Title: Comparative evaluation of models of housing with care for later life
Authors: Karen Croucher, Leslie Hicks, Mark Bevan and Diana Sanderson
Affiliations: Karen Croucher and Mark Bevan work for the Centre for Housing Policy and Leslie Hicks for the Social Work and Development Unit, all at the University of York Diana Sanderson is an independent consultant
Recent years have seen the emergence of a range of housing options for older people that seek to provide, on one site, for people requiring minimal support and for those with more intensive support needs. This evaluation, funded by the Joseph Rowntree Foundation, looked at seven different housing with care schemes over a two-year period. These had been developed by several different providers with different funding arrangements, although it proved impossible to recruit a private sector provider.
Two of the schemes can be characterised as “village” developments, the first comprising 300 cottages, 49 extra care flats and a large care home facility on a 240-acre estate. The second was made up of 152 bungalows alongside a central complex housing a care home and a range of community facilities. Both schemes were operated by charitable trusts, as was a city development across three sites, 80 flats in the centre, 54 flats on the outskirts and a 13-bed nursing home, and a development by a housing association in partnership with local social services of 39 flats and a 15-bed respite/residential unit in a town centre.
Two schemes were operated by housing associations, 40 new flats with shared facilities on the edge of a village and 40 flats and communal facilities converted from a former seaside hotel and located alongside local primary health care services. The final scheme was one of several in the north of England operated by a not-for-profit limited company, providing 53 flats on a leasehold basis.
In all schemes individuals had their own home and all provided 24-hour staff cover.
The researchers explored “what works best” from the perspective of a range of stakeholders, looking at issues such as engagement with the wider community, choice and control, and the impact of different models on individuals with different needs at different points in their lives. Interviews and focus groups were held with 156 residents across the different locations and with managers and front-line staff, and a common data set was completed for each of the developments. This included profiles of the residents and staff at each site, the accommodation and services, the funding sources and charges, and the criteria for entry and residence.
Individuals in all locations spoke of their motivations for moving into a housing with support option. These can be broadly categorised as “non-care” and “care-related”, although for many there was a complex mix of reasons, some prompted by factors such as bereavement or illness. Many had been in housing need while a small number had moved from residential care others were keen to avoid that option. Whether requiring support or not, safety was a primary concern, with most seeking a secure, accessible, affordable place to live. The schemes varied in terms of entry criteria, for example level of required support (some only accepted those with existing needs, others required independence at the point of entry) or income levels.
A range of other features made the individual schemes distinctive. Those developed by the local statutory sector in partnership with housing associations were likely to be responding to specific local need while independent providers could be more autonomous and potentially innovative. Larger schemes offered a wider range of facilities and amenities, although size did not influence the level of support provided.
The larger schemes offered social advantages in terms of a wider range of interest groups. The design both of individual units and of the development as a whole was critical to quality of life and maintaining independence, with some evidence that designs had focused on wheelchair access at the expense of sensory or cognitive impairment. Those in more isolated locations could feel cut off. More generally however, contrary to some perceptions, residents did not appear to be separate from their wider communities and were keen to maintain social networks and activities. Not all, however, supported sharing their own facilities with the wider community, as was the remit in a number of the schemes.
The level of more intensive support that could be offered to individuals varied and could depend also on the capacity of other local providers to contribute to the support package. Most schemes tried to support residents who were developing dementia, at least initially, although only one could provide, in the care home element, for more challenging behaviours. End-of-life care could be offered in several of the schemes.
Schemes varied in terms of funding arrangements and the extent of any public subsidy. One scheme was subsidised by the charitable trust behind its development one, with owner occupiers or leaseholders, was based on self-funding and the remainder were self-funding but often with the inclusion of state benefits. Charges across schemes varied but were not inconsiderable nonetheless residents tended to consider that housing with care provided value for money and was cheaper than alternatives such as residential care. There were instances however of individuals being reluctant to purchase support at the level which they were assessed as requiring.
Once they had made the transition to housing with support, most residents put great store on the combination of independence and security, both physical security and the availability of on-call support. People could choose what they wanted to do and could maintain their own privacy. Several advantages of age-segregated living were highlighted, including the sense of security and of sanctuary. Each scheme was developing as a community, enhanced where there was a stable staff group engagement with the wider external community could be on their own terms. Disadvantages of schemes could include the development of gossip and rumour, tensions between those on state benefits and others, and isolation for some who were more frail. Residents could vary in age span across four decades disability rather than age appeared to be more of a potentially divisive factor although one scheme had had particular success in integrating the fit and the frail.
Provision of support for increasing numbers and needs, as people age, is of course a key contemporary challenge. An increasing range of providers and of options that embrace both housing and support can transform the challenge into an opportunity, allowing individuals to pursue an option they consider might best meet their needs and preferences. The literature review conducted at the start of this project had indicated that the evidence base for housing with support at that stage was relatively limited. This evaluation has allowed a range of different housing and support arrangements to be compared and has highlighted a variety of dimensions which distinguish the different models. Importantly, though possibly frustratingly, no single model appeared to be distinctly more effective than others.
A key factor is the extent to which individuals are likely to be supported to the end of life in schemes which they enter. There has been interest in the development of what have been termed “continuing care” communities, initiatives providing levels of support ranging from independent to intensive. Not all the schemes explored in this study aspired to continuing care but it was evident that while there was careful discussion of selection criteria for entry to the housing and support development, there was less consideration and greater uncertainty around exit criteria.
Commentators have expressed concern about the promotion of age-segregated communities, particularly the larger villages. For residents themselves the benefits of security and sanctuary, together with the selective maintenance of “outside” contacts appeared to outweigh any such concerns.
Alison Petch is director of Research in Practice for Adults. Ripfa promotes the use of evidence informed practice in the delivery of adult social care services. More information at www.ripfa.org.uk
● The literature review which prefaced this study is reported in Croucher K, Hicks L and Jackson K (2006) Housing with Care for Later Life: A Literature Review, York: Joseph Rowntree Foundation
● Croucher K, Pleace N and Bevan M (2003) Living at Hartrigg Oaks: Residents’ Views of the UK’s First Continuing Care Retirement Community, York: Joseph Rowntree Foundation
● Bernard M, Bartlam B, Biggs S and Sim J (2004) New Lifestyles in Old Age: Health, Identity and Well-being in Berry Hill Retirement Village, Bristol: The Policy Press
● Bernard M, Bartlam B, Sim J and Biggs S (2007) Housing and care for older people: life in an English purpose-built retirement village, Ageing and Society 27 (4), 555-578
● Evans S and Means R (2007) Balanced Retirement Communities? A Case Study of Westbury Fields, Bristol: University of West of England
This article appeared in the 22 November issue under the headline “Models of housing in later life care”