Crossing the housing and care divide
Progress in achieving any real integration of housing and social care has been slow.
Launched in 1995, the Crossing the Housing and Care Divide Programme aimed to stimulate innovative service development that would highlight the potentially central role that housing can play in community care.
This report documents the challenges faced and lessons learnt by these projects. The projects demonstrate that:
- efforts to integrate housing with community care services continue to be plagued by problems with joint working;
- achieving sustained and real dialogue with users remains difficult;
- there is still a great deal of work to be done in order to define, monitor and evaluate the quality and effectiveness of services.
The report provides a useful summary of policy changes over the last six years and concludes with national, regional and local good practice recommendations for inter-agency working, use of new technology, user involvement, management, quality and value for money, and sustainability.
The fundamental role of housing in community care has long been acknowledged. However, progress in achieving any real integration of housing and social care has been slow. The Crossing the Housing and Care Divide Programme was launched in 1995, jointly sponsored by the Housing Corporation and Anchor Trust. Its aim was to stimulate service developments that would enable the potential of the housing role at the centre of community care to be recognised. The Programme was independently evaluated, and the lessons and conclusions that have emerged from this process are wide-ranging.
Efforts to integrate housing with community care services continue to be dogged by problems associated with joint working.
The projects demonstrated that joint working was more likely to be successful if:
- the agencies had a prior history of partnership working and enjoyed a relationship built on trust and mutual respect;
- the projects developed complementary aims and objectives that allowed all partners to pursue their own organisational goals and not just those of the project;
- the projects enjoyed the support and on-going involvement of key stakeholders.
However, it is feasible that in some instances inter-agency working may not be the most realistic approach and that alternative strategies for delivering coherent and co-ordinated services should be found.
Organisations which had a culture of user involvement and a well-resourced infrastructure of user groups and networks were better able to sustain user confidence and involvement.
The projects funded under the Programme encountered the following challenges:
- the need to identify the range of users or communities that could be involved in aspects of service planning, delivery and evaluation;
- tensions between user interests and 'professional interests';
- the need for user involvement to be adequately resourced.
Achieving sustained and real dialogue with users is a difficult task, which should not be underestimated. Planners and policy-makers need to recognise the complexity and resource implications involved.
Quality and value for money
There is still a great deal of work to be done in order to define, monitor and evaluate the quality and effectiveness of service. This work requires a well-resourced infrastructure.
In particular the projects demonstrated:
- the lack of hard data currently available to illustrate the effectiveness of services;
- the need for staff to be adequately supported in their monitoring role.
Without adequate systems in place imaginative projects will find it difficult to mainstream innovation at a time when the national and local policy context demands clear evidence of effectiveness.
Background and context
The nine projects funded under the Programme were explicitly to develop services at the interface between housing and personal care systems and focus on services for older people. The Programme funded projects under three broad headings:
- Information and advocacy;
- New technology;
- Management and support services.
The general aim of the Programme was to stimulate change, which would:
- enable housing to become a more integral part of community care;
- lead to greater interagency working;
- enhance the involvement of users in the planning, monitoring and delivery of services;
- deliver a high quality of service more cost effectively.
From its inception the Programme operated in a period of significant policy turbulence, including a change of government. As a result the policy context was very different at the time conclusions were drawn in 2000. The major shift was that national priorities were strongly endorsing the aims of the Programme. The value of the Programme therefore shifted during its life from its potential to shape and inform future policy for housing and community care, to the identification of the lessons which could contribute to the more effective implementation of current policies.
Many of the issues addressed by the projects funded by the Programme continue to be key pre-occupations of policy. For example, Supporting People (Department of Social Security, 1998) and Modernising Social Services (Department of Health, 1998) both place an emphasis on: prevention; partnership working as a means of delivering quality services; on user involvement; and on monitoring effectiveness. The NHS Plan (Department of Health, 2000) and the Strategy for Housing and Older People from the Department of the Environment, Transport and the Regions also take forward these themes.
Projects in the Crossing the Housing and Care Divide Programme
Information and advocacy
- A national voluntary organisation, with partners from local statutory and non-statutory sectors, introduced a common application form, registration system and clearing house for applicants to sheltered housing.
- The social care section of a small housing association was funded to provide culturally sensitive domiciliary care services to black and minority ethnic communities, as well as to develop an information and advocacy service.
- The 'care arm' of a large housing association established an advocacy service to provide support and advice to older homeless men and women in London.
- A housing association employed a co-ordinator to provide advice, information, support and advocacy to older people in a rural area of England.
The improvement of public access to information is a cornerstone of the Government's policies to modernise the public sector. The projects funded to improve access to information demonstrated many of the challenges inherent in this work, these include:
- the absence of advocacy services in some localities and a shortage of sufficiently skilled staff in others;
- the need to employ professionals with a wide range of skills and experiences which are difficult to articulate in job descriptions;
- the need for agencies developing advocacy and information services to be seen as 'independent'; this is particularly important if the initiative is regarded as potentially threatening to partner agencies.
The Government places great emphasis on the use of new technology to improve service delivery within the public sector. However, the projects funded to explore how new technology can be used to improve the quality of life of older people demonstrated how difficult it is to introduce new IT systems. These difficulties are particularly acute when the goodwill and commitment of partner agencies is also required. The experiences of the projects suggest that:
- there is a need to develop 'in-house' IT expertise in order to ensure that the introduction of new systems to meet the needs of the modernising agenda is not fraught and costly;
- if agencies need to purchase IT, the process is made simpler if it is facilitated by a member of staff who has sufficient knowledge and experience of both the core business of the agency as well as the implementation of new technology.
- A London Borough's community alarm service developed its operations to allow automatic monitoring of the delivery of domiciliary care services to older people through the installation of telecom equipment in their homes.
- A district council, in partnership with a range of agencies, established a project seeking to monitor the delivery of care packages to older people in rural areas.
Management and support services
- A national voluntary organisation employed a manager to co-ordinate the provision of day and respite care for older people in rural areas. The service was provided to small groups of older people who visited the homes of trained volunteers.
- A national voluntary organisation explored the scope for extending the range of services offered by Home Improvement Agencies (HIAs) to older people.
- A voluntary care agency was funded to develop respite care and domiciliary services which would enable people with dementia and their carers to remain in their own home.
Although three projects were specifically funded under this theme, all of the projects revealed important managerial and organisational issues for services that cross the housing and care divide. The experiences of the projects suggest that:
- joint working can be improved if agencies are willing to provide joint training in order to facilitate a better understanding of the roles and responsibilities of partner agencies and professionals;
- organisations need to acknowledge that the activities associated with data collection and monitoring are time-consuming and require a degree of experience. Unless these activities are formally built into existing workloads and staff are adequately trained they are unlikely to prioritise them over direct contact with service users.
Evaluation themes and lessons
Partnerships built on existing relationships seemed to experience fewer problems associated with working across organisational boundaries. Agencies who had previously worked together were more likely to have a realistic idea of what the partnership would involve.
Joint working between organisations that had never previously worked together was more difficult to initiate. This was particularly evident in the lack of success projects had in working with the health service.
An element of 'value added' appeared to be an important motivating factor behind many of the partnerships. That is, joint working was more likely to be successful if the aims and objectives of the project allowed all partners to pursue their own organisational goals and not just those of the project.
A lack of understanding about the roles of different professions and agencies often undermined efforts to work in partnership. This was particularly evident in the relationships between the NHS and local authorities.
Health and local authority staff continue to have distinct professional working practices including different assessment procedures and different interpretations of eligibility criteria which makes partnership working difficult. These difficulties were further compounded by a lack of appreciation about the role of housing in relation to health.
The support and on-going involvement of key stakeholders was an important factor influencing the ability of some projects to work across the housing and care divide. The involvement of people with knowledge of local 'politics' and an understanding of the key planning processes was particularly useful.
The projects demonstrated the need for partnerships to be based on joint working activity at different levels throughout the organisation. This multi-level approach to partnership working is further complicated by the need to sustain these relationships over time.
While few projects involved users directly in their design, many were informed by local and/or national research on user's views and experiences.
Projects differed in how users and carers were defined and within some projects there was a lack of clarity about whether it was towards users or carers that the service was targeted.
Some projects aimed to involve advocates to articulate the views of users. However the lack of well-developed networks of trained advocates limited their ability to do this.
External evaluations of services, including the views of users, were undertaken by a number of projects. However, there was a tendency to see the evaluation as an end in itself rather than as a means of developing more user-driven services.
The extent to which projects were able to involve users and obtain their views was largely dependent on whether or not the organisation had previously invested in developing an infrastructure to support user involvement.
The success of some projects in achieving user involvement could be linked to the personal attributes and skills of the staff appointed. These include: local knowledge; capacity to respect 'lay' as well as professional perspectives; persistence and commitment.
The degree to which it was possible to engage users on management teams or steering groups was limited. When users were involved their attendance was reported to wane over the course of the project and their involvement was often described as tokenistic.
Management and organisational issues
Some projects provided only limited management support for operational staff. Where staff did not have sufficient managerial guidance on how to set up and manage monitoring systems and support with developing links at the strategic level, projects did not have the capacity to be sustainable.
In some localities, where there has been a growth in jobs within the service sector, projects had difficulty recruiting sufficient numbers of staff.
A major determinant of the success of projects was the degree to which the skills of the project staff matched the roles they were expected to undertake. Key skills appeared to be 'networking' and monitoring experience.
In some instances the job description of project managers did not reflect the range of tasks that had to be carried out or the relevant skills required. This meant that only part of the project was fully developed or that progress slowed down whilst managers developed some of the required skills.
Quality and value for money
The projects' attempts to monitor their performance were not entirely successful and the 'quality' of the services being provided proved difficult to define and measure.
Most projects provided some information about inputs but this was usually limited to staff costs. Few projects were able to calculate outputs and to link these with inputs, let alone specify how the production of outputs might contribute to the achievement of longer-term outcomes.
There appeared to be an assumption across the Programme that because projects were developing innovative services this, in itself, was a guarantee of 'quality'. Little attempt was made to monitor the quality of new services to see if they were either acceptable to older people or whether they were meeting their needs effectively.
Despite a lack of evidence, most partner agencies thought the projects were providing value for money because their organisation had not had to invest significant resources in the new service. As a result these new services were greatly appreciated.
Despite the difficulties projects had in demonstrating value for money, many of the organisations could identify unanticipated benefits. For example, projects were able to pilot quite challenging approaches which allowed risks to be taken outside mainstream provision.
Project impact and sustainability
Most projects did not continue as recognisable entities once their funding ended. This reflects the limitations of short-term funded projects. Unless there is an explicit contract to mainstream the work of a project then its chances of securing future funding are usually low.
The Programme demonstrated many of the dilemmas facing initiatives of this type where there is an underlying tension between the requirements of rigorous experimental design and the need for flexibility in the drive to succeed.
The issue of securing funding was complicated by the difficulties of producing evidence on costs and benefits to feed into value for money assessments. It is this sort of data that commissioners require in order to let contracts.
Although the majority of projects did not continue in their existing form once their funding ended they all contributed to the flow of change locally.
The researchers believe that it is unlikely that different organisations and locations will be able to deliver to nationally imposed timescales for joint working. The expectations built into some policy developments are unrealistic given the local circumstances. Incremental approaches may be a surer way to success, with people on the ground monitoring their progress on a ladder of indicators, and planning a strategy for progress with timescales and aims which are supportable locally. However, if the arrangements for the partnerships are too complex or commitment is lacking at some critical level then it may be more realistic to look for alternative approaches.
The policy shifts towards multi-disciplinary teams, user-led needs assessment and a social model of health and disability have opened up some of the long-standing debates around generalist and specialist training. However, recognition of the skills needed to operate within partnerships has not been strongly evident. The projects demonstrated how important it will be to get real shifts in all aspects of training for staff operating within the majority of agencies if the policy aims relating to housing and community care are to be achieved.
The Government's commitment to involve users and citizens more extensively will inevitably lead to greater demands being made on these groups. Consideration needs to be given at a national and local level about how best to co-ordinate the demand for user involvement to prevent overload, tokenism and disillusionment.
The Programme sought to use innovative approaches to tackle long-standing problems. While the concept of innovation can be difficult to define, in relation to the Programme it meant either the introduction of an existing approach into a locality/ agency for the first time, or the application of an existing approach to a new area of service delivery. The researchers believe that whilst it may be sound advice to avoid constantly re-inventing the wheel, often the process of getting to 'the wheel' is essential and enables organisations to develop the capacity to deal with problems on an on-going basis.
About the study
The evaluation of the Programme and its constituent projects was carried out by a team of researchers from the University of Bristol. Paul Burton and Alex Marsh provided advice and technical support to the projects, to assist 'self-evaluation'. Lyn Harrison and Ailsa Cameron conducted the external evaluation via interviews with staff of the projects and, key local agencies, and through consideration of the projects' own materials.