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									Clean break

Integrated housing and care pathways for homeless drug users

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                                                                           Clean break – Research report

1.    Introduction ...................................................................1
Background to the study...............................................................1
Who this report is for ..................................................................1
Methodology .............................................................................3

2.    The strategic context......................................................4
National Drugs Strategy................................................................4
Drug use and crime .....................................................................4
Drug use and homelessness ...........................................................5
Other impacts associated with drug use ............................................6
Why housing matters ...................................................................6

3.     The case study boroughs .................................................9
The London context ....................................................................9
Havering……............................................................................ 10
Islington….. ............................................................................ 10
Newham….. ............................................................................ 11

4.     Scale of housing need amongst treatment users............... 12
Data sources ........................................................................... 12
NDTMS………. ........................................................................... 12
Assessment of housing needs in the case study boroughs ...................... 14
Summary and implications of the findings........................................ 15

5.     The role of housing in supporting treatment outcomes ..... 17
Housing and the treatment journey ............................................... 17
Housing needs at different stages of the treatment journey.................. 18
Housing as a stable base for engagement in treatment ........................ 20
Housing for a ‘fresh start’ ........................................................... 21
Housing as a reward/sanction ...................................................... 23
Creating a community of peers..................................................... 25
Housing as a stop-gap ................................................................ 25
Summary and implications of the findings........................................ 25

6.     Access to housing and related support ............................ 27
Pathways to housing and support .................................................. 27
‘General Needs’ social housing ..................................................... 28
Accommodation for homeless households ........................................ 29
Supported housing and floating support .......................................... 31

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Private rented properties ........................................................... 32
Cross authority services ............................................................. 32
Summary and implications of the findings........................................ 33

7.     Barriers to housing access for drug users ......................... 34
Shortage of affordable housing ..................................................... 34
Unpopularity of drug users .......................................................... 34
Local connections and local authority boundaries .............................. 34
Funding responsibilities.............................................................. 35
Ineffective pathways into and out of services ................................... 36
Problems proving identity ........................................................... 36
Poor needs data....................................................................... 37
Staff expertise and knowledge ..................................................... 37
Complex needs ........................................................................ 38

8.     Recommendations ........................................................ 39
Making the case for resources for homeless drug users ........................ 39
Strengthening partnerships at regional and local level......................... 40
Making best use of available resources ........................................... 41

Figure 1 – Incidence of missing accommodation status data .................. 14
Figure 2 – Assessments of need for case study authorities..................... 15
Figure 3 – Response to Clean break findings ..................................... 16
Figure 4 – Treatment options ....................................................... 17
Figure 5 – Views about suitable housing for drug users......................... 19
Figure 6 – Service users views on the need for ‘clean’ accommodation ..... 22
Figure 7 – Access to a range of housing in Newham ............................. 24
Figure 8 – What professional stakeholders want ................................. 26
Figure 9 – What service users want ................................................ 26

Appendix A............................................................................. 43

                                                                 Clean break – Research report

The connection between drug misuse and homelessness is strong. The two
problems can cause and reinforce each other. Tackling one without at the same
time addressing the other can lead to failure. Despite this, agencies and
commissioners who are trying to support homeless drug users, work in isolation
from each other. Clean Break was developed in response to the frustrations of
Homeless Link members who all too often see the efforts of homeless people going
into treatment going to waste when no suitable accommodation is available. If the
two sectors had the opportunity to work closer together the investment, both
personal and financial, could be used more effectively.

Clean Break has focused on how housing and treatment services can work together
more effectively to support treatment outcomes and reduce the risk of
homelessness amongst drug users engaging in treatment1. In the three case study
areas, its impact has already been felt. This report sets out the main findings
from research in the case study areas and sets out recommendations for responding
to these.

We hope this report will stimulate change at national and local levels, bringing
together planners, commissioners and providers to develop pathways that reinforce
the efforts of individuals as they seek to leave a life of homelessness and drug use

We would like to thank London Housing Foundation, London Boroughs of Newham
and Islington and the Housing Corporation for funding this research. We would like
to thank all three London Boroughs; Newham, Islington and Havering for taking part
in the research. We would also like to thank Tribal Consulting for carrying out this

This report, and the toolkit providing practical solutions to the findings of the
research, are available online at

Jenny Edwards
Chief Executive
Homeless Link

                                                               Clean break – Research report

Homeless Link and Tribal would like to gratefully acknowledge the important
contribution provided by the multitude of agencies and individuals who have
supported the Clean Break study and development of the Toolkit. This includes:

•   agencies working with drug users in the London boroughs of Newham, Islington
    and Havering and elsewhere and who have participated in the Clean break
    research and/or provided examples of good practice for inclusion in the Toolkit

•   service users in the London boroughs of Newham, Islington and Havering who
    gave up their time to be interviewed as part of the Clean Break study

•   the London Housing Foundation, London boroughs of Islington and Newham, and
    the Housing Corporation all of whom provided the funding to make the research
    and development of the Toolkit possible

•   the members of the local and national steering groups for the Clean Break
    study, including the National Treatment Agency, Home Office, London
    Probation, London Housing Foundation, National Housing Federation, Greater
    London Authority, Housing Corporation and Drugscope.

Alice Evans, Head of Policy Analysis, Homeless Link

Jane Luby, Director of Consulting, Tribal Consulting

May 2007

                                                               Clean break – Research report

1.   Introduction
     Background to the study
     Clean Break was initiated by Homeless Link in 2005. Its aim has been to find
     sustainable solutions to shortage of housing and related support for homeless drug
     users seeking to reduce or end their problematic drug use. The desired outcomes
     were better treatment outcomes for homeless drug users, the agencies that work
     with and fund services for them, and the communities in which they live.

     The objectives were to:

     •   quantify the scale of need for accommodation for those seeking to end or
         significantly reduce problematic use of illicit drugs

     •   identify the current supply of accommodation and how/when it can be

     •   quantify the shortfall in suitable accommodation

     •   understand the extent to which systems for accessing housing and related
         support help service users end or reduce problematic use of illicit drugs

     •   identify good practice solutions to increase the supply and timeliness of
         appropriate accommodation to support treatment outcomes

     •   increase the awareness of key stakeholders and their willingness to devote
         resources to the problem.

     Working together with Tribal, Homeless Link successfully secured funding from
     the London Housing Foundation to enable the research to proceed. This initial
     support was important in enabling the study to attract further funding from the
     Housing Corporation, the Safer Islington Partnership and the Newham Substance
     Misuse Partnership.

     Who this report is for
     This report is one of several produced as part of the study. It summarises the
     findings from each of the three case study boroughs and highlights the
     implications of these for national, regional and local stakeholders. The primary
     audiences are national, regional and local commissioners and strategic leads for
     housing and drug treatment services, however the findings will also be of interest
     to providers of housing and drug treatment services.

     Detailed reports on the findings have also been produced for each of the case
     study boroughs. Finally, a Toolkit has been prepared to support other local
     authorities and their voluntary, statutory and private sector partners to assess the
     need and current supply of housing and related support in their area, and to
     create pathways to an appropriate and timely supply of these services for drug
     users engaging in treatment.

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        Scope of the study
        The study focused on the housing and related support needs of homeless people
        without dependents living with them, who have a history of problematic drug use,
        who are or who have engaged in structured treatment services, and who are in
        one of three broad groups:

        •    ‘clean’ from illicit drug use

        •    using prescribed substitutes only

        •    still using illicit (primarily Class A) drugs but aiming to achieve a significant
             reduction in their use.

        This study has not focused on the housing and support needs of those who do not
        wish to reduce their drug use and who may be accessing harm reduction services
        only (for instance needle exchanges).

        The term ‘homeless’ has been used to refer to anyone who does not have
        appropriate and secure housing, irrespective of whether or not they meet the
        criteria of statutory homelessness. Problematic drug use has been regarded as
        that which includes Class A drugs and creates social, psychological or health
        problems for the user.

        The term ‘structured treatment’ has been used to refer to tier 3 or 4 treatment
        services as defined by the National Treatment Agency2, which are aimed at
        enabling the individual to end or significantly reduce their drug use and which
        may include: detoxification services; residential rehab; drugs counselling; group
        or one to one work; day programmes; methadone maintenance or reduction

        So far the study has focused on London as this is the area for which funding
        became available. However it is hoped that many of the findings, and the tools
        developed to assist authorities and their partners to address some of the problems
        found, will also be highly relevant to areas outside London. Homeless Link’s aim
        is to extend the study to areas outside London as soon as funding becomes
        available, including an urban area without acute housing shortage and a rural
        area, so that the particular needs and circumstances of those types of areas can
        be explored and addressed.

 An explanation of the Tier system used to classify drug treatment services can be found at

                                                                   Clean break – Research report

          The study has used an action research approach, focused on three case study
          boroughs in London: Islington, Newham and Havering. Through the experiences of
          these three boroughs, the aim was to highlight the problems experienced by
          homeless drug users engaging in treatment when trying to secure housing and
          related support, and solutions to address these.

          The different elements of the study have comprised:

          Data analysis – primarily data from the National Drug Treatment Monitoring
          System (NDTMS), Drug Interventions Record data, homelessness returns made by
          local authorities to central government, and Supporting People client records.

          Stakeholder interviews – including stakeholders from the Drug Action Team (DAT),
          Drug Interventions Programme, housing (covering the housing register,
          homelessness assessments and management of temporary accommodation),
          treatment agencies, providers of supported housing, prisons (including CARAT
          teams), and Probation.

          Service user interviews – 41 face to face peer interviews were carried out with
          drug users in the three case study boroughs, including those who are rough
          sleeping, in hostels and supported housing, and those in private rented or social
          housing. People who were clean, on prescribed substitutes only or still using
          drugs problematically were interviewed.

          Literature review – including national, regional and local strategies, plans and
          research in this field.

          Identification of good practice – through the interviews with national, regional
          and local stakeholders, and a call for good practice to Homeless Link members,
          we sought examples of good practice.

          Several of the research tools used (for instance stakeholder and service user
          interview schedules) are included in the Clean Break Toolkit3.

          The project had a national steering group that included representatives from: the
          National Treatment Agency; Home Office; London Probation; Greater London
          Authority; Housing Corporation; National Federation of Housing Associations;
          Chartered Institute of Housing; London Housing Foundation and Drugscope. Local
          steering groups were also established for each of the case study boroughs.


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      2. The strategic context
          National Drugs Strategy
          In 2006/7 national and local government invested around £600 million in drug
          treatment services. The national Drugs Strategy 2002 focuses on the most
          dangerous drugs, damaged communities and problematic drug users and aims to
          reduce the supply and use of illegal drugs, and reduce levels of drug-related

          The aim of the substance misuse services funded by national and local
          government is to enable service users to maximise their potential to:

          •   control, reduce or achieve abstinence from drug use

          •   improve their health, social functioning

          •   minimise their own and their community’s exposure to public health risks

          •   reduce their involvement in criminality.

          Sustainable Communities: Settled Homes; Changing Lives
          Government policy on homelessness is outlined in the document Sustainable
          communities: settled homes; changing lives. This strategy aims to tackle
          homelessness and to halve the number of people living in insecure temporary
          accommodation by 2010. It focuses on:

          •   preventing homelessness
          •   providing support for vulnerable people
          •   tackling the wider causes and symptoms of homelessness
          •   helping more people move away from rough sleeping; and
          •   providing more settled homes

          The strategy builds on the 2003 report More than a Roof and continues to
          recognise that the personal and social causes of homelessness must be tackled
          alongside structural issues, such as housing supply.

          Drug use and crime
          Drug use is regarded as a significant cause of acquisitive crime levels (such as
          shoplifting, burglary, vehicle crime and robbery. Three quarters of crack and
          heroin users have reported that they commit crime in order to feed their habit4.

          The Government has set itself ambitious targets to reduce crime in high crime
          areas by 15 per cent by 2008 and to reduce re-offending rates by five per cent in
          2008 and 10% by 2010. Tackling drug related crime through the Drug

    Quoted at

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           Interventions Programme (DIP) is a critical part of Government policy in this area.
           DIP targets support at drug using offenders to enable them to kick their habit
           through partnerships between criminal justice and treatment agencies. It aims to
           break the cycle of drug use and crime by intervening at every stage of the
           criminal justice system to engage drug users in treatment. Research has shown
           that for every £1 spent on treatment, at least £9.50 is saved in health and
           criminal justice costs5.

           ‘Reducing Re-offending: a national action plan’6 highlighted the importance of
           stable accommodation for offenders to the achievement of Government targets to
           reduce offending. It introduced a performance indicator for the prison service to
           increase the number of prisoners released with somewhere to live. There are also
           plans to measure the number of prisoners in suitable accommodation at the end
           of a licence/order compared to the start.

           The Prolific and Priority Offenders scheme7 was introduced in September 2004.
           The aim is to provide focused interventions for the 10 per cent of offenders who
           commit 50 per cent of all crime. Each local authority area has drawn up a list of
           its most prolific offenders who are then targeted with a range of prevention,
           detection and rehabilitation measures8. Initial indications suggest that a high
           proportion of these prolific and priority offenders (PPOs) are substance misusers
           who commit high levels of acquisitive crime to fund their drug dependency and
           that many are also homeless.

           Drug use and homelessness
           There are well established links between drug use and homelessness, which
           suggest that drugs and other problematic substance misuse is a contributing
           factor to homelessness.

           Most studies of the levels of substance misuse amongst homeless people focus on
           homeless people living in hostel accommodation. Estimates of the prevalence of
           problematic substance misuse amongst this group of homeless people vary, but
           can be as high as 80 per cent9.

           Estimates from local stakeholders during the Clean Break study suggest that the
           proportion of single vulnerable people accepted as statutory homeless that are
           engaged in problematic drug use can be as high as 35-50 per cent.

 Godfrey C et al (2004) Economic analysis of costs and consequences of the treatment of drug misuse: 2-year
outcome data from the National Treatment Outcome Research Study Addiction Volume 99 Number 6, 697-707

    Home Office (2004) Reducing re-offending: a national action plan Home Office

    For more details see

    There are three strands to the National PPO strategy: prevent and deter; catch and convict; rehabilitate and resettle

    Letter to DATs from Director of NTA, December 2002

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           Research into the relationship between homelessness and substance use amongst
           rough sleepers carried out in 200110 found 83% were currently using illicit drugs
           and that use of heroin and crack cocaine increased with the period of time spent
           homeless. Almost two thirds (62%) had been homeless for more than six years and
           almost half had been homeless continuously since they were 18 or younger.
           Almost two thirds reported that drug or alcohol use was the main reason that they
           had become homeless.

           Other research11 found that, amongst rough sleepers, the most common reasons
           given for tenancy breakdown were drink or drug related. Long-term drug users in
           particular reported a series of tenancies lost (30 in one case quoted in the
           research) because of their lifestyle and offending history.

           Other impacts associated with drug use
           There are also many other documented social and human costs of drug use

           •   higher rates of divorce, relationship and family breakdown

           •   health risks for the unborn children of drug or alcohol misusing mothers

           •   higher levels of children taken into care or placed on the ‘at risk’ register

           •   higher levels of teenage suicide

           •   higher levels of psychiatric disorder

           Why housing matters
           Until recently the National Drugs Strategy focused largely on getting drug users
           into treatment quickly, and maintaining them in treatment for at least 12 weeks.
           Research has suggested that this is the time required to have any lasting

           In 2004 the Audit Commission14 reported that there was an overemphasis on
           treating the addiction of drug users and insufficient focus on providing the wider
           range of support needed. It concluded that housing, social care and other
           services must provide users with services to maintain progress made during
           treatment. The Commission noted that one in ten drug users starting treatment

     Fountain J and Howes S (2001) ‘National Addiction Centre, London – based on interviews with 389 rough sleepers

     ODPM (2002) Helping rough sleepers off the street Office of the Deputy Prime Minister

  Godfrey C et al (2002) The economic and social costs of class A drug use in England and Wales, 2000 Home Office
Research Study 249

     Gossop M et al (2005) Treatment outcomes: what we know and what we need to know National Treatment Agency

     Audit Commission (2004) Drug Misuse 2004 – reducing the local impact

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        has no fixed address and that as many as one in three are in some form of housing

             ‘[Funders should] spend more money on the back-end of treatment – housing,
             training, employment. You spend all that money on treatment and it’s
             wasted in the end’ Service user

        There is very little UK based evidence of the effectiveness of housing on the
        achievement of treatment outcomes. However, there is strong research evidence
        from the US15 of the importance of housing and housing services in reducing drug
        use. A review of existing research in 2001 found the following:

        •    A review of 14 demonstration projects in the U.S. found that it is extremely
             difficult to help chemically dependent homeless individuals unless they are
             provided with a secure, comfortable and supervised placed to live. It was also
             found that the provision of housing, food, health care and other services may
             be a hook for attracting and maintaining clients in treatment.

        •    A study of 171 clients who participated in community-based drug treatment
             programs in Los Angeles found that meeting housing services need had a
             significant impact on reducing drug use. Among those who received help with
             locating housing, there was a 50 per cent reduction in drug use, compared to a
             23 per cent reduction among those who did not receive help with locating
             housing, and a 41 per cent reduction among those who did not declare a need
             for housing services.

        •    Several programmes which demonstrated a need for longer term or permanent
             housing for individuals who complete treatment programs. A lack of such
             housing is a major barrier to continued recovery.

        •    A study of 517 patients enrolled in a Veterans Affairs outpatient detoxification
             program demonstrated that the provision of supported housing can contribute
             to successful outcomes, (e.g. continuing and completing further treatment).

        The study concluded that existing research had demonstrated the importance of
        housing in providing treatment and recovery services to homeless and at-risk
        individuals. It recommended that individual communities ensure access to a
        comprehensive package of services and range of housing including:

             -    entry level shelters where alcohol and drug use is permitted,

             -     post-detoxification stabilisation services,

             -    residential recovery facilities,

             -    transitional housing,

   Kraus D (2001) Housing for people with drug and alcohol addictions: an annotated bibliography City of Vancouver
Housing Centre, Canada

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                -    low demand (wet) housing,

                -    supported housing, and

                -    permanent housing, some of which is alcohol and drug-free.

           It also noted that housing alone is not a guarantee that people will remain clean
           or their housing will remain stable. Many will require further support or

           Another, more recent US study, monitored the abstinence rates of three groups
           who were randomly assigned different housing situations: no housing, housing
           with the need to remain abstinent, housing with a requirement to remain
           abstinent16. The study found that participants that were provided with housing
           had significantly better abstinence rates and retention rates than those who were
           not provided with housing. For those engaged in initial day-treatment
           programmes, those in housing where abstinence was a requirement had better
           abstinence than the other groups.

           In the UK, users of treatment services are also convinced of the importance of
           housing in helping them to achieve their treatment goals. A large-scale survey of
           substance misusers carried out by Addaction17 found that 83 per cent felt stable
           housing was one of the most important support services required to help them
           stay clean. The study also found treatment providers consistently highlighted
           housing as a principal concern for both male and female service users when re-
           entering the community18. Forty per cent of service users interviewed stated that
           a lack of stable housing is the main barrier to them achieving their treatment

           Research cited by the Social Exclusion Unit suggests that stable accommodation
           can make a difference of over 20 per cent in terms of reduction in reconviction20
           and that ex-prisoners with an address on release are three times more likely to
           get a job.

  Milby JB et al (2005) ‘To house or not to house: The effects of providing housing to homeless substance misusers in
treatment’ American Journal of Public Health, 95 pp 1259-1265

     Drainey S (2005) Aftercare Consultation 2005: the service user perspective Addaction, London

     Drainey S (2005) Aftercare Consultation 2005: the service user perspective Addaction, London

     Stephenson M (2005) National Aftercare Survey - Year 3 Addaction, London.

     Social Exclusion Unit (2002) Reducing reoffending by ex prisoners Cabinet Office

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3.        The case study boroughs
          The London context
          Since age and deprivation are strongly associated with problematic drug use, the
          demographic make up of an area will affect the levels of drug use locally, and
          therefore the numbers of drug users for whom housing is needed.

          London has a young population compared to the rest of the country. Although the
          proportion of under 15 year olds is similar to that of the rest of England, the
          city’s 15-34 year old population is disproportionately large. 15-34 year olds
          account for nearly a third of London’s population compared with just over a
          quarter in England and this rises to 38 per cent for inner London21. This
          population profile inevitably impacts upon the levels of problematic drug use in
          the capital.

          London is a major hub for illicit drugs, with Class A drug use particularly high
          compared to the rest of England. Approximately 1 per cent of Londoners are
          estimated to be problematic (rather than recreational) drug users22 amounting to
          around 74,000 people. The last fifteen years have seen an increase in the number
          of people engaged in poly drug use (often involving heroin, cocaine and alcohol).

          The ability of drug users to access the housing they need varies across different
          areas, according to the supply of housing locally and its relationship to demand,
          and the political will to invest in or allocate housing to drug users. Housing in
          London is under enormous pressure, with high levels of homelessness and around
          60,000 household in temporary accommodation. Over 150,000 households are
          overcrowded, more than half the national total, with some 61,000 of these
          severely overcrowded23.

          Competition for housing in both the private and socially rented sectors is fierce,
          and drug users are competing for housing with a wide range of other client

          As in other areas of the country, authorities in London are looking at ways to
          reduce the incidence and the fear of crime. Tackling substance misuse is seen to
          be an important part of strategies to reduce crime, however authorities can differ
          in the extent to which they seek to achieve this through a balance of punitive and
          supportive measures for drug users.

          Havering, Islington, and Newham are three very different London boroughs as
          described below.

  Smith R (2007) The highs and lows 2: A report from the Greater London Alcohol and Drug Alliance Greater London

  Hay G et al (2006) Estimates of the prevalence of opiate use and/or crack cocaine use (2004/5) London Region
Centre for Drug Misuse Research, University of Glasgow


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           Havering is the second largest London Borough in area, covering 46 square miles,
           half of which is in the Green Belt24. Havering is an area of moderate affluence
           compared to its inner London neighbours, but has significant pockets of

           Havering has a relatively low unemployment rate but a relatively low average
           income compared to other London boroughs. It has a high proportion of residents
           educated to A level and below, but not at higher levels.

           Almost 23 per cent of the population is aged 60 and above, the highest proportion
           of older people of all London Boroughs. The borough has the lowest proportion of
           black and ethnic minority residents in London, with 95 per cent of the population
           from the white ethnic group26.

           Owner occupiers predominate in Havering; 80 per cent of properties are owner
           occupied (compared with about two-thirds nationally) 14.5 per cent are socially
           rented and 5.5 per cent are rented privately – less than half that for London as a
           whole. In 2005/06, 623 households approached the council as homeless, of which
           309 cases were accepted.

           Overall, Havering is the fourth safest borough in London, but crime, disorder and
           fear of crime rank very highly in a list of public concerns amongst Havering

           In 2004/5 Havering had an estimated 843 problematic drug users and, in 2005/6,
           461 were in treatment.

           Islington is an inner London borough with an unusual mix of wealth and
           deprivation sitting side by side. Although it is home to some of the wealthiest
           people in London, all of its wards are in the most deprived 5 per cent in the
           country. Whilst having a higher proportion of graduates than the national
           average, it also has a higher than average number of residents who have no

           Islington has a relatively young and rapidly growing population. It also has a high
           number of single households, ranking 5th out of 33 London authorities. The
           population of Islington is extremely mobile, showing a 10 per cent change in
           2000/1 and residents originate from many different countries. 70 per cent of the
           population in Islington is born in the UK compared to 91 per cent in England and

 Havering Homelessness Strategy, 2003

     Adult Drug Treatment Plan 2006/07 Part 1 (October 2005) Havering Drug and Alcohol Action Team

  Adult drug treatment plan; Havering Community Strategy update 2005; Health profile for Havering, 2006,
Department of Health

                                                                                  Clean break – Research report

        Wales. Just less than a quarter define themselves as from a black and minority
        ethnic background.

        Almost half of Islington’s housing stock is social housing, just over a third owner
        occupied, and the remainder rented privately.

        Islington is a high crime borough, with 43 per cent and 40 per cent of its residents
        regarding drug dealing and drug taking as a ‘major problem’. It has the 3rd
        highest estimated number of problematic drug users in London (4,667) and the
        fifth highest number in some form of treatment.

        Newham is an outer London borough to the east of the city, with many
        characteristics of an inner city borough. It is London's second-most ethnically
        diverse borough and also one of the most deprived. The borough will host the
        Olympic Games in the summer of 2012, and this has triggered a major
        regeneration project around the Stratford area.

        Newham is a relatively young borough; 40 per cent of the borough’s population is
        under 25, compared to 31 per cent for London as a whole. Only a third of
        Newham's population of 244,000 is of White British origin.

        Half of Newham’s housing stock is owner occupied, a third socially rented and the
        remaining fifth privately rented. Around 1,400 households are accepted as
        homeless every year.

        Newham has one of the highest crime rates in the country. In 2005, 75 per cent
        of Newham residents stated that fear of crime impacted greatly or moderately on
        their safety and quality of life. In 2005/6 it had the seventh highest number of
        drug related offences in London.

        Newham had an estimated 2,338 problematic drug users27 in 2004/5 which was
        the 13th highest in London. 1,051 Newham residents entered drug treatment in

  G Hay et al., 2006, ‘Estimates of the prevalence of opiate use and/or crack cocaine use (2004/5), London Region’
Centre for Drug Misuse Research, University of Glasgow

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4.   Scale of housing need amongst treatment users
     Data sources
     The Clean Break study found that the commissioning and planning of housing and
     related support services for drug users is currently hampered by poor data
     systems. Information about the accommodation and related support needs of
     drug users engaging in treatment services is hard to gather at the local or national

     There are a variety of national data sources that can provide information about
     the housing and related needs of drug users, but each contain weaknesses which
     significantly reduce their usefulness for service planning and commissioning.
     These include:

     •   National Drug Treatment Monitoring System – Records accommodation status
         and other characteristics of those engaging in structured (tier 3 and 4) drug
         treatment services

     •   Drug Intervention Records - Records the accommodation and other needs of
         those arrested for drug related crime, together with action taken to respond
         to these

     •   Supporting People client record forms – Can record problematic drug use
         amongst users of Supporting People funded services

     •   Homelessness returns made by local authorities (P1E) – Provides an
         opportunity for local authorities to record problematic drug use amongst
         households accepted as statutory homeless

     •   OASys - Collects accommodation and other needs data for those offenders who
         are subject to supervision by the probation service or are prisoners serving a
         sentence of 12 months or more

     A fuller description of each data source, how it can be accessed, and its
     usefulness for accommodation needs assessments is provided in the Clean Break

     National Drug Treatment Monitoring System
     The NDTMS is the only national source of data about drug users in treatment
     (rather than a wider population of drug users). It should, in theory, provide
     valuable information about housing and related support needs. However in
     practice this may not be the case for a number of reasons. These reasons are
     addressed below. We have focused on the NDTMS due to its importance for any
     needs assessment for those accessing structured treatment services, and because
     it illustrates the challenges for all data systems designed to collect needs data for
     drug users.

                                                                               Clean break – Research report

           Overlapping accommodation categories

           From April 2006 drug treatment agencies have been asked to state the type of
           housing occupied by their service users according to the following categories28:

           •   no fixed abode

           •   temporary

           •   traveller

           •   supported housing

           •   rented

           •   hostel

           •   owned accommodation.

           These categories are overlapping - for instance a nightshelter could fall into
           several of these categories. Unless it is clear how treatment agencies are
           interpreting these categories locally and doing so consistently, it is very difficult
           to interpret them for needs assessment purposes.

           Reliability of self-reported housing status

           Treatment agencies largely rely on service users to self-report their
           accommodation status, and this approach does always not result in accurate
           reporting. For example, there may be an incentive for those leaving prison to
           claim to be ‘no fixed abode’ as they receive a higher discharge grant as a result.
           Those in the community charged with an offence may also report that they have
           stable accommodation, even though they may not, in the belief that it will
           increase their chances of securing bail.

           Need for housing outside borough of normal residence

           Drug users are a relatively transient group and some account needs to be taken,
           when interpreting NDTMS data, of the extent to which drug users may wish to
           relocate to another local authority area at some point during or after their
           treatment. Anecdotal evidence suggests, for instance, that around half of all
           service users placed in residential rehab outside their host borough, may choose
           to remain in that area rather than return. Others may choose to relocate to get
           away from former drug using or dealing associates, and some need to relocate for
           safety reasons.

     Further changes are planned to the accommodation data collected in 2007

                                                            Clean break – Research report

Missing data

The provision of information about a person’s accommodation status is not
mandatory in the NDTMS system, and a high proportion of records may have this
information missing. The proportion of records with missing accommodation data
for 2005/6 in the case study boroughs was as follows:

   Figure 1 – Incidence of missing accommodation status data

    Borough        Nos in treatment     % NFA         % Not NFA          % Data
                   2005/6                                                Missing

    Havering       460                  4%            64%                32%

    Islington      1,537                14%           78%                8%

    Newham         1,050                13%           68%                19%

Housing status v housing need

The research revealed that triage assessments undertaken by treatment agencies,
may simply reproduce the accommodation status categories recorded for NDTMS
purposes and do not necessarily include an assessment of how appropriate that
accommodation may be, or any action needed as a result. Interviewees during
the Clean Break study suggested that the absence of established and clear
pathways into housing and related support services can also discourage some drug
treatment agencies from appropriately assessing and responding to housing needs
(for instance by referring onto agencies that can help to meet those needs).

Assessment of housing needs in the case study boroughs
The Clean Break study used a variety of data sources (including estimates from
local stakeholders) to build up an estimate of the numbers of drug users in each
local area requiring accommodation or support to support their achievement of
treatment outcomes. In each case the combination of sources used, and the
reliability assumed for the estimates, was different.

In all of the case study boroughs information about those who present for housing
assistance was not collected in a form that assisted with future service planning
and commissioning. Where there are multiple access points to housing in a local
area, it can be difficult to assess the degree of double counting from different
sources. An individual may present as homeless at the homeless person’s unit
for instance and, upon rejection, also apply to a local hostel provider. It can also
be impossible to extract separate figures for those who are accessing treatment

Due to unreliability of local data sources, it was sometimes necessary to express
need for accommodation and support ‘units’ as a range. The estimated level of
housing need for drug users in each of the case study boroughs is shown below in
Figure 2.
                                                             Clean break – Research report

      Figure 2 – Assessments of need for case study authorities

Borough     Nos in        Nos.             % of those     Sources used
            treatment     requiring        in
            2005/6        housing          treatment

Havering    460           57-119           12% to 26%     Treatment agency
                                                          assessments and housing
                                                          referral data

Islington   1,537         200- 350         13% to 23%     Referrals to Supporting
                                                          People team plus estimate
                                                          from statutory homelessness

Newham      1,050         250              24%            Referrals to Substance
                                                          Misuse Housing Advisors

  Summary and implications of the findings
  The absence of reliable data sources on the housing and support needs of drug
  users has a number of implications for service planning and commissioning:

  •   It weakens the case for new service provision for drug users with funders and
      other important stakeholders.

  •   It hampers the ability to achieve value for money from scarce resources by
      ensuring that they are targeted where needed most.

  •   It increases the risks from new service delivery, particularly specialist housing
      requiring capital investment which cannot easily be used for other purposes.

                                                         Clean break – Research report

Examples of how two of the case study boroughs are responding to the findings
are outlined below: Figure 3.
   Figure 3 – Response to Clean break findings

    The London borough of Islington is exploring the scope to establish a
    single assessment and referral point for drug users (as well as other
    clients at risk of homelessness) needing supported housing or support.
    The aim is to ensure, as far as possible, a single gateway to services and
    consistent collection of needs data that can feed into future service
    planning and commissioning.

    The London borough of Newham is establishing a data system to record
    the needs of drug users referred to the Substance Misuse Housing
    Workers. This will enable the recording of needs (rather than just
    where service users are referred to) and identification of service users
    experiencing repeat homelessness.

                                                                                   Clean break – Research report

     5. The role of housing in supporting treatment outcomes
        Housing and the treatment journey
        In England most drug treatment is undertaken in the community rather than in a
        residential setting. Although homeless drug users may be more likely to access
        residential treatment services than their adequately housed peers29, the findings
        from Clean Break showed that the majority of service users of no fixed abode are
        undertaking treatment in the community30. The range of treatment services for
        homeless drug users in shown in Figure 4 below.
             Figure 4 – Treatment options

              In-patient detoxification – Detox is usually undergone as a means of
              cleaning opiates and other drugs out of the body prior to residential
              rehab or community based treatment services.

              Residential rehabilitation – Rehab is typically provided in two stages,
              each lasting about 12 weeks. The ethos and programme offered in
              rehab can vary, but all usually aim for complete abstinence from all
              drugs and alcohol and involve a mixture of group work, counselling and
              other practical and vocational activities. This is the most expensive
              treatment and is increasingly only provided where community treatment
              options have been tried and failed.

              Prescribing Programmes31 – Methadone or other substitutes for opiates
              may be prescribed by a GP or a specialist prescribing service in order to
              stabilise or reduce drug use. The aim is to maintain the service user at
              a level of drug use at which they are able to maintain a ‘normal’ life, or
              to reduce the amount of drugs prescribed until the service user is
              eventually drug free and no longer experiences withdrawal symptoms.

              Other structured interventions – Other treatment services that may be
              accessed by homeless drug users include: cognitive behavioural therapy;
              relapse prevention therapy; coping skills; motivational intervention;
              family therapy; group work; education and life skills; creative activities.

  Gossop et al (2001) NTORs After Five Years: Changes in substance misuse, health and criminal
behaviour during the five years after intake National Addictions Centre
   Analysis of NDTMS data returns in one of the Clean break case study boroughs showed that just under a third of NFA
clients accessing treatment were in residential rehab.

   Analysis of NDTMS data returns in one of the Clean break case study boroughs showed that around a third of NFA
clients were accessing GP or specialist prescribing services.

                                                                                  Clean break – Research report

           Housing has historically been perceived to be an ‘aftercare’ service that will be
           required after the service user leaves treatment. However, reflecting the fact
           that only a third of those who are homeless are likely to be in a form of
           residential treatment, it is now regarded as a ‘wrap-around’ service which should
           form an integral part of the care plan throughout treatment.

               ‘….drug treatment systems should be well integrated with other systems of
               care and social support, to provide opportunities for drug users to receive
               appropriate housing, social support, education and employment to maximise
               treatment gains and enable reintegration into local communities32.’

           Engagement with treatment services lasts for five to seven years on average for
           those with heroin or crack dependencies, and will vary across service users. Some
           people may dip in and out of treatment whereas others will remain in treatment
           almost indefinitely33.

           Although treatment does work34 and cumulative benefits are often gained from
           successive treatments, relapse is common. Some will leave treatment with lower
           levels of drug use and progress to achieve other positive outcomes, whereas
           others will relapse. Treatment should therefore be regarded as a journey that
           may involve several stages and setbacks35. Housing and support services, as well
           as the access arrangements and pathways to them, need to recognise the
           likelihood of relapse and should be able to respond with alternative housing
           and/or additional support where necessary

           Housing needs at different stages of the treatment journey
           During the Clean Break study stakeholders were asked what types of housing they
           thought were suitable for drug users at different stages of their treatment
           journey. Their views are summarised in Figure 5 below.

     NTA (2006) Models of Care for treatment of adult drug users: Update 2006 National Treatment Agency

     NTA (2006) Models of Care for treatment of adult drug users: Update 2006 National Treatment Agency

   Gossop et al (2001) NTORs After Five Years: Changes in substance misuse, health and criminal behaviour during the
five years after intake National Addictions Centre

 Glossop M et al (2001) NTORS after five years: The National Outcome Research Project National Addiction Centre

                                                                                     Clean break – Research report

             Figure 5 – Views about suitable housing for drug users

              People who are clean from illicit drugs and prescribed substitutes –
              There was a fairly widespread consensus across stakeholders that most
              of the people within this group would be able to live successfully in
              independent accommodation, although many would require visiting
              support. Estimates made during the Clean Break study suggest that
              around 5-10 per cent of drug users engaging in treatment services and
              needing accommodation will be in this category.

              People who are clean from illicit drugs but using prescribed
              substitutes – Most stakeholders thought that this group would benefit
              from a mix of independent and supported accommodation, and that
              most would require visiting support. Estimates made during the Clean
              Break study suggest that around 20 per cent of drug users engaging in
              treatment services and needing accommodation will be in this category.

              People who are attempting to reduce their intake of illicit drugs –
              Most stakeholders felt that this group would benefit from supported
              accommodation with scheme-based support or regular visiting support.
              Estimates made during the Clean Break study suggest that 35-50 per
              cent of drug users engaging in treatment services and needing
              accommodation will be in this category.

              Chaotic drug users36 – Stakeholders largely believed that chaotic drug
              users not engaging in treatment, or only accessing harm minimisation
              services, would require supported accommodation with 24 hour staff
              cover in order to manage the risks to themselves, their fellow residents
              and the surrounding community. Estimates made during the Clean
              Break study suggest that around 25 per cent of drug users engaging in
              treatment services and needing accommodation will be in this category.

         The fluctuations in a person’s drug use from heavy to minimal makes planning for
         this group particularly challenging. Provision needs to be readily available for
         those who relapse, or who experience other crises in their life that could increase
         their vulnerability to relapse.

         Views on the range of housing services for drug users varied according to whether
         people viewed housing as a resource to encourage engagement in and adherence
         to treatment, or as a service in its own right.

  The term ‘chaotic drug use’ is used here to refer to harmful drug use that does not follow a regular pattern and
which the user finds difficult to regulate. It can include poly drug use, heavy drug binges and other risky drug taking
behaviour, and may be combined with serious mental or physical ill health.

                                                                                 Clean break – Research report

        There is little guidance from national agencies on what type of housing would
        most effectively support treatment outcomes. Instead guidance issued to date37
        tends to list and provide examples of models that commissioners and providers
        could consider.

        Although there is good research evidence in the role of wraparound services, and
        housing in particular in supporting treatment outcomes, there has been little
        systematic review of the effectiveness of different models of supported housing
        or indeed its advantages over ‘general needs’ housing.

        Some of the ways in which housing can be used to support treatment outcomes
        are described below.

        Housing as a stable base for engagement in treatment
        The role that housing plays in providing drug users with a stable base to engage
        with treatment services and begin to effect change in their lives is well

        The provision of accommodation can be particularly important for those who are
        ‘hard to reach’ and/or only engaged in harm minimisation services. This will
        include those that are rough sleeping for some or all of the time.

            ‘When I’m sleeping rough, all I do all day is earn money to do drugs. I could
            do with somewhere to live but don’t do anything about it. I live in a
            warehouse in a little office and we’ve got mattresses, candles and a
            radio…Even if I got a script for methadone, I’d still use heroin while I’m on
            the streets.’ Service user

            ‘My lifestyle does increase my drug use - being on the streets and sleeping
            rough. I need help around housing as well as around drug use. If someone
            would just give me a hostel place or a room it would be a roof over my head
            and I would be able to be with my partner’. Service user

            Where I live I need to be out of my nut. I wouldn’t be able to sleep, can’t
            wash, can’t brush my teeth, there’s no water’. Service user

      At the time of the study, all of the case study boroughs had the greatest shortages
      of accommodation for active drug users, including those involved in chaotic drug
      use (although Islington had a service in development). Chaotic drug users in
      particular are often turned away when they apply for housing, due to the lack of
      suitable options (unless they meet the criteria for statutory homeless assistance),
      or are referred to nightshelters across London.

      All of the rough sleepers interviewed during the Clean Break study were poly drug
      and alcohol users. Research from the US has shown that accommodation can be a

  Office of the Deputy Prime Minister and Home Office (2005) Housing Support Options for People who Misuse
Substances ODPM

                                                                                  Clean break – Research report

      ‘hook’ to engage chaotic drug users into services and eventually more structured
      treatment services38.

      Some poly drug users were part of couples that were rough sleeping together.
      Anecdotally, treatment agencies are reported to be often unwilling to treat drug
      users with co-dependent partners, unless they are willing to split up, because of
      the very high failure rates in these cases. Several service users complained at the
      lack of accommodation for couples and some attributed their rough sleeping to
      this. It may also be the case that the lack of stable housing for this group is having
      a direct impact on their ability to access treatment.

      Some stakeholders expressed a need for specific high supported accommodation for
      women who are chaotic drug users, who may also be sex working and/or
      experiencing domestic violence, and who may need a place of safety in which they
      can begin to stabilise. Others highlighted the difficulties of encouraging some very
      vulnerable women to leave co-dependent and often violent partners.

             Housing for a ‘fresh start’
      There were very strong messages from the service users interviewed during the
      Clean Break study about the need to be able to live away from other active users
      when attempting to reduce or end their own drug use. Housing drug users engaging
      in treatment away from active and unengaged drug users can be extremely difficult
      in both general needs and supported housing, however.

      In areas of high housing demand such as London, there can be many years of
      waiting before a current/former drug user could hope to be offered a social housing
      tenancy in a popular area away from drug dealers. Even when specific access rights
      to social housing are negotiated for drug users it can be difficult to negotiate
      suitable properties. The types of properties that drug users want – street
      properties (rather than flats on estates) in nice areas not known for drug dealing –
      are exactly the same properties that those with the highest priority for rehousing
      usually want. They also tend to be areas where housing allocations officers can
      expect the most vociferous complaints from neighbours if things start to go wrong.

   Kraus D (2001) Housing for people with drug and alcohol addictions: an annotated bibliography City of Vancouver
Housing Centre, Canada

                                                      Clean break – Research report

Figure 6 – Service users views on the need for ‘clean’ accommodation

 ‘To stay clean in an environment like this hostel is impossible. Drugs
change hands pretty regularly. Who lives near me does make a difference
because it rubs off on you if they are using.’

‘Where I am is a bad, bad place……Everybody is scoring. I can hear what
people are getting up to in here. People knocking on my door, asking for foil
and Rizlas, it is so tempting. I could do something for myself but not here.’

‘The trouble with living here is that everybody is at different stages so there
is conflict when people are using and you’re trying to stop’

‘The temptation would be in your face all the time if you were on a drugs

‘Where I am - it’s perfect. Don’t know any drug users here, just the

‘ [Things could be improved] if places like [treatment provider] worked
alongside the housing department and made sure that people with drugs
problems don’t get sent or bullied into moving into known drugs estates.’

‘[People like me need] a nice flat in a nice road … no druggies or alcoholics’

‘[People like me need] a flat in a drug free environment, not a notorious

‘This was a rough place. We were all lumped together; people like me who
wanted to get better along with people who sold drugs outside the place.’

[Commissioners should] provide an environment that is safe for people who
don’t want to use drugs. It’s a battle within yourself, never mind having to
put up with other people’s habits.’

 ‘You get dealers waiting for you outside these places like [drug treatment
agency]. If you can’t score on the street you can score inside those projects
– this is wrong.’

‘Where I live means everything to me. I don’t socialise with people in this
place ‘cos they are using and this don’t help me.’

‘Do not send us on an expensive treatment programme only to house us in a
hostel where people are using all around us. You are setting us up to fail.’

                                                                                    Clean break – Research report

      Housing as a reward/sanction
      Current/former drug users in the case study boroughs were accessing a variety of
      housing types. This includes supported accommodation specifically for drug users
      commissioned with the involvement of the DAT, as well as ‘generic’ supported
      housing for single homeless people. These two types of services were very
      different in both ethos and aims, with the former strongly linked to treatment aims
      and the latter focused on housing/homelessness aims.

      Services commissioned specifically for drug users were more likely to include an
      element of compulsion for service users (for instance a threat that accommodation
      would be lost if the individual did not adhere to treatment goals). ‘Generic’
      homelessness services tended to be focused on maintenance of housing and
      management of client risk.

      Examples of services encountered during Clean Break showed that access and
      continued occupation of housing is commonly used as both an incentive, and a
      sanction. And, there appears to be fairly widespread support amongst professional
      stakeholders for these models, and indeed from some service users.

                 ‘I’m tested every week – this keeps me sane and careful’ Service user

                 ‘They do room checks here which is good for me as it keeps me on my
                 toes’ Service user

                 [What is good is] they don’t allow drugs or drinks in here. You’re kicked
                 out if you use on the premises, and they tell my old friends I’m not here’
                 Service user

                 ‘[People in my circumstances need]:

                 …a hostel where they do drugs tests every week, so it’s only people who
                 are serious who would want to stay there’ Service user

                 ….a place with really strict rules – no drugs or alcohol except on
                 prescription’ Service user

      Recent draft guidance issued by NICE39 suggested that incentives can be
      successfully used to encourage reductions in drug use. This is supported by
      research evidence, but the guidance reported that there is no similar evidence to
      support the use of sanctions. There is some evidence from the case study
      boroughs to suggest that supported housing schemes that make continued
      occupation of housing contingent upon adherence to treatment goals experience
      high rates of eviction/abandonment.

  National Centre for Clinical Excellence (2007) Drug misuse - psychosocial: NICE guideline (draft for consultation)

                                                           Clean break – Research report

Some examples of supported housing services that use incentives/sanctions to
encourage adherence to treatment goals are included in the Clean Break Toolkit.
To make these services successful, it is important that a robust and adequately
resourced relapse policy is in place which is flexible at the same time as ensuring a
clearly defined and consistent approach. Service users must also have readily
available access to the treatment services that can support them to comply with
occupancy conditions, and alternative accommodation to move to if a full relapse
cannot be avoided.

Newham’s experience suggests that neither a supported accommodation model or
threat of accommodation loss is always required to achieve good outcomes. This is
shown in Figure 7.

     Figure 7 – Access to a range of housing in Newham

      Substance Misuse Housing Advice Workers in the London borough of
      Newham refer non-statutory homeless clients to a range of housing
      options in the borough. These include bed and breakfast
      accommodation, private sector tenancies, private sector leased
      properties and supported accommodation. Floating support is provided
      for those in non-supported accommodation.

      Access to all these forms of housing is contingent upon the individual
      engaging with treatment services in order to address their problematic
      drug use. Applicants can be placed in bed and breakfast
      accommodation for a week or so to enable them to demonstrate this
      willingness to engage in treatment. The workers liaise closely with
      treatment agencies to check this and placements in bed and breakfast
      will be terminated if the service user is unwilling to comply. Bed and
      breakfast placements may continue for up to three months whilst
      suitable move-on is identified in supported or private rented housing.

      Once a tenancy in supported or private rented housing has been
      allocated this is not terminated if engagement with treatment services

Some professional stakeholders and service users expressed the view that a move to
progressively better quality or more secure housing was an important reward for
those doing well in treatment. For some service users this clearly had a symbolic as
well as a more practical value for them.

        ‘It’s a nice flat, making me feel good about myself.’ Service user

        ‘It’s my own place. I’ve never had my own place. It’s good to see your
        name on the tenancy form. I’m now somebody.’ Service user

        ‘Part of my recovery is moving on, and that means space of my own and a
        key to my front door.’ Service user
                                                           Clean break – Research report

Creating a community of peers
Some service users and stakeholders felt there were benefits to be gained from the
peer support that would result from living alongside other similarly motivated
service users. Some supported housing schemes for drug users are designed with
communal facilities to encourage mixing between residents and to hold group
sessions between staff and residents.

There needs to be easily accessible alternatives for those who relapse in order to
maintain this self-supporting environment. Without this there is a danger that
residents will be evicted without alternative housing being available and lose touch
with treatment services.

        ‘[People in my circumstances need]:

        … a hostel like this with other residents who can support each other in
        recovery. A kind of halfway house so you can prepare yourself for an
        independent life.’ Service user

        …to be with other people in recovery, to share hopes with, not needles.’
        Service user

Housing as a stop-gap
The limited availability of accommodation means there are often periods when
people have no permanent or semi-permanent options available to them. Some
stakeholders highlighted the need for short stay accommodation. This
accommodation could be used for a few nights or weeks as a stop-gap measure
whilst service users are awaiting a place in residential rehab or supported housing
scheme, or as a place of respite to put relapse management strategies in place.

Two of the case study boroughs had no arrangements in place to provide this short
stay immediate access accommodation. As a result people were either left to make
their own arrangements and were sometimes ‘lost’ in the process, or had to remain
in an expensive rehab place until alternative accommodation could be found. The
third borough regularly uses bed and breakfast accommodation for this purpose.

Summary and implications of the findings
Housing and support services need to be flexible enough to respond to changes in
the individual’s levels and patterns of drug use as well as their other needs. Most
stakeholders saw a need for a range of housing options for drug users engaging in
treatment as summarised below and described in more detail in Appendix A.

                                                           Clean break – Research report

    Figure 8 – What professional stakeholders want

    A range of accommodation including:

       •   general needs housing with floating support for those who are

       •   supported accommodation for active drug users who are not yet
           fully stable

       •   24-hour supported accommodation for chaotic drug users

       •   very short stay accommodation to bridge gaps in service
           availability, or enable respite.

Any needs assessment has to address both the numbers and type of accommodation

It is important that commissioners have clearer evidence of the relative costs and
benefits of types of housing models, so that they can target limited resources to
those that have most impact.

More research into the effectiveness of different housing models in supporting
treatment engagement and outcomes is required to inform these assessments and
to give commissioners a clearer idea about the most effective forms of housing
models. When providing supported housing that is just for clean and/or stabilised
drug users, alternative accommodation for those for drug users who relapse should
be available. This will help to prevent repeat homelessness and/or disengagement
from treatment services.

    Figure 9 – What service users want

           •   To be away from active drug users when seeking to end/reduce
               their own drug use

           •   Good quality housing as a reward/incentive for positive
               treatment outcomes

           •   Being able to access support with both drugs and housing at the
               same time

           •   Having access to ongoing support in the post-treatment period

                                                            Clean break – Research report

6.   Access to housing and related support
     Pathways to housing and support
     The previous section has noted the need for a range of housing options for
     current or former drug users engaging in structured treatment. Existing
     sources of supply and their suitability and availability for current or former
     drug users are discussed below, including: general needs social housing;
     temporary accommodation for statutory homeless households; supported
     housing and floating support; private rented properties.

     The findings from the research in case study boroughs showed that access to
     an adequate and appropriate supply of housing for drug users was most likely
     to happen where strong partnerships between housing and treatment agencies
     were in place.

     In some cases it is normally possible to plan to meet housing needs, for
     instance in the case of those leaving prison or residential rehab. Both groups
     can be highly vulnerable to relapse during the first few days after discharge,
     which makes it imperative that stable housing is available to them as soon as

     In all three case study boroughs good planning for discharge from prison or
     rehab appeared to be taking place, however this was sometimes thwarted due
     to the lack of housing options. Where none were available service users were
     sometimes left to make their own arrangements which could include staying
     with former drug using associates. Examples were quoted of prisoners being
     discharged without warning, and service users having to remain in expensive
     rehab placements due to a lack of housing options.

     Treatment or Criminal Justice sector staff are often the overall case managers
     for drug users. It was felt that they were not best placed to carry out
     assessments of housing need and make appropriate referrals, due to their lack
     of housing knowledge and expertise. Where specialist housing workers were in
     post to work with drug users and/or offenders this seemed to work best. It
     appears to be important that they work closely together with housing
     colleagues rather than recreating a whole new system. Where specialist
     workers or access points to housing are shared across more than one authority,
     the ability to develop the types of strong relationships needed at the local
     level, and thereby negotiate access to housing, is likely to diminish with the
     number of authorities covered.

                                                        Clean break – Research report

‘General Needs’ social housing
Drug users in all three case study boroughs were accessing general needs social
housing through two main routes:

•   Statutory homeless/housing register applications;

•   Special nomination arrangements negotiated for current/former drug users.

General needs social housing is the preferred type of housing for many current
or former drug users. Stakeholders interviewed during the Clean Break study
felt that it was suitable for those that had stabilised or ended their drug use.
Some stakeholders thought that it should be targeted at those who have a
reasonable chance of being able to gain paid employment because of the
lower rents than those charged in the private rented sector.

Areas with a good supply of social housing offer the scope to ‘scatter’
current/former drug users, without creating a concentration in any one area,
although in reality it can be difficult to gain access to properties in areas
without significant drug dealing/taking via this route.

The Clean Break Toolkit describes the registration and allocation systems that
commonly apply to social housing provided by housing authorities and
registered social landlords. The main drawback is the delay that usually
occurs between the need for and availability of suitable accommodation. This
makes it an inflexible resource for those needing accommodation quickly e.g.
leaving rehab, prison or needing short term respite accommodation.

Social housing landlords are nervous about housing current or former drug
users because of the fear of increased management difficulties, anti-social
behaviour and/or crime. This is despite the fact that they will often receive
referrals of drug users through the normal allocation pathways without
knowing. Nevertheless there is scope to negotiate special allocations of social
housing or the award of additional priority within such systems, as some
examples within the Clean Break Toolkit show. These examples suggest that
the following factors increase the ability to negotiate special access to social

•   Where access is for those who have completed residential rehab or who
    have otherwise demonstrated a sustained ability to remain abstinent from
    drug use;

•   Where a conditional tenancy is given for an initial period which enables the
    tenant to be easily evicted if they relapse and cause management

•   Where the ability to live independently has been carefully assessed and the
    tenant will be provided with floating support to increase the chances of
    successful resettlement.

                                                                     Clean break – Research report

         Accommodation for homeless households
         The Clean Break Toolkit describes the assessment arrangements for current or
         former drug users applying as homeless and the types of accommodation commonly
         used. The Clean Break study revealed a broadly similar approach to the assessment
         of homeless drug users across the three case study authorities. This is not
         surprising given that all housing authorities have to follow Statutory Homelessness
         Guidance when assessing individual cases40. Drug use in itself – problematic or not –
         does not confer priority status for statutory homelessness assistance. Intentional
         homelessness is assumed by some authorities where the individual has lost their
         home due to drug use but has not engaged in treatment services to remedy that.

         The assessment made by housing authorities is typically focused on determining
         whether a statutory duty exists, and appears to rarely cover needs that fall outside
         that question. Drug use is largely incidental to the assessment as it does not in
         itself confer priority status. This means that problematic drug use, if present, may
         not be identified or responded to by the caseworker through referrals to specialist
         support or housing.

         There are two key learning points from the Clean Break study in relation to the
         statutory homelessness functions. The first is that drug users accessing housing via
         the statutory homelessness route appear to be much less likely to get the support
         they need with drug treatment and housing related support than those via a non-
         statutory homelessness route. The second is that there is scope to use some of the
         housing options used for statutory homeless households for those who are non-
         statutory homeless. These points are both discussed in more detail below.

         In all case study boroughs, at the time of the study, there were typically two routes
         operating by which drug users may access housing - largely on the basis of whether
         they are owed a statutory housing duty from the authority. Perversely, it appears
         to be those who are owed a statutory duty who may get least access to support or
         treatment. Whilst this group were at least provided with some form of housing,
         this did not necessarily take account of their need for related support or indeed the
         impact of location on ability to engage in treatment and adhere to treatment goals
         (or indeed the impact of any continuing drug use on their close neighbours). The
         inverse was true for those trying to access supported housing via the non-statutory

         Where supported housing was not being used for statutory homeless drug users this
         was sometimes due to a failure to recognise and respond to drug use during the
         statutory homelessness assessment. Other reasons can include:

               •   Historic arrangements under which voluntary sector providers of supported
                   housing have regarded themselves as filling the gap in housing services for
                   non-statutory clients rather than providing for those for whom the local
                   authority has a statutory responsibility

     Available from

                                                            Clean break – Research report

     •   Reluctance of generic low supported accommodation providers (which may
         form the bulk of supported housing provision in most areas) to take drug
         users – particularly where specialist substance misuse support is not
         provided, and there are no referral routes out of the services for those who
         begin to use actively/chaotically

     •   Housing allocation systems which deem those in even temporary supported
         housing to be adequately housed, thereby leading to a loss of statutory
         homeless status and resistance from service users to being referred to
         supported housing

The impact of this can include:

     •   Housing of active drug users in shared accommodation alongside families,
         vulnerable 16 and 17 year olds, and those seeking to abstain from/stabilise
         their own drug use

     •   High levels of eviction and abandonment amongst active drug users
         accepted as statutory homeless, leading to serial homelessness and an
         inability to engage successfully with treatment services.

So whilst in theory this group may have a much greater chance of being allocated
permanent social housing, the absence of support may increase the chances of
abandonment or eviction before they are able to realise that opportunity.

Where access to specialist services is arranged for this group (for instance floating
support working with those in council hostels and bed and breakfast) this appears
to produce good results.

Pathways in Newham for non-statutory and statutory service users are already
integrated to a great extent, and the borough is considering further integration to
ensure that statutory homeless households are referred into supported
accommodation where appropriate, and that move-on accommodation will be
available for those who need to move due to decreasing or increasing needs.      The
pathway in Newham is shown in the Figure below.

                                                                  Clean break – Research report

                DIP/Prisons    Probation         Treatment Agencies
   Advice Centre                                          Other

                          Assessment &

                             Stage One
                          Chaotic drug users

                       Stage Two
                       Continuing drug
                       users aiming to
                       reduce & not yet stable                                   Treatment
                       Stage Three
                       a) Stable & on script only
                       b) Stable & clean
                       Stage Four
Floating               a) Social housing (for stat.
Support                Homeless & other priorities)
                       b) Private rented

Supported housing and floating support
A significant proportion of drug users are likely to benefit from supported
accommodation and yet many supported housing providers routinely exclude drug
users from their schemes. Similarly, some generic floating support services exclude
drug users.

Supported housing providers with only low levels of staffing and support can be
nervous about taking current or former drug users because of the inexperience of
their staff and/or because of fear of management problems if individuals relapse to
more chaotic/active drug use. These fears do not appear unfounded. Examples
were quoted in all of the case study boroughs of inappropriate referrals to low
support housing schemes because of a shortage or total lack of more suitable
accommodation options.

Authorities may be able to encourage providers of low support generic supported
housing to take a more flexible approach to housing drug users if they provide
training for the staff of generic projects, specialist substance misuse input where
required, and help providers to find alternative accommodation for those whose
needs are no longer compatible with the service.

Many Supporting People commissioners are now reviewing their services and looking
at the scope to remodel existing services to cater for a higher level of needs. It is

                                                            Clean break – Research report

important to ensure that the needs of drug users engaged in treatment are
considered during this process.

Private rented properties
The private rented sector is being increasingly used by local housing authorities to
house statutory and non-statutory households. Where households are dependent
upon housing benefit to pay their rent, landlords often need an incentive to take
them as tenants due to fears that they may experience management problems and
delays in housing benefit payments.

There is wealth of guidance now available to DATs and their partners on the use of
the private rented sector for drug users, which is summarised and referenced in the
Clean Break Toolkit. Newham is a good example of a borough that successfully and
routinely uses the private rented sector for drug users.

The ability to use the private rented sector for drug users will vary from area to
area however, and it is important for substance misuse commissioners and their
partners to be realistic about this. Unlike social landlords, private landlords rarely
have a social purpose but instead have usually invested in ‘buy to let’ property to
make profit – either on an ongoing basis out of rental income or through longer
term increases in the value of the property. Nevertheless many areas with high
demand for private lets (for instance Brighton and York) are reporting good success
in encouraging private landlords to take tenants on housing benefit.

The supply of housing from the private rented sector can be highly volatile and
volume and price will be subject to changes in the market. In areas of intense
housing demand neighbouring authorities can compete for places from landlords.
Whilst encouraging authorities to use this sector to its full potential, the
Government should also encourage authorities to monitor supply from this source
regularly so as to pick up early on any changes in market conditions that could
threaten supply.

Where there is an existing scheme in a local area, DATs/DIPs should be encouraged
to work alongside or integrate their service with the existing one.

Cross authority services
Whilst many drug users may wish to remain in their borough of usual residence in
order to maintain informal and formal support networks, a significant proportion
will wish or need to move from their local area to a new authority. This may be to
break ties with old drug taking/dealing associates, and in some cases to ensure
safety after threats have been made.

Whilst there was some evidence in the Clean Break study of cross authority
collaboration and reciprocal referral arrangements, many authorities appear to
refer to accommodation elsewhere without any dialogue with the ‘receiving’
borough, and often due to local shortages rather than as a planned and positive
move. This is reported to often be the case for people leaving residential rehab
and choosing to stay in the area of that service. Substance Misuse commissioners in
areas with a high concentration of residential rehabs have reported that around 50
per cent of those completing rehab choose to stay, often without arrangements
                                                            Clean break – Research report

having been made by the referring authority to arrange or pay for housing and
other aftercare.

One Youth Offending team described a number of cases when they had sought
accommodation for young people elsewhere in London on safety grounds (for
instance after death threats from former gang associates), but had found it almost
impossible to arrange for this to happen.

The barriers to accessing cross authority services for drug users are discussed in
more detail in the next section.

Summary and implications of the findings
Although this section of the report has identified much scope to use existing
housing services more effectively for drug users, this can be extremely difficult to
achieve without strong partnerships being in place at both a strategic and
operational level.

If these partnerships are not established and increased access to housing and
related support not achieved, the continuing impacts will be that:

     •   those trying to reduce or abstain from drugs will be forced to live alongside
         those still actively using

     •   inappropriate referrals will be made to existing supported housing

     •   chaotic drug users will have to sleep rough or move out of borough

     •   people will become ‘lost’ in the system

     •   there will be an increased risk of relapse and wasted investment

One of the Clean Break case study authorities is now putting in place plans to build
upon and strengthen existing relationships at both the strategic and operational
levels across housing and treatment agencies. This will be achieved via:

     •   Joint training sessions and forums involving housing and treatment agencies

     •   A joint action plan to respond to the findings of the Clean Break study
         between the DAT and SP partnership boards

     •   A strategic review of SP funded services which are currently or could
         potentially support drug users involving all relevant voluntary and statutory
         sector partners

                                                            Clean break – Research report

7. Barriers to housing access for drug users
 Shortage of affordable housing
 The general and acute shortage of affordable accommodation in London inevitably
 affects the ability of drug users to access suitable housing options. It is not the
 role of this study to comment on how national, regional and local government
 should address those shortages. However it is important to recognise that whilst
 they continue, it will remain a constant challenge to find housing for drug users. In
 this context there may be little prospect of success in some areas, unless dedicated
 and specialist attention is focused on this problem at the local level.

 Unpopularity of drug users
 The problems of general housing shortage experienced by the general population
 and discussed briefly above are exacerbated many times over for drug users.

 Drug users are only one of many client groups that housing and social service
 authorities are trying to respond to the needs of; and they are by no means the
 most popular. There is much anecdotal evidence of services for drug users (housing
 and otherwise) that have had to be abandoned whilst in development due to
 vociferous opposition from the local community.

 There are currently dedicated funds available from central government for
 treatment of drug users and this has led to a focusing of resources into treatment
 for this group. There is no dedicated fund for housing or housing related support for
 drug users and the comparative difficulties that drug users face in accessing
 housing, compared to their ability to access treatment, reflect this. Supporting
 People is designed to meet the housing support needs of this group along with many
 others such as older people and people with learning disability

 The Clean Break Toolkit provides some advice on how to develop services for drug
 users successfully, however additional guidance on effective approaches to gaining
 local support for such services would be welcome.

  ‘I’ve never had such a bad service in my life from the council. I felt humiliated,
 victimised. I had a nervous breakdown, emotionally destroyed. This could be
 improved – by getting rid of people who are judgemental in the housing
 department.’ Service User

 Local connections and local authority boundaries
 The importance of being able to make a fresh start when attempting to end or
 significantly reduce drug use was reflected in many of the comments made by
 service users and professional stakeholders interviewed during the Clean Break

                                                            Clean break – Research report

[I would like} a flat, but not in Islington. There are too many druggies around’.
Service user

‘I would want to choose the borough that I live in and move to a borough where I
wasn’t known as a user and could get a job.’ Service user

Moving between boroughs is possible in theory for those seeking both general needs
and supported accommodation. Some Choice Based Lettings Schemes operate on a
multi-landlord or sub-regional basis, therefore offering some scope to move
between areas. However accommodation accessed through this route will rarely be
available at short notice.

Supported housing funded by Supporting People is subject to grant conditions set by
the department of Communities and Local Government (CLG) which are meant to
stop authorities limiting access to their temporary supported housing to those who
have a local connection. In practice, and based on anecdotal evidence, some
authorities appear to be ignoring this and putting pressure upon providers of short
term accommodation-based services to take a greater proportion of local people.
There appear to be no effective sanctions that CLG can take in these cases.
Providers will be understandably reluctant to complain to CLG in these cases as
they depend upon future funding from the same authority in order to remain

Supported housing residents often require a whole raft of services in addition to a
home, such as health, social care, and drug treatment needs. This additional drain
on local resources is understandably unwelcome when resources are finite and
needs exceed capacity to respond – as is the case in many London boroughs. Giving
local people priority access to accommodation in their own borough can be
beneficial as it enables them to stay close to their established support networks. It
can also be beneficial for providers to work with a greater proportion of ‘local
people’ as this may help to create local partnerships and gain access to local
resources such as move-on housing.

Funding responsibilities
Shortage of ongoing revenue funding is a significant barrier to the development of
new housing for drug users.

The Clean Break Toolkit contains a description of the different funding sources that
can be used to fund housing and related support for drug users. What this shows is
that a variety of funding sources can be used to fund the revenue costs of
supported housing or other housing related support services. Whilst this can be an
advantage, by giving scope for joint funding arrangements, it could also act as a
disadvantage if individual funders assume that it is the other agency’s
responsibility to ‘foot the bill’ for the housing related support needs of drug users.

At present DIP main grant and Pooled Treatment Budgets can only be used in
exceptional circumstances to add funds that will ‘enhance’ housing related support
for drug users, and only where other targets are met. However the pressures on
these funding sources, are replicated across others, such as the Supporting People

                                                          Clean break – Research report

Local Area Agreements may offer new scope to bring together resources from a
whole range of sources to meet the needs of homeless drug users.

Ineffective pathways into and out of services
The findings from the Clean Break study suggest that even where there is no
funding for additional services, there are advantages to be gained from more
effective pathways between, and deployment of, existing services.

There are a number of steps that authorities can take to implement more effective
pathways that are outlined in the Clean Break toolkit and which include:

•     Ensuring all providers are clear about their own role in the network of
      housing and treatment services for drug users, and that of other service

•     Ensuring housing and treatment/aftercare providers are clear about their
      need to support each other’s work and what this means in practice

•     Embedding partnership working through joint training, integrated team
      working, clear expectations in service specifications, and other such methods

•     Ensuring an appropriate and adequate supply of move-on accommodation
      from temporary supported housing for those who need higher and lower

The Toolkit also recommends a single point of access to a network of housing
services for both statutory and non-statutory homeless clients which:

•     Enables access to services to be determined by locally and regionally agreed

•     Ensures that agreed pathways are adhered to

•     Reduces the need for multiple relationships and time intensive liaison across
      a group of stakeholders

•     Enables the collation of information about needs at a single point

•     Ensures equitable treatment of service users according to their needs.

Problems proving identity
One of the current barriers to accessing housing for some drug users (rough sleepers
in particular) is their inability to prove their identity for housing and benefit
purposes. We were told of cases where individuals were without benefits for
months at a time (up to seven months in one case) whilst proof of their identity was
being arranged.

Whilst treatment agencies could play a more active role in helping service users
gather evidence of their identity, partnership working is also required at the
national level where identity requirements for benefits are established. Reduced

                                                           Clean break – Research report

identity requirements can be agreed for housing benefit purposes and may be
suitable for other benefits, where there are clear policy grounds for doing so.

‘I got no ID so people don’t help you, like HPU. When you’re moving around you
lose things. The council should be helping me. They always turn their back on me
‘cos I can’t prove who I am. I went straight from the hospital suffering from blood
clots on my legs but they turned me back because I needed three sets of ID’
Service User

Poor needs data
As noted in section 4, the housing and related support needs of drug users are
currently poorly recorded, assessed and collated. This makes the planning and
commissioning of new service provision very difficult and reduces ability to argue
for more resources.

The NDTMS data system is the logical place to record information about housing
need amongst drug users engaging in treatment. Whilst changes are being
introduced to the way accommodation status is recorded for those engaging in
treatment services, these changes still appear inadequate and more work is

The Clean Break Toolkit provides guidance on the types of information that can be
gathered locally to inform needs assessments.

Staff expertise and knowledge
Some of the current gaps in or barriers to services experienced by drug users can be
attributed to a lack of staff expertise or knowledge both at the operational level
(for instance lack of knowledge about services and how to refer) and the strategic
level (for instance poor understanding of the links between housing and drug use
and how to engage key partners).

Some of the tactics that can be employed to address these weaknesses include:

     •   Joint housing and treatment agency forums

     •   Joint training across housing and treatment agencies

     •   Job shadowing

     •   Written referral pathways to key services that are kept up to date and
         widely circulated

     •   A single assessment and referral point for key services

     •   Collation of evidence about the impact that stable housing can have on the
         achievement of treatment outcomes and vice versa

     •   Raising awareness and commitment amongst council members and senior
         officers through events, research and joint commissioning bodies.

                                                                         Clean break – Research report

         Complex needs
         The results of the Clean Break study suggest that it is continuing drug users and
         those who are engaged in chaotic drug use for whom there is least appropriate
         housing. This appears to be due to a variety of reasons:

           •   Housing providers could house active drug users but are often misinformed or
               concerned about the possibility of prosecution under section 8 of the Misuse of
               Drugs Act 197141

           •   Services developed specifically for active drug users require specialist staff
               and the ability to deliver high support – both of which are expensive

           •   Active drug users are associated with increased levels of crime, anti-social
               behaviour and drug dealing – all of which are likely to increase opposition from
               local people

         All three of the case study boroughs were found to have the largest gaps in their
         supply of accommodation for continuing drug users and chaotic drug users. Whilst
         there were also shortages in ‘clean’ accommodation options (accommodation
         where service users would not be in close proximity to active drug users), these
         were less acute and there was usually more scope for remodelling and/or
         negotiating increased access to existing services for this group.

         An analysis of the Supporting People strategies of 11 London boroughs revealed that
         nine had identified at least one gap in services for drug users and/or people with
         complex needs. Several had identified gaps in accommodation for both clean and
         continuing drug users.

         Some boroughs are currently referring their chaotic drug users to large hostels in
         central London or to those outer London boroughs where there are night shelters.
         These services are not always set up to cope with the high levels of need amongst
         chaotic drug users however. Many nightshelters operate with a high proportion of
         volunteers for instance.

         Research carried out by Homeless Link in 2002 found that staff working with
         homeless people with multiple needs were often not adequately trained in key
         areas of specialist need, and that there was an ‘alarming’ lack of formal
         arrangements between homelessness agencies and statutory services when dealing
         with service users with multiple needs.

           “Research and data suggests that, due to the rise in the availability of drugs,
           hostels are working with far more complex and challenging residents”42

           “The successful resettlement of people with multiple needs has become the
           biggest challenge and concern for those working in the homelessness sector” 43

     Flemen K (2005) Drugs on premises: the updated legal position KFX

     Hostels Capital Improvement Programme, Policy Briefing 12, ODPM

                                                                     Clean break – Research report

8.         Recommendations
           Making the case for resources for homeless drug users
           Homeless drug users are competing for scarce housing and treatment resources
           with a range of other groups. The complexity of their needs, transient lifestyles,
           unpopularity with the local electorate, and current shortage of reliable needs
           data, all mitigate against appropriate access to services. However failure to
           address these barriers identified lead to poorer outcomes and wasted resources
           for individuals and communities. Housing and treatment agencies should work
           together at the national, regional and local levels to collect, collate and evidence
           the business case for investment in services.

           The NTA, Home Office and CLG should:

               •   Jointly commission research to evaluate the policy and financial impacts of
                   different types of housing (and housing locations) on drug treatment
                   outcomes and of different drug treatment services on homelessness

               •   Revise the data collected through NDTMS and other relevant data systems
                   to provide more meaningful data about the housing and support needs of
                   drug treatment users to feed into local and regional needs assessments

           The CLG should:

               •   Issue guidance to local housing authorities encouraging them to work in
                   partnership with DATs, Supporting People commissioning bodies and
                   providers, to undertake accommodation and support needs assessment for
                   drug users in their area, and specify the key features of a robust
                   assessment in the guidance

               •   Provide guidance to local housing authorities to enable them to identify,
                   record (through P1E data) and respond to problematic drug use amongst
                   homelessness applicants, even when incidental to the assessment of
                   whether a statutory housing duty exists

           A local partnership of the DAT, housing authority, Supporting People
           Commissioning Body and housing and treatment providers should:

               •   Ensure that individual needs assessments cover both the housing and
                   treatment needs of homeless drug users and that this data is recorded in a
                   systematic way

               •   Conduct an overall assessment of housing, support needs and treatment
                   needs of homeless drug users, and the capacity of current resources to
                   meet those needs

     Supporting People with multiple needs, Homeless Link 2002

                                                           Clean break – Research report

 Regional Housing Boards, NTA Regional leads, Regional Offender Managers and
 regional third sector leads should:

    •   Collate the information from local needs assessments in order to develop
        regional needs assessments for homeless drug users which will inform the
        planning, commissioning and development of regional and sub-regional

 Strengthening partnerships at regional and local level
 The need to work across the housing, health and criminal justice sectors to
 address the needs of drug users is well accepted at the national level and
 reflected in strong partnerships across relevant Government departments. These
 partnerships are not always reflected at the regional or local level however and
 need more support and encouragement to develop and flourish.

 The Treasury should:

    •   Establish a national fund focused on the development of sustainable
        partnerships to meet the needs of homeless drug users and demonstrate
        the ‘invest to save’ benefits of effective services

 CLG, Home Office and NTA should:

    •   Jointly issue guidance to regional housing boards highlighting the
        expectation that they will give particular attention to the needs of
        transient, socially excluded and/or ‘unpopular’ groups, including drug
        users, in their regional housing strategies

    •   Jointly issue guidance to local authorities highlighting the expectation that
        they will give appropriate attention to the needs of transient, socially
        excluded and/or ‘unpopular’ groups, including drug users, in their
        homelessness and housing strategies

The Department of Health should:

    •   issue guidance to social services authorities and primary care trusts
        encouraging them to work in partnership with housing and drug treatment
        agencies to meet the mental and physical health needs of drug users

 Government Offices should:

    •   Encourage local authorities to ensure that Local Area Agreements give due
        regard to the needs of homeless drug users either individually or

 Regional Housing Boards should:

    •   Set out in their Regional Housing Strategy an expectation that new
        investment in housing for drug users will take place where local needs
        assessments indicate that there are gaps that cannot be filled by increased
        access to, or more effective use of, existing provision
                                                         Clean break – Research report

   •   Consider how Regional Planning Guidance can be used to encourage and
       support the development of housing and other services for homeless drug

The Audit Commission and Healthcare Commission should:

   •   Incorporate an expectation of partnership working both within and across
       authorities to meet the needs of homeless drug users into their inspection
       frameworks for housing, support and treatment services, and monitor the
       establishment and effectiveness of these partnerships

Making best use of available resources
Commissioners and service providers need to take a ‘whole system’ perspective
that recognises the inter-relationships between different housing services, and
between housing and treatment services.

The NTA, Home Office and CLG should:

   •   Jointly issue guidance to housing authorities, providers, DATs and
       Supporting People commissioning bodies on the development of effective
       services for homeless drug users (building upon the research into the
       effectiveness of different housing and treatment models)

A local partnership of the DAT, Supporting People Commissioning Body, and
housing and treatment providers should:

   •   Undertake a strategic review of their housing and support services for drug
       users engaged in treatment so as to achieve a network of services that
       work together in a mutually supportive way

   •   Ensure that pathways into housing, support and treatment services are
       clear, understood, and accessible to those in need

   •   Ensure barriers to housing and treatment access are understood and
       addressed from a partnership perspective – for instance by ensuring that
       housing providers are supported by specialist drug services to take more
       homeless drug users

   •   Provide training and briefings for housing and treatment providers on how
       to identify and respond to the housing, support and treatment needs of
       homeless drug users

   •   Support providers to remodel supported housing, where appropriate, to
       achieve a better fit with the priorities identified during the strategic

                                                        Clean break – Research report

NTA regional leads, Regional Housing Boards, Regional Offender Managers and
regional third sector leads should:

   •   Develop regional strategies for responding to the needs of homeless drug
       users, which may, for instance, include proposals for joint commissioning,
       cross authority protocols and pathways, reconnection policies and inter-
       authority mobility arrangements

                                                                 Clean break – Research report

Appendix A
Accommodation types for drug users

Accom         Key features                   Who suitable for

General         Privately or socially        Particularly suitable for those who are:
needs           rented
                                               Not active problematic drug users
                Rents affordable in
                socially rented housing        Highly motivated to remain
                No direct links to a
                support service, however       Capable of successfully sustaining a
                tenants may receive            tenancy, with floating support
                floating support               where necessary

                Fully self-contained         Social housing is particularly suitable
                                             for those for whom work is important
                                             for recovery, due to lower rents in that

Supported       Usually temporary            Particularly suitable for:
accomm          housing for up to 2 years
with            with assured shorthold         Those who are thought to be
regular         tenancies                      particularly at risk of tenancy
visiting                                       breakdown
support         Self-contained or shared
                – shared could be based        Those thought to be at particular
                on the Half-way House          risk of disengagement from
                model                          treatment services

                Continued occupation           Those who will benefit from regular
                can be dependent upon          support and encouragement from
                adherence to treatment         staff and/or peers
                regime if required (for
                instance via drug testing)     May need separate schemes for
                                               people who are i) clean ii) clean
                Staff available during the     except for prescribed substitutes
                day, plus communal
                areas to facilitate peer
                support/group sessions

                Units can be scattered if

Supported       Normally include at least    Particularly suitable for:
accomm          10 units to spread costs
with 24         of on-site staff               People who need period of
hour onsite                                    assessment to determine risks/needs
                                                            Clean break – Research report

Accom     Key features                  Who suitable for
support     Normally short stay           (inc non drug related needs)
            accommodation only            People who may be a risk to
            Need onsite staff office      themselves, neighbours or wider
                                          community if left unsupervised
            Units tend to be small or
            involve sharing of            People who are particularly
            facilities to compensate      vulnerable and at risk of harm or
            for costs of staff            abuse from others if left
            accommodation                 unsupervised

            Rents, service charges        People experiencing temporary crisis
            and support charges tend      and who need intensive support
            to be high                    May need separate schemes for
            Could be a cross-borough      people who are i) working to reduce
            resource                      illicit drug use ii) using in a ‘chaotic’
                                          way, if providing clustered units

                      Foundation 2007 May 2007

Charity no. 1089173             The individuals in the photos illustrating this report are not
Company no. 4313826             necessarily drug users.

                                Cover photos 1 and 4: Thames Reach, photography Len Cross

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