Health CommitteeWritten evidence from the National Housing Federation (LTC 55)

1. The Scope for Varying the Current Mix of Service Responsibilities so that more People are Treated Outside Hospital and the Consequences of such Service Re-Design for Costs and Effectiveness

1.1 There is real potential to alter the current mix of service responsibilities to ensure people are able to live and receive treatment in their own home, rather than in hospital. Good housing is a fundamental part of this kind of care and support, as it helps people to manage their conditions more effectively and independently.

1.2 Housing is a vital part of an integrated health and social care system, which prioritises preventative care and speeds a person’s recovery to independence. The White Paper “Caring for our Futures” supports this, stating: “housing plays a critical role in supporting people to live independently, and helping carers to support others more effectively ... Fragmented health, housing, care and support are letting people down. A failure to join up also means that taxpayers’ money is not used as effectively as possible, and can lead to increased costs for the NHS.”

1.3 Joining-up health, care and housing would produce clear benefits in terms of both costs and improved outcomes for those living with long-term conditions. Department of Health research1 has found that investment in housing-based care services (rather than more traditional services like residential care) produces better health outcomes and gives people greater independence. It also reduces costs for the taxpayer by avoiding hospital admissions and reducing the number of children taken into care. Our report, “Providing an Alternative Pathway”, shows how housing can be used effectively as a health and care service and highlights the savings that can be made. It showed that integrated services can deliver savings of up to £17,992 per person per year, when compared to less integrated pathways. In one of the report’s examples, a housing service saved a total of £241,670 to local health and social care budgets in just 18 months.

1.4 More specifically, investment in housing-related support services are also cost-effective as they often reduce the need for more intensive care interventions, such as a move to a care home.2 A review of the Supporting People programme (which funded housing related support services from 2003–09)3 found that a £1.6 billion investment in housing-related support services generated an annual cost saving of £3.41 billion to the taxpayer.

1.5 Frontier Economics found that capital investment in specialist housing with care and support for nine client groups delivered an annual net benefit to the exchequer of £639 million. This includes £219 million a year from older people’s housing, £199 million a year from specialist housing for adults with learning disabilities and £187 million a year from specialist housing for people with mental health problems.4 The Department of Health has since highlighted the findings of this research to local authorities commissioning these kinds of services5

2. The Readiness of Local NHS and Social Care Services to Treat Patients with Long-Term Conditions (Including Multiple Conditions) within the Community

2.1 Although there are examples of innovative services which allow those with a long-term condition to be managed within the community, they are not yet common practice. Partnerships between the local NHS, social care commissioners and housing providers are key to achieving better outcomes and reducing costs, yet a number of significant barriers to full integration still remain across the design, commissioning and delivery of services. One of the main challenges is the need to join-up strategic and local commissioning between housing, social care and health.

2.2 NHS trusts and local commissioners need to focus on preventing hospital admissions and readmissions by investing in support services and specialist housing. Housing organisations have a good track record of providing specialist housing and delivering services focussed on restoring independence—for example, by adapting the homes of people with long-term conditions to prevent falls and other accidents. These services have been proven to prevent admission and readmission to hospital, allow re-ablement after an accident or illness, delay the need for intensive care services and reduce the likelihood of emergency admissions.6 One case study of an individual with dementia living in Extra Care housing shows savings of up to £17,222 a year to health and social care budgets.7

2.3 The Federation’s most recent report, “Dementia: Our Housing Challenge”, highlights how the NHS and social care commissioners can use housing as part of the treatment for people living with dementia. Dementia is a significant challenge for the NHS with an estimated 40% of hospital beds occupied by people with dementia.8 Currently 60% of people with dementia enter hospital from their own home, but just 36% return home after discharge.9 People with dementia stay longer in hospital than other patients who go in for the same procedure and are often subject to delays when leaving.10 The longer the hospital stay, the worse the effect on the symptoms of dementia and the person’s physical health. Longer admissions also make discharge to a care home and the prescribing of antipsychotic drugs more likely,11 which are often not the best option for the patient. People with dementia in hospitals are also dying at a significantly higher rate than people without the condition.12

2.4 The Dementia Commissioning for Quality and Innovation (CQUIN) payment framework aims to incentivise the identification of patients with dementia to ensure appropriate referral and follow up after they leave hospital. Part of this referral stage should include engagement with services in the housing sector to ensure patients are able to return home as quickly as possible.13 There is a need for similar incentives for early-intervention across the health and care system to ensure people get the support they need to live independently for as long as possible.

3. The Practical Assistance Offered To Commissioners To Support The Design Of Services Which Promote Community-Based Care And Provide For The Integration Of Health And Social Care In The Management Of Long-Term Conditions.

3.1 For effective integration, it is crucial that housing be considered at every stage of service planning, commissioning and delivery. However, there is a lack of practical assistance for commissioners to support them in redesigning services to support independent living in the community and to support integration of services across housing, health and social care to manage long-term conditions.

3.2 The Health and Social Care Act 2012 does not provide a specific framework for housing to engage with health and vice versa. Though the draft Care and Support Bill creates an environment more conducive to this, it does not guarantee it. We are particularly supportive of Clause 4 in the draft Bill, which promotes co-operation between the local housing authority and the adult social services departments. These two teams should work together to identify gaps in specialist housing provision by establishing and maintaining a register of adapted and accessible housing, as part of their oversight of the local care market.

3.3 However, the draft Bill is lacking a duty for co-operation between health and housing. Local authorities, the NHS and other local partners must align priorities and funding streams to both deliver and gain local support for services like specialist housing. The Bill and accompanying guidance could do more to ensure local authorities consider housing when recommending the most relevant service for a patient’s circumstances. This would also encourage Clinical Commissioning Groups and Health and Wellbeing Boards to see specialist housing and related adaptation and support services as part of the solution when considering an individual’s care and support needs.

3.4 The draft Bill needs to be amended to support local authorities to join up housing, care and health to create more outcomes-focused commissioning through pooled funding. This will provide vital preventative care and support services, saving the NHS and local authorities a significant amount of money by reducing demand and providing effective alternatives through more preventative services that intervene earlier or cost less than traditional service.

4. The Ability of NHS and Social Care Providers to Treat Multi-Morbidities and the Patient as a Person rather than Focusing on Individual Conditions

4.1 The most effective examples of the NHS and social care providers treating multi-morbidities arise when the patient is treated as a person, rather than just for one individual condition or illness. While there are many NHS and care services that do this already, it is far from the standard experience of health and care. To achieve this more consistently, local authorities and the NHS need to engage and partner with services traditionally viewed as “health-related” like housing. Housing associations are more than just an important stakeholder in local service provision. Experienced community providers like housing associations can be the driver and delivery channel for integrated offers that respond to the whole person. This might include a specialist package of support and accommodation, or simply a co-ordinated offer of a timely home adaptation.

4.2 For example, housing can play a key role in end-of-life care, when patients often have several different illnesses. The Good Death project, established by Public Health North East and managed by the housing association Home Group, brought together housing, health and social care services to make practical arrangements for residents to enable them to remain in their own homes for as long as possible at the end of life. A support officer worked with 63 people over the course of nine months to make small adjustments to their living conditions. The project saw a 10% reduction in accident and emergency attendances, and a 55% cut in GP consultations among its clients. Participants also reported a 65% increase in their feeling of “being in control” over the course of the project, and a 74% increase in their quality of life.14

4.3 However, in a recent survey by the Local Government Information Unit, only a quarter of councils said that their housing departments were engaged with end-of-life care issues,15 despite the often crucial role of housing in improving the quality of a person’s life when they have multiple morbidities near the end of their life. The survey also found that many councils see end-of-life care as being a priority, but have yet to put in place the necessary structures to deal with it.

4.4 As the new commissioning structure beds in, health providers and commissioners should be open to developing new partnerships that meet the needs of the whole person. This could include partnering with housing providers to create clearer referral routes between services, and using the home as a hub to deliver care. Clinical Commissioning Groups should also be open to these kinds of approaches when deciding how to commission, as well as what services to prioritise. Health and Wellbeing Boards can also play a role by supporting the pooling of funds or appointing a lead commissioner to deliver more integrated services in the local area.

5. Current Examples of Effective Integration of Services Across Health, Social Care and other Services which Treat and Manage Long-Term Conditions

5.1 For integration to be effective, Health and Wellbeing Boards and Clinical Commissioning Groups need to look beyond traditional health and care interventions. When services like housing-related support can be accessed as part of a wider package of support, individuals are able to both manage multiple and long term conditions more effectively, and pressure on the NHS alleviated.

5.2 The following examples show how housing can be effectively integrated across health and social care:

Housing with care and support enables people to remain independent and receive care services in their own home rather than moving to a care home.

Preventative services, such as housing-related support, reduce the need for more intensive care, reducing overall demand on the care system by helping people live independently in their own home.

Reablement services get people home from hospital quickly, prevent hospital readmissions and help them to recover their independence after illness.

Timely home adaptations assist with discharge home from hospital, facilitate the delivery of care in people’s own homes, and encourage independent living.

Good quality homes help to maintain good health, speed recovery from illness and reduce the incidence of respiratory and other diseases.

5.3 If housing is effectively used to help treat long-term conditions, demand on the care system would be reduced and the reach and outcomes of existing care services would be improved. Appendix 1 details further examples of well integrated services which effectively treat and manage long-term conditions.

6. The Implications of an Ageing Population for the Prevalence and type of Long Term Conditions, together with Evidence about the Extent to which Existing Services will have the Capacity to Meet Future Demand.

6.1 The likelihood of disability, illness and poor health increases as people age. More people are living longer with more complex conditions such as dementia and chronic illness. An estimated 3.9 million (33% of people aged 65–74 and 46% of those aged 75+) have a limiting long-standing illness and there are 700,000 people in the UK with dementia, with numbers likely to increase to 1.4m in the next 30 years.16

6.2 Levels of unmet need in terms of care and support for older people are deeply worrying. Budget increases for social care have failed to keep pace with the needs driven by demographic change and rising costs of equipment and staff.17 Many thousands of vulnerable people are still not receiving the care or support they need. The Commission for Social Care Inspection estimated a shortfall of 1.4m hours of care in 2006–07 to 450,000 older people.18

6.3 Some specialist homes are being developed for older people, but as demand outstrips supply older people will find it increasingly difficult to secure a suitable property. Supply in some areas is falling rather than rising, as traditional forms of sheltered housing are decommissioned where they no longer meet current expectations. A conservative estimate suggests there are already around 70,000 people aged 60+ in urgent need of housing and related support services.19 However, an ageing population brings new opportunities to develop housing and services which take into account the high levels of owner occupation and housing equity owned by older people. Households of people over 65 collectively own around £500bn of unmortgaged property equity,20 while over 50s account for 40% of consumer spending, 60% of UK total savings, and 80% of the nation’s wealth.21

7. The Extent to which Patients are being Offered Personalised Services

7.1 In its 2010 Adult Social Care Strategy, the UK government set an ambitious target of having all council-funded service users and carers on personal budgets, preferably as a direct payment, by April 2013.22 As of March 2012, 53% of on-going users of community services in England were on personal budgets,23 an increase of 38% on the March 2011 figure.

7.2 The Federation, however, is concerned that an emphasis on personal budgets overshadows the full benefits of personalisation. The principle of personalisation encourages concentration on outcomes determined by people and communities and engaging solutions beyond the narrow definitions of social care. The overall aim is to secure a shift to a position where as many people as possible are enabled to stay healthy and actively involved in their communities for longer and delaying or avoiding the need for targeted services.

7.3 To achieve this aim, local authorities need to facilitate a broad range of choice in the local care and support market, including housing options, and personalise the way in which care and support services are delivered wherever people live. Local councils, the NHS and their local partners need to integrate health and social care commissioning around agreed outcomes to support independence, working closely with housing providers to continue developing a wide range of options that enable independent living.

7.4 This will help to promote the delivery of a broader range of housing, home adaptations and support service designed to offer living environments which enable people with care and support needs to live independently in the community. Once an effective care market is in place, people also need to have the information and advice, including advice on housing options and adaptations, to make care and support decisions which work for them.

APPENDIX 1

Case Study 1: Housing and Independent Living

Andy, aged 32, was diagnosed with schizoaffective disorder and Bi-Polar affective disorder when he was 18 and has a long history of acute in-patient admissions and safeguarding concerns. A rehabilitation service, provided by the housing association Look Ahead, has helped him to live independently in a relatively short period of time and at less cost than residential care—the more common approach. It is estimated that this service has saved the NHS and local authority £241,670 by enabling Andy’s quick transition from in-patient service to living with only minimal need for care and support.24

Look Ahead’s service provides intensive support for up to 11 individuals in self-contained accommodation and is staffed 24 hours a day. Residents have usually come from residential care and long-term in-patient stays prior to moving in and the service supports them to become fully independent. The service is a product of integrated working at its best as it was originally commissioned as part of a joint commissioning strategy by the local NHS and local authority following the closure of an in-patient rehabilitation ward.

One year after moving to the rehabilitation service, Andy successfully applied to do a nursing diploma at City University, and volunteers for Tower Hamlets Centre for Mental Health. Six months later, Andy moved to his own flat with continued support from Look Ahead’s floating mental health service. Once Look Ahead is happy that he is well settled and can live independently, he will be discharged from the service.

Case Study 2: Living in the Community

Anna, aged 30, has autistic spectrum disorder and a learning disability. She does not use words to communicate. After a year in an assessment and treatment hospital, Anna is now happily living in her own home, developed by Dolphin Square Foundation and managed by Yarrow in London, with round the clock support from a small well-trained team.

Close partnership working between three main agencies—Westminster Social Services, Kingswood NHS Assessment and Treatment Unit and Yarrow—meant that there was a shared awareness of Anna’s very complex needs and a joint willingness to seek solutions. Throughout the planning process, Yarrow Housing and the Dolphin Square Foundation frequently met with Westminster social services and Kingswood NHS Assessment and Treatment Unit to identify ways of improving the living environment for Anna. Triple glazing and sound proofed walls ensure that neighbours are not disturbed by Anna’s vocalisations or loud music. A chromotherapy bath, which provides a body massage with a whirlpool with coloured jets, was fitted to help Anna relax, be calm and have fun.

If Anna had not moved to her new home, she is highly likely to have remained in an assessment and treatment service, which would not have benefited her overall wellbeing. Not only are the fees for this type of service £3,500 per week, but the review of Winterbourne View highlighted the importance of reducing long-term stays in assessment and treatment centres. After the initial service to support Anna’s transition to her new home tapers off, this services shows an annual saving to health and social care budgets of £17,992, as compared with Winterborne View.

Case Study 3: Importance of Housing in Well-being

Following a motorbike accident, Bruce needed multiple operations—including the amputation of a leg—and was left tetraplegic. After his discharge from hospital, he was unable to walk or take care of himself and after three months, he attempted suicide. Bruce was referred to Papworth Trust by the senior rehabilitation consultant at Addenbrooke’s Hospital. Through the support of the housing association Papworth Trust, he is now living independently and is recovering from his severe depression in his own purpose designed home.

The specialist design of Bruce’s flat has been fundamental in enabling Bruce to live independently. The kitchen work surfaces and oven are at a height that he can use and the flat’s sinks and hob are height adjustable. Light switches are at elbow height, heating controls are accessible to him and doorways are wider than normal to allow access for his wheelchair.

Case Study 4: Living Independently in Extra Care Housing

Grace, aged 74, has dementia and until recently was neglecting her health and having difficulty managing at home on her own. Moving to an Accord Housing extra care scheme has meant that she can continue to have a home of her own, with access to care and support when she needs it.

A local authority social worker reviewed Grace’s care needs and she was referred to Accord Group’s Moxley Court extra care scheme by a joint housing and social care allocation panel. If she had been moved to a residential care home under an “Elderly Mentally Ill” placement, would have cost up to £600 per week—whereas residence in a scheme like Moxley Court only costs £300 per week.25

Even with her dementia, Grace can live independently in her own self-contained flat with care and support staff available at all times. She also has access to a range of communal facilities, including a hairdressing salon and assisted bathing service. Grace says that she is much happier at Moxley Court and staff have helped her to mix with other residents in the scheme.

Living in an extra care scheme means that Grace’s care providers are able to be responsive rather than reactive. Ensuring Grace is in the most appropriate housing, with the care and support she needs, has prevented hospital admissions which may have occurred if she was left in her own flat.

9 May 2013