal stability.

This approach recognises that people who have endured complex trauma – including experiences of violence, childhood abuse, time in care, or military service – should not have to prove their ‘housing readiness’ to access a permanent home.

The model was developed by Dr Sam Tsemberis, a clinical psychologist working in a New York hospital. Observing that many of his patients were homeless, Dr Tsemberis realised it was impossible to address their mental health needs without first resolving their housing situation.

He founded Pathways to Housing, a non-profit organisation, to develop and pilot the model and so it is sometimes known as the Pathways model. The success of this pilot led to wider adoption and the eventual scaling of Housing First across the US, including its integration into federal homelessness policies.

To date, 12 significant studies have compared the impact of Housing First to traditional, treatment-first approaches. These include studies of types considered the gold standard in evaluation science.

This evidence consistently demonstrates that Housing First increases housing stability and reduces chronic homelessness.

It therefore positions Housing First as an ‘evidence-based’ intervention – especially notable given that few other homelessness interventions have undergone such rigorous evaluation.

The strong evidence for Housing First has contributed to its widespread adoption. In the US, it is central to the response to chronic homelessness and is embedded in government policy. Many other countries, including the four nations of the UK, have also introduced the approach.

• In England, the 2017 Autumn Budget allocated funding for three Housing First pilots in the West Midlands, the Liverpool City Region and Greater Manchester. Separately, individual organisations across the country have adopted Housing First approaches.
• In Scotland, a 2018 government report on ending homelessness committed to “a national shift towards rapid rehousing by default, including Housing First”. This prompted the launch of the Housing First Pathfinder programme in 2019, rolling out the model across multiple local authorities. Individual organisations and local authorities have also adopted Housing First, embedding it further into Scotland’s strategy to end homelessness.
• In Wales, the government has funded pilots of Housing First programmes, signalling support for wider implementation through reports published in 2019. These efforts laid the groundwork for broader adoption across the nation.
• In Northern Ireland, government-supported pilots have also taken place. The Northern Ireland Housing Executive’s homelessness strategy for 2022-2027 makes “a long-term commitment to the extension of… Housing First provision”, embedding the model into the country’s strategic approach to addressing homelessness.

In 2016, Professor Nicholas Pleace of the University of York’s Centre for Housing Policy wrote Housing First Guide Europe. This examined how the approach had been implemented across the continent, including in
the UK.

Professor Pleace noted that “the core principles of Housing First in Europe are drawn directly from the Pathways model” developed by Dr Tsemberis. However, he emphasised that in implementation “there are significant differences between some European countries and North America, and between European countries themselves”. He concluded: “The core principles for Housing First in Europe do not exactly mirror those of the original Pathways model.”

Housing First, as originated by Dr Sam Tsemberis (above), is a very precise service delivery model.

It is a specific intervention that was implemented in a certain, consistent way and then its impact scientifically evaluated.

Dr Tsemberis has described Housing First as a complex clinical and housing intervention comprised of three major components:

a) Programme philosophy and practice values

b) Permanent independent housing

c) Community-based mobile support services

He adds that “each of these factors includes both structural and operational aspects”.

The model is specifically for those who have experienced chronic homelessness. In the US, this is defined as someone who has been homeless for the long term and who is also living with either substance misuse or mental illness.

Housing First as originally conceived has five key tenets:

1. Consumer choice: Housing First programmes offer people choice over where they live, and influence over
what support is provided to them.

2. Separation of housing and treatment: Access to housing is immediate. Engagement with treatment, or being free of substance misuse, is not a prerequisite to a home.

3. Provide services to match needs: Housing First provides or co-ordinates a range of services for those in the programme. These go beyond those focused solely on housing.

4. Recovery-oriented service philosophy: Continuing support is provided to those in the programme. That support continues for as long as the individual needs it.

5. Social community integration: Housing First provision is not separated from wider communities. Housing is ‘scattered’ – in other words, there are not specific streets, neighbourhoods or buildings which are Housing First. Properties are instead spread within communities and individuals are supported to live as a full part of those communities. Homes are provided on a permanent basis.

It is difficult to reliably assess the current impact and effectiveness of Housing First approaches in the UK, to confidently state that they are making a difference compared to “business as usual”, or to state that the impact they are having is likely to be as big as that seen in North America.

There are several reasons for this uncertainty:

• Divergence from the original model: As Housing First Guide Europe makes clear, the term ‘Housing First’ denotes a broader set of practices in the UK than those defined by the original Pathways model. In many cases, UK programmes incorporate aspects of the model’s philosophy without strictly adhering to its original framework. Sometimes the approach has been subsumed into existing approaches. This deviation means that the results from the studies in North America, which evaluated a highly structured version of Housing First, cannot be directly applied as evidence for the varied implementations seen in the UK.
• Broader target population: In the UK, Housing First is frequently extended to people beyond those experiencing chronic homelessness, the group for which it was initially designed and rigorously evaluated. This broader application can dilute the comparability of outcomes with the North American context, in which the intervention’s success came from being targeted at those with the most complex needs.
• Different context: The original model was developed in a very different context from the UK’s. The US has a weaker social safety net, with limited state support available throughout people’s lives. For those experiencing chronic homelessness, large congregate shelters were often the default before Housing First. In the UK, emergency accommodation tends to be higher quality, with smaller, self-contained options more common. Longer-term solutions were also more available. For example, London’s Clearing House model, established in 1991 and co-ordinated by housing associations with support from the Greater London Authority, embodied many Housing First principles, offering stable, unconditional housing with support.
• Limited robust evidence: While some evaluations of UK Housing First pilots have been conducted, they are less rigorous than those which have taken place elsewhere. This limits the ability to make definitive conclusions about the causal impact of UK programmes.

These factors collectively make it challenging to gauge the effectiveness of UK Housing First programmes with the same level of confidence as their North American counterparts.

While existing evaluations of Housing First in the UK show promising results, the lack of gold-standard trials makes it difficult to measure the approach’s precise impact here. This hinders efforts to scale the approach and allocate resources effectively.

Ideally, there would be a large-scale trial across the UK. The devolved nature of homelessness policy may make this impractical, however, and so the next best option would be randomised controlled trials in each of the four nations. Synthesising findings from these trials with international evidence would deepen understanding of how Housing First performs in different contexts.

Such studies are resource-intensive, but conducting them across key UK regions could help manage costs and enhance the reliability of the findings.

There are also bodies with the expertise available to support such trials, such as the Centre for Homelessness Impact.

Individual service delivery organisations could make changes to improve their understanding of the impact of their Housing First work.

Some of these changes could also be applied more broadly and include:

• Being open to participation in evaluation processes run by external partners: The Centre for Homelessness Impact, for instance, runs a Test & Learn programme.
• Becoming more disciplined in documenting models: What precisely does the intervention involve? What outcomes are expected? How will they be measured, by whom and when? Ensuring consistent use of established terminology is key – misuse or varied interpretations can lead to confusion. Clear definitions within and between organisations help to ensure everyone is on the same page and support meaningful comparisons.
• Taking care with fidelity to existing models: Where a specific model is being implemented following success elsewhere, ensure that it remains faithful to the original intervention and is not subsumed into an existing model. Where practice diverges from the original model, be clear on the nature of this difference and the reason for it, and document both.
• Being precise with target groups for an intervention: Housing First, as originally designed, was for a very specific group of individuals. In the UK, it has been applied more widely but often in an undefined way. With any intervention, it is important to be clear on which exact group it is intended to help and not assume that it will make a similar difference to others outside that group.
• Capturing cost data: While there are many assertions in the UK sector that Housing First is cost-effective, there is currently a lack of comprehensive studies evidencing this and limited cost-benefit data. Gathering this evidence would help clarify the financial implications of implementing Housing First at scale.
• Tracking people over longer periods of time: Longer-term studies conducted in other countries indicate that the positive impact of Housing First may lessen over time. It is important to track outcomes over extended periods to understand whether a similar trend occurs in the UK and to assess the long-term sustainability of the approach.

No. Current evidence suggests that Housing First, particularly the philosophy behind it, does make a positive difference.

What is less clear is whether its impact in the UK mirrors the successes observed in other countries. This is due to the lack of comprehensive, rigorous evaluations that compare Housing First to business-
as-usual in the UK.

A more systematic approach is needed to fully assess the impact of Housing First in the UK and to compare its performance with international evidence.

• What does the term ‘Housing First’ mean to you? Has your definition changed after reading this article? If so, how and why?
• How good do you think your organisation is at evaluating the impact of its interventions for homelessness or other issues? What could improve this further? How could you contribute to this?
• What one point in this piece do you want to share with colleagues who may not have read it? And how will you share it?

Housing First is grounded in the notion that housing is a basic human right and should be the first step in addressing chronic homelessness. Initially developed in North America within the mental health sector, it was implemented as a well-defined intervention and rigorously evaluated.

The success of early programmes led to international interest, including in the UK, where it has been endorsed and piloted by government initiatives and individual organisations.

However, its implementation here has often diverged from the original model, and it has not been rigorously compared to business-as-usual approaches or other similar models.

To strengthen the evidence base, more rigorous, long-term evaluations are needed, along with a synthesis of new and existing high-quality studies.

Next, answer the questions below. Get all the questions correct and you will receive a certificate confirming your award of 30 CPD minutes within 10 working days via email. Get any questions wrong and you can retake the test by refreshing your web browser.

• Homeless Link, About Housing First
  
• TEDx (2012), Housing First: Sam Tsemberis at TEDxMosesBrownSchool
• Pathways Housing First Institute website
  
• US Department of Housing and Urban Development’s Office of Policy Development and Research (2023), Housing First: A Review of the Evidence
  
• Ministry of Housing, Communities and Local Government (2024), Mobilising Housing First toolkit: from planning to early implementation
• Tsemberis, S. (2012), European Journal of Homelessness: Volume 6, Issue 2, Housing First: Basic Tenets of the Definition Across Cultures
  
• Wilson, W. and Loft, P (2021), House of Commons Library Research briefing, Housing First: tackling homelessness for those with complex needs

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