There is growing interest and investment in housing schemes for older people that combine independent living with relatively high levels of care. This review looks at UK evidence around issues of independence, social integration, and the capacity of housing with care to meet a range of care needs. It focuses on primary research and service evaluations, drawing out key messages for service providers and commissioners.
The evidence base is small. However, it provides valuable insights into how well housing with care serves current policy objectives, and whether it meets the needs and aspirations of older people. The evidence supports the idea that housing with care promotes independence, and generates high levels of resident satisfaction; messages around other key areas are more ambivalent, however.
There is growing interest and investment from both the public and private sector in housing schemes for older people that allow independent living to be combined with relatively high levels of care. Reflecting the current emphasis on evidence-based policy and practice, researchers at the Centre for Housing Policy at the University of York conducted an extensive search for empirical research evidence published since 1999 relating to housing with care for later life. They found just eleven UK studies that sought to evaluate rather than describe schemes, encompassing 24 different schemes. The review of these studies found.
- UK studies consistently demonstrated that it is the combination of independence and security that residents value. However, residents and providers do not always seem to have a shared understanding of what constitutes ‘independence’.
- Housing with care offers opportunities for social interaction and companionship, and there is much evidence of mutual support and neighbourliness. However, people who are very frail or who have sensory and cognitive impairments are consistently reported to be on the margins of social groups and networks.
- In some circumstances housing with care can provide an alternative to residential care, but the evidence suggests that it is not always a substitute for these settings. Residents moved to residential or nursing home care for a number of reasons, including increasing care needs and their own or their relatives’ preferences for something different, or perhaps something more.
- Evidence suggests that housing with care can have a positive impact on the health and well-being of residents, and that it is beneficial to their quality of life. However, studies relied heavily on expressions of resident satisfaction/contentment in arriving at their assessments; more robust quality of life measures were lacking in the evidence base.
- The evidence on the cost-effectiveness of housing with care is particularly limited and sometimes contradictory. Such as there is seems to indicate that housing with care may be more expensive than residential care, but may be cheaper than care delivered into ‘ordinary’ housing settings.
Evidence from the UK
There are great expectations of housing schemes for older people that combine independent living with relatively high levels of care. In particular, these schemes are thought to: promote independence, reduce social isolation, reduce the use of institutional facilities, provide a home for life, and promote a better quality of life for residents. There is, however, only a small body of empirical evidence from the UK to illustrate how well different housing with care schemes actually work. The researchers identified eleven UK studies of housing with care which have been published since the review of evidence presented to the Royal Commission on Long Term Care in 1999.
The diversity of provision is obvious even among the relatively few schemes evaluated, making generalising problematic. The UK evidence base supports the idea that housing with care promotes independence and generates high levels of resident satisfaction. However, particularly with regard to those who are very frail, there are more ambivalent messages regarding social isolation, the capacity of housing with care to be an alternative to more institutional models of care, and the capacity of housing with care to support people with severe dementia-type illnesses, and improve the quality of life of residents.
There are clear messages from residents across a range of settings that housing with care offers them a combination of independence, privacy and security. It is this combination that is greatly valued and which appears to offer a solution to some of the challenges and uncertainties of later life. Although residents regularly cited independence as one of the major benefits of housing with care, there is some evidence that residents’ expectations of care were not always met. This suggests that providers’ understanding of ‘independence’ is not always in line with that of older people themselves, particularly with regard to the amount of support older people wanted. Various authors highlight the need for accurate promotional material that makes clear exactly what is on offer in different schemes.
Reducing social isolation?
In terms of reducing social isolation, one of the key objectives of housing with care, the evidence is much more ambivalent. Within housing and care schemes many older people do find greater opportunities for social interaction and companionship and there is much evidence of mutual support and neighbourliness. However, those with physical, cognitive and sensory impairments are consistently identified across studies as being on the margins of social groups and networks, and in some cases the focus of hostility. The integration of the fit and frail does not appear – on the basis of these studies – to always work well from the perspective of residents.
An alternative to residential care?
It appears that housing with care can provide an alternative to residential care for some people in some circumstances, but the evidence consistently reports numbers of people moving on from housing with care into both residential care and nursing homes. Reasons for moving on can be mediated by a number of factors including increasing care needs and residents’ and relatives’ preferences for something different or maybe something more.
Home for life?
What is meant when a scheme is described as a ‘home for life’? Clearly this term is open to wide interpretation. The evidence clearly shows that in many schemes, residents moved on from a housing-with-care setting to other forms of care, both nursing home and residential care. Only one scheme with an on-site care home came near to offering a home for life, albeit within the boundaries of the scheme rather than the residents’ homes. People with challenging or high-risk behaviours associated with severe dementia could not easily be accommodated within the schemes evaluated here. On a related point, a major gap in the evidence relates to end-of-life care in housing-with-care settings. None of the studies addressed this issue, or how palliative care services have been integrated into care provision.
Health status and quality of life?
Only two of the eleven UK studies attempted to measure the impact of housing with care on health status. These studies indicated that housing with care helps maintain the health status and well-being of residents over time in comparison with community samples. It is difficult, however, to generalise from such a small body of evidence, particularly when the health status of residents on entry to different schemes can be highly variable, depending on the particular entry criteria operated by different service providers. There is also some evidence that housing with care may reduce the demands made on NHS services.
A number of studies showed care needs increased following entry to housing with care. However, this increase in care was attributed to better needs assessment and the identification of formerly unmet needs. It is self-evident that care needs will increase over time as the residents get older, and this does raise the question of how well schemes can maintain the balance between fit and frail residents if that is a scheme’s stated intention. The little evidence we have here seems to suggest that this maybe problematic.
Studies relied heavily on residents’ expressions of contentment/satisfaction to make assessments of quality of life. More robust quality of life measures might be usefully employed in any future studies.
Is housing with care cost-effective?
The complexities of costing services are well documented. Where studies attempted to make comparisons between the costs of different types of provision, the evidence is limited and sometimes contradictory, although it seems to indicate that housing with care may be more expensive overall than residential care, but may be cheaper than care delivered into ‘ordinary’ housing settings. However, direct comparisons are difficult to make as housing with care is supposedly offering a better quality of life, alongside greater independence and autonomy. Another key question here relates to the ability of residents to afford the services within housing and care schemes. Evidence seems to suggest that affordability is an issue for those who are not eligible for means-tested benefits.
Gaps in the UK evidence base
Currently the UK evidence base tells us little if nothing about a number of key topics. These include:
- how well different models of housing with care work for older people from different ethnic groups;
- the quality of life in the specific context of housing with care;
- the role of ‘telecare’ and other assistive technologies – their usefulness and acceptability to residents, and impact on staffing requirements;
- gender roles and relationships in highly feminised environments;
- end-of-life care;
- who is best served in a housing-with-care environment – the fit and the frail, or just the frail?
- under what circumstances should people be expected to move on to different forms of care provision, and who decides?
Evidence from other countries
This evidence base is predominantly from the USA, with a small number of studies from Australia. No evaluations were found of schemes from countries with similar state welfare provision to the UK (e.g. Sweden, The Netherlands, and Denmark). The international literature does not significantly assist in filling the gaps in the UK literature identified above, although there are some useful insights into areas yet to be explored in the UK, particularly the gendered nature of continuing care retirement communities, and the different types of social networks developed by single women and married couples. In parallel with the UK literature, evidence points to the social marginalisation of the very frail, carers, and those with sensory and cognitive impairments.
About the project
The review was written by researchers at the University of York – Karen Croucher, Karen Jackson and Leslie Hicks. The full review examines the UK evidence in detail, and reports evidence from the wider international literature. In conducting the review, the researchers:
- searched 14 relevant electronic databases using complex, purpose-designed search strategies;
- searched for grey literature via contacts with known experts in the field, and website searching;
- applied a pre-determined set of inclusion/exclusion criteria to the set of references retrieved to ensure only relevant material entered the review;
- extracted data from individual studies onto a pro-forma set up using an Access database.
Searching and retrieval of the literature took place in the summer of 2004, with follow up searches shortly before publication to ensure inclusion of any more recently published evaluations.