Lack of stable accommodation makes it almost impossible to recover from substance issues. In the third of our latest commissioning series, we look at strong partnerships across the homelessness and substance misuse sectors.
If it’s possible to draw any positives at all from the COVID pandemic, one might be that it demonstrated what proper joined-up action can do when it comes to tackling homelessness.
In 2020, the ‘Everyone In’ scheme saw 37,000 people who were either sleeping rough or at risk of sleeping rough moved into emergency accommodation, showing ‘just how much can be achieved with the right political will and investment’, said Shelter.
However, a letter to the prime minister signed by 30 homelessness organisations in June this year pointed out that rough sleeping rates since then have actually gone up, rising by 26 per cent between 2021 and 2022 – the biggest year-on-year percentage rise in nearly a decade (DDN, July/August, page 5).
As the letter pointed out, the average age of death for someone experiencing homelessness is 43 for women and 45 for men. What’s more, according to ONS, almost two in five of these deaths are related to drug poisoning (DDN, December 2022/January 2023, page 4). Homelessness and unstable housing also ‘substantially’ increase the risk of acquiring hepatitis C and HIV among people who inject drugs (DDN, April 2021, page 5), and according to Crisis, two thirds of homeless people cite drug or alcohol use as a reason for first becoming homeless in the first place.
These are clearly people who desperately need support, and that support hasn’t always been available. A report from St Mungo’s found that in 2018-19, 12,000 people who were either sleeping rough or at risk of doing so missed out on the drug and alcohol treatment they needed.
All of which clearly reinforces the need for effective joint working between the drug treatment and homelessness sectors, something that’s often been patchy, to say the least. ‘I think it’s not unlike trying to square the circle of dual diagnosis,’ says director of recovery and resettlement at Ara in Bristol, Robbie Thornhill. ‘There’s the historical idea that we have to fix one before we fix the other.’
Things seem to be changing, however. ‘I do think now, with Dame Carol Black particularly, there’s more understanding about how vital stable and secure housing is to drug and alcohol treatment. We’ve been working at the nexus of homelessness and drug and alcohol treatment since 1987 and I really feel there’s a momentum behind looking at the two together.’
Bristol is a magnet for people from across the South West and South Wales, and as a result is an expensive city to live in. ‘According to the Shelter stats, we have 19,000 people on the social housing waiting list,’ says Thornhill. ‘So if you’re a single male between the ages of 18 and 35 you won’t get housing – they’re advising people to look at private rented options.’
These are also very thin on the ground, however. Properties at the Local Housing Allowance rate – used to calculate housing benefit for tenants in the private rented sector – are in incredibly short supply, and ‘obviously you have everyone going for those’, says Thornhill. ‘So if you don’t have the social housing option, and people aren’t able to access private rented, it’s really difficult – some of my staff can’t get rental properties. And the vulnerable and disadvantaged people we look after aren’t at the same starting line as everyone else – they’re way back.’
Bristol City Council commissions four homelessness pathways – men’s, women’s, mixed and substance use – with the latter run by Ara. It also commissions ROADS – the Recovery Oriented Alcohol and Drug Service. ‘We sit in the middle of the Venn diagram between the two,’ says Thornhill. ‘We support people who are homeless or at risk of homelessness and looking to recover from drug or alcohol misuse.’
There are 6,500 dependent drinkers in Bristol and 5,000 opiate users, and like elsewhere that opiate population is aging one. Ara provides a range of housing options – for people who are abstinent, stable on prescriptions or simply motivated to address their drug and alcohol issues. ‘We have different levels, and we also have different sub-contractors,’ he says. Of 140 units, 76 are administered directly by Ara, 54 with one contractor, and ten with another.
Partners include the Junction Project and The Bridge Project, and the strength of the partnership is that ‘we each offer slightly different things’, he says. ‘When someone comes in, there isn’t a template offering of “this is what you must do”. Some people are more likely to benefit from a mutual aid and fellowship approach, while with others it might be more about motivational interviewing. It’s about making sure that we orientate the service to what they need.’
The partners connect every three or four weeks for operational management group meetings, as well as every six weeks to two months for strategic management group meetings. There are also regular meetings with the council, which are led by Ara with other partners attending when they need to.
One recent innovation has been to use funding from the Housing Support Grant for a service that’s able to work with people in hostels, emergency accommodation, supported accommodation and the private rented sector, as well as those being discharged from residential rehab, prison or hospital.
‘The council approached a few different providers and talked about how best to use the money,’ he says. ‘We have some challenges in Bristol around access to treatment and continuity of care, and housing definitely exacerbates some of the wider issues that people have.’
The council was looking for a way to provide treatment for those unable to access current services, underpinned by the need to help sustain tenancies. ‘So where people are in private rented, helping them to maintain that if things like anti-social behaviour have become a problem with their drinking or drug use. Or if they’re in temporary accommodation, supporting the council to look for ways to get them into other offerings – the homelessness pathways or non-commissioned services where we can make sure they have the stable and secure housing they need to engage in treatment.’
The service launched in July, and is contracted until March 2025. ‘Some of the money we get through the rough sleeper initiative is year-on-year, so having the opportunity to do it for that length of time is fantastic. As well as the increase in the NDTMS numbers we’re going to see because of the group work and one to one, we’ve also worked the current ROADS providers to make sure that people are engaged with treatment – and we’re going after their drop-offs. Where people are falling out of treatment we’re saying, “What’s your need, how can we support you back into treatment – and is housing a part of this?”.
The new service has a team of ten, all with different specialisms. ‘We have two dual diagnosis workers, and they’re doing one-to-ones with people. A lot of people who are dropping out aren’t able to engage in groups because of their experience or type of trauma. We also have two community engagement brokers – if you’re entrenched quite often your social networks have changed or atrophied entirely so these guys are out there working with people at the drop-ins and giving people some of the resilience they need to maintain their recovery.’
So for areas still trying to develop strong partnerships across the treatment and homelessness sectors, what are some of the key lessons? ‘Firstly, we’ve been lucky enough to develop the KPIs with the commissioners,’ he says. ‘There’s a quantitative element to that – they need to see the numbers go up – but what we’ve done is some sophisticated work looking at strategic outcomes for the housing support grant and saying, “How can we fill in the gaps and do something that hasn’t been done before – and doesn’t overlap with services – to improve the stats?”’
The other essential is to make full use of partnerships, he stresses. ‘We’ve engaged One25 – a specialist charity that works with sex workers and vulnerable women – and subcontracted one of their team. I could have maybe recruited someone from one of the specialist women’s organisations – leaving them with a gap – but the idea of that rainbow team approach is that they have reach-back into the wider knowledge of that service. Where there are partners who know more than you, embrace that.’
One key gap is community detox, he states. ‘If you live alone you can’t do community detox because people worry about the effects in the first week. We’ve set something up whereby our workers are able to provide that check-in, and it means that people who weren’t able to access community detox now can because our workers can go and see them once or twice a day – it seems odd to me that stuff like that isn’t already in place.’
Ultimately, it’s about innovation, he states. ‘Using the housing support grant in innovative ways to solve the problems that people know exist, but haven’t addressed. I’d be really keen if people in other areas wanted to come and talk to us about this – it’s early days but the stats are fantastic. I’d be happy to talk to anyone.’ DDN
Bristol City Council and its partner organisations, including Ara, have received a range of support from national charity Homeless Link, including training and consultancy.
This series has been produced with support from an educational grant provided by Camurus, which has not influenced the content in any way. See the July/August and September issues for parts one and two.