Two forms of provision for older people combine housing with care: residential care and sheltered housing. Christine Oldman, of the Centre 
for Housing Policy at the University of York, conducted an overview of the relatively new forms of enhanced sheltered housing and examined claims that they could reduce reliance on or even replace residential care. The 
study found:

• Residential care and the newer forms of sheltered housing accommodated people with similar levels of frailty but the structural boundaries between the two provisions were quite rigid, leading to different financial and other outcomes for those living in them.
• Tenants in the enhanced sheltered schemes generally had higher disposable incomes and rather more choice and control over their lives than their residential care counterparts. Schemes, however, were not generally cheaper than residential care. 
• A further important difference between residential care and the new forms of sheltered housing was the greater involvement of relatives in the latter.
• Within the new sheltered housing schemes, there were differences in what they were aiming to achieve and how they were organised. They varied in their approach to providing a home for life, in the extent to which they were a direct alternative to residential care and whether accommodation and care were provided by the same organisation.
• Enhanced sheltered housing schemes aimed to deliver services according to independent living philosophies and to create an active community. These aspirations could be hampered by admission criteria which focused on dependency levels. 
• There was a tension between developing an active community and operating as an alternative to residential care. Older people living in three York housing schemes regarded them as a place to live in rather than a place to die in. They did not want to live in a place where everyone was frail.
• The researcher concludes that there are some major policy obstacles to be addressed before the concept of 'your own front door' can become a reality for older people living in every type of communal setting. Current funding and registration requirements operate to create the rigid boundaries.

The policy background
Residential care is regarded as costly, unpopular and, sometimes, inappropriate. The Royal Commission on the Funding of Long-term Care called for further expansion of alternatives to residential care, including the development of innovative housing schemes. The limitations of traditional sheltered housing are being addressed through the emergence of various forms of 'very' sheltered housing broadly distinguishable from the original model by:

• the provision of a meal/meals;
• the provision of additional services;
• the possibility of a more barrier-free environment.

In some ways, residential care and sheltered housing have moved closer together. Some residential care has become more domestic in feel and the newer forms of sheltered housing are accommodating people with similar levels of frailty to those living in care homes. But structurally the boundaries between the two provisions are rigid and hence outcomes can be quite different. 

• In residential care accommodation, living costs and care and support are not individually charged for. Instead the resident pays a single weekly charge which covers the different components. The provision is registered under the Residential Homes Act 1984 (to be superseded in 2002 by the Care Standards Act 2000) and people living in such accommodation are not eligible for Housing Benefit and other community benefits. 
• By contrast, sheltered housing is not registered, although from 2002, under the provisions of the Care Standards Act, domiciliary care going into a scheme is likely to be regulated. Occupants are tenants or leaseholders and hence have housing rights. They are charged separately for accommodation, living costs and care and support, and, hence, potentially have more choice and control over their lives. Eligible for Housing Benefit, tenants typically have higher disposable incomes than their residential care counterparts.

A major factor in the development of the newer forms of housing and care provision has been the availability of Housing Benefit to fund housing and support costs. From April 2003, the support element of a rent will come out of the Housing Benefit system and move into the new Supporting People grant - cash-limited monies administered by local, mixed-agency, commissioning panels.

Differences between residential care and the newer forms of enhanced sheltered housing
The study compared the financial circumstances of people who were similar in terms of their care needs but some of whom lived in residential care and some in very sheltered housing. Disposable income (after accommodation, living and care and support costs have been paid for) was higher for the sheltered housing tenants. Table 1 shows the principal costs of living in very sheltered housing for a particular couple in the study who were both seriously considering moving to residential care. As very sheltered tenants they were receiving Income Support and the double rate of Attendance Allowance and had over £100 in income left after the main accommodation, living and care costs had been paid for. In residential care, the charge for each would have been £230 a week; they would not receive Attendance Allowance but would both get the personal allowance (or disposable income) of £15.45 a week.

A second key difference between residential care and very sheltered housing lay in the greater sense of independence which the sheltered housing tenants appeared to have. All forms of the enhanced sheltered housing were predicated on the concept of having 'your own front door'. This seemed to make it more possible for providers to deliver services according to independent living philosophies. Moreover, tenants were more able to continue with life as before, such as preparing and cooking meals, or having others do so on their behalf, or having grandchildren to sleep on the settee.

A further difference between residential care and the newer forms of sheltered housing was the involvement of relatives in the latter. Relatives were often an important source of care and support and their contribution to life in the schemes made the transition from the previous home to the new sheltered home less of a break with what had gone on before. In residential care, relatives usually play only the role of 'visitor'. The study suggested that the enhanced sheltered housing schemes received a hidden subsidy from relatives' informal caring. 

Regardless of any subsidy coming from informal care, the available evidence suggests that very sheltered housing is usually more expensive when comprehensive costing exercises are conducted. However, where only accounting costs are used it can be a favourable cost option due to economies of scale and the role of Housing Benefit. These conclusions may change with the introduction of the Supporting People grant.

Differences between the various forms of enhanced sheltered housing
The new forms of sheltered housing are not homogeneous but, for convenience, all the various forms of new provision are referred to as 'very sheltered housing'. All the different models were committed to the idea of 'ageing in place' but varied in how they approached the problematic concept of a 'home for life'. The different proportions of older people who move into residential care from very sheltered housing were an indicator of how effective very sheltered housing could be as an alternative to residential care. Some models were closer to residential care than others. Some models choose their tenants from those who would, in other circumstances, have been admitted to residential care. Others, most notably those evolving from traditional sheltered housing, claimed to be a key element in local preventative and rehabilitative community care policies.

The schemes in the study were largely non-registered although a few schemes provided both registered and non-registered units. Most providers said they wished to avoid registration, equating the latter with: the 'pauperisation' of their residents (due to low disposable incomes), high costs of meeting registration requirements and, most significantly, a threat to the principles of independent living they espoused. Some registration and inspection units required very sheltered housing to register under the Residential Homes Act. It is unclear what will happen when the Care Standards Act comes into force. Although most schemes may remain non-registered because older people are living in their own homes, the level of personal care being delivered could result in registration being expected.

The issue of registration has had an influence on models of care. It is often supposed that where accommodation and care are delivered by different organisations, registration will be 'avoided' and occupants will feel more empowered, for example they could refuse care without risking losing their tenancy. However, other providers argued strongly for integrated models where accommodation and care were delivered by the same organisation. It was felt that with these models the demarcation of activities into care or support or housing management was avoided and that it was easier to achieve a 'seamless service'.

Moving into and living in the new models
In Britain, making a conscious decision to opt in later life for some form of communal living is rare but not unknown. The study reviewed a limited number of innovative schemes which sought out the positive benefits of community life. In comparison with residential care, very sheltered housing provided: 

• more space;
• flexible care;
• a vibrant community.

The 45 square metres of one very sheltered flat compared favourably with 10 square metres of a room in a residential home. 

Unlike residential provision, care hours for any one person could reduce as well as increase but the total number of care hours going into schemes also varied, for example, one scheme had 180 hours a week and another 300. Some schemes imposed limits to the number of hours going into a scheme; others did not.

Service delivery was based on independent living philosophies but schemes varied in their capacity to create vibrant communities. Admission to schemes was usually governed by strict allocation criteria which focused on dependency and not on social needs or aspirations. Those providers who admitted only the more frail were possibly hampering the concept of a lively or 'balanced' community.

Preferences for a balanced community
Interviews with tenants which centred around their accounts of moving into and living in the schemes suggested that the principal benefits were an improved quality of life and an enhanced feeling of both physical and psychological security. The majority of tenants believed they were enjoying a new lease of life, that their physical and mental health had improved and that they could do things now which they had not been able to do for some time. One daughter said of her mother:

"I can't believe what is happening. She was a hermit. She seemed to hate people. Now she powers around the scheme joining in."

An important factor behind older people's high levels of satisfaction appeared to be that not everyone they lived with was very disabled. 

The case study schemes were mainly examples of where accommodation, care and support were provided by the same organisation but there was some evidence emerging from some of the tenant interviews that people preferred having some choice over care and support provision. The few that did have alternative or additional help to that provided by the scheme seem to enjoy the flexibility that gave them. 

Conclusion
Very sheltered housing seemed to be a more attractive environment than residential care but there are structural or policy obstacles to very sheltered housing replacing residential care. At the present time, the issues of registration and funding are tied up together. If a scheme is registered, people are automatically ineligible for Housing Benefit and they are left with a personal allowance of £15.45 a week. The study suggests that there could be advantages in de-coupling registration and funding and looked at them completely separately:

• Registration and regulation. The Residential Homes Act and its successor the Care Standards Act are intended to provide protection and ensure standards are adhered to. Consideration needs to be given to devising a system of regulation for very sheltered housing which is user-centred, does not threaten the concept of 'your own front door' and is separated from the funding question. Separating the issues of funding and registration would mean that people could continue to receive Housing Benefit if their scheme was registered. 
• Funding the various components of living in communal provision. The study proposes that, in all forms of provision, older people could be charged individually for accommodation, living costs and care and support. This would give older people greater choice and control.

About the study
There were three components to the study: a literature review, semi-structured telephone interviews with the main providers of very sheltered housing and other key players and case study evaluations of innovative housing and care provision in York. One of these schemes was developed and managed by the Joseph Rowntree Housing Trust and was a sheltered housing scheme with flats, registered under the Residential Homes Act, within it and the other two were City of York supported housing schemes which previously had been residential care homes.

How to get further information
The full report, Blurring the boundaries: A fresh look at housing and care provision for older people by Christine Oldman, is published for the Foundation by Pavilion Publishing (ISBN 1 84196 007 1, price £13.95). 

Click on the 'order report' icon in the left margin to order online.