The Next Best Thing

Imagine you live in a small to medium sized city. I also want you to imagine that you have had a heart attack. You get rushed to the emergency room in an ambulance. Paramedics have been keeping you alive with really intensive assistance.

Given the nature of your situation, you are a top priority when you arrive at the ER. Oodles of resources are allocated to your condition. ER nurses, doctors and other health staff have applied their expertise to your immediate needs. It is the best your small to medium sized city has to offer.

They page for a cardiologist. One is not available. They are busy with other people with heart issues. Now what? I know, let us put you on a waiting list. If you are still alive and it can be confirmed that your heart is still unwell when a cardiologist is available, then you will be seen. In the meantime, we will have you fill out a bunch of forms and paperwork, a lot of which have nothing to do with your heart condition.


There are going to be people in your community that you think will benefit from Permanent Supportive Housing. Like most communities, you will not have enough PSH, or your existing PSH is filled with many tenants that do not actually require PSH. What happens in most of these communities is that they create waiting lists for PSH.

Let us be clear: waiting lists are a game of survivor. Waiting lists favour people with lower acuity. Waiting lists are cumbersome and administratively expensive to maintain. Waiting lists do not work for households that need the resource the most. People deteriorate and even die while on waiting lists. They languish in shelters or receive survival supports on the street. Their homelessness and dependency becomes even more institutionalized and normalized.

If you had a heart attack and a cardiologist was not available, you would want the next best thing. It may be an ears, nose and throat specialist, or a gynaecologist, or a paediatrician, or an oncologist, or generalist, or any type of medical doctor. It may be that this person is keeping you alive until the cardiologist is available. But the point is: you get served and you get the next best thing.

In the delivery of housing resources to people experiencing homelessness, we have to get into the mindset of delivering the next best thing. When there is not a PSH unit available, we need to think creatively: what would a more intensive Rapid ReHousing program look like? What could a re-think of transitional housing as intensive interim housing look like? Would might master leasing of a couple of apartments as bridge housing look like? Is there a possibility of converting a shelter or part of a shelter to be more housing like?

The point is people with deepest needs require service as immediately and as intensely as is feasible, with a strong housing focus (the only known cure to homelessness). Waiting lists are not in anyone’s best interest, whether that be looked at from the service providers perspective of the end users perspective. We need to have a solution-focused, action-orientation and not a waiting list, bureaucratic orientation.

Iain De Jong

About Iain De Jong

2 Responses to “The Next Best Thing”

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  1. I always appreciate your emergency room analogies because of my personal experience with three of the four acuity examples you gave in our training (heart attack, broken leg, cut finger; thankfully I’ve never had to deal with an axe to the head). It’s a clear, immediately-understandable explanation of how homeless services ought to be applied and (sadly) rationed. And it really illuminates the absurdities of how we have traditionally been rationing services.

    I think part of how we got to that point was a lack of understanding that we are literally talking life-and-death for a good number of the people we deal with. And a long-standing attitude around matching up resources with what someone “deserves” (in quotes because that is such a subjective criterion as to be useless). Somehow there isn’t much talk about whether rich people get what they deserve, or deserve what they get, but for poor people it’s always about deserving.

    And then there is the problem of fraud. For poor-people-programs, there is much time, money, and effort put into preventing fraud. For rich-people-programs, fraud is always dealt with after the fact and far too frequently by just a slap on the wrist.

    Okay, time to climb down from the soapbox. Thanks for the thought-provoking blog post!