Pathways to preventionMaximising the opportunities of the integration of health with social care and housing for the benefit of low income, older home-owners

April 2011

Housing, people and communities

www.hact.org.uk

AcknowledgementsFriends Provident Foundation and HACT provided funding for the Network.

Pathways to prevention is published by HACT in partnership with ADASS and British Geriatrics Society

Orbit and Housing LIN provided sponsorship for this publication.

Author: Tamsin Stirling, HACT Associate

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HACT’s Fit for Living Network1 looked at new ways of improving the health and well-being of the most vulnerable and marginalised older home-owners who are living on low incomes in the poorest quality and most unsuitable housing conditions.

Information about the work of the Network and its publications are online at www.hact.org.uk

ContentsIntroduction 3

Why is this an issue that needs attention? 3

What are the current drivers for health and social care? 4

Housing, health and social care: cost benefits 4

Housing, health and social care: the personal perspective 5

Maximising the opportunities: what can be done? 7

Utilising the Joint Strategic Needs Assessment Process 7

Health and Well-being Boards 8

Practical initiatives 8

What can be done to integrate health, social care and housing for the benefit of low income older home-owners 11

Annex 1: Resources from the Fit for Living Network 12

Annex 2: Members of the Fit for Living Network 14

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Introduction

HACT’s Fit for Living Network produced this paper as a tool to:• enable a range of organisations that

work in communities, including housing organisations, Home Improvement Agencies and Age UK/Age Concern groups, to engage locally with the health and social care sectors, and

• make the case for housing interventions for older low income owner-occupiers, particularly those that are low cost, to be an integral part of health and social care planning and provision.

This paper is endorsed by the Association of Directors of Adult Social Services2 and the British Geriatrics Society3.

Why is this an issue that needs attention?

The links between poor health and housing have been extensively researched and documented4. The main health conditions with an identified causal link to an aspect of housing include respiratory conditions, accidents (particularly falls), mental ill-health and cancers5.

Research published in 2010 by the University of Warwick examined the cost savings to health from housing interventions, using a methodology enabled by health focus of the Housing Health and Safety Rating System6. The research confirmed that the one-off cost of works to improve poor housing gives an annual financial saving to the health sector. It also found that low cost interventions provide particularly good value in terms of health

and well-being benefits7.

Research in 2010 by the University of Birmingham identified 10 high impact changes with regards to prevention in older people’s services, a number of which have direct links to housing - falls prevention, housing adaptations, practical housing related support and re-ablement8.

Older people are the main users of health services and social care services9 and are also the age group most likely to live in poor housing:

• 90% of people of retirement age live in general housing (as opposed to specialist retirement or extra-care schemes)

• 75% of older people are home-owners and there are more low income home-owners than tenants

The older people who are at the most risk of health problems are to be found living in the worst housing which is primarily concentrated in the private sector. Consequently, poor private sector housing increases the incidence of hospital admission and GP visits for older people and can create additional pressures on social care services, in particular admission to residential care.

Many older home-owners face significant problems when trying to maintain, repair and improve their homes and older home-owners with sensory impairment, dementia or other age-related conditions face particular challenges.

What are the current drivers for health and social care?

The current policy context provides a range of opportunities within which practical links between health, social care and housing can be developed and improved. Specific policies and initiatives include:

• personalisation10

• personal budgets, in both social care and health

• Quality, Innovation, Productivity and Prevention (QIPP) – the NHS efficiency drive

• payment by results• the emerging public health agenda,

including health and well-being boards and the role of local authorities

• improving health pathways• GP commissioning11

• the 30 day post-discharge responsibilities of hospitals (through which they will be sanctioned for patients who are re-admitted within 30 days).

These all emphasise the need to ensure that health, social care and housing services meet the needs of individuals in a holistic way. An individual’s health problem may well have housing as its source. Cold, damp, disrepair, inaccessible rooms, design hazards causing a higher risk of falls, lack of handrails – all can have significant impacts on health and social care. The health prevention role of housing is recognised in the 2011 public health white paper12.

The new role of the Health and Well-being Board, using the Joint Strategic Needs Assessment (JSNA) as a basis, has the potential to encourage more integrated

needs assessment and commissioning. Ensuring all available data, including that held by housing and housing support organisations, is fed into these processes is critical.

The establishment of the Integrated Care Organisation (ICO) within the NHS aims to remove artificial boundaries between hospital and community healthcare services. Although this is focused on integration between secondary and primary care, more progressive approaches to creating ICOs include social care and housing.

In addition, a significant driver is the need to make savings. Health is expected to make efficiency savings of £20billion between 2011 and 2014. A crucial element to achieving these savings is the QIPP (quality, innovation, productivity and prevention) agenda. This agenda, although primarily focused on productivity, creates an environment where innovation and integration can flourish.

Analysis by the Health Services Management Centre at the University of Birmingham, suggests that social care costs will double in twenty years without fundamental and ongoing reform13.

Housing, health and social care: cost benefits

The NHS spends £600million treating people every year because of ‘category 1’ hazards14 in poor housing, the vast majority being associated with falls15. A range of evidence demonstrating the cost benefits of home repairs, adaptations and hospital discharge housing related help has been identified:

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• the interim findings of an evaluation of handyperson services, (which provide fast, low cost help with adaptations and repairs), indicates that, for every £1 spent on these services, £1.70 was saved, the majority to social services, health and the police16

• hospital discharge schemes offering housing help to speed up patient release save local government social care budgets at least £120 a day17

• an analysis by Care and Repair Cymru of the outcomes of their Rapid Response Adaptations programmes identified that every £1 spent generated £7.50 cost savings to the NHS. These savings were associated with speeded up hospital discharge, prevention of people going into hospital and prevention of accidents and falls in the home18

• the national evaluation of the Department of Health Partnerships for Older People Projects pilots (POPPs) found economic benefits from targeted intensive interventions to prevent crisis (e.g. falls services) or at a time of crisis (e.g. rapid response hospital admissions avoidance services) or post-crisis re-ablement services. For every £1 spent on such services to support older people, hospitals were found to save £1.20 in spending on emergency beds19

• each year 1 in 3 people over 65 and almost 1 in 2 people over 85 experience one or more falls, many of which are preventable20. A single fall at home that leads to a hip fracture costs the state £28,665 on average – over 100 times the cost of installing hand and grab rails in the average home21. Hip fractures are

the event that prompts entry to residential care in up to 10% of cases22

• where it is appropriate, postponing entry into residential care for one year saves an average of £28,080 per person23

• providing an adaptation in a timely fashion can reduce social care costs by up to £4,000 a year24

• adaptations can reduce the need for daily visits and reduce or remove costs of home care (savings range from £1,200 to £29,000 a year)25

• Dorset Partnership for Older People Project (part of its Total Place pilot) identified evidence of cost savings from the work of Housing Options for Older People Case Workers addressing housing and support in the home issues for individuals. This work reduced the need for care home placements and home care packages by 60, a cost saving of over £1million26

Housing, health and social care: the personal perspective

The brief case studies below demonstrate the significant personal impact of small input interventions that link health, social care and housing in highly practical ways.

Mr Rogers, 76 years old with a hearing impairment

Mr Rogers was unable to be discharged from hospital because he could not hear the door bell at home and consequently essential nursing visits could not be made. He was referred to the hospital discharge scheme run by a local housing association (and funded by the PCT).Within 24 hours, an intercom was fitted, enabling Mr Rogers’ quick return home and resulting in significant savings for the hospital. [Source: Black Country Housing Group www.bcha.co.uk]

Mr Green, 73 years old with brain injury, mobility problems and diabetes

Mr Green was admitted to hospital following a fall. The hospital discharge visit found unsafe gas appliances and electrical wiring. Most of the work was arranged by the local Care and Repair Agency with funding from a hospital discharge repairs grant, while the local Minor Electrical Works hardship fund was used to replace the unsafe cooker. The Care & Repair caseworker assisted Mr Green to access Pension Credit and Attendance Allowance. Prior to this, he had no knowledge of the benefits he was entitled to and had taken out a bank loan to meet his daily living costs. Mr Green is now living safely at home, feeling more confident, is better off and making less use of health services.[Source: Bristol Care and Repair www.bristolcareandrepair.org.uk]

Mrs Morgan, a single woman in her mid sixties, severely affected by rheumatoid arthritisMrs Morgan contacted her local Care & Repair Agency due to problems with the gas fire in her home. An assessment visit was carried out which revealed that she was unable to carry out a range of daily tasks such as bathing, toileting, using stairs internally and externally, using the telephone etc, without discomfort and risk of injury.Mrs Morgan had had years of involvement with the health service (both GP and hospital), but her home conditions had never been addressed. She was not aware of the wide range of assistance that was available to her. As a result of the intervention of the Care & Repair Agency, adaptations were funded to Mrs Morgan’s home, she was provided with equipment (funded by a charity), her disability benefits were increased and she was pro-vided with assistance to access a disabled parking badge.As a result, Mrs Morgan’s safety and well-being were significantly improved and six years later, she remains living independently, is making fewer visits to her GP and has had fewer hospital admissions.[Source: Bristol Care and Repair www.bristolcareandrepair.org.uk]

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Maximising the opportunities: what can be done?

Getting strategic

In order for housing to be truly integrated with health and social care, links need to be made at the strategic level as well as within the delivery of frontline services.

Utilising the Joint Strategic Needs Assessment process

The public health white paper Healthy Lives, Healthy People27 notes that local authorities and GP consortia will each have an equal and explicit obligation to prepare the Joint Strategic Needs Assessment (JSNA), and to do so through the arrangements made by the health and well-being board. It is crucial that this process utilises available data on private sector housing, held by both local authorities and by local housing and housing support agencies.

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Bristol City Council cross referenced data produced by its work using the Housing Health and Safety Rating System to identify hazards within private sector homes with Primary Care Trust health profiles and local authority statistics. By doing so, data about people and data about properties were effectively brought together. The resultant health and housing evidence was fed into the JSNA and informed a range of initiatives to tackle the problems identified. These include subsidised loans for home-owners to enable them to improve their homes and home adaptations.

The council also set up a programme of Home Action Zones to target ten areas of the city where the most significant impact in improving housing conditions and health could be achieved. Residents of the Home Action Zones can access a range of services linked to Housing Health and Safety Rating System hazards such as energy efficiency improvements, home fire safety checks, and small adaptations and equipment such as bath boards, grab rails, WC pan risers and grabbers/pickers.

Bristol City Council has also made good use of the Chartered Institute of Environmental Health’s Toolkit HHSRS Cost Calculator28. Using the toolkit, the council found that the total cost of dealing with expected occurrences of excess cold in Bristol would be £2.2million with a resultant saving to the NHS of £7.4million, a payback period of around 3 months.

[Source: Local Government Improvement and Development (December 2010) Joint strategic needs assessment: vulnerable adults, housing and support – a collection of case studies

Health and Well-being Boards

Health and Well-being Boards are being established in all local authorities, involving key agencies across the health, public health and social care landscape. The Health and Social Care Bill currently states that the functions of the Board will be to:

• encourage health and social care partners to work in an integrated way

• encourage health-related service providers to work closely with boards (and this could include housing and support)

• carry out any functions of the local authority, as determined by the local authority

Membership will vary but, as a minimum, they will involve:

• at least one elected councillor• Director of Adult Social Services• Director of Children’s Services• Director of Public Health• a representative of the local Health-

watch organisation, which is responsible for public and patient involvement in health

• a representative from each relevant GP Commissioning Consortium

• any other representative that the local authority thinks appropriate

There is a clear case for housing to be involved in this forum, either through the Director of Adult Social Services (where housing is a joint responsibility) or directly in two-tier arrangements. Likewise, housing and housing support providers may

wish to make the case locally for inclusion, given their perspective and reach into communities.

The Health and Well-being Board, working with partners and drawing on local information derived from the JSNA, will prepare a health and well-being strategy. It will be important to ensure that data is available and the case is made for understanding and meeting the needs of poor vulnerable older home-owners.

Practical initiatives

Some of the interventions and initiatives that enable older home-owners living on a low income to live independently in their own homes for as long as they choose and reduce their use of health services involve relatively small amounts of resources. These small interventions can have significant impacts on individuals’ health, well-being and quality of life, as well as reducing costs to health and social care services.

The types of initiatives and schemes that could be integrated into health and social care commissioning arrangements include those set out below.

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Handyperson, small repair and minor adaptation services

Handypersons carry out small home repairs and minor adaptations to help older and disabled people to remain living independently in their own home. Typical services include:

• falls and accident prevention checks and action to reduce risk

• assistance with hospital discharge services, e.g. moving beds and furniture

• home safety checks

• fire safety such as installation of smoke alarms, electric blanket checks, chip pan/fat fryer exchange

• signposting clients to other services29

Handypersons services may be provided by Home Improvement Agencies, Age Concern/Age UK groups, housing associations or other voluntary sector agencies.

An example of a handyperson scheme is Bristol Care & Repair www.bristolcareandrepair.org.uk/repairs.html

Housing’s contribution to re-ablement services

In some areas, Home Improvement Agencies have utilised re-ablement monies that were allocated by the Department of Health in late 2010/early 2011. Examples of how this funding has been used by Home Improvement Agencies include:

• the development of a cross-tenure electronic GP referral process aimed at older people in fuel poverty (Blackpool)

• the development of a three month pilot re-ablement scheme focused on telecare and minor adaptations, with a commitment to further funding if the pilot demonstrates savings (West Cheshire)

• a re-ablement pilot, involving the Home Improvement Agency case worker being co-located with the hospital case work to co-ordinate discharges from hospital (Stoke)

• hospital discharge work delivered by the handypersons service (Bexley)

[Source: Foundations www.foundations.org.uk]

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Schemes to reduce hospital admission and re-admission

For older people returning from hospital to their own home (around 90% of all those older people being discharged from hospital), a fast track housing repairs and adaptations on prescription approach can speed up discharge and reduce readmission.

An example of repairs on prescription operates in Sandwell (only available to council tenants).

www.webwell.org.uk/General-Housing-Information/Repairs-on-Prescription-for-Sandwell-Residents.htm

Hospital discharge schemes involve offering a range of support to enable older people to leave hospital in a timely fashion. The support offered can include arranging for aids and adaptations to be made, homecare and handyperson services, links to befriending initiatives and community alarm services and help with accessing benefits. They can also involve reconnecting people with their families and ensuring that they are engaged back into the community and are not isolated. Income maximisation can also be part of the service.

An example of a hospital discharge scheme is Willow Housing and Care www.willowhousing.org.uk

There are a number of housing interventions that can reduce hospital re-admission rates. One of the most significant is falls prevention. The Department of Health has identified that poor and cold housing can contribute to falls30.

Some housing organisations/Home Improvement Agencies provide falls prevention services working in partnership with health and social care as part of falls care pathways. Such services identify those at risk and reduce the incidence of falls and the impact a fall can have on health, well-being and independence. In doing so, the services link assistive technology, telecare, aids and adaptations and housing support services.

Home Improvement Agencies (HIAs) are identified by the Department of Health31 as critical partners in falls prevention:

‘with the diverse range of services which HIAs provide in many communities, including information and advice services about local housing and support options, HIAs are critical partners with whom commissioners should engage as part of an integrated approach to

falls prevention services.’

An example of a falls prevention service is Walsall Housing Group

www.whg.uk.com/main.cfm?Type=fps&MenuId=162&MainParentMenuID=20

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In addition, there is an opportunity to raise awareness of the health benefits of housing initiatives at a local level through, e.g. information and training on healthy home awareness for health professionals by local Care & Repair or Home Improvement Agencies31.

What can be done to integrate health, social care and housing for the benefit of low income older home-owners?

The Fit for Living Network would like to see:

• the remit of Health and Well-being Boards include the issues and opportunities raised in this paper as part of their responsibilities for addressing

the wider social determinants of health• initiatives and schemes that address

the needs of vulnerable older home-owners living on low incomes, such as handyperson, repair and adaptation services, integrated into health and social care commissioning arrangements

• hospital discharge planning, processes and procedures for older people fully encompass housing-related issues.

The Network also supports the recommendations of the All Party Parliamentary Group on Housing and Care for Older People’s Living Well Inquiry which reported in July 201133. These include the development of a new overarching vision of housing for older people which includes all tenures, the production of national guidance on hospital discharge and improved delivery of adaptations.

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Annex 1: References1http://www.hact.org.uk/fit-for-living 2http://www.adass.org.uk 3http://www.bgs.org.uk 4CLG (various) Housing, Health and Safety Rating System CLG London5Blackman T (2005) Health Risks and Health Inequalities in Housing Assessment Toolkit http://www.dhcarenetworks.org.uk/_library/Resources/Housing/Housing_advice/Health_Risks_and_Health_Inequalities_in_Housing_-_and_Assessment_Tool.pdf 6The Housing, Health and Safety Rating System is used to assess conditions in all private properties including those that are owner-occupied. Properties are assessed against 29 potential hazards, including issues such as ‘excess cold’, ‘falls on stairs’, ‘damp and mould growth’ and ‘noise’. When a hazard is identified in a property, two tests are applied:

• What is the likelihood of a dangerous occurrence as a result of this hazard? • If there is a dangerous occurrence, what would be the likely outcome?

The likelihood and the severity of the outcome combine to generate a hazard score. Hazard scores are divided into 10 bands, with Band A being the most serious and Band J the least serious. Hazards which fall into bands A to C are called Category 1 hazards. Councils have a duty to take some enforcement action where Category 1 hazards exist.7University of Warwick (2010) Linking Housing Conditions and Health: A Report of a Pilot Study into the Health Benefits of Housing Interventionshttp://www2.warwick.ac.uk/fac/cross_fac/healthatwarwick/aboutus/ormandy/linking_housing_conditions_and_health_2010-02-24.pdf 8University of Birmingham (2010) The billion dollar question: embedding prevention in older people’s services – 10 high impact changes http://www.hsmc.bham.ac.uk/publica-tions/policy-papers/policy-paper-eight.pdf 9Department of Health (2001) National Service Framework for Older Peoplewww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066 10The Housing LIN has produced a briefing on housing support and personalisation www.housinglin.org.uk/Topics/type/resource/?cid=8169 11The Housing LIN has produced a briefing on the new NHS commissioning landscape and its impact on housing and care for older people www.housinglin.org.uk/Topics/type/resource/?cid=8169 12HM Government (2011) Healthy Lives, Healthy People: Our strategy for public health in England www.dh.gov.uk/en/Publichealth/Healthyliveshealthypeople/index.htm 13Glasby et al (2010) The case for adult care social reform – the wider social and economic benefits www.hsmc.bham.ac.uk/news/pdfs/social_reform-final_report-feb2010.pdf 14See 4 15M Davison et al (2010) The real cost of poor housing BRE

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www.brebookshop.com/details.jsp?id=325401 16Department of Communities and Local Government (February 2011) Handyperson evaluation: interim findings http://www.communities.gov.uk/publications/housing/handypersonevaluation17Personal Social Sciences Research Unit for Department of Health (2010) National evaluation of POPPs www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publication-sPolicyAndGuidance/DH_111240 18Care and Repair Cymru (2010) Care & Repair Service Impact Report – 2009-10 Reporting Year – Rapid Response Adaptations Programme19Joseph Rowntree Foundation (2011) How can local authorities with less money supportbetter outcomes for older people? www.jrf.org.uk/publications/local-authorities-better-outcomes-older-people 20National Institute for Health and Clinical Excellence (2004) Clinical Practice Guidelines for the Assessment and Prevention of Falls in Older People, www.nice.org.uk/CG21 21Laing and Buisson (2008) Care of Elderly People: UK market survey 200822Department of Health (2009) Falls and fractures: effective interventions in health and social carewww.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@pg/documents/digitalasset/dh_109122.pdf23see 17 24Care & Repair England (2010) Time to Adapt: home adaptations for disabled peoplewww.careandrepair-england.org.uk/timetoadapt.htm 25Heywood et al (2007) Better outcomes, lower costs http://odi.dwp.gov.uk/docs/res/il/better-outcomes-report.pdf 26Bournemouth, Dorset & Poole Total Place Pilot: Final Report 2010 www.dorsetforyou.com/index.jsp?articleid=394358 27HM Government (2010) Healthy Lives, Healthy People: Our strategy for public health in England www.dh.gov.uk/en/Publichealth/Healthyliveshealthypeople/index.htm 28Chartered Institute of Environmental Health (2008) Good Housing Leads To Good Health: A toolkit for environmental health practitioners www.cieh.org/policy/Good_Housing_Leads_to_Good_Health.html 29Communities and Local Government (2011) Handypersons Evaluation - Interim key findings http://www.communities.gov.uk/publications/housing/handypersonevaluation 30see 1831see 1832http://www.careandrepair-england-hhhl.org.uk/evidence.htm 33All Party Parliamentary Group on Housing and Care for Older People (July 2011) Living Well Inquiry http://counselandcare.org.uk/pdf/living-well-at-home

Annex 2: Members of the Fit for Living NetworkSue Adams, Care & Repair England

Marjory Broughton, South East England Forum on Ageing

John Bryson, independent consultant working with Warwick University

Martin Cheeseman, independent consultant working with local government

Patrick Conaty, Common Futures

Stewart Fergusson, Orbit Housing Group

Domini Gunn-Peim, Chartered Institute of Housing

Lindsay Hay, Bristol Care & Repair

Naomi Kingsley, London Rebuilding Society

Malcolm Levi, Chair of the Network

Jane Minter, Housing 21

Joe Oldman, Age UK

Fred Payne, Bankers Benevolent Fund

Jeremy Porteus, Housing Learning and Improvement Network (LIN)

Shaun Robinson, Foundations

Sandra Spence, Black Country Housing Group

Danielle Walker-Palmer/Andrew Thompson, Friends Provident Foundation

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About HACTHACT works with the housing sector, government, civil society and communities to develop and share innovative approaches to meeting changing housing need.

HACT believes housing provides a foundation for changing people’s lives for the better. We seek to influence housing practice and policy to transform lives and strengthen the resilience of communities.

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About our funderThe Friends Provident Foundation is a grant-making charity concerned with how the financial system can produce social as well as economic goods and services – the Right Use of Money.Established as part of the demutualisation of Friends Provident Life Office in 2001 and the floatation of Friends Provident plc, Friends Provident Foundation is an independent charity and has its own Board of Trustees. http://www.friendsprovidentfoundation.org

About our sponsorsOrbit Heart of England is a leading provider of affordable housing across the Midlands. An Investors in Excellence and Investors in People accredited organisation, we manage over 15,000 rented, leasehold, sheltered and supported homes, with an annual turn-over of almost £67 million in 2010/11. We work to build brighter futures for people and communities through a ‘customer first’ approach and actively engaging with our customers. http://www.orbitheartofengland.org.uk

The Housing Learning and Improvement Network (LIN) is the leading ‘knowledge hub’ for a growing network of 5,700 housing, health and social care professionals in England involved in planning, commissioning, designing, funding, building and managing housing, care and support services for older people and vulnerable adults. For further information about the Housing LIN and to access its comprehensive list of on-line resources, visit www.housinglin.org.uk