The long journey home: designing better supported housing systems

In this blog, Seth Reynolds, Principal: Systems Change at NPC, sets out the need for a systemic approach to tackling our supported housing crisis. This blog marks the publication of a new report on supported housing by Rethink Mental Illness.   

A safe, stable, and affordable home is a foundation of good mental health and wellbeing–for anyone. For people with mental ill-health, having a stable home is even more vital, because inadequate or unstable housing can worsen mental illness. Yet accessing and maintaining a conventional home can be a challenge for some people with severe mental illness. 

Long-term supported housing–providing a stable home alongside support services–has been shown to offer a solution. It can have a positive impact on health and wellbeing, reduce homelessness, relieve pressures on social care, health, and criminal justice systems, and ultimately reduces demand on the public purse. 

Why then, if it is so effective and has such wide-ranging benefits, are we so short of it? Why is it so hard to access for those that need it?  

We’re not just a bit short. We’re chronically short. The National Housing Federation has identified a 210,000 shortfall in necessary supported housing units, set to rise to 350,000 by 20451.   

Increasing supply is vital. However, building units alone won’t solve the problem. Supported housing is not one-size-fits-all. For example, the housing and support needs of people leaving prison are different to those of people leaving hospital. Step-down (temporary/ transitional) accommodation needs to be designed differently to longer-term supported housing. Access to services, community, and infrastructure must also be considered. The processes that govern how people are referred to and access supported housing–whether from hospitals, probation, or the community–are also critical to determining how the system works.  

A complex picture: understanding the nature of the problem  

Given their years of supporting and housing people with mental ill-health, Rethink Mental Illness are well aware of the systemic nature of this issue. For this reason, they invited a team of consultants from NPC with expertise in complex systems analysis and design, as well as in building innovative investment models, to help them better understand the systemic factors limiting the supply and potential impact of supported housing.  

To do this, we convened stakeholders from across the supported housing system, including: representatives from NHS Trusts, local authorities, housing associations, charities, and people with lived experience of supported housing.  

With their input, we produced a user-centred systems model that summarises some of the key factors affecting the supported housing system. We put people’s lived experience at the centre of this model, and complemented these with data and evidence that shows how such experiences play out at scale across the system.  

The resulting report, published today, shows how policies, processes, and practices within these systems can be bureaucratic and dehumanising–the exact opposite of what people with mental illness need. We heard cases in which the process of accessing supported housing actually made a condition worse. A support system which, for some, actually hinders not helps clearly needs a rethink. 

The report also describes how shortages in supported housing create stresses in other systems. For example, people with severe mental health needs who find themselves in the hospital system frequently end up there–occupying scarce hospitable beds they no longer need for extended periods, simply because of a lack of suitable discharge accommodation. This is currently a factor affecting availability of NHS beds and has significantly worsened in recent years. The total number of days in which patients were unable to be discharged due to a lack of available supported accommodation increased by 70% between August 2021 and July 2022 

Similar knock-on effects are seen in other systems. Shortfalls in supported housing impact on the number of people rough sleeping, and on capacity in shorter term, transitional accommodation. Similarly, many people leaving prison with mental health needs lack suitable accommodation, which increases the risk of reoffending, placing further strain on the criminal justice system. In our research, we heard how some people intentionally align their offending cycles with the seasons, to ensure they at least have a warm prison bed for the winter. A lack of suitable housing is actually pushing people to crime.   

Changing these outcomes will require a cross-system approach. For example, service users told us how getting referrals from the health system can be slow, inconsistent, and confusing due to the lack of effective coordination between health, housing, local authorities, and voluntary sector providers. Or as one user said: ‘There are a lot of unnecessary arguments about whose budget is paying for it.’ 

Building a different system 

The next phase of our work with Rethink will involve piloting new approaches to supported housing in three locations in the UK. Ensuring that these systemic and interconnected challenges of referrals, transitions, commissioning, budgetary processes, etc, are understood and addressed will be key to the success of this work.  

Of course, as important as they are, better coordination processes won’t build more supported housing. Major change is needed in the investment and supply models, which this work will also be addressing, and which will be the subject of our next blog.   

We hope that addressing each of these critical aspects of this highly complex system together in this way will help provide sustainable pathways to a better supported housing system and, in doing so, help many people with long-term mental illness finally find home. 

To download the full report, visit Rethink Mental Illness’s website.   

This is the first in a series of blogs that NPC will be producing on the supported housing system and how to fix it. In our next blog, David Neaum, NPC’s Senior Consultant for Impact Investment, will be discussing how blended finance models could unlock the investment needed to significantly scale-up supply.