Response to Homelessness 2020 strategy – A discussion paper Contacts: Deborah Fewster Strategy, Advocacy and Policy Advisor Inner South Community Health Service 03 9684 4288 [email protected] Sue White General Manager, Complex Care and Dental Inner South Community Health Service 03 9534 8166 [email protected] Contents Introduction Context for this submission  Homelessness and the Victorian community health sector  Homelessness and the Inner South Community Health Service Response to Homelessness 2020 – A discussion paper  Homelessness and social inclusion  Prevention and early intervention  Whole‐of‐government approaches  Focus on the individual Conclusion p. 3 p. 5 p. 5 p. 6 p. 9 p. 10 p. 13 p. 18 p. 20 p. 21 2
Introduction Poor health and wellbeing are both a cause and consequence of homelessness, yet there has been limited intersection between the key policy frameworks in these two domains – and the attendant service systems – to date. That is not to say it hasn’t happened, but rather that the intersection has been piecemeal and the opportunities not fully realised. Right now, Australia’s Federal, State and Territory governments are at the crossroads in both policy domains. They have: 
signed off on an ambitious target to halve homelessness by 2020 and offer supported accommodation to all rough sleepers who need it; and 
flagged wholesale changes to Australia’s healthcare system, in order to redress current access and equity issues and meet emerging challenges. In both domains, stakeholders describe the reform agendas as ‘once‐in‐a‐generation’ opportunities to effect positive and lasting change. Inner South Community Health Service contends that both reform agendas are contingent upon the interdependent relationship between health and homelessness being recognised in strategic vision, policy frameworks, funding models and service development and delivery. In this response to Homelessness 2020 strategy – A discussion paper, Inner South Community Health Service: 
flags the opportunities and challenges associated with the conceptual framework that is guiding the development of the Victorian Government’s homelessness strategy; 
articulates community health’s current role in the prevention of homelessness, early intervention and support for people experiencing (or at risk of) long‐term/ongoing homelessness, and identifies future opportunities for government to harness the sector’s ‘first to know’ capacity and local networks; and 3

highlights aspects of Victoria’s unique community health model (cited nationally as a best‐practice model) that could inform the interface between homelessness specialist services and mainstream services in a future service delivery framework. From our perspective, it is difficult to conceive of a homelessness response that does not contain a health response and where health – in particular, community health – is not a designated leader. 4
Context for this submission Homelessness and the Victorian community health sector Inner South Community Health Service (ISCHS) is one of 100 community health services operating across 300 sites in Victoria. There is a community health service in every local government area of the state. Community health services respond to the social and economic health needs of local gazetted populations across age and life continuums. They provide a platform in every local community to deliver a comprehensive range of primary health care support services and health promotion. The Victorian community health model is increasingly held up as a pre‐eminent model by local, state and federal governments across a diverse range of policy domains (including primary health and early childhood development). Features of the model include: 
strong local partnerships; 
co‐located services (‘one‐stop shops’); 
multi‐disciplinary teams; and 
service ‘wrap‐around’( for example, comprehensive intake and referral processes, care planning, case conferencing and person‐centred service models, including assertive outreach models that engage ‘hard to reach’ populations with multiple and complex needs). In the homelessness space, community health services can (and many already do) play a critical role in the prevention of homelessness, as well as early intervention and support to people who are at risk of, or already experiencing, long‐term homelessness. The programs and services provided by many community health services (such as casework/counselling and group work in the areas of family violence, mental health, drug and alcohol, management of personal finances) and the populations they serve (a focus on those who are most disadvantaged or at risk) position community health as a key ‘first to know’ agency. 5
Homelessness and the Inner South Community Health Service Inner South Community Health Service (ISCHS) is a major provider of health and community services in the inner southern region of Melbourne, servicing a catchment of 177,000 people. In addition, ISCHS delivers a small number of regional and statewide programs. The agency plays a leadership role in the Inner South East Partnership in Community and Health, an alliance of 47 health and community support agencies driving systems change in Stonnington, Glen Eira and Port Phillip. ISCHS is also part of an Opening Doors Local Area Service Network (Southern Metropolitan Region – Inner/Middle). The conceptual framework for ISCHS’s work is the social model – rather than the medical model – of health. In other words, ISCHS recognises that a myriad of social, economic, cultural and political factors impact on an individual’s (or a community’s) health and wellbeing, including precarious housing. Consequently: 
ISCHS’s programs and services – and its advocacy and research interests – span a wide range of policy domains and service systems, including housing and homelessness; and 
ISCHS has a strategic focus on reducing health inequities. This means that whilst we are a mainstream agency delivering a wide range of universal services, many of our programs and services intentionally target individuals and groups whose experience of social exclusion means that they may not readily access mainstream services. Our catchment Inner South Community Health Service provides a small number of regional and statewide services, however, its catchment principally spans two local government areas: Port Phillip and Stonnington. These two LGAs are part of the ‘city core’ statistical subdivision. 6
This area has eight per cent of Melbourne’s population, but 24 per cent of its homeless people according to the latest Census data1. Successive waves of gentrification in Port Phillip and parts of Stonnington have significantly reduced the availability of safe, affordable housing for people on low incomes. There is high unmet demand for all forms of housing, including private rental, community housing and public housing in ISCHS’s catchment. As of September 2009, the Office of Housing’s South Melbourne/Prahran ‘wait list office’ had the state’s third‐highest public housing waiting list for ‘early housing’.2 This category includes people who are experiencing, or at risk of, recurring homelessness. Our clients Homelessness and precarious housing consistently present as significant issues for clients of Inner South Community Health Service, particularly those on statutory incomes, those living with a mental illness and/or those whose drug or alcohol use has become problematic for them. In a recent ISCHS survey: 
30 per cent of ISCHS clients said they had experienced homelessness; 
11.5 per cent reported they were experiencing primary, secondary or tertiary homelessness at the time of interview; 
28 per cent said their current housing didn’t meet their needs; 
37 per cent had concerns in relation to paying rent and/or bills; 
28 per cent said they worried about being able to afford where they lived; and 
7 per cent of all respondents had moved four times or more in the last 12 months. 1
C Chamberlain and D MacKenzie, David, Counting the Homeless 2006, Canberra: Australian Bureau of Statistics, 56pp, Catalogue No. 2050.0. 2
September 2009 data is published at http://www.housing.vic.gov.au/applying‐for‐
housing/waiting‐times 7
ISCHS currently delivers a suite of programs and services that span the homelessness continuum, from prevention and early intervention right through to support for individuals who are experiencing (or at risk of) long‐term/ongoing homelessness. These programs and services include (but are not limited to): 
family violence casework/counselling and group work; 
financial counselling; 
a pre‐school to school transition program that targets local children who have experienced social, emotional or developmental delays and who are growing up in families with high levels of mental illness, family violence and social isolation; 
a range of targeted mental health programs, including the Personal Helpers and Mentors Scheme (PHaMs), which assists people with a mental illness to secure and/or maintain housing, enhance their independent living skills and build community connections; 
drug and alcohol services; 
a Community Connections program that provides casework support, information and assistance to people with complex needs who are homeless, at risk of becoming homeless or living in insecure housing; 
SAAP support to homeless young women engaged in sex work; 
an SRS outreach program that provides links to allied health services and facilitates social and recreational opportunities; 
a General Practice Innovations program that provides outreach medical services to clients at Sacred Heart Mission and Hanover; 
dental/oral health clinics; and 
ConnectED and Better Care for Older People (these two initiatives are part of the Victorian Government’s Hospital Admission Risk Program, which aims to reduce the preventable use of hospital emergency services by maintaining health and wellbeing of key population groups, including people who are homeless). As a ‘first to know’ agency, ISCHS (and the community health sector more broadly) is positioned to play a potentially greater role in prevention and early intervention as part of the Victorian Government’s future Homelessness 2020 Strategy. 8
Response to Homelessness 2020 – A discussion paper In this section of our submission, Inner South Community Health Service responds to four key areas outlined in Homelessness 2020 strategy – A discussion paper: 
Homelessness and social inclusion; 
Prevention and early intervention; 
Whole of government; and 
Focus on the individual. 9
Homelessness and social inclusion Moving from case to cause Inner South Community Health Service supports the Victorian Government’s use of social inclusion as the conceptual framework for the Homelessness 2020 strategy. A core strength of the social inclusion framework is its identification and examination of the structural drivers of disadvantage. Inner South Community Health Service sees the application of the social inclusion framework in homelessness as a positive step forward in that it: 
represents a move away from the agency approach that underpinned policy development earlier this decade – an approach that focused attention (blame) on the lifestyle and behaviour of individuals; and 
places greater emphasis on tackling the root causes of homelessness. Implicit in this is an acknowledgement that without significant changes at the ideological and structural level, any effort to reduce homelessness will be diminished. Given that many of the structural factors that shape the risk and onset of homelessness – for example, poverty, unemployment, lack of affordable housing – also shape the risk and onset of poor health and wellbeing, it would seem that Homelessness 2020 strategy – A discussion paper gives tacit recognition of the need to bring health inequalities into the social inclusion space. While this is ‘par for the course’ in the United Kingdom and many European nations, there has not been a strong health inequalities thread running through Australia’s National Social Inclusion Agenda. In light of this (and given the health/homelessness policy divide described in the introduction of this submission), Inner South Community Health Service believes that it is 10
critical that the Victorian Government in its Homelessness 2020 Strategy moves beyond tacit recognition of health inequalities. Recommendation: That the Homelessness 2020 Strategy provides a clear articulation of the relationship between health inequalities and homelessness. The social inclusion framework: implications for when, how and where to respond The social inclusion framework – and the attendant emphasis on structural factors – also signifies a major focus on the prevention of homelessness. This, in turn, signals a greater role for mainstream services, such as community health, in developing population‐level protective factors. The proposition put in the Discussion Paper, that prevention becomes the sole preserve of mainstream service systems, is broadly welcomed by Inner South Community Health Service. Aside from the capacity, resourcing and interface issues already flagged in the Discussion Paper, a critical challenge for the Victorian Government will be clear and consistent articulation of what is prevention and what is early intervention. As Mallett has noted, in youth homelessness research, policy and practice, the two terms have often been conflated or used interchangeably and this has “inadvertently stalled conversations about ways universal policy and service domains can address structural factors that cause homelessness.”3 3
S Mallett, Youth homelessness Prevention and Early intervention: A brief historical overview of key frameworks in Australia’ in Parity Vol 22 (2) March 2009 11
Mallett describes the implications as two‐fold: 
firstly, “responsibility for prevention has shifted from government and community to the homelessness and personal/familial support service sector ... the lack of a universal commitment and approach has led to the service sector being left to pick up the coordinating role, devolving governments of responsibility and laying the responsibility of solving societal issues in the hands of under‐funded and under‐
resourced community services”. These services are also being expected to intervene into homelessness. 
secondly, “broad‐based universal prevention approaches have largely become tokenistic, ad hoc, and placed in the too hard basket”.4 Recommendation: That the Homelessness 2020 Strategy avoids the pitfalls of the past and provides clarity to both mainstream and homelessness specific service systems by articulating a clear and consistent conceptual framework for prevention and a clear and consistent conceptual framework for early intervention. Inner South Community Health Service believes that these frameworks need to be clearly established and communicated in advance of decisions being made about an array of “central issues”, including resource allocation. 4
IBID. 12
Prevention and Early Intervention Prevention: comments and recommendations Notwithstanding the definitional/conceptual issues Inner South Community Health Service has already flagged in this submission, ISCHS broadly supports the proposition that prevention of homelessness should sit with mainstream services and advocates a lead role for the community health sector. A critical challenge will be to integrate the homelessness prevention agenda with population health planning. In particular, intentional links will need to be developed between the Homelessness 2020 Strategy and the new Public Health and Wellbeing Act 2008. Early sections of Homelessness 2020 strategy – A discussion paper describe how the Victorian Government will facilitate social inclusion by linking into the key reform strategies of: 
the whole of government Integrated Family Violence Response; 
the Victorian Mental Health Reform Strategy 2009 – 2012; 
Directions for out‐of‐home care to reform child protection, placement and family services; 
the Blueprint for Education and Early Childhood Development; and 
The Victorian State Disability Plan 2002‐2012. The Public Health and Wellbeing Act 2008, set to take effect on 1 January 2010, is a significant omission from this list. The Act, which has a strong prevention flavour, focuses particularly on the ‘environmental factors’ (social determinants) that influence health, including housing and support. It effectively legislates that public health and wellbeing are the responsibility of all government departments and all levels of government in Victoria. The Minister for Health and senior bureaucrats have sent clear signals that the Government will require action from many service areas that are not usually viewed as health services, 13
including housing, in order to deliver on its prevention agenda. Cross‐departmental and inter‐sectoral accountability will be driven through four‐year State Public Health and Wellbeing Plans. There will need to be an articulation of the relationship between this work and the Homelessness 2020 Strategy. Early intervention – comments and recommendations Through programs such as Reconnect, specialist homelessness services have demonstrated their capacity to achieve good, sustainable outcomes for young people who are at risk of homelessness or in the early stages of homelessness. However, early intervention opportunities often exist before engagement with homelessness services. Consequently, Inner South Community Health Service supports the Discussion Paper’s proposition that early intervention should sit with both specialist homelessness services and mainstream services. In relation to the role of mainstream services, ISCHS advocates a substantial role for the community health sector in the 2020 Homelessness Strategy: 
As detailed earlier in this submission, community health is a key ‘first to know’ agency: many of the personal factors that are precursors to the homelessness event are health issues, for example, chronic disease, drug and alcohol use and mental illness. 
In addition to being able to identify people at risk of homelessness, community health services often have the in‐house capacity and/or networks to actually address the individual/familial level causes of homelessness. 14

Crane, presenting on best practice in early intervention, has highlighted that “early intervention agencies are malleable to their local service system, filling in gaps and making connections, and making it easier for other agencies to be helpful” and “early intervention requires having multiple flexible roles but coherently linked by a well‐
founded practice framework that others can understand”.5 These are hallmarks of the community health sector, as detailed in earlier sections of this submission. A critical challenge that will need to be resolved is the interface between the specialist homelessness service system and mainstream service systems, in particular the issue of local area/regional partnerships. ISCHS is involved in a number of local networks (including an Opening Doors Local Area Service Network) and, at this point in time, actively maintains 70 partnerships (including the Inner South East Partnership in Community and Health). ISCHS’s experience would be typical of other community health organisations. A number of these networks have a degree of cross‐over (for example, some of the same players around the table). In terms of catchment planning and local/regional action plans, it is questionable whether another new network needs to be added to the mix. Consideration should be given to the role of these existing networks in facilitating the implementation of the Homelessness 2020 Strategy. 5
P Crane, Early Intervention into Youth Homelessness Where are we up to? Where should we go?, presentation to Victorian Youth Homelessness Conference, Melbourne, 28 October 2009, accessed at http://www.chpevents.org.au/download/Phil%20Crane.pdf 15
Long‐term or ongoing homelessness – comments and recommendations The Federal Government’s Homelessness White Paper describes the way in which “homelessness removes stability and connection in people’s lives. People who move away from their home and local community often leave behind important supportive relationships and networks. This makes it harder to participate in employment, maintain children’s education and retain contact with family and friends.”6 Community health services are embedded in their local communities. They have a strong focus on care in the community as well as community participation. They are non‐
stigmatising spaces. Along with community centres and neighbourhood houses, community health services have a unique capacity to help people re‐establish connections in their community of origin or forge new connections in their community of choice. The Homelessness 2020 Strategy should acknowledge – and allocate resources to foster – the community health sector’s role in facilitating social inclusion for people who are experiencing long‐term or chronic homelessness (as well as attending to their health and health‐related support needs) 6
Commonwealth of Australia, The Road Home: a National Approach to Reducing Homelessness, 2008 16
Case study In 2008/09, the Department of Education and Early Childhood Development funded a pilot ‘Transitions to School’ initiative in the City of Port Phillip. The project, led by Inner South Community Health Service, involved a partnership between ISCHS, one kindergarten, four primary schools and a St Kilda‐based youth service to improve the transition to school for local children experiencing social, emotional or developmental delays and growing up in families with high levels of mental illness, family violence and social isolation. The program determined the type of information school staff – including school welfare coordinators – needed in advance, in order to get the transition right. A protocol and information tool were developed to aid, amongst other things, parent/school communication. Both research and practice reveal that chronic school absenteeism often begins in the preparatory year. It is often associated with families that have problems with mental health or substance abuse. Long‐term, poor transitions can result in early school leaving, long‐term unemployment or underemployment and a wide range of spin‐off effects, including poor health and wellbeing, precarious housing and homelessness. The ‘Transitions to School’ initiative highlights the contribution that the community health sector and other mainstream service systems can play in an inter‐sectoral homelessness strategy. 17
Whole‐of‐government approaches Earlier parts of this submission have already drawn attention to some of the critical challenges to whole‐of‐government approaches in homelessness that the Victorian Government will need to address in the 2020 Homelessness Strategy. These challenges include: 
the marginalisation of health inequalities in the social inclusion space in Australia; and 
the absence of an overarching policy framework that bridges the homelessness/health divide. Recommendation: A first step in navigating that divide and realising the Discussion Paper’s whole‐of‐
government vision is to have a comprehensive understanding of what the Government is already funding in each portfolio, the policy frameworks and the policy implications. For example, in relation to the White Paper policy of ‘no exits into homelessness’ from hospitals and a range of statutory services, it is important to note that the community health sector currently partners with the acute service system to provide the Post‐Acute Care (PAC) program. This program comprises care coordination and service brokerage for people recuperating from a period of hospitalisation. As an example, Inner South Community Health Service is involved in the Inner South East PAC program. As part of this, a number of ISCHS staff are based at the Alfred Hospital and are available to tailor care packages for people being discharged into the local community. These packages may include home care, personal care, nursing, delivered meals, allied health, childcare and transport. 18
All members of the community who have been in a public hospital and require services during their recuperation can access the PAC program, although ISCHS particularly targets people without supports at home and who may be vulnerable to re‐admission. The program is part of a continuum that includes: 
the Hospital Admission Risk Program (HARP), another Victorian Government initiative also involving community health. HARP, as detailed earlier in this submission, aims to reduce the preventable use of hospital emergency services. It targets a number of population groups, including people experiencing homelessness; and 
an ISCHS innovation – the GP Innovations Program – which, as detailed earlier in this submission, provides outreach medical services to clients at two specialist homelessness services (Sacred Heart Mission and Hanover). ISCHS believes that the Post‐Acute Care program could potentially serve as the building block to realise the policy of ‘no exits into homelessness’ from hospitals and related settings. Recommendation: The PAC program is but one example of the need to comprehensively map the current policy and program landscape. For Inner South Community Health Service, this example highlights the inherent value in cross‐government policy development – one proposition outlined in the Discussion Paper. The Discussion Paper also flags the alignment of targets and outcomes where funding is administered separately through different government departments. This is another key area of interest to Inner South Community Health Service, which currently derives program funding from 55 different funding sources. 19
Focus on the individual A ‘focus on the individual’ clearly has application in early intervention and responses to long‐
term/chronic homelessness and is supported by Inner South Community Health Service. However, it is unclear how this articulates with the prevention agenda (which presumably will focus on broad‐based responses to the structural causes of homelessness). Again, this reinforces ISCHS’s earlier recommendation that there is a need for a clear conceptual framework around prevention and early intervention. The community health sector is evidence of the way in which a ‘focus on the individual’ and broad‐based responses to health inequalities can co‐exist and, indeed, complement one another. Community health services: 
undertake broad‐based prevention through population health planning and health promotion; and 
at the individual level, person‐centred approaches are embedded in all aspects of the community health model, including: co‐located services (‘one‐stop shops’); multi‐disciplinary teams; and service ‘wrap‐around’( for example, comprehensive intake and referral processes, care planning, case conferencing and person‐centred service models, including assertive outreach models that engage ‘hard to reach’ populations with multiple and complex needs). Recommendation: Inner South Community Health Service believes these features have application in a new outcomes‐focused homelessness service delivery model and that the Victorian Government should better leverage the community health platform in its new Homelessness 2020 Strategy. 20
Conclusion Inner South Community Health Service welcomes the Victorian Government’s commitment to fostering social inclusion and to delivering on the ambitious targets to reduce homelessness that are mapped out in the Federal Government’s Homelessness White Paper, The Road Home. ISCHS agrees with the broad sentiment that this is a ‘once‐in‐a‐generation’ opportunity to effect change, but believes that the opportunity will not be fully realised unless health inequalities are brought into the picture and unless there is high‐level intersection between health and homelessness research, policy and service delivery systems. ISCHS believes that the community health sector has a critical role to play in the new Homelessness 2020 Strategy and looks forward to the opportunity of working with the Victorian Government to progress the agenda. 21