DSH0002

Written evidence submitted by the Older People and Frailty Policy Research Unit

Supported Housing Inquiry – call for evidence to support the committee

Who we are:

The Older People and Frailty Policy Research Unit (OPFPRU) was established in January 2019 and is funded by the National Institute for Health and Care research (NIHR) working directly with the DHSC for five years. The OPFPRU is a collaborative partnership between the University of Manchester, Newcastle University and the London School of Economics. The Unit produces high quality evidence addressing the critical questions related to the health and social care needs of older people in England.  Acting as a long-term resource for policy research and rapid-response service, we provide evidence for emerging policy and practice needs.  The team also offers advice to policy makers, senior civil servants and analysts on the evidence base and options for policy development.

The research:

This research was undertaken by the NIHR Older People and Frailty Policy Research Unit (OPFPRU) in response to a request by the Department of Health and Social Care related to supported housing.  Specifically, to understand what are the characteristics of people who are living in and who move to supported housing, including where possible, what levels of care do people in supported housing receive.  The research included three strands of activity:

1. A rapid scope of UK supported housing research published in the past 10 years (2011-2021) to identify what is known in the literature about the characteristics of people who live in supported housing, and the evidence for outcomes for this group.
2. Preliminary analysis of the characteristics of older people living in different types of supported housing in England using two data sets:

a)      Health Survey for England (HSE)

b)      English Longitudinal Study of Ageing (ELSA)

The following submission includes all three pieces of research undertaken and findings.  It is relevant to the questions on the quality of data on supported housing and the government’s current proposed actions to improve supported housing.  The full policy briefing reports are linked under each specific report in this document and can be found on the NIHR Older People and Frailty Policy Research Unit please see www.opfpru.nihr.ac.uk

This submission presents independent research funded by the National Institute for Health and Care Research Policy Research Unit in Older People and Frailty. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Policy Research Unit Programme Reference Number PR-PRU-1217-21502

1.A rapid scope of UK supported housing research published in the past 10 years (2011-2021)

Full Report – Link Here

Overview

Supported housing is where accommodation is provided alongside support, supervision or care to help people live as independently as possible in the community.[1] The sector is diverse in terms of providers (e.g., housing associations, local authorities, charities and voluntary organisations) and in terms of size and scale. The way accommodation and support services are delivered is also variable, with some organisations providing both aspects and others separate aspects. Some common terminology to refer to different concepts of supported housing includes: Retirement living/retirement villages, offering independent living in a village scheme where care can be arranged separately if needed[2]; Sheltered housing, which usually offers support from a warden, 24-hour emergency support and communal areas[3]; Assisted living or extra care housing, which offers more tailored 24-hour support.[4]

Main findings

A substantial, wide-ranging scoping review of the academic and grey literature around housing and adult social care published in 2015 gathered UK evidence published from 2003-2013.[5] A total of 119 articles, reports and other documents were included. The evidence includes housing and prevention of the need for adult social care; housing and delaying the need for adult social care; alignment of housing with the integration of health and adult social care; and cost and cost-effectiveness studies. The review revealed some ‘good evidence’ about several housing interventions, including housing with care for older people, aids and adaptations, and handyperson services in preventing and/or enabling people to live independently in their own homes. There were evidence gaps regarding prevention of the need for adult social care, enabling independent living, integration and cost-effectiveness.

The quality of the evidence base covered in this scoping review appears to be mixed at best. Many studies were not robustly designed or published in peer-reviewed journals, and much evidence came from bodies with an interest in the area and public sector organisations. The range of methodological approaches was limited, with very few randomised controlled trials, cross-sectional or longitudinal studies, and much evidence from evaluations of a small sample or a single case study. The review authors noted a methodological challenge in this area, that there may be little interest among providers in research comparing their approach with their competitors and a reluctance to share commercially confidential information.

This challenge was echoed in a more recent short scoping exercise that considered issues relating to a potential evaluation of the Care and Support Specialised Housing (CASSH) programme.[6] Desk-based research found ‘good evidence for the benefits of extra care housing for older people’, and cites evidence including savings to the NHS, reductions in social care spend and improvement in residents’ personal and mental health. However, the overall strength and quality of this body of evidence is not clear. In qualitative work, the researchers highlighted the significant difficulty they found in obtaining data about the operation of the CASSH programme and in speaking to providers, and suggested that this might hinder a formal evaluation.

The ECHO study [7],[8] took a longitudinal qualitative approach (2015-2017) to explore how care is negotiated and delivered in extra care housing. It involved 51 residents from four schemes (one of which offered specialist dementia care), and managers and staff from each scheme. Residents appreciated the flexible nature of care provision that was able to respond to their changing needs, which may have been permanent or temporary. However, managers, staff and residents reflected on a changing profile of residents, seeing more residents entering services with higher support needs, which challenges the ability of services to function in the flexible manner intended by extra care housing. The research team also published a paper offering a critical consideration of the effectiveness of outcomes-based commissioning in adult social care within extra care housing.[9] The core issue is that since both housing and adult social care are intimately interrelated in this kind of setting, care commissioners need to understand the worlds of housing commissioners and providers, and vice versa.

One peer-reviewed paper reported the findings of a health needs assessment of the population of a UK sheltered housing service.[10] It explored tenants' perceptions of health and well-being (n = 96 participants), analysis of the service's health and well-being database, and analysis of emergency and elective hospital admissions (n = 978 tenant data sets for the period January to December 2012). Tenants did not have a consensus understanding of the terms health and wellbeing and used them synonymously, but felt that the communal environment supported their personal responsibility to maintain their well-being, and supported their sense of safety and security. Barriers to sustaining wellbeing included population ageing, poor knowledge of services and how to access them. The most common reasons for emergency hospital admission were circulatory and respiratory diseases and ill-defined symptoms; neoplasms were most common for elective admission.

Another peer-reviewed study combined data from four separate studies where participants were older people either living in care homes or extra care housing or receiving care at home.[11] All of these studies asked participants to rate their control over daily life, using the Adult Social Care Outcomes Toolkit (ASCOT). After controlling for differences in age, ability to perform activities of daily living and self-rated health, the evidence showed that the setting had a significant effect on older people's sense of control. Residents in extra care housing reported similar levels of control over daily life but consistently report feeling more in control than older people receiving care at home.

Other peer-reviewed papers reported relevant findings regarding the demographic, health and socioeconomic characteristics of people living in supported housing settings, but used longitudinal data from the 1990s and early 2000s and hence were not included further in this brief summary note.[12] [13] [14]

One project[15] explored life expectancy in a case study of Whiteley Village, a charitable retirement community for around 500 older adults with limited financial means, consisting of three tiers of housing (cottages/almshouses, extra care flats and a nursing home). The study found that men and women have both benefited from moving into a cottage/almshouse, most notably women who have seen an increase in life expectancy of 1.3 - 4.9 years compared to the general female population.

A report from 2015 drew on data gathered from survey questionnaires distributed to seven different luxury retirement villages with extra care, run by two housing with care providers. [16] Out of 743 residents, 201 residents from 158 households returned partially completed surveys (response rate of 27.1%). The findings were generally very positive in terms of quality of life, sense of control and feelings of loneliness. However, the sample consisted of largely affluent and healthy respondents.

Evidence including economic estimates

One briefing reviewed existing evidence regarding the impact of sheltered housing and made initial estimates as to the cost savings that could be achieve in a range of fields.[17] It included 52 academic papers and policy reports related to the social value of sheltered housing. Several papers reported benefits of specialist housing for older people, where improved physical and mental health has been quantified and compared with control/similar older populations or national averages. A much smaller number of studies went on to monetise these potential benefits in terms of cost savings to the NHS and/or social care. The estimates of the social value of sheltered housing totalled £483m per year, the majority of which was attributed to a reduction in inpatient stays (£300m) and health and care costs of hip fractures prevented (£156.3m). However, once again, the vast majority of this evidence is not from academic papers and its strength and quality is unclear.

Work with the ExtraCare charitable trust took a longitudinal approach (2012-2018) to explore the impact of 13 ExtraCare villages, with 162 residents and 39 controls at baseline. [18],[19] Key findings were that there were improvements in personal health (e.g. increase in level of exercise, reduction in falls risk, delay in increase of frailty), psychological well-being (e.g. decrease in anxiety, improvements in memory and cognitive skills), social well-being (86.5% of residents were ‘never or hardly ever’ lonely). The study also found lower healthcare costs, e.g., reducing GP visits, fewer days per year in hospital, living in ExtraCare saves the NHS around £1,994 per person, on average, over five years.

Work in Southampton reviewed evidence on housing with care and constructed estimates of financial impact of housing with care, applied to the Southampton context to develop projected estimates for the locality.[20] The evidence review acknowledged the limited body of research available, but it suggests positive health impacts of housing with care coming through reductions in numbers of GP visits, community health nurse visits, non-elective admissions to hospital, length of stay and delayed discharges from hospital, and ambulance call outs, typically linked to reduced incidence of falls. The financial benefit to the NHS was estimated at £2,000 per person per year. This means that Southampton’s current provision of housing with care (around 170 units) has been producing a cost benefit of over £334,000 per year, and is estimated to increase to £890,000 if the city realises its goal to supply 450 units of housing with care.

An evaluation of Extra Care Housing in Wales (2016-2017)[21] found that resident experiences were very positive, highlighting safety, security, social interaction, but there was some confusion over charges for services. Demand for local authority services was outstripping supply, but the report cautioned that this was based on waiting list evaluation and that little is known about demand for full or shared ownership. The total cost of developing the extra care schemes developed by housing associations (n=45, data available from n=41) was around £350m, meaning the average cost was £8.5m and the cost per bedspace[22] was £120k (ranging from £50k - £200k).

2a. Preliminary analysis of the characteristics of older people living in different types of supported housing in England using Health Survey for England (HSE)

Full Report – Link Here

Overview

The data come from the Health Survey for England (HSE) 2013. In the Aids and Adaptions section of the HSE 2013, respondents were asked whether they were living in any type of supported housing. This section was specifically designed for the Older People’s Care and Support study (OCAS, led by CPEC at LSE and University of East Anglia) funded by the Nuffield Foundation. The question relating to supported housing was not repeated in other years of the survey, so we only have one year of data to work with. 

Findings

Among 2,233 people in the survey, 4.3% (n=95) were living in warden maintained or sheltered accommodation, 0.5% (n=10) were living in extra care housing, and 0.5% (n=10) were living in other types of supported housing. In total, 115 people in the sample reported living in supported housing, accounting for 5% of community-dwelling older people.

Older people living in supported housing differ from those not in supported housing in terms of age profiles, functional capability, marital status, housing tenure, and care use. Among people living in supported housing, 64% were aged 75 and over in 2013. In contrast, 41% of older people not living in supported were aged 75 and over. Such a difference is statistically significant (χ2=31, p-value<0.001). 59% of people living in supported housing are women, and 53% of people not in supported housing were women. However, such a difference is not statistically significant (p-value=0.17).

Among 115 older people living in supported housing, 37% did not have functional disability and 36% had at least one ADL limitation. For people not living in supported housing, the proportions were 70% and 12%, respectively. These differences are statistically significant. 79% of people living in supported housing were single. Here single people refer to those who were never married, widowed, separated, or divorced. In comparison, 40% of people not living in supported housing were single. Such a difference is statistically significant. 80% of older people in supported housing were living in rented housing. The proportion is significantly lower (only 16%) among people who were not living in supported housing. 

Older people living in supported housing were more likely than those not in supported housing to use informal care, formal care, and day centre services. 42% of people in supported housing were informal care recipients, which is significantly higher than the proportion among those who were not living in supported housing (20%). The same can be said about formal care and using day centre services, and the proportions are 20% and 6%, respectively.

2b. Preliminary analysis of the characteristics of older people living in different types of supported housing in England using English Longitudinal Study of Ageing (ELSA)

Full Report – Link Here

Overview

The data was drawn from the English Longitudinal Study of Ageing (ELSA). ELSA is a biennial household panel survey that collects information on the demographic characteristics, socioeconomic position, and comorbidities of individuals aged 50+ in England. Details of the study design are given elsewhere.[23] ELSA was started in 2002, and so far, there are nine waves of ELSA. This report used the most recent wave of ELSA (wave 9 in 2018-2019). Variables on housing and care receipt are not available in every wave of ELSA. Appendix 1 shows the availability of the housing and care receipt variables in each wave of ELSA.

Housing

We categorised supported housing into five types:

(1)    living in a nursing home or residential care home;

(2)    living in an ordinary or retirement house with meals and warden/porter services included in the with the accommodation or in the last rent payment;

(3)    living in an ordinary or retirement house with warden/porter services included in the with the accommodation or in the last rent payment;

(4)    living in a retirement house with no meals and warden/porter services included in the with the accommodation or in the last rent payment; and

(5)    living in an ordinary house with no meals and warden/porter services included in the with the accommodation or in the last rent payment.

Frailty

We assessed frailty using the frailty index, whereby we selected information on 60 functional, psychological, and social deficits within the range of data variables in ELSA.[24] All binary variables are recoded, using the convention that ‘0’ indicates absence and ‘1’ presence of a deficit. For ordinal and continuous variables, coding is based on the distribution of the data. Deficit points are summed for each individual, and divided by the total number of deficits, to produce a frailty index with a range from 0 to 1. Higher scores indicate greater frailty. Following Clegg et al.,[25] we categorised the frailty index into frailty (> 0.36), pre-frailty (>0.24-0.36) and non-frailty (≤0.24).

Informal and formal care

We categorised the respondents as having informal care if they received help from: (1) husband/wife/partner; (2) son; (3) daughter; (4) grandchild; (5) sister; (6) brother; (7) other relative; (8) friend; or (9) neighbour (Appendix 2). We categorised the respondents as having formal care if they received help from: (1) home care worker/ home help/ personal assistant; (2) a member of the reablement / intermediate care staff team; (3) voluntary helper; (4) warden / sheltered housing manager; (5) cleaner; (6) council’s handyman; (7) member of staff at the care/nursing home; or (95) other formal helpers.

Among 8,557 respondents, 0.67% (n=57) lived in a nursing home or residential care home; 0.02% (n=2) lived in an ordinary or retirement house with meals and warden/porter services included in the with the accommodation or in the last rent payment; 0.81% (n=69) lived in an ordinary or retirement house with warden/porter services included in the with the accommodation or in the last rent payment; and 2.96% (n=253)  lived in a retirement house with no meals and warden/porter services included in the with the accommodation or in the last rent payment. The bivariate analyses show that older people living in supported housing differ from those not in supported housing in terms of age profiles, marital status, frailty status, and care receipt.

June 2023