This Briefing is aimed at providers of housing, support and social care that accommodate older people and will be of particular interest to those who provide “general needs” accommodation, sheltered housing, almshouses or extracare schemes. Its key messages are applicable to all parts of the UK although the commentary on the Care Act applies to England. As a devolved function links to comparable legislation by devolved governments are included.
In July of this year Genesis Housing sponsored a report by Martin Wheatley of the Smith Institute entitled “Are Housing Associations Ready for an Ageing Population?”. The report added strength to our evolving thinking on some of our established themes such as:
- Investment in prevention
- Fundable models of service
- New approaches to revenue and capital funding
- Relationships with and the structure of the statutory sector
Martin Wheatley’s report focuses on housing associations and older people. This briefing also focuses on older people and very much includes housing associations but also includes the very many other organisations providing services to older people in a variety of housing situations. We’re focussing on the following key themes:
- The Care Act & comparable legislation in devolved parliaments
- Evolving, Remodelling & Diversifying Services for Older People
- Commissioning Relationships
- Funding Sources
- Fundable Technology for Older People
We used the term “the Silver Surge” to describe the much discussed demographic that is the impact of the increasing number of people aged 65 and over, and what this means to organisations providing services to people with additional needs.
The purpose of this Briefing is not to look at innovative service models, which is very much what our clients do daily. It is more about supporting their development by identify the “big picture” issues around funding streams, commissioning relationships and the nature of the changing social market within which we operate.
The “Silver Surge” has been talked about for years, but what does it look like in statistical terms? Here are some headline statistics.
- The population of people over 65 in the UK in 2014 was 11.1m or 17.4% of the total population. By 2050 this figure will be 25%.
- The population of people between 65-85 is increasing by 2.5% annually and the over 85 population is increasing by 3% annually.
- Within the next 20 years there will be 14m people over the age of 65 of whom 3m will be over 85, which equates to 5% of the population.
- Currently, 40% of people over 65, 59% of people over 80 and 78% of people over 85 have a disability.
- 90% of people over 65 live in unsupported accommodation (i.e. housing with no staff presence), although within the social housing sector that figure falls to 60%.
- NHS expenditure on people over 65 is double that of people under 65 whilst expenditure on people over 85 is 3 times that of people aged between 65-75 years of age.
- There are now more people in the UK aged 60 and above than there are under 18
The development of specialist housing has reduced over time whilst the population of over 65s has increased. The development of new accommodation-based schemes currently occurs at the rate of 15% of the actual demand. Increasingly the emphasis is on enabling older people to continue to live at home by adapting their physical environments and providing additional services to assist them to “stay put”. This principle places a particular focus on social landlords given the concentration of this and wider social need within social housing stock of all types.
Within specialist provision such as almshouses, sheltered, sheltered plus and extracare schemes there will be an expectation that providers should provide a wider and deeper range of services to older people based on a wider and deeper set of commissioning relationships than they have hitherto enjoyed.
The Care Act (England) & Comparable Legislation From Devolved Parliaments
The Care Act, which is in part a response to the Silver Surge but applies to adult social care in England only, sets out a new way of structuring social care. It looks at the creation and maintenance of “wellbeing” as a means of investing in preventative services, which our sector is very well positioned to do much more of.
The direction of travel is similar in Northern Ireland (which has led the way), Scotland and Wales.
The Care Act, whilst primarily aimed at the statutory sector, opens doors for housing providers to get involved in the implementation of some of the Act’s key themes around:
- Preventing the need for care and support through the promotion of wellbeing initiatives
- Delaying the need for care and support by delaying the onset of social care needs
- Reducing the need for care and support by providing enabling services
There are a considerable number of existing and new community-based and innovative services that housing providers can develop in response to this.
The Care Act requires services to be integrated where it will positively impact on wellbeing. Providers of housing, support and social care to older people must evidence wellbeing and prevention and of the positive outcomes for health and social care expenditure as a consequence.
There is £5.3bn in the form of The Better Care Fund, jointly administered by Health & Wellbeing Boards and Clinical Commissioning Groups. It’s intended to assist the statutory sector to implement arrangements for the Care Act and to fund services that focus on wellbeing and prevention as a consequence of those arrangements. These services need to demonstrate how a “social care” service can deliver health outcomes, as many of our services do already.
The Care Act requires local authorities to ensure that people have proper information and advice. This is also about prevention; it’s not just advice about how to access services, it’s also advice about how to avoid the need for them. For example, services around insulation and energy efficiency might save the NHS some of the £864m it spent (2011 figures) on the health consequences of excess cold, damp and mould in peoples’ homes.
The Care Act requires local authorities, in conjunction with their partners, to produce a “Market Position Statement” based on having undertaken care and support assessments according to a common national framework. Having done so, local authorities will be able to identify needs locally and procure the means to meet them on the basis of diversity and quality of service.
Housing Providers are in a good position to influence and respond to Market Position Statements with preventative, enabling services. If you Google “market position statement older people” and read some of the results, you’ll see what we mean.
We should view the Care Act as the overarching framework for a new social market in England in which housing providers are in a good position to do more for their older tenants and develop further as social businesses.
Evolving, Remodelling & Diversifying Services for Older People
Throughout the UK there are already many good examples of successful projects within the sector and they include such services as:
- Tenancy sustainment services, which allow older people to stay put in dispersed accommodation within the parameters of safety and choice
- Sheltered housing & Almshouses
- Sheltered housing Plus
- “Home From Hospital” services
- Domiciliary care services
- Grant funded projects, for example, associated with health and wellbeing outcomes or isolation
This is not, of course, an exhaustive list.
Part of the role of our sector is and always has been to provide preventative services to people with additional needs, including older people. Support Solutions UK believes that, in the case of the “Silver Surge”, this is more important than ever. It derives huge benefit to older people, saves the public purse a lot of money and takes pressure off local authorities and the NHS.
Non-statutory providers often have problems in engaging with statutory sector partners and in getting recognition for the social and cost-benefit of the services we provide, which is necessary for providers to have the confidence to design and develop new and even better services.
The cost-benefit of investment in preventative services for older people needs to recognised and quantified. Relationships and formal arrangements with the NHS and local authorities need to be developed.
Increasingly local authorities are struggling to fund registered care home provision. In an era of personalised approaches with the emphasis on independence sector providers have the opportunity to respond.
This requires non-statutory providers to evolve, remodel and diversify the services they provide in conjunction with statutory sector partners.
These types of services are cheaper to provide than registered care homes or other more institutional services. They are examples of investment in prevention, not emergency responses to avoidable crises. Preventative services of this nature reduce the need for, and cost of, emergency interventions.
If structured correctly they reduce costs that local authorities incur in meeting the housing, support and social care costs of older people. They also impact positively on the NHS by reducing the number of non-elective hospital admissions, reducing pressure on GP surgeries and community nursing teams, reducing the length of stay in hospital.
Our sector is not fully engaged with the statutory sector for a number of complex reasons. The role of the sector in providing preventative services and the associated cost-benefit is not well understood by the statutory sector. For example, there has been a great deal of agonising within the NHS over “bed-blocking” by elderly patients because there is insufficient “homecare” to facilitate safe discharge from hospital. Many of the people within the NHS who make these assertions do not necessarily analyse what they mean by “homecare” and if they did they might well understand that part of this assistance could be an enhanced form of Housing Management: the sorts of tasks and functions that complement the work and reduce the costs of domiciliary carers and community nursing teams to enable older people with additional needs to live safely in their own accommodation be it in “general needs” housing, sheltered, almshouse or extracare accommodation.
We made the point above that the NHS often doesn’t understand the cost-benefit of preventative enabling services of this nature. Local authorities often do to the extent that they are increasingly funding non-registered accommodation as an alternative to the significantly more expensive registered care home options and often with better outcomes assuming that it is an appropriate solution to the needs of the older person.
For both NHS and LA partners it is important that providers engage appropriately in the sense that we are able to set out the outcomes for the older people we accommodate and support, and also identify the cost-benefit: how much money are we saving them and how and where are we taking pressure off their services?
Increasingly the sector is examining Social Return On Investment (SROI) as a means of quantifying both social and cost-benefit. Given the existing and rather fragmented commissioning infrastructure at statutory sector level, and the preoccupation with cost, it’s probably best for us to focus on cost-benefit, as commissioners are primarily concerned with “their” budget rather than anyone else’s. So our approach to SROI, for now at least, needs to focus on how much money we can save different commissioners. If and when we get a unified joint commissioning infrastructure we can all focus on value before cost in the knowledge that, where preventative services are concerned, the value (both financial and social) will always be much greater than the cost.
As our recent briefings illustrate Support Solutions UK has become heavily involved in advising organisations on the cost-benefit of prevention and enablement and how to use SROI methodologies.
We should acknowledge the need to evolve, remodel and diversify the types of services we provide to people with additional needs in general and, given the focus of this briefing, older people in particular.
This is partly a by-product of reducing levels of public funding and the concomitant reductions in statutory services. There is an expectation that our sector broadens and deepens the scope of its service provision. There is an expectation that we measure our outcomes better, that we focus more on doing things that reduce costs and pressure on the statutory sector, that we personalise and individualise our services more. Some Older People have personal budgets so are effectively their own commissioners.
There is an expectation that we restructure funding for our services; reduce dependency on public sector revenue and move to a position where we access a wider range and larger number of smaller revenue streams and consequently a wider range of funders who will be looking for different outcomes both in terms of the people we work with, in this case older people, and in terms of impacts on their own services and costs. We’re thinking of the NHS and local authorities in particular.
We can envisage funding models for older peoples’ services reflecting a diversified, broadened and deepened set of service offerings with funding from the NHS, local authority commissioners, personal budgets, Housing Benefit, non-statutory one-off grants, social investment (capital and revenue) and private capital.
When working with statutory sector funders we should assume an increasingly outcomes-based, payment by results funding system measured against either or both of outcomes for people and cost-benefit for funders.
Statutory sector funding will become increasingly integrated between health and social care and respective UK national parliaments are legislating accordingly. An example of this in England is the £5.3bn Better Care Fund, which we commented on in our “Care Act” section above.
Non-statutory grants, for example, from the Big Lottery Fund and charitable foundations will be short-term and focussed on a specific outcomes-based theme. An example is BLF’s “Rethink Good Health” programme to prevent alcohol misuse amongst older people (now closed to new applicants).
Social Investment is not such a well-explored funding option for services for older people but it should be as this Big Society Capital blog post shows. We are in a process of transition as far as funding is concerned and the rising cost of social care for older people will force the development of new revenue and capital funding approaches.
Our sector is, for the most part, not sufficiently confident or knowledgeable about how social investment works but it is really important that we change this situation.
To quote the Big Potential “social investment means finance provided for (social) organisations, which the investor expects to get back and to create social impact”.
Social investment can take the form of both revenue and capital. Perhaps the best-known vehicle for social investment revenue is the Social Impact Bond, which is a contract between the public sector and providers “in which a commitment is made to pay for improved social outcomes that result in public sector savings”.
Housing Benefit is one of the better known but still widely misunderstood revenue streams which funds much more than many people think. Support Solutions UK is very well known for accessing Housing Benefit to fund Enhanced Housing Management tasks, which are especially beneficial in services for older people. There is a complex technical framework known as the Exempt Accommodation rules, which we have used to good effect since 2005 to maintain and improve levels of revenue. This works extremely well for HB eligible residents in sheltered, extracare, almshouse and dispersed (“general needs”) lettings and it’s usually possible to protect the finances of self-funders as well.
A number of our Briefings focus on this as part of the increasingly complex jigsaw of funding streams that collectively enable us to fund and deliver services for older people. It is as important as ever to ensure that your organisation accesses this funding. It benefits the older people you work with, your services and the local authority too, which reclaims the revenue from the UK Government provided your claims are properly structured, which is where Support Solutions UK is also important. In addition we will structure your claims to reflect the model and description of your service ensuring compliance with the HB regulatory framework. We will negotiate your claims non-adversarially with HB colleagues.
Private Investment is a feature of a more diverse Social Market. Housing providers are responding in different ways to the Silver Surge and to other people with additional needs.
Where a housing provider wants to withdraw from sheltered or supported housing, private investment gives the housing provider the funding they want and the redemption of public subsidy originally used to fund the properties that are now the object of acquisition. Such arrangements can be structured to provide for the properties to remain in use as “general needs”, sheltered or supported housing.
Alternatively, a housing provider might want the capital investment/receipt but also to retain the ongoing management of the properties, which are purchased or used as security against any capital investment. In such a case, the investor would not only provide capital but also lease back to the housing provider the properties purchased, part-purchased or used as security.
Private investment can take different forms and be structured in different ways. It has been part of the social housing and care sectors for many years. Its presence as a form of investment within the Social Market is more recent. Support Solutions UK has developed the right contacts to be able to broker arrangements where a housing provider is looking for investment for new or existing schemes for people with additional needs or looking to dispose of or refinance property assets.
Fundable Technology for Older People
One example of an approach to delivering services to older people is Housing Proactive, an efficient and extremely effective housing management system based around increasing daily contact.
In services for older people providers are increasingly struggling to fund their often-outmoded alarm systems, which ironically many of their residents don’t actually need or engage with. This is unfortunate when you consider a significant amount of alarm calls are for housing management reasons and not emergencies but whilst housing management activity is fundable by Housing Benefit it is not when mediated through a traditional alarm system.
Furthermore traditional alarm systems are not personalised or enabling technologies. Housing Proactive is, in our view, by far the best example of a methodology that makes a big difference to the independence and security of older people in a variety of accommodation settings including “general needs”, sheltered, extracare.
It also happens to be highly fundable because it is Housing Benefit eligible. This means a housing provider can normally recover the cost of the service making it effectively “free” to those in receipt of housing benefit. Support Solutions UK can advise you on this process. There are also no capital or other setup fees, which makes adoption straightforward.
Ultimately we predict that an increasing number of organisations will move away from service models that have compulsory participation in reactive personal alarm style services because there is a growing acknowledgment that the efficacy and outcomes of those services is proportionally poor compared to the number of services users that have had service provisioned for them.
For example, why buy and pay for personal alarms for 1000 people, when only 250 users in that group might engage with the service or have their alarm anywhere near them? Where Housing Providers want to continue to provide some kind of alarm services, they would often be better served signposting residents to specialised providers of dispersed alarms or recommending that residents buy one of the many mobile phones available with panic button technology built in to them, such as those available from Doro.
Instead, housing providers should be increasingly focusing their efforts on deploying systems that actually help them as housing providers make informed decisions and have measurable positive outcomes. It goes without saying that those services also help service users with higher housing management needs, but service models that equally benefit the housing provider as well as the service user do exist and should always be explored.
By developing service models that have significant benefit to the housing provider as well as the service user, those service models also become easier to fund through funding streams like Housing Benefit if you can robustly demonstrate and evidence efficiencies in how the housing provider operates it stock.
Ultimately housing providers would be well served by investing in services that actually increase the quality and frequency of contact, because services like this can – in addition to allowing housing providers to better understand the changing needs of its tenancy base and plan accordingly, as a by-product reduce social isolation, improve safety, and reduce reliance on other services for those groups. It’s at that juncture a housing provider is able to start evidencing that what it does can actually save money for health and social care, without straying in to any grey areas about whether the services it provides were actually necessary in the first place, which is the case where a housing provider is providing alarms to tenants directly competing with a local authority providing the same services.
Housing providers might well be better served by simply becoming “really expert” at their housing related contact and evidencing the other positive outcomes of that contact.
As for the kinds of technologies and services that will go on to most effectively assist older people in their homes James Batchelor the founder of the British technology company Alertacall is certain that there are 3 you should focus on in particular:
- Focus on improving contact. By focusing on technology that improves the frequency and quality of human contact you will yield other by-products like a reduction in social isolation and discover more about service user needs.
- Use technology that you know works now. Only deploy technology that you are certain an overwhelming majority of your customers can use immediately because otherwise you could potentially isolate them and will waste money.
- Make sure it works anywhere. Make services harmonious by deploying technology that works anywhere, whether sheltered, extracare or “general needs” because as the boundaries between those settings get blurred it is possible you will move to the same service model for all of them.
If you contemplating different service models for your older service users you’ll be pleased to discover that in our experience most people are absolutely at ease with things changing – even dramatically, if it will yield positive outcomes.
When you hear “Oh they won’t like what we’re planning one bit, they won’t like the change” what’s possibly being expressed is an anxiety connected with the uncertainty of the outcome of the project or simply the work which might be required to drive the project to completion. However, change is almost never an issue. Most people are content with the idea of positive change.
However, what people often do become anxious about is uncertainty over the outcome of change and that is why presentation of ideas to residents, and good communication skills are essential for any project that you’re embarking on. It is uncertainty not change that causes anxiety.
Service providers can sometimes present an overwhelming number of options to service users, creating elevated levels of uncertainty about what a future service is going to look like. If you are going to implement a new service or change an existing one, it would be prudent to ensure project managers and suppliers are skilled at conveying its benefits to the service users, to reduce any anxiety about any uncertainty and by doing so, you can be confident about change, the reception from service users and the future.
The “Silver Surge” is an expression to describe the growth in numbers of and demand for services from older people. It will place financial and operational strain on existing local authority and NHS services. It is both a challenge and an opportunity for sector providers.
Providers need to provide a wider range of enhanced services to older people; meeting a wider and deeper range of need and targeting outcomes for people that are preventative and enabling in nature and that impact positively on statutory services and costs. Providers need to adjust to a Social Market with a diversity of funding sources, commissioners and service models.
This reflects the principles that underpin health and social care legislation as predominantly devolved functions across the UK; these are very much based around wellbeing, prevention and enablement.
Providers need to evidence the cost-benefit and wider social outcomes of their services in ways that are persuasive to NHS, local authority and other funders who might invest in preventative, enabling services.
As well as acknowledging a changing and diversifying pattern of both revenue and capital funding structures, providers need to recognise changing, diversifying commissioning relationships and expectations. The extent to which any provider believes they can progress or even tread water, based on historical funding streams, existing commissioning relationships and established models of service is the extent to which they will fail the people they work for and the people who work for them. What is required is a re-evaluation of funding, service delivery models and commissioning relationships.
Housing, support and social care providers are in a good position to influence and respond to the new care and support agenda, which is based on the sector’s historical strengths around prevention and enablement.
Housing providers need to act now to deploy fundable systems to older service users across their stock in order to better understand how their housing needs will change as they continue to age, improve their access to services like repairs and to improve regular communication. By taking a proactive and preventative approach to managing housing this will improve outcomes for residents and better equip the housing provider to develop the opportunities of the Silver Surge.
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