Better care, better lives: A personal perspective on integrating housing, care and health

Written by Hannah Miller, recently retired as Executive Director of Adult Services, Health and Housing at LB Croydon, and currently working with the Department of Health National Helping People Home Team.

It is important that housing is not overlooked in the rush towards integration of health and social care. The key role of housing in the prevention agenda is not always given the status it merits .This is surprising given that the preventative role of housing is not new for those of us who recall the vision behind the Supporting People (SP) agenda with housing, health, probation, as well as, social care around the table in the SP Commissioning Body.

In my view, this focus has gradually been lost with successive reductions in SP budgets with the removal of ring-fencing and as council budgets came under pressure. This loss of focus has been exacerbated by the mainstreaming of SP budgets into overstretched local commissioning budgets.

Although housing is recognized as a key determinant of health, a trick was missed with the setting up of the Health and Wellbeing Boards (HWBBd). Many boards do not have representation from either senior housing officers or members. The Croydon HWBBd did comment on the Housing Strategy and received reports on homelessness and health including commissioning a Joint Strategic Needs Assessment chapter, but this is not universal. However, whoever is in power post the general election this May needs to relook at the membership as well as the remit of the HWBBds and ensure that housing is given equal status with health and social care.

There has been some debate as to whether the Care Act 2014 has fully recognized the importance of housing in meeting the assessed needs of older people with people taking differing views. I recently heard the main strands of the Care Act neatly summed up as "Wellbeing - Integration - Personalisation'. To my mind housing has a major role to play in each of these. Last autumn, 400 plus older people in Croydon told us that what mattered most to them with regard to health and social care was:

• Getting the right information and advice to stay healthy and well;
• Skilled health and social care professional intervention to get them well and back home if they need to go into hospital;
• Advice and support to stay in their own homes as independent as possible for as long as possible with a minimum of intervention;

No-one aspired to be moved through a series of housing settings leading eventually to institutional care. This is not to under value the role of supported housing or care home settings but what older people want is to stay in their own home or at least within the same community near to their informal support networks. This is a key challenge for health, housing and social care economies. What tools do they have to help achieve this goal and are these are all being fully exploited? Some of these are:

• Telehealth / telecare and other forms of assistive technology together with digital solutions. Can we develop their use to combat social isolation?
• Disabled Facilities grants now part of the Better Care Fund (BCF). Can these be used more imaginatively?
• Housing Revenue Account (HRA) capital used for adaptations to council properties for old and disabled people. For example, Croydon used HRA monies for a program of wet room installations in special sheltered housing for older people to replace bathrooms now redundant due to the increased infirmity of tenants.
• Home Improvement Agencies. How many BCF plans have invested in these? But essential for hospital discharge and for enabling healthier environments for older people to live in which will help avoid hospital admissions. There are a rich variety of case studies from Croydon to demonstrate the benefits of such investment both to individuals and to the system.
• Challenge for estate regeneration programs to enable the redistribution of larger social housing properties for families by providing bungalows and low rise retirement apartments as well as extra care schemes within the same communities so older people do not need to move away.
• Whatever your views on the' bedroom tax'- exempting older people did little to help with redistribution of larger properties to overcrowded families with children. Financial incentives although very generous in Croydon did not have huge success in persuading older people to downsize.

I also believe that much sheltered housing is no longer fit for purpose, both as an outdated model of provision and because of stock condition. When Croydon removed sheltered housing wardens some years ago, despite pressure from some tenants, it was identified that out of hundreds of tenants living in 26 sheltered housing blocks that only 35 people had a complex care package. Many were still going out to work, had no contact with the wardens or calls from the telephone help line and were younger and fitter than me! This whole concept needs an overhaul with emphasis on retirement housing as opposed to sheltered housing and many more resources put into extra care provision as a genuine alternative to a care home.

A few other thoughts is where does housing for older people sit within the personalisation agenda and the move now towards personal health budgets in addition to those in social care? Furthermore, where does housing feature in the move to outcome based commissioning for the needs of the whole population of older people?

We talk a lot about the different cultures of health and social care staff coming from their different history, funding, language and accountability. But the cultural gap is there just as much with housing staff.

When I brought adult social care and housing into the same department in 2008, I found very different ways of looking at our customers. The trick was to try and get the best from both cultures and mesh them together so they had respect for each other's professional base. This was not helped by legislation that did not talk to each other and different ways of looking at needs assessment.

In Croydon, a relatively high percentage of the customer base was in common. Out of 14,000 tenancies, about 1,500 had household members known to adult social care. Tenancy officers were overburdened with isolated vulnerable people with mental health issues including dementia. The solution, we set up specialist tenancy officers to deal with the vulnerable who worked closely with social workers so relieving both hard pressed general fund social workers and mainstream tenancy officers.

With system and service integration on the rise, it is interesting to note that the BCF Guide to leadership talks about system leadership for health and social care not being a set of competencies and skills but being a mindset. The challenge post election is to ensure that housing providers from all sectors take their place as full players in the Integration Game as it moves to the next chapter.

Adapted with kind permission from a presentation given by Hannah Miller to the All Party Parliamentary Group on Housing and Care for Older People on 9 March 2015

Published on 24 March 2015 by the Housing LIN