Making housing and community care work

Lynn Watson

Community care policy makes many claims about enabling people to live more independently and direct the course of their own lives.

These claims do not square with the findings from the 21 projects in the Foundation's Housing and Community Care programme. There is much poor quality accommodation, haphazard funding of support services, lack of access to housing for those who want to move from a family or institutional setting, and reliance on a limited range of specialist residential provision.

The research suggests that it is not that we no longer need 'bricks and mortar' solutions, but that housing and community care policies could be more imaginative and closely integrated with general plans for improving, extending and making most effective use of the local housing stock.

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Summary

Summary

Research overview

This Foundations considers the findings on recent developments in housing and community care from 21 research projects carried out between 1993 and 1996.

The research exposes some major problems and policy contradictions, as well as highlighting positive examples of services and organisational practice which have helped people to find suitable housing and support. The main problems identified and the key implications from these and the examples of good practice are shown below.

Main problems

  • The latest official guidance on housing and community care (1997) says that 'housing providers, including local authorities and other social landlords, have a key role in making suitable housing available to vulnerable people'. In many areas, however, the only housing on offer is in unpopular and rundown districts which make people feel isolated and unsafe.
  • The narrow reach of community care needs assessment leaves many people without access to support services. This makes it difficult to develop preventive, housing-based strategies aimed at assisting people to sustain their accommodation or to set up in their own home. The problem is made worse by the cutbacks and threats to housing benefit payments, which have until now played a crucial part in supporting people to live relatively independently in the community.
  • Many people have great difficulty getting their housing and support needs recognised by hard-pressed agency 'gatekeepers' who may wish to discourage what they regard as non-priority applications. Independent sources of information and advice are few and far between and people often rely heavily on service professionals, who may be budget managers or linked to particular types of service. These problems can be particularly acute for people who live with their parents or in residential care and who wish to move into their own homes.

Key implications

  • There should be a major housing initiative in support of the central community care goals of promoting independent living and social integration. This would extend across all tenures and bring together four disparate elements: the reshaping and conversion of unsuitable and outdated specialist provision; the return to active life of private sector properties which have fallen into disuse or disrepair; the development of accessible housing, such as Lifetime Homes, and popular types of non-standard provision (such as small schemes of cluster flats with communal areas); and the expansion of property-related services, such as 'staying put' and care and repair schemes.

  • National guidance should be issued on the kinds of preventive housing and support services to be included in local strategies. Again, these should cut across tenure boundaries and remove the continuing anomalies which make access to services dependent on living in particular forms of accommodation. The dual aims should be: to ensure the development of a strong service infrastructure offering a variety of options; and to give people the opportunity to make proper plans for their future, rather than having 'community care' thrust upon them at a time of personal or family crisis.

  • There should be official encouragement for the setting up of advice and advocacy services, with central involvement by those using services and a specific brief to explore and explain local housing and support options. The aims should be: to assist individuals to make informed decisions and to negotiate their housing and support arrangements; and to provide a sound funding base for existing and emerging consumer-based advocacy and advice organisations.

Two key themes which affect the quality of provision thread through all the studies . These themes are:

  • the integration of housing and support within mainstream provision;

  • the influence of the service user in the design and delivery of services.

These affect where people end up living, the degree to which they have choice, and whether their needs are really assessed properly. Each of these three aspects is dealt with in turn below. This Foundations then turns to two areas which can improve the integration of housing and support and the extent to which service users' voices are heard: access to information and advice, and funding mechanisms.

Where people live

The location of housing for people with support needs emerges in the research as an issue which has received too little attention in local and national debate about the suitability of different forms of accommodation. The uneven distribution of specialised and supported housing within towns and cities, together with the concentration of available council and local authority properties in certain areas, can undermine intentions to provide wider housing opportunities and move away from segregated provision.

These difficulties have been exacerbated by developments in national housing policy, in that people who need additional support have been viewed as a residual and problematic group within an increasingly residual public housing sector. This negative stance, while paradoxically offering greater access to housing, is at odds with the more upbeat 'independent living' rhetoric of community care policy statements.

The research indicates that most local authorities do not explore the spatial distribution of housing for people with support needs. Where location is considered, this is generally in terms of the proximity of new supported housing to transport and local amenities. One authority which has looked more fully at the distribution of different forms of accommodation and types of household comments in its strategy:

"A lot of people do not like the areas in which they live. They feel unsafe and that they are picked on because of their disabilities."
"It is clear that people are being required to move within the city in order to gain access to the support and care they require."

The significance of living in a 'good' or 'bad' area is demonstrated in the studies which report the experiences of tenants and housing applicants. For example, people may be unwilling to move out of a hostel environment because they assume they will be re-housed in an unpopular area:

"I had one bad experience. The place threw me into a reclusive, defensive state, full of anxiety. I had a breakdown whilst I was there."

These fears are confirmed by support staff:

"We don't push people into re-housing. That is how people get placed inappropriately and end up being homeless again."

The research provides both positive and negative examples of people's experience of 'neighbourhood' and the importance attached to living in a supportive environment.

Bob lives in a council flat which is too small for him to move around in a wheelchair. He needs overnight assistance at times, but does not have room to accommodate anyone else. He relies extensively on his friends and neighbours for practical help and would therefore prefer to have adaptations carried out rather than to move to another property.

Alistair moved from a residential home into a bungalow, but later returned as it did not work out. He had got to know...people who took advantage of him. "They completely did what they wanted, and that is not what I call independence...It is a bit unnerving, to say the least. Some nights I sat in front of the telly shaking like a leaf."

The reality of choice

Some local plans for housing and community care still depend solely or mainly on attracting resources to add to the supply of long-established forms of specialist accommodation. This perpetuates a 'special needs economy' in housing and support, where progress is measured in terms of the number of new 'places' created in this way. This may be particularly evident in the case of provision for people with learning difficulties.

Most people with learning difficulties have not had the chance to choose the kind of house they live in, the people they live with, how they are supported or who they are supported by. If people do have a choice, then it is...between different residential care homes that happen to have a vacancy.

People with similar needs are lumped together...This approach...is most commonly in evidence in services for people who have challenging behaviour, usually with disastrous consequences.

"What's choice got to do with it? If a suitable vacancy is available - right, you make the most of it. You go where they can take you." (manager)

The studies of housing preferences show that most people are looking for self-contained housing, with a minority expressing a positive preference for shared living or accommodation with live-in staff.

"They didn't want to give me a flat until they knew I could look after myself on my own...When you know you can do it, you can do it. It just took a long time to convince them."
"I don't think I would manage it, completely on my own...I feel I have to have someone around me, a member of staff to be there."

Among those living in (or wanting to move to) their own homes, there is an increasing demand for adaptations, with the number of requests growing at a rate of 15 per cent a year since 1990. Delays are common and the process of obtaining funding and carrying out adaptations can be tortuous and fraught with problems:

"I will have died of old age before they get there. I've really almost written the bungalow off. They hope, probably, that I will just do something on my own and go away. Find somebody to take me in and they won't ever have to bother with this council place."
"At the end of the day, they sort of did what was in the book: people in wheelchairs need this, this and this, and that is what I got. The fact that I'm different was neither here nor there as far as they were concerned ...but I'm here now and it is working out quite well."

The many older people who want access to bathing facilities constitute an inconveniently large group of adaptation applicants, and therefore make an obvious target as 'low priority' when budgets are tight and savings have to be found.

Assessment of needs

The professional determination of needs is central to resource rationing through needs assessment, and yet assessment is expected to empower service users and enable them to express informed choices about the kind of services they want. The process is further compromised by the fact that certain needs go unrecorded because they fall outside the funding criteria and the social services authority does not want to find itself obliged to meet them. There can be discrepancy between the needs identified and the services people actually obtain:

"What I wanted was a chair for going out, but they gave me an indoor chair and ordered me to take it."

Far from being empowering, needs assessment can be an unnerving and uncomfortable event. People may feel that they are on trial, that they will 'fail' the assessment with disastrous results and that they are not in control of the process.

"I thought she (the occupational therapist) would think 'oh, she can't even put her key in the door."

Mrs RB became frustrated during the home visit when it was suggested she needed more help. She suddenly got up and did a little dance and pointed out to the OT (occupational therapist) "I was a very energetic woman."

Access to information and advice

A focus on needs assessment can obscure the fact that statutory services are provided within a legal framework that gives people certain rights. These are not always properly explained by the organisations concerned, so that people are left unsure of what they can ask for and unable to challenge professional opinions or decisions:

"The lady (housing officer) said to me, 'Are you a one-parent family?' and I said, 'No,' and she said, 'Well, I don't think you will get much joy out of us,' but because of one's mental health state, or whatever, I think they have to allocate a certain number of council flats to people who have physical or mental disabilities...I believe that is the case."
Mr and Mrs Mohan are both wheelchair users and live with their three children in a two-bedroom flat...The couple asked about the possibility of a transfer. They were told that there were many other people waiting to be re-housed and that the council did not have any properties to allocate, and particularly not bungalows ...They did not make an application.

Where people are offered some form of needs assessment, they will be ill-equipped to influence the outcome if they do not know what services are (or might be) available to them. This may be compounded by not knowing what factors are going to count for or against them:

We found evidence that (older) people sometimes withhold information...and that this works to their detriment. For example, people may worry that if they disclose a health problem, they will not get the kind of housing they feel they need.

Advocacy and self-advocacy groups are not yet common, but the research shows that they can have a considerable influence on the way services are planned and organised. Some groups organise training for professionals and carry out service evaluation, as well as offering help and advice to individuals and families Advocacy groups can also help people to move 'beyond services' by building up wider social networks:

Most people did not have any friends apart from staff, the people they lived with or the people they met at a day centre.

What is required is time, patience and social contact...These are commodities which are in short supply...what is really needed is a plentiful supply of support 'with a light touch'.

Finding and funding support

There has been an absence of broad thinking about how support services should operate across different housing tenures and different kinds of accommodation. The gap in funding for those who do not qualify for community care needs assessment is highlighted in several of the studies, as is the arbitrariness (from the individual's point of view) of access to services offering flexible support. There are serious shortfalls in care support for people with medium and low support needs...

Housing management staff and those in voluntary agencies are concerned about their capacity to cope with the growing number of vulnerable people living in unsuitable areas and estates with no other support. Tenants often have immediate needs which do not fall within the definition of intensive housing management support; housing support workers often find themselves in situations where someone needs personal assistance, counselling or other forms of assistance and they are the only ones around to provide it.

The continued development of floating support schemes is threatened by housing benefit cutbacks and restrictive funding criteria. Such schemes offer support which is not attached to a particular property and which can fluctuate in response to changing needs.

The research shows that managers are concerned that the growth in individual spot purchasing arrangements may also make it more difficult to sustain these kinds of broadly-based services: "We don't want to get into the care management system, or any other form of spot purchasing, because this would make our funding system too insecure." With respect to housing benefit, there is widespread anxiety about both the constantly changing rules and the varying local interpretations of rates and eligibility: Many practitioners thought that there was no policy or practice agenda, either at central or local government level, which recognised and supported the function of housing benefit as a way of maintaining vulnerable people in the community, cost-effectively and in relative independence.

There is a rent stop. It affects young people, homeless people and people with mental health problems. Landlords charge a higher rent, which housing benefits don't meet. The tenants don't have the resources to challenge this. They pack their bags and leave - or the landlord tells them to leave. Competitive tendering for housing management and the spot purchasing of individual care services were both at an early stage at the time the research was carried out.

More recently still, we have seen the introduction of the Community Care (Direct Payments) Act 1996, which empowers social services authorities to make direct cash payments to people who want to buy in and set up their own support services. The research identifies the need for a delicate balancing of purchasing priorities: spot purchasing can be highly beneficial in certain situations, but too heavy a reliance on spot purchase arrangements will ultimately reduce individual choice and destabilise service networks.

The need for a service infrastructure also extends to direct cash payments, as many people need initial or long-term assistance to help them manage their support. Policy implications 'Housing and community care' is still a long way from being a defined and coherent area of policy-making.

Housing policy in the 1990s has led to a continuing decline in the availability of good quality housing for rent in areas where people want to live, while community care policy encourages the trend away from a 'special needs' approach by promoting independent living, individual choice and the mixing of formal and informal support. The achievement of these goals is dependent on a good supply of suitable housing. This major disconnection between different policy arms is compounded by the failure to devise a comprehensive funding system that recognises changes in the way services are delivered and in the kinds of accommodation required.

Taking the housing perspective on community care, as this body of research does, it is clear that preventive strategies, which help people to stay in their homes or to settle into suitable accommodation, are both poorly developed and difficult to implement within the present uncoordinated and unstable funding framework.