Developing a system response to health and homelessness: The important role of health leaders

Abstract

This article examines the role of health leaders in the early stages of a community response to address health and homelessness in London, Ontario. Specifically, we explore how leaders from large healthcare-providing organizations have influenced the dynamics of the entire community response. We argue that the high level of engagement from health leaders has been a key ingredient in the early successes of the new approach in London, in part because it validated the reframing of homelessness as a healthcare issue—importantly, changing perceptions about who shares the responsibility to address it.

Introduction

August 1, 2022, was supposed to be an important day for Londoner Jessica Beacham: she was taking possession of her own apartment. This marked an important step after completing a drug rehabilitation program, and many years of struggle living unhoused on London’s streets. Her journey included many interactions with London community organizations including shelters, hospitals, healthcare providers, and the police. Tragically, she never moved into that apartment. Beacham’s body was found on July 20, 2022 in the Thames River in downtown London—a death described as “emblematic of our failures as a city.” ¹ In the words of a case manager at Ark Aid Street Mission, “her death is nobody’s fault and it’s everybody’s fault.” ² Beacham was the 34^th death among the unhoused population in 2022. ³

On August 2, 2022, a group called #TheForgotten519 (a reference to London’s 519 area code) launched a hunger strike on the front steps of London City Hall. A frontline worker set up a tent and pledged to fast until a list of demands were met, hosting evening events with those wishing to express solidarity. ⁴ This came at a time when initial conversations were already underway between the City of London and anchor community institutions about working together differently in response to the mounting homelessness crisis in London. ⁵ On August 5, #TheForgotten519 announced the end of the hunger strike, after several meetings with the City of London and other partners yielded agreement on a list of immediate actions to support London’s unhoused residents. ⁶

What followed was the emergence of a remarkable new collaboration: the launch of a “Whole of Community System Response” (WCSR) to health and homelessness in London, bringing together more than 200 leaders from 70 organizations “with a pledge to do things differently.” ⁷ Importantly, executive leaders from several health sector organizations were involved from the outset and have actively demonstrated the “principled leadership” required to effect system change. ⁸

Homelessness is, unfortunately, a growing concern with far-reaching implications. Although exact numbers have been difficult to ascertain, between 2020 and 2023, London organizations estimated that nearly 200 individuals associated with homelessness-serving organizations died and estimates of the number of people who were experiencing homelessness ranged from 1,700 to 2,100 during that time. ⁹ Among these individuals, approximately 600 were identified as “high-acuity” meaning that their social and personal conditions are severe, which can include physical health, mental health, substance use health, and/or deprivation of basic needs like food, water, housing, or systemic barriers to accessing services. ¹⁰ This population also has a profound impact on local healthcare. Individuals experiencing homelessness have been found to consume nearly twice the length of stay (15.4 vs. 8 days) when admitted to hospital at more than twice the cost ($16.8k vs. $7.8k) when compared to the national average for people not experiencing homelessness. ¹¹ Clearly, something needs to change.

This article examines the role of health leaders in the early stages of the whole of community system response in London, Ontario. Specifically, we examine how the leadership of health executives has influenced the dynamics of the whole of community response. The intention is to capture the early process evolution in London, identifying important lessons that may be relevant to other communities.

Methodology

This article draws on publicly available records of the WCSR to health and homelessness in London: media articles, published reports, and commentary about the WCSR in the public domain including on social media. It also reflects perspectives shared at an event hosted at Huron University College in November 2023, bringing together leaders to reflect on the first year of the WCSR. Speakers at the event included leaders from the City of London, London Health Sciences Centre, St. Joseph’s Health Care London, the Middlesex London Health Unit, London Inter-Community Health Centre, Atlohsa, and London Cares. Importantly, the WCSR is still in early formative stages in London. A more robust research agenda is emerging, which will extend over several years. An evaluation framework is being developed that will include mixed qualitative and quantitative approaches and four research teams have been convened on specific areas of investigation. A Theory of Change document is being co-created with partners from across the system.

What is a “whole of community” response?

The term “whole of community” has been used sporadically to describe collaborative policy responses in various contexts: physical activity interventions ¹² and efforts to address childhood obesity ¹³ in Australia; an approach to climate resilience in the United States’ Federal Emergency Management Agency ¹⁴ ; integrated approaches for addressing alcohol-related harms ¹⁵ ; and elsewhere. The term generally refers to collaborative, intersectoral efforts or interventions in a defined community.

In London’s context, the use of this term emerged to express the “pledge to do things differently” ⁷ —specifically, a commitment from London organizations and leaders to intentionally work together to address the city’s escalating homelessness crisis. In May 2022 (a few months before the hunger strike), Lynne Livingston, as the city manager leading the civic administration, initiated a series of meetings with the leaders of “anchor institutions” in London including several healthcare organizations to inform the development of the City of London’s strategic plan. In these meetings, the mounting crisis and unacceptable loss of life among unhoused Londoners was a recurring topic of conversation and shared concern. ¹⁶

During initial meetings, Livingstone recalls asking the leaders of these anchor institutions if they would attend a meeting about a city-wide response to homelessness in London: “without hesitation, all of them said yes.” An initial meeting of major organizations occurred in July 2022. The hunger strike added pressure and increased public expectation for swift action. Livingstone—recognized as “a key architect of the health and homelessness plan” ¹⁷ —recalls starting to use the language of “whole of community” around this time to express what would be different. In her words, “it was about getting everyone in the same room—businesses, health agencies, non-profits, education, and government at all levels—and figuring out how we’re going to solve this together.” ¹⁸

The process that followed included three large summits held from November 2022 to January 2023, attended by more than 200 leaders from 70 London organizations resulting in the release of a shared plan, Health and Homelessness in London, Ontario: Whole of Community System Response, released in February 2023. ⁷ It is described as “an ongoing community process that has brought together dozens of organizations and hundreds of individuals representing many different sectors across healthcare, education, business, social services, first responders, municipal services, and development amongst others.” ¹⁹

The WCSR centres around an “all doors lead here” approach including an integrated, multi-agency and interprofessional population-specific model. The implementation is driven through a new system governance initiated in March 2023, an intersectoral collective resembling a collaborative governance regime. ²⁰ In practice, the language used most closely reflects the literature on collective impact ²¹ including an emphasis on a common agenda and “backbone support” to coordinate the engagement of partners. Several multi-organization tables have been established to lead implementation of various parts of the plan. A shared evaluation framework, which takes a trauma and violence-informed approach to data collection and applies health equity principles, has been developed collaboratively across partners to shape a robust research agenda ahead. ²²

In sum, the whole of community approach is an intentionally integrated and intersectoral effort towards a shared purpose: to collectively redesign a “people-centred and housing-centric” system of support in London. ⁷ For decades, organizations in London have worked to support the unhoused population. Importantly, there are existing longstanding relationships and dynamics between them (e.g. service agencies receiving funding from the city; existing partnerships and/or competitive dynamics over scarce resources). Establishing a new collaborative governance regime requires overcoming well documented collective action obstacles,^23,24 including overcoming sectoral divides and organizational self-interest across highly heterogenous actors. ²⁰ This shift is facilitated by a shared governance model: a common purpose and values; multiple intersectoral tables to lead various components of the implementation plan; and sharing of information and data and resources to achieve common goals.

What is markedly different about the WCSR is the creation of a robust collaborative governance regime, engaging and organizing the contributions of heterogenous actors; and more importantly in doing so, empowering a community of organizations with a collective capacity to act. Although still in its early stages, it marks a new path forward to end homelessness in London.

Influence of health leaders in shaping London’s WCSR

Executive leaders from the London’s major healthcare institutions have been central players in the WCSR from its genesis. London City Manager Lynne Livingstone’s earliest conversations about convening a first meeting included several health executives: Jackie Schleifer Taylor, President & CEO of LHSC; Roy Butler, President & CEO of St. Joseph’s Health Care; Scott Courtice, Executive Director of the London Inter-Community Health Centre; Alex Summers, Chief Medical Officer of Health; and Beth Mitchell, CEO of the Canadian Mental Health Association Thames Valley Addiction and Mental Health. Executive leaders from these and other organizations have played a visible role in the leadership of the WCSR from the very first summit in November 2022 and throughout the process to today. How have health leaders influenced the dynamics of the WCSR?

Although in early stages, there are at least three observable influences. First, the active participation and leadership of health executives has provided helpful validation for the WCSR. Although each of these leaders are well known in London, they generally take on public roles on behalf of the organizations they serve. The first summit allowed this group of leaders to present themselves as a highly visible collective. At the first summit, President & CEO of LHSC (London’s largest healthcare organization) Schleifer Taylor made a clear expression of her organization’s commitment to the WCSR—and her belief in the success of the process. The media narrative following the summit further captured this vote of confidence. “If we just get the right people in the room who can understand our individual parts of the system, but be really open to the understanding that there’s an integrated need, then we can actually come up with fabulous new ways of doing things.” ²⁵ This sentiment was echoed by others. Scott Courtice, Executive Director of London Inter-Community Health Centre stated, “The situation is so dire that the only way we’re going to solve it is if we take the best of London and apply it. We’ve been in our own sectors and silos for too long but we need an all of community response to solve this, and I’ve walked out today feeling like we made a big step.” These expressions of validation and support can fuel confidence in others, and sense of optimism that the WCSR will enable meaningful change towards the shared goal of ending homelessness in London.

Second, the engagement of health leaders has contributed to reframing homelessness as a healthcare issue in the local public discourse. The link between health and housing is well documented ²⁶ and long understood among those who work directly with the unhoused—including medical professionals in London. ²⁷ However, shifting public perceptions of housing as a healthcare issue—away from a longstanding perception of homelessness as a social issue—has been more recent. Sadly, the reporting on Beacham’s life after her death underscores why this shift is so important. Beacham was treated in a hospital after her hands and feet were severely impacted by frostbite. It is reported that she was told by a physician to stay warm and keep her feet up—a near impossibility in her situation—and “it wasn’t a medical issue, but a social issue and there was nothing more he could do.” ²⁸

A centrepiece of the WCSR is the declaration that housing is healthcare. ²⁹ While this framing is not a London innovation ³⁰ —housing is one of the articulated social determinants of health and this idea is foundational to well established Housing First principles—general perceptions can be slow to change. After decades of reporting on homelessness in London, the terms “health” and “homelessness” now occur together in most local media stories on the topic. In 2022, the London Free Press printed four stories (at the end of the year, centred around the summits) including the terms “health and homelessness” with a notable increase to 49 stories in 2023; for CBC (Canadian Broadcasting Corporation) across Canada, the number of stories using this language jumped from zero in 2022 to 17 (almost all about London) in 2023. ³¹

Framing shifts how a policy issue is understood, and perhaps more importantly, the constellation of actors understood to hold responsibility for addressing it. Health leaders have been vocal in their shared commitment to being part of a community-wide solution to end homelessness in London. In their own words in an opinion editorial in the London Free Press, the LHSC and St. Joseph’s Presidents & CEOs together said it this way: “Simply put, housing is healthcare. We at LHSC and St. Joseph’s are steadfast in the belief that access to healthcare is a fundamental human right and that all community members deserve a safe place to call home—a place where their well-being can be nurtured. Together with our community partners, we are deeply committed to advancing this plan and being part of tangible solutions that will foster a healthier community for us all.” ³²

The willingness of health leaders to collectively step forward to share responsibility for solving what has long been regarded as a social issue represents a fundamental shift in London—and, a shift that would have been a near impossibility without health executives at the table.

Finally, the engagement of health leaders in the WCSR has translated into a significant investment of resources into implementation. Partners engaged in the WCSR ¹⁶ acknowledged the significant resources committed by large healthcare organizations including the London Health Sciences Centre, St. Joseph’s Health Care London, the London Inter-Community Health Centre, the Middlesex London Health Unit, the Thames Valley Family Health Team, and the Canadian Mental Health Association Thames Valley. This contribution has included executive-level service in leadership roles in most of the WCSR implementation tables, an openness to sharing resources and data, and central involvement in creating the first hubs in London.

Large healthcare organizations bring not only influence, but significant resources. In the early days of the WCSR, the shared commitment of health leadership has allowed staff from human resources, finance, decision support, communications, and others to form some of the “backbone” infrastructure required to stand up the response. This willingness to contribute real and in-kind financial supports takes strong leadership. However, it’s an investment that’s likely to see return as it’s been well documented that the care of people experiencing homelessness is much more costly ³³ than the average and, quite frankly, dollars that could be better spent supporting these people outside of hospitals.

In addition, through the advocacy of senior executives, financial contributions from LHSC and St. Joseph’s Health Care Foundation’s Finch Mental Health Fund (which were subsequently matched by Western University) have supported establishment of a violence and trauma-informed research and evaluation strategy that is being embedded into the WCSR. In a plan endorsed by London’s City Council in March 2024, four research and evaluation teams have been established via open invitations to researchers, evaluators, frontline staff and people with lived experience from across our community. With focus on (1) outcomes and experiences of our population, (2) experiences of direct service providers, (3) structures, processes, and costs, and (4) overall WCSR evaluation, these teams will work together to adopt a Learning Health System ³⁴ approach embedded within WCSR.

Lessons and implications

Homelessness continues to be an escalating crisis in cities in Canada and around the world. The loss of Jessica Beacham and so many others is, frankly, unacceptable. For decades, significant work has been done to improve the services and supports to vulnerable residents—but it has not been enough to meet the escalation of need, let alone to solve the problem. Homelessness is a classic “wicked problem” where the complexity and interconnectedness of underlying issues, as well as the lack of a single or coordinated entity with the capacity to solve the problem in its many forms, makes meaningful progress very difficult. ³⁵ To end homelessness in London, a new approach was urgently needed.

Importantly, the WCSR in London marks a departure point. It is a community-wide effort to acknowledge that what has been done has not worked (or not worked well enough) and a shared decision to make a collective effort in forging a different path forward. Although it is still early stages, the establishment of a collaborative governance regime (and its endurance over more than a year, with long term commitment)—and, the convergence of actors and organizations willing to share ownership of a problem and invest together in a solution is in itself a success. The high level of engagement from top health leaders in London has been one of the key ingredients to make this emerging shift possible. Health leaders have provided important validation of the WCSR approach, aided in reframing longstanding perspectives about homelessness in London, and invested critical resources in the implementation now underway. This puts in practice the expectation that personally working towards the betterment of a community at large to address societal issues contributing to health disparities is the healthcare executive’s responsibility ³⁶ ; and, demonstrates the transformative power of “principled leadership” in efforts to make system change. ⁸

London’s WCSR is still emerging. Over the coming years, the WCSR will be supported by a robust and collaborative evaluation effort, including a process review involving longitudinal qualitative and quantitative data. However, an early lesson from the formation of the WCSR is how impactful it can be when health leaders choose to engage in their community in new ways, seeing beyond the traditional organizational boundaries and bridging longstanding sectoral divides. In time, the London WCSR may well demonstrate the transformative power that comes from leaders across sectors aligning to do together what none of them can do on their own, in shared commitment to the community they serve. In the words of health executives: “The relationship between health and homelessness goes in two directions. Homelessness can directly influence a person’s health status and, in reverse, health status can contribute to or increase a person’s risk of experiencing homelessness. [We] know that having a place to live is essential to health. We see first-hand how patients experiencing homelessness face additional barriers to maintaining wellness, which often leads to increased emergency department visits and hospital admissions. […] We know this data is an underrepresentation of community members experiencing homelessness and that the magnitude of the impact extends far beyond our hospital walls. We must do better for our neighbours.” ³²