Planning for older people at the health/housing interface

Lyn Harrison and Frances Heywood

Housing issues are of fundamental importance to the health and independence of older people.

Previous research projects exploring the views of older people living in their own homes have revealed their needs for housing services. However, this analysis of community care plans and Director of Public Health reports in three health regions found they made little provision for such services.

The researchers conclude that the housing needs of older people are not being addressed systematically through any of the mainstream planning processes associated with health, housing and community care.

Summary

Summary

Housing issues are of fundamental importance to the health and independence of older people. Previous research projects exploring the views of older people living in their own homes have revealed their needs for housing services. However, this analysis of community care plans and Director of Public Health reports in three health regions found they made little provision for such services. The plans reviewed were from the year 1996/7; this was before the advent of Primary Care Groups but at a time when, in some of the areas studied, GPs were already administering 30 per cent of the Health Authority budget. The study found:

  • Only a small minority of community care plans mentioned any housing issues other than homelessness. Half the Director of Public Health reports, including those from areas with some of the worst housing in the country, made no mention of housing factors.
  • The housing issues affecting the majority of older people were not usually mentioned in community care plans, nor was there normally any attempt to consider the scale of the remedies needed.
  • In most reports, there was little mention of GPs or other primary care workers.
  • Projects linking health, housing and social care agencies were not routinely mentioned in community care plans. While there were some examples of good practice, overall the level of provision was inadequate in relation to the scale of the need.
  • Less than a third of all authorities made use of health monies available for care in the community for housing projects.

Background

The study was based on the premise that good housing (economical, not isolated, secure and warm) and good housing services (housework, repairs, decorating, gardening, simple adaptations and better heating) are vital for helping older people live independently, as well as for preventing ill-health. 

It has proved difficult to demonstrate the nature and magnitude of the effect that housing conditions have on health. This study did not aim to add fresh evidence to this debate, but drew on reviews undertaken by a number of authors. For at least a quarter of a century, research projects with older people have revealed that the worry of maintenance, cleaning and gardening are major issues for them. 

Building on their previous work, the researchers aimed to examine:

  • the extent to which GPs or primary health care teams (or data provided by them) are involved in joint planning;
  • the extent of effective joint planning between health and housing;
  • the level of resources and the types of services available to older people living in their own homes.

Community care plans 

Most community care plans contained little about housing issues (see Figure 1). Housing issues affecting older people were not usually mentioned, nor was there any attempt to consider the scale of the remedies needed. What there was mostly included in scattered references; very few plans had distinct sections addressing housing issues for older community care clients.

The only issue covered by nearly all plans was adaptations for disability. The great majority made no mention of cold, damp or dangerous housing. One research study in Scotland has shown that the inability to cope with the garden was the most common factor causing older people to move to sheltered accommodation; however, only one of the 37 plans analysed had any proposal for action on gardening.

In most plans, there was little mention of GPs or primary health care workers. A minority of local authorities had a place for GPs on the working groups which fed into the Joint Consultative Committee, but enquiries revealed that these places were not necessarily taken up. Also, the Joint Consultative Committee is only responsible for allocating the small amount (less than one per cent) of health authority money earmarked as joint finance. Some plans gave little or no evidence of joint finance expenditure at all; 12 out of 37 described housing related projects they were supporting. 

Only 18 projects in 37 reports linked health, housing and social care.

Reports from Directors of Public Health 

Since many Director of Public Health reports focus on different issues from year to year, care must be taken in concluding a department has little interest in housing just because it is not well covered in one particular year's report. Allowing for this, however, it still seemed striking that in 28 out of 39 reports there was not even a statement that housing was an important component of health, and in 18 cases there was no mention at all of housing factors which impinged on health, even though these reports came from areas with some of the worst housing in the country. 

There were also few references to primary health care in public health reports (6 out of 14 in one region). What references there were, however, revealed some extremely positive attitudes about the potential for greater collaboration with primary health services and planners. One report included the views of five primary health care teams and was rich with examples of housing issues affecting health, all stemming from the firsthand knowledge of primary health care workers.

Obstacles to effective joint planning

These statistics suggest that the planning systems operating at the time were failing to deliver appropriate care and support for older people where health and housing issues overlap. The researchers identified a range of possible problems, some of them very deep-seated, which were shaping professional behaviour in this policy area. 

Concepts of health and housing
The words 'health' and 'housing' have come to have very narrow meanings in policy and practice. 'Housing' is seen as the allocation, maintenance and management of stock in the public sector; 'health' has become restricted to the services provided by doctors and nurses. As a result, professionals such as occupational therapists and environmental health officers, who have key information on housing/health links, are not generally involved in planning services for older people.

Monitoring the impact of housing on health
There is a view that, since the vast majority of houses are no longer unfit, housing is no longer the cause of health problems. Concentrating on the physical condition of housing, however, ignores other issues affecting older people's health, such as depression and isolation, hypothermia and accidental injuries. Information from older people themselves on how their housing is affecting their well-being is not routinely sought or collated. No frontline professional is required to collect data on the housing circumstances of older people they see. There is little local scientific research on the evidence of links between housing issues and health. No one is obliged to publish the findings every year and answer for them. 

The role of public health
Most public health doctors have taken on a major role in advising local health authorities on commissioning medical services and the focus of their work has therefore shifted away from more preventative work. 

Public health doctors do not have any statutory authority to direct other agencies, such as local authorities, so are not in a position effectively to champion the need to consider housing's impact on health or to co-ordinate the work of all professionals in this field. Public health departments have a limited input to local planning and although they may put considerable skills and resources into producing reports and recommendations they have no power to enforce these.

Planning of health and community care
National priorities are very significant in driving the planning process at local level. This can filter out expressions of need from users and from frontline staff which do not fit these priorities.

Decisions about joint planning have become the province of senior managers and tend to be tied to the allocation of resources for bids, rather than relating to the overall level of need.

The nature of the services needed
Older people in our society tend to have low status. The 'hands-on' housing services needed by frailer older people in their homes are also low status. Housing support in the domestic setting is not a priority since its impact is 'invisible'. Non-housing professionals who work with older people are not usually well-informed themselves about the range of possible options for older people which exist across all tenures. At another level, older people's anxieties may prevent them from seeking help. Many fear the disruption or cost of building work or being forced to leave their own home if they admit to any problems.

Conclusion

The researchers conclude that the housing needs of older people are not being addressed systematically through any of the mainstream planning processes associated with health, housing and community care. 
Whilst there are some fundamental social and institutional reasons as to why this might be, the researchers suggest that the following could lead to improved practice:

  • the collection, co-ordination and monitoring of information from older people themselves and the frontline staff who routinely have access to older people in their own homes; with Directors of Public Health responsible for gathering this information;
  • central government placing requirements on, and giving authority to, Directors of Public Health to identify need, set objectives and monitor outputs and outcomes in relation to these objectives;
  • Directors of Public Health being given authority to influence bodies outside the NHS;
  • modest incremental shifts from the mainstream budgets of local agencies to ensure appropriate resources to meet the level of need;
  • creating the political will to provide the resources needed for these services by making these housing needs more visible and stimulating demands on politicians at local and national level;
  • rigorous monitoring of health and social care outcomes where good housing services are provided.

About the study

The research involved a comprehensive review of community care plans and of the Reports of Directors of Public Health within three health regions within England. In addition, a small number of field visits were made. The researchers also drew on their own previous research and a non systematic review of key literature relating to planning, community care and primary health care.

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