The results of the present study, focusing on the (dis)similarities between people with SMI in supported housing and supported independent living programs in The Netherlands, reveal that differences between these two groups are much smaller than one would expect. Participation in occupational activities, attending a day centre, number of (unmet) needs and quality of life do not differ greatly. This calls the Dutch allocation system to housing programs into question: are we dealing with a flexible system that contributes to positive outcomes for individuals, or is there a lack of methodical assessment of people with SMI when applying for either supported housing or supported independent living in the community? For instance, more than one-third of Dutch residents in supported housing have at most mild functional problems according to their HoNOS scores. This suggests that at least a part of these people might currently receive a higher level of care than is actually required, and perhaps also wished for by residents themselves. This is a pressing issue, taking the long and persisting waiting lists for this type of care into account.
We did find differences between the number of unmet and met needs of Dutch service users with different levels of functioning, regardless of type of housing program. In the domains of mental health care and services, people coping with (very) severe problems not only have more met needs than people with no to mild problems, but also more unmet needs. Although care is provided, some needs in these domains remain difficult to meet. For example, prescribed antipsychotics can reduce psychotic symptoms, but at the same time can cause hindering side effects. In the area of activities of daily living, people with severe impairments also have more unmet needs.
The composition of the service user population in supported housing and supported independent living in England differs to some extent to that in The Netherlands, e.g., with respect to gender (more males), civil status (more persons who have never been married) and diagnosis (more persons with schizophrenia). This suggests that the English service users possibly are more similar to the long stay population from the closed or reduced mental hospitals. Deinstitutionalization in The Netherlands has taken place at a much slower pace, if at all, and has resulted since the 90s in an increase of small scale residential facilities in the community. These facilities are open not only for people residing in the mental hospital but also for those who never entered such a long stay trajectory. Despite these different deinstitutionalization processes, the overall effect on the people with SMI in housing programs seems small. However, we did find differences in the extent to which English and Dutch service users participate in occupational activities. In The Netherlands, participation rates are much higher. This might be a consequence of the similarity of English service users—more than the Dutch service users—to the long stay population of mental hospitals. Furthermore, Dutch governmental policy in the 90s created possibilities for RIRCs to invest in the development of projects concerning occupational activities. This has resulted in a wide range of projects with different levels of structure and demands for participation offered by RIRCs, e.g., day centers, sheltered employment projects and job coaching. It is not clear if English service providers have similar facilities.
Although English and Dutch service users in supported housing and supported independent living have a comparable total number of needs, the English have a lower number of met needs. Only in the mental health care domain, English people in supported independent living have slightly more met needs. This can be seen as a small but further confirmation of the more chronic nature of the psychiatric problems of English service users. Another (perhaps additional) explanation can be the policy of Dutch RIRCs to distinguish themselves from the mental hospital, in not providing psychiatric treatment. This may have consequences for the way psychiatric problems are dealt with by care coordinators, who perhaps lack skills to observe and monitor these problems properly. However, differences in unmet needs for this domain are negligible. Overall, it seems that Dutch community care may be more able to address the needs of their service users, though more information is needed about the level of functioning of the English service users to substantiate these findings.
One should be aware of some limitations in the reported studies. Our study and those of Priebe et al. and Slade et al. have a cross-sectional design, which entails that relationships between cause and effect cannot adequately be determined. Furthermore, the participants in the study of Slade et al. are slightly different (more females) from that in the study of Priebe et al.
Comparisons between housing programs in different countries are difficult. Descriptions of residential facilities and the care they provide vary in their characteristics and terminology. For example, in the present study the Dutch supported independent living program is compared to the English floating support program. They seem to be similar programs, except for the latter program to be limited to a fixed period of time whereas the first—in principle—is provided indefinitely. This could be a limitation to the strength of this comparison. To further establish the (dis)similarities between quality and nature of the community housing programs in The Netherlands and England (and in other countries that experienced deinstitutionalization) in depth research into among other things the independency of living space (e.g., in The Netherlands all residents in supported housing have their own bedroom), autonomy of residents and the scale of residential homes is needed. In these comparative studies, it is also important to take into account some contextual factors, such as social policy regarding employment of people with SMI, economic factors and access to healthcare.
Finally, Dutch hospital based mental health institutions also provide supported housing and supported independent living programs in the community, but these facilities were not taken into account. A comparative study between supported housing and supported independent living provided by hospital-based facilities versus RIRCs is needed in the future.