Scottish Government

Tribal prepared this literature review for the Scottish Executive Development Department to support their review of housing provision for older people in Scotland, and to inform the development of policies aimed at integrating services for older people. It is generally accepted that the existing specialist housing stock is becoming increasingly unfit for purpose, and that changes in demography and demand for housing are likely to have a significant impact on requirements for provision into the future. This research considers the evidence relating to older people's decision making and the different forms of delivery available across the UK.

Main Findings

• The increasing population of older people in Scotland will lead to further pressure on services for older people while changes in gender balance and tenure balance towards owner occupation will impact on older people's housing options and choices.
• Decisions about moving in older age are complex and are highly dependent on individual circumstances. Health related issues are the most common reason for moving, with outcomes being most positive for those that have planned their move for some time.
• Sheltered housing provides social contact and a secure environment that appeal to many older people. Extra-care or very sheltered housing is becoming increasingly popular as an alternative to residential care or high intensity care at home. It provides flexible care and accommodation suited to those with mobility problems. However, the majority of older people stay in general needs housing and many move within this to a property that more closely suits their needs.
• Older people are keen to stay in their own homes. They are guided in their decisions by aspirations for security, accessibility (both internally and externally) and sufficient space, with many considering two bedrooms to be a minimum. Care at home services (both high and low intensity) form a vital means of enabling older people to stay at home.
• Access to services for older people is problematic for those in rural areas and for those from minority ethnic groups.
• Retirement communities and co-housing communities for older people have been introduced into the UK from abroad. Retirement communities have proven popular with those able to afford them. Co-housing for older people has been slow to deliver in the UK so far, but may suit future groups of older people.
• Evidence relating to the cost-efficiency of extra-care housing compared to residential care is mixed. It is improved by large-scale provision, but this is problematic in rural areas where intensive home care may be more cost effective.

SETTING THE CONTEXT

Policy and Social Context

Since the 1980s there has been a growing focus throughout housing and social care policy on community care, facilitating older people to remain in their own homes. Scotland is now making progress towards a national strategy for older people, in line with progress across the rest of the UK.

Strategies developed by local authorities in Scotland include community care plans and local housing strategies. These strategies go some way in directing the delivery of services for older people, though there is a need to join up strategies for older people, so that housing, health and social services meet the overall housing and support needs of older people. The development of a national strategy should aid this process.

Changes in demography indicate a considerable increase in the number of older people in Scotland, particularly of 'very old' people (aged 85+). In particular there is anticipated to be a growth in older men. Trends towards high proportions of older people in remote rural areas also seem set to continue. These demographic changes will lead to further pressure on services for older people, while changes in gender balance and tenure balance towards owner occupation will impact on older people's housing options and choices.

Housing aspirations, expectations and decisions in older age

Older people are keen to stay in their own homes. Security and accessibility are weighed against each other in the desire for ground floor access. Space is also important, and means that two bedroom properties are increasingly seen as a minimum for many older people. Internal accessibility is important, as is the provision of local services.

Around half of all older people do not consider the possibility of a need to move, and often find that the decision is forced on them by health and mobility requirements. Those that take time over the decision and think ahead are generally more satisfied with the outcomes of their move. While many older people choose to avoid sheltered housing, those who have moved there are satisfied with their choice. Moves tend to relate to a 'push' from inappropriate existing accommodation, rather than the 'pull' of the new alternative.

There is considerable movement within general housing in the owner occupied sector, often to a property with improved ground floor access or closer to shops and local amenities. Financial concerns are also of considerable importance for this group, and this may become more important following recent rises in property prices.

Social exclusion is an issue for many older people. Those in poverty experience problems of fuel poverty and difficulties with home maintenance. Older people in rural areas often experience poor housing conditions, social isolation, and limited access to sheltered housing. Minority groups make up a small proportion of the older population. While their service needs are similar to majority groups, their access to housing and services is much more limited. Differences between ethnic minority cultures are also significant, particularly in relation to family support.

DELIVERY OF HOUSING WITH CARE

Care at Home

Care at home is available across all tenures. However, lack of awareness of eligibility to services, particularly for those over 75 years, appears to restrict access. High levels of support can reduce the need to enter residential care, while low level, preventive care has been identified as important in preventing dependency, reducing isolation and improving confidence.

Property based services include care and repair services (providing assistance with home maintenance) and the provision of aids and adaptations (to facilitate staying at home). Both play a key role in enabling older people to remain in their own homes. There has been a renewed focus on care and repair services, following the findings of the Housing Improvement Task Force, which has led to improvements in service provision. Home adaptations have been found to provide very good value for money in relation to reducing dependence.

Sheltered and Extra-care Housing

Sheltered housing is specialist accommodation for older people with on-site housing support. The proportion of older people living in sheltered housing has remained at around 5% since the 1980s. However, much of the traditional sheltered housing stock is now ageing, and is no longer considered fit for purpose for the following reasons: small property sizes; difficulties with access to first floor properties; limited service provision in local neighbourhoods; changes to working practices for wardens; increasing age of residents; and over-provision in some areas possibly related to low demand.

The role of the scheme manager in particular has changed. They tend not to be resident on site. Instead there are duty or mobile managers, backed up by the use of community alarms. They play an increasingly professional role across a diversified range of specialisms including tenancy support, social activities, housing management, resident involvement, financial advice, and joint working with other professionals.

Private sheltered housing is becoming more common; around 5.5% of sheltered housing provision in Scotland is now in private schemes. The buildings are generally to a higher specification and in better neighbourhoods than public sector provision. The emphasis is on property maintenance and personal care tends to be managed by the resident or their family, rather than through social services. Satisfaction ratings with these schemes have been high.

Following the identification of difficulties with traditional sheltered housing schemes, there has been a shift in focus towards the development of very sheltered or extra-care housing. In 2001 this accounted for 5% of all sheltered accommodation in the UK. It aims to replicate the advantages of living at home, while providing flexible care. Support is delivered by one dedicated team, often based on site. Satisfaction levels are high, particularly in relation to access to care and the provision of meals.

There is some discrepancy between research findings relating to the value for money provided by extra-care housing over residential care. Cost efficiency can be most readily achieved through increasing the scale of the scheme, including the integration of sheltered units.

Alternative Forms of Housing and Support

Assistive technologies have become increasingly varied in their applications for older people. These include sensors and detectors in the home, which are linked up to a telephone careline, and digital medical monitors which enable doctors to monitor patients from a distance.

Co-housing models were developed for older people in the Netherlands and Scandinavia, and the concept is starting to take root in a small way in the UK. However, existing regulation and practices of housing associations make it more difficult to establish and manage such schemes here. High levels of owner occupation also create complexities. Co-housing provides independent living within an active community environment. Such communities do not provide formal care or support. The optimum number for an older people's scheme has been identified as 30-40 people, in 24 units.

Continuing care retirement communities have been introduced to the UK from the USA. Some have been developed privately, and some by not-for-profit organisations. They are geographically segregated from other residential areas, and in the UK they range in size from 120 to 320 units with community facilities.

They aim to provide a 'home for life' and have been found to be fairly exclusive. Nevertheless, satisfaction among residents is high, with privacy, assistance, independence, security and access to facilities being most popular.

Methodology

Literature for this review was identified through a range of searches. This included internet searches of key websites and searches on databases covering academic references, practice and professional journals, national and local government publications and non-governmental research reports. The search considered all literature since 1980, though the focus during the review was on more recent research findings.

Consultation was also undertaken with a range of Scottish local authorities to identify any research carried out at a local level for their own policy developments.

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