Older People and Housing JSNA | Boltons Health Matters
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Older People and Housing JSNA

Abstract

This is the JSNA chapter on older people and housing. Theme chapters summarises implications for commissioning, who is at risk and why, the level of need in the population, service provision and use, unmet needs, what works in terms of evidence, community views and priorities, any related equality impact assessments, unmet service needs/gaps and recommendations for further needs assessment work. 

Introduction

One of the major challenges for housing is to continue to plan and deliver a strategy that meets the needs of our ageing population.  Housing is a key determinant of health, and the need for suitable accessible accommodation and adapted properties will become more evident as health and mobility issues increase with the age profile.

The key accommodation types in Bolton for older people are:
• Living in own/family home;
• Supported Accommodation (e.g. sheltered or extra care housing where people live in their own home but can access some form of support);
• Specialist Care provision (e.g. residential or nursing care).

Older people who continue to live in their family home (of all tenures) are likely to be under occupying and may also struggle to heat their home during winter months.  Older people living in homes in the owner occupied sector, who are asset rich and cash poor, may struggle to finance the necessary adaptations to make their homes more suitable to their needs and to help reduce the risk of falls.  Those living on their own are more likely to be socially isolated, as a result of limited interaction.

Although research into housing choices and aspirations of older peoples suggests most participants wish to remain in their current home for as long as possible, there are housing options alternatives which can help maintain independence.  These options have traditionally been to downsize to a smaller property or bungalow, or move into specialist or supported accommodation such as Sheltered or Extra Care Housing.

The availability of suitable and affordable properties in Bolton is low within the owner occupier sector, although there are a small number of shared ownership properties.  This is particularly the case for those people with equity less than £100,000, or even £150,000 (which is at least 30% of the older people population).  Supported/specialist housing can provide a good alternative for older people, providing a safe, secure, and warm environment and also opportunities for greater social interaction.  The vast majority of supported accommodation in Bolton is in the social rented sector.

Implications for Commissioning

Preventative (housing) services
Develop a service which provides initial assessment, information, advice, and signposting to support housing, and if required, care services.
Promote and develop housing services that can improve wellbeing and quality of life through improving the home itself i.e. heating and insulation, help with repairs and adaptations.
Promote equity release as an option for older people requiring repairs and adaptations.
Promote the development of long-term low level support services which provide flexible support services (cross tenure) to vulnerable older people and help prevent crisis situations arising. This could be built on community alarm services.
Promote social wellbeing through facilitation of community activities, and voluntary roles such as befriending.
Promote re-enablement services (relating to home environment), following hospital admissions.

Accommodation based services
Make the best use of sheltered and Extra Care resources, through:
• Promoting supported housing to older people (and families/carers);
• Offering flexible support options within schemes;
• Potentially widening out support and activities into the community;
Decommission supported housing where no demonstrated demand for this type of accommodation.
Develop specialist housing (with care, where appropriate) where demand has been established for this type of provision in specific areas of Bolton.  This should offer different tenure options.
Promote the re-provision of supported housing (where accommodation does not meet accessibility requirements or aspirations of older people - i.e. to better meet future needs/aspirations).

Who's at Risk and Why?


Older people are more at risk of developing health issues, falls, and mental health problems as a result of poor housing, inaccessible housing, and social isolation associated with old age.  Those particular at risk are older people:
• Living in poor quality housing (as a result of damp, cold, repairs required);
• With long term conditions (more affected by environmental conditions);
• With mobility issues and living in housing with poor accessibility (more likely to fall);
• Living alone (social isolation/loneliness);
• From less affluent backgrounds and living in more deprived neighbourhoods (statistically more likely to have health problems, and die at an earlier age).

The Level of Need in the Population

A key challenge for organisations working with older people across the country, and in Bolton, is the growing number of people in the older age groups (over 75).  Those aged over 80-85 will suffer from the greatest ill health and require higher levels of support.

The most recent population projections from the Office for National Statistics predict substantial growth in the older population of Bolton.  The over 65 population will grow from 44,700 at present to 61,400 by 2030 (an increase of 16,700).

Of most concern is the increase of people aged over 85 from 5,700 at present to 10,100 by 2030 as many of these people will require a high level of care need.

Under-occupation and equity

The Housing Needs Survey 2011 indicates that 60% of people in older households live alone and that 71% of older people are under-occupying their properties by one or more bedrooms.

Housing type
The Housing Needs Survey 2011 indicates almost one quarter (23%) of older households live in terraced accommodation which can be difficult to repair, insulate and adapt; 24% live in bungalows and 15% in flats.

Living alone
Projections suggest that the number of people living alone will increase, particularly in the over 75 age group where the number will grow from 9,823 at present to 15,462 by 2030.

Tenure
There are differences in health needs across different tenures, with those in rented accommodation tending to have higher health needs.  In Bolton people aged 65-74 tenure is 75.7% owned, 15.7% rent from the Council, 5.0% are other social rented, and 4% rent privately or are living rent free.  Looking at older age groups there is a fall in ownership (64.8% for those aged 75-84; 56.2% for those aged 85+) and an increase in renting from the Council (20.1% for those aged 75-84; 21.2% for those aged 85+), other social rented (8.8% for those aged 75-84; 13.1% for those aged 85+), and private rented or living rent free (5.8% for those aged 75-84; 9.6% for those aged 85+).

Tenure and health/mobility
There are differences in potential needs by tenure types in Bolton.  Those living in rented accommodation are more likely to have long term limiting illnesses or disabilities, although the differences become less marked in the over 75 age categories.

Demand for adaptations from older households
There is very clear evidence that the number of people with mobility difficulties increases with old age. 
The proportion of those with mobility difficulties in the lower limbs (e.g. difficulty walking up or down stairs) is 42% in Bolton men aged over 65 (compared to 20% for those aged 45-64 and 6% for those aged 18-44).  Similarly, in Bolton women aged 65 and over 50% have lower mobility difficulties (compared to 21% for those aged 45-64 and 8% for those aged 18-44).

The proportion of those with mobility difficulties in the upper limbs (e.g. difficulty holding, gripping, or turning things) is 22% in Bolton men aged over 65 (compared to 13% for those aged 45-64 and 4% for those aged 18-44).  Similarly, in Bolton women aged 65 and over 42% have lower mobility difficulties (compared to 19% for those aged 45-64 and 6% for those aged 18-44).

The most common adaptation needed in Bolton is walk in shower/wet room.  This is needed in 7.8% of households (2,085).  Following this is a downstairs bathroom or toilet in 4.1% of households (1,140), a stairlift in 8.0% of households (1,043), stair rails/handrails in 3.5% of households (970), handrails in the bathroom or bath rails in 3.4% of households (946), and advanced technology based support in 3.0% of households (824).

Moving home
The factors underpinning the decision to move or to stay include attachment to current home, complexity of family/caring relationships, neighbours and neighbourhood, access to services and amenities, and health and wellbeing .

In addition, 34% of older people responding to the Housing Needs Survey suggest they would consider supported housing.  Of those choosing existing sheltered accommodation, 88% have long-term health conditions.

The levels of equity will affect the type of provision that may be required.  The Housing Needs Survey 2011 indicates the following level of equity older owner occupiers have in Bolton:
• Less than £50,000 – 14%
• £50,000 to £100,000 – 20%
• £100,000 to £200,000 – 33%;
• £200,000 and above – 12%;
• Not known – 20%.

Older people who are thinking about moving are equally split between moving to own without a mortgage (41%) and renting (41%).  The minimum bedroom requirement for these people saying they would like to move is two in most cases (60%), followed by one (23% of cases) and three (15% of cases).

Current Services in Relation to Neeed

The following services are available to older people in Bolton:
• Specialist housing such as Sheltered and Extra Care accommodation provide housing with support services specifically designed to assist older people, and accounts for approximately 85-90% of the support funding available to older households in Bolton.  (Note: the amount (and proportion) of funding for accommodation based services has been reducing since 2009/10, and will continue to do so due to planned decommissioning);
• According to the locally developed Index of Potential Care Need (available on Bolton’s Health Matter’s here) 76% of sheltered housing is located in Segments A-D i.e. the areas where people have the highest risk of developing care needs (and are located in the more deprived Wards);
• The following shows the numbers of units of each type of accommodation:
-Extra Care Housing (social rented) = 299 units;
-Extra Care Housing (shared equity) = 21 units;
-Core Sheltered (social rented) = 1,995;
-Older People’s Intensive Managed Housing (social rented) = 1,735 units;
-Housing with Community Alarm (social rented) = 436;
- TOTAL = 4,486 units.
• In addition to affordable options, there are approximately 300-350 older peoples housing schemes in the private sector;
• Housing advice services offer a wide range of advice and guidance on housing options for older people;
• The ‘Find a Home’ team assist people to access social rented properties;
• The Bolton Care and Repair Partnership coordinates services to assist older people live independently in their own home.  Services available include repairs, adaptations, insulation, energy efficiency, and alarms.  In 2011/12 Care and Repair had over 2,500 customer enquiries and completed 1,165 jobs for vulnerable customers;
• There are a number of 24/7 community alarm providers in Bolton.  The majority (99%) of supported accommodation for older people have alarm systems in place.  Careline is the largest provider outside of supported accommodation delivering a service to 2,000 homes, and there are other providers;
• Telecare can be stand-alone systems, or add-on equipment to the community alarm system.  Telecare is electronic equipment which can monitor customers if they get out of bed, fall, leave the house, or monitor gas emissions, temperature etc. and help keep people safe.  There are currently around 257 customers using Telecare through Careline, and additional customers through Eldercare community alarm and with stand-alone units (where the carer responds).

Projected Service Use and Outcomes

The increase in the older population and particularly those over 85 suggests that there will also be an increase in the numbers of people with mobility issues and those with long-term conditions including dementia and mental health issues.  This will result in an increase in:
• Demand for physically accessible properties (within all tenures);
• Demand for aids, adaptations, and equipment;
• Demand for advice, information, and short-term support;
• Demand for the provision of long-term support.

The model above details our proposed future accommodation and support model for older people:

• Existing unsuitable older people accommodation will be decommissioned;
• Good quality specialist extra care and sheltered accommodation will be available with on-site support services;
• Older people’s accommodation will be available with a menu of support options including floating support services and technology based solutions such as Telecare;
• Advice and support services will need to be improved across all agencies to ensure older people are aware of all their options and services join up effectively.  Our vision would be to have a ‘One Stop Shop’ approach to advice and support;
• Housing services can assist people to live independently in their own home, and help prevent the need for more intensive services such as hospital and residential care.  Services would include:
-Repairs and renovations;
-Financial services;
-Energy efficiency;
-Falls prevention and support for hospital discharges;
-Home security;
-Aids and adaptations;
-Technology based support services;
-Handyperson services;
-Disabled adaptations;
-Floating support;
-Gardening services;
-Community links – befriending, active ageing etc.

Evidence of What Works

Providing an Alternative Pathway
Details case studies that have benefited from integrated housing, care and support services. The report illustrates examples of how local authorities, housing providers, GPs and acute trusts work together to provide alternative care pathways that reduce the demand they have for other services and improves quality of life for customers.
Putting in place these pathways can:
• Deliver savings across the NHS and Adult Social Care;
• Prevent the need for high level social care;
• Prevent health emergencies;
• Delay moves to residential care;
• Reduce admittance to hospital;
• Prevent mental health and wellbeing deterioration;
• Support people to remain living independently as long as possible.
Excluded Older People
This report evidences the importance of early intervention, joined-up services, and accessible environments to older people’s quality of life.  Three key ways are highlighted in which respondents say provision needs to improve if older people are to enjoy a better quality of life:
• Joined up services are key;
• Intervening early is important, and investment in low level prevention can reduce costlier interventions later;
• Older people generally know what they need and want, and they should be involved in the design and delivery of services.
Use of Resources in Adult Social Care: A guide for local authorities
This guide offers a range of evidence to help local authorities continue the move to support people in their communities and to continue the trend of reduced use of residential care.  Recommendations based on the evidence include the need for:
• A comprehensive and well-articulated prevention strategy;
• Whole system governance arrangements in place for driving forward the prevention, efficiency and wellbeing agenda;
• Proactive approaches in place to identify older people at risk of deterioration in order to intervene early;
• A comprehensive range of non-case managed ‘wellbeing services’, probably commissioned from the third sector;
• The mainstream application of Telecare;
• A reasonable volume of Extra Care or supported housing;
• Well-functioning reablement and intermediate care services;
• Formal arrangements in place for joint working between health and social care to support people with long-term conditions or complex needs.
Local evidence of demand
Demand for Sheltered Housing/Extra Care Housing:
• Performance figures suggest the utilisation of Sheltered Housing (i.e. the proportion of time the properties are occupied) is between 93% and 99%.  Those for Extra Care Housing are between 89% and 95%;
• 32% of older people currently living in sheltered accommodation are over 80, and this increases to over 50% in some under one roof schemes;
• 7% of people in sheltered accommodation have care needs;
• On average 65% of people in Extra Care schemes have assessed eligible care needs, but this varies across locations from a low level of around 30%, to a very high level of 97%;
• Analysis of people moving into Extra Care in 2012 shows that 69% of the total people are over 70 when they move into Extra Care, with 42% of the total being over 80 years old;
• 66% of people start to look at moving to sheltered type properties between the ages of 50-70, with the majority being in their 60s.  People are also looking at this type of property into their 80s, and a few in their 90s;
• Expressions of interest in properties remains stable, with a slight increase in expressions on sheltered bungalows;
• BME communities indicate a preference for more independent or dispersed properties within their community rather than ‘under one roof’ options.
Using data such as age profiles, health statistics and socioeconomic data, in addition to evidence around existing provision and demand, we can predict the type and location of housing required in the future.
The borough would benefit from different, and mixed tenure options – owner occupation, equity stakes/shared ownership models and rental opportunities (affordable and market rent).  The areas we should consider for this type of provision would be:
• Astley Bridge, Bromley Cross;
• Blackrod;
• Smithills, Heaton, Lostock;
• Hulton, Westhoughton;
• Little Lever/Kearsley.
If demand increases for social rented stock, or if any schemes were to be decommissioned, then re-provision of units through redevelopment or remodeling of sheltered stock should centre on the following areas:
• Breightmet/Tonge;
• Farnworth/Harper Green;
• Rumworth/Deane;
• Great Lever;
• Town Centre.
Demand for non-accommodation based services:
• Alarm calls Careline: There are over 14,000 emergency calls to alarm providers annually and approximately 5-6,000 mobile response call outs to customers homes in the year 2011/12.  Key reasons for call outs were falls, mobility issues, and feeling unwell;
• Telecare: There are over 250 Telecare customers in Bolton with an alarm and response service and more customers with stand-alone equipment.  Those who require response and new referrals average at about 130-140 per year over the last four years;
• Other non-accommodation based support services: A pilot two year floating support scheme (2008-10) did show some demand for this type of service, particularly for people over 75 and from all tenures including owner occupiers; 25% of people on the housing register would be interested in being supported at home if this was available.  The evaluation of the floating support scheme indicated that the support required tended to be either short-term (one off type support) or for a long-term need - wellbeing check/befriending type services.
Further key sources for information on effective interventions and evidence-based policy are highlighted on Bolton’s Health Matters

Community Views and Priorities

Stakeholder Consultation: Joint Housing Plan for Older People
A summary of key findings from this range of consultation events:
• Access to services is difficult, as many potential service users are not aware of their existence, or what each service can offer, and to whom;
• Frontline staff should be able to screen people, identify if they need support and offer the appropriate independent advice and support or signpost to the relevant service;
• There is a need to be more flexible with provision allowing customers to choice the level of support required;
• Service users prefer consistency in the people who provide services and consistency in advice and information given as well as the support and care provided;
• Stakeholders identified the need to share data across services more effectively.
Key service improvements identified were:
• Improve data and information collection/sharing;
• Ensure right (well trained and knowledgeable staff) at front end;
• Screening and assessment of individual need;
• Recognising choice/aspiration and managing expectations;
• Joined up communication and marketing;
• Provide flexible services that promote independence;
• Monitoring outcomes to ensure targeting resources effectively regarding prevention.

Older Person’s Housing Needs Survey
This survey was undertaken to understand the current housing situation and future housing needs of people over the age of 50 on the housing register and to understand the current and future requirements for care and support:
• 1,519 completed telephone interviews;
• Good geographical spread across the borough;
• Of those who said their current property requires repairs (286) 46% would remain in their house if these repairs were made;
• Of those who said their current property requires adaptations (327) 57% would remain in their house if these adaptations were made;
• 61% of respondents said their first choice for a future property would be a bungalow;
• 78% of respondents were interested in a property specifically for people aged 50 and over;
• 60% of respondents want to remain in their current neighbourhood;
• 78% of respondents would use warden support if it was available;
• 76% of respondents would use an emergency alarm service if it was available;
• Only 27% of respondents have applied for a property over the last 12 months.

Community Alarm Survey
The survey aimed to determine customer satisfaction and the importance customers placed on various aspects of the service. The survey found that:
• Only two thirds of respondents wore their Careline equipment all the time;
• Over half the respondents were not interested in any of the additional services Careline were thinking of offering;
• Respondents agreed that Careline helped them to stay in their own home, where they felt safer knowing help was at hand if needed.  It provided reassurance for friends and family, and was good value for money.

Consultation with Ward Members: Remodeling of Bolton at Home properties and potential decommissioning as sheltered
• Councillors understood the problems associated with sheltered housing regarding quality and demand and generally supported the need for change;
• Particular support was given to the introduction of flexibility to service provision, and the option to opt out (and not pay) if a service is not required;
• The main concerns were around the impacts on people currently living in the properties were:
-Being left without a service;
-Having increasing numbers of young people or those with complex needs moving onto the scheme, including under one roof schemes with restricted access;
-That some properties would be better to knock down than re-let due to their condition or impact on the surrounding population;
-What will happen to community rooms.

Equality Impact Assessments

No recent local equality impact assessments have been carried out that we are aware of.  If you are aware of any such work locally please let us know at Bolton Health Matters

Unmet Needs and Service Gaps

• One point of access to advice and information around housing, adaptations, support, and care services.
• Services which help maintain social wellbeing, reassurance, and ensuring home and health needs, particularly within own home.
• More flexible support options within existing sheltered accommodation.
• Specialist older peoples’ housing with mixed tenure model/in the private sector.

Recommendations for Further Needs Assessment Work

• Identify potential demand for Extra Care housing, Retirement Villages with Care etc. (look specifically at those with long-term limiting health conditions, and/or older owner occupiers).
• Identify demand for supported and accessible housing within different tenure types.
• Identify the impact of preventative and accessible housing services on reducing need for higher level social care, on health services, and on the health and wellbeing of customers.

Key Contacts

• Tim Bryant - Head of Commissioning, Adult Social Care
• Andrew Walton - Older Peoples’ Commissioning manager, Adult Social Care
• Vicky Walker - Older People’s Housing Strategy Coordinator, Adult Social Care
• Michelle Horrocks - Housing Strategy Unit Manager, Development and Regeneration

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