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Solving homelessness: We can't let alcohol dependence stop people getting help

Nadine Ezard - ABC The Drum
February 2016

When it comes to solving homelessness we know what works. Mostly what we lack are the resources and political will to make it happen.

More social and affordable housing; greater efforts to support young people and families; employment and training opportunities; and access to a range of services, from health to education, when and where it’s needed.

Even for roughsleepers – the most visible and entrenched group of homeless people – a combination of the above responses are likely to prove successful.

But among this subset there are a significant minority of people – those who are heavily alcohol-dependent – for whom homeless agencies and health services struggle to offer a way out.

Alcohol dependence affects almost half of Sydney’s adult homeless population. It would be a similar story in other Australian capital cities.

About 30% of homeless people admitted to St Vincent’s Hospital Sydney have a primary diagnosis related to alcohol and/or other drugs.

For this core number of vulnerable roughsleepers, every approach to get them into long-term and sustainable housing has largely failed.

That’s because most homeless programs in Sydney – and across Australia – require abstinence before long-term support and accommodation are provided.

For many severely alcohol-dependent roughsleepers, it’s a condition they’re not able to meet, and so they go without the help they need.

But overseas – particularly in Canada, the US, and the UK – there is a trend towards supporting this group in a way that’s both novel and is proving successful.

Known as ‘managed alcohol programs’, or MAPs, these initiatives provide accommodation without insistence on abstinence.

On the contrary, beverage alcohol is provided to residents in standardised doses at set intervals – a process that is actively managed and subject to ongoing assessment.

At face value, such an approach seems counter-productive or defeatist.

How can supplying alcohol to someone who is dependent on alcohol do anything but deepen the problem?

However, the idea is that by providing a safe space and a controlled drinking environment, participants can more readily access shelter, food, hygiene facilities, health care and other supports.

While the evidence base is limited, so far evaluations of MAPs overseas tell us they are reducing alcohol use, days intoxicated, police contact, jail time, healthcare costs, emergency department contacts and hospital admissions.

Encouraged by what we’ve seen – and because there are currently no MAPs operating in Australia – St Vincent’s Hospital Sydney and a range of other partners, including the Foundation for Alcohol Research and Education, conducted a feasibility study to consider whether a MAP might work on our shores.

Not only did we find a MAP would deliver far better outcomes for this group of homeless people, but at a fraction of the cost of our current – and mostly unsuccessful – response.

As part of our study, we enlisted the help of 51 severely alcohol-dependent, chronically homeless people; regular users of short-term homeless shelters and emergency medical care – the most expensive end of the health system – and people in consistent contact with the police, justice and correctional systems.

With long histories of multiple attempts at treatment for alcohol dependence, this group of people indicated strong interest in participating in a MAP.

Involving clients in the planning and delivery of the MAP is crucial to its success.

Fifteen members of this group alone were responsible for emergency department presentations at St Vincent’s Hospital totalling $1.3 million over one year.

We estimated that the reduction in cost to St Vincent’s hospital from supporting just these 15 via a MAP was $718,000, while at the same time offering the chance of far better and consistent care and attention than they’re currently able to access.

Once other community savings are taken into account – housing, police, court costs, custody – and then combined with the operational costs of running a MAP, we estimated the service would deliver savings of around $32,000 for each homeless individual, or $480,000 in total.

That’s an extraordinary result and likely represents an underestimation of the total reduction in costs given the participants are likely to also attend other city hospitals, primary care outlets and ambulance support.

We think our study makes an overwhelming case for trialling a MAP in Sydney’s inner city and potentially other parts of Australia where there are similarly large numbers of severely alcohol-dependent people sleeping rough.

Our next step is to talk to governments, business leaders, philanthropists and homeless service providers about how we might move ahead to this next stage.

For St Vincent’s – led by the example of our founders, the Sisters of Charity, who have always looked for new and different ways to help disadvantaged people – we can’t not pursue this opportunity.

Establishing a MAP could offer a rare glimpse of hope for some of our most vulnerable citizens.