March 1998 - Ref 358
Assessing housing needs in community care

Housing need is assessed in many different circumstances in community care whether as part of assessments undertaken by social services; hospital discharge; applications for renovation or other grants from housing or environmental health departments; and allocation procedures of housing agencies. This study, by researchers at the Centre for Housing Management and Development at the University of Wales, Cardiff, examined the way housing needs were assessed in these different circumstances. The main findings were:

• Community care assessments routinely included housing need, but the method used varied according to the approach of the individual care manager responsible.
• Housing needs assessments often did not take place on discharge from short-stay hospitals. Medical staff tended to assume that vulnerable people would be best off in residential care or a nursing home.
• In discharge from long-stay hospitals the degree of disability meant that housing needs were always a central issue and the occupational therapist usually adopted a key role.
• The length of time people had to wait for assessments for aids and adaptations greatly hindered the effective working of community care.
• Housing organisations or departments were usually only involved in assessments where access to public rented housing or to aids and adaptations were an issue. Amongst those interviewed, there was a consensus amongst all parties that no further involvement was appropriate in most cases.
• Many housing organisations had changed their allocation policies to take account of community care, but when allocating housing to community care users they often delegated responsibility to medical advisors rather than involving housing officers.
• There were substantial differences in approaches to the assessment of housing needs both between and within professions. This influenced the extent to which the voice of the user was heard and their choices respected.

Background

The early 1990s witnessed major changes of policy and practice relating to community care. Opinions about these changes have been mixed: the objectives of promoting greater user involvement and of increasing opportunities for independent living in the community have been widely welcomed, but there has also been considerable scepticism as to whether local authorities had the resources or the imagination to adapt and deliver effective services in the new environment.

Research and informed comment immediately before and after the introduction of the Government's community care reforms indicated a rather gloomy prognosis. Critics have suggested a number of problems and this research set out to assess the following assertions:

• social services departments do not adequately consider housing issues during community care assessments;
• housing agencies do not become involved in community care assessments because of uncertainty about what is involved and concern about resources;
• there are substantial differences between different professional approaches to assessment, with each profession taking different views about peoples' ability to live independently;
• user choice is limited both by lack of service provision and the approach of professionals;
• housing allocation policies have not been adapted to meet new demands from community care.

Consideration of housing needs

Apart from problems in discharge from short-stay hospitals, housing needs were routinely considered in community care assessments. The personal approach of individual care managers and the system within which they were working influenced whether personal and emotional factors were considered alongside practical ones.

Apart from the care manager, who set the framework for the assessment of housing needs, the key person was the occupational therapist (OT). He or she was usually given the role of assessing the capacity for independent living in different situations. OTs generally concentrated on the physical aspects of the property and the functional capacities of the person being assessed, mainly because of pressures of time and resources. Community OTs in particular were often under substantial pressure and were unable to spend time getting to know the person being assessed and their individual needs and wishes. However, in the context of discharge from a long-stay hospital, OTs were able to work with the person being assessed for longer periods of time and did not have responsibility for resource management. They adopted a more holistic view of needs which attempted to respect people's feelings and views.

In certain settings, such as acute hospitals, housing issues were not considered to the same extent as elsewhere. This applied in cases of short stays of a few days, perhaps for routine operations, when a patient was unlikely to be brought to the notice of a social worker, and where discharge was expedited in order to free a bed, very often with only a few hours' notice. For older people particularly, this could mean a discharge to a cold, lonely home, without any home care or necessary aids in place.

Medical staff tended to assume that vulnerable patients would be best off in residential care or a nursing home, and that going home imposed too much risk. Such subjective judgements were often reinforced by supposedly objective measures which focused on the physical and functional incapacities of the people being assessed. It was left to social workers, where they had been involved, to try and advocate for assessments which took account of what the patient would prefer. The extent to which they felt able to challenge the views of the medical professions depended on the individual involved.

In long-stay hospitals, the length of time patients needed for rehabilitation also gave more time for the assessment process. But more importantly, the degree of disability meant that housing was always a central issue, with the goal of 'going home' as the primary objective of all concerned. Although there was occasional conflict between medical professionals and social work staff as to whether a nursing home might not be a more suitable option, generally decisions about appropriate housing were left to the OT. With no responsibility for case or resource management the OT was able to adopt a more impartial approach.

Involvement of housing agencies

The research confirmed that housing agencies were not generally involved unless issues such as access to public rented housing or aids/adaptations were concerned. Interviewees from all parties felt that this was an appropriate level of involvement. Many housing departments ceded decision-making power to health or social services professionals because they were perceived to have the expertise and skill to undertake these assessments. Allocation schemes were largely concerned with easily measurable and 'objective' factors concerning housing conditions rather than the health or social factors applicable in the context of community care.

The key player in bringing housing issues into a community care assessment was the OT and this makes the links between housing and OTs very important. Most case study schemes were aware of this and had developed such links but these could be further strengthened. One case study, for example, had a special housing needs OT appointed by social services to work specifically with the housing department on all housing applications and transfers where adaptations or special properties were needed.

Differences in assessments

The study did find evidence of different approaches to assessment by different professionals. Medical professionals' preference for using residential care set them apart from other professionals. Individual care managers' approaches also varied. Some were happy to support independent living, even where physical conditions were considered problematic, because of their commitment to advocacy. Others gave precedence to professional definitions of the suitability of housing accommodation and less weight to emotional needs or the preferences of the person being assessed.

Limits to user choice

The key service shortage identified was in the provision of aids and adaptations, leading to delays in assessment and installation. Lack of resources could result in people being unable to use facilities in the home, and in cases of discharge home from hospital after severe stroke or other trauma, meant that people were often in effect 'camping out' in one room, in totally unsatisfactory circumstances.

Otherwise, the extent to which the voice of the user was heard and their choices respected depended on the individual assessor. There were examples where professionals decided on the appropriate form of shelter and used various techniques to ensure that this was implemented, despite opposition from the users themselves. Assessors sometimes set the terms of the assessment and marginalised the input from the people being assessed. Nevertheless, there were also examples where assessors went to considerable lengths to ensure that people's preferences were met even when this was considered to be inappropriate according to professional criteria.

Housing allocation policies

Housing departments had reviewed their allocation policies in various ways to take account of changing attitudes towards community care. Some of these were more complete than others and recognised that needs arising from community care could not be prioritised in the same way as other more traditional housing needs.

The case study schemes made extensive use of medical points for prioritising those with community care needs, though there were other possibilities, including systems for by-passing points schemes in cases of exceptional need. Housing officers widely regarded medical assessment as being a technical matter beyond their capacity. Many therefore relied on doctors to determine priority. The medical assessment was seen as being objective and also had the advantage of being more readily accepted by applicants.

Conclusions and implications

In general, the research did not find a gloomy picture of the state of housing needs assessments. Collaboration between housing and social services agencies was in some cases well developed and there was a degree of understanding of the other's position. Nevertheless, the researchers conclude that a number of issues need further attention:

• Policies for discharge from short-stay hospitals currently do not take account the desire of some people for independent living or ensure that housing needs are assessed.
• The outcome of assessment may vary considerably depending on the individual assessor. These differences raise the question of whether there should be a standard approach to assessment. In the housing context, there is currently no consistent view of the balance between practical and personal housing needs in assessment.
• Occupational therapists play a key role in the assessment of housing needs for adaptations, but their role could be expanded to include involvement in other assessments, such as housing allocation. There is a case for housing departments either to employ their own OTs or to have direct access to OTs in social services departments.
• Lack of resources devoted to aids and adaptations can hinder the opportunity for independent living.
• The use of medical priority procedures in housing allocation policies means that many housing departments are effectively delegating responsibility to medical advisers. This underestimates the contribution that housing officers can play, and places a great deal of reliance on the objectivity of points schemes.

About the study

The research was undertaken by John Parker, Chris Allen, Bridget Franklin and David Clapham at the Centre for Housing Management and Development at the University of Wales, Cardiff. Five case studies in local authority areas were undertaken with extensive interviews with health, social services and housing professionals as well as users of services. Observation of assessment processes was also undertaken.

How to get further information

A report entitled The Right Home: Assessing Housing Needs in Community Care is available from Isabel Sawyer at the Centre for Housing Management and Development, University of Wales Cardiff, Centre for Housing Management, PO Box 906, Cardiff, CF1 3YN. Tel: 01222 874462, email: sawyeri@cardiff.ac.uk; price £9.50 (inc. p & p).