Written by Stewart Greenwell, Associate, Practice Solutions Ltd
On 10th July 2015, Practice Solutions Ltd convened a round-table discussion on extra care housing for older people in Wales, chaired by David Brindle of The Guardian. This blog provides an account that meeting which considered the proposition that extra care housing in Wales, as a concept and a provision, is still relatively underdeveloped.
There are almost 1,500 units of accommodation, of which 300 have been developed by the private sector. The challenges set out were whether it is important that there is an agreed concept, or at least a set of agreed principles.
Secondly, the round-table considered whether extra care housing is simply another step on the road that still leads to some kind of institutional care for older people, e.g. hospital, care home or nursing home.
Thirdly, contributors discussed if 'extra care' can be appropriate for older people with cognitive impairment and if so, what does it need to include in the design, the staffing and the culture?
Lastly, it posed the question whether 'extra care' can offer benefits to older people, such as reducing hospital admissions, providing better access to community health services and encouraging older people retain, regain and indeed acquire skills and interests that make for a fulfilling life. A tall order in three hours!!
There was an early agreement that a unifying concept would considerably help the debate and the development of policy and would complement the overarching objective of much Welsh Government policy, that of 'promoting independence'.
Contributors also recognized that the Social Services and Well-being (Wales) Act 2015 has, at its heart, placing the citizen at the centre of all considerations about what makes up the very best care and support. Residential care is seldom seen as an option of choice by relatives and professionals and remains something to turn to on behalf of older people 'when all else fails', whereas 'extra care' is a housing choice. This is not to resign residential care to being worse than 'extra care', but to be clear about their fundamental differences. 'Dementia Care Matters' has shown that there are ways in which practice in residential care can be exemplary and at best liberating for the people who live and work there.
A number of the contributors have been involved in developing key principles in their own work and some of these may serve as helpful guidance as we take this further. They included: purpose-built self-contained accommodation (your own front door); support available 24/7; a thriving community, 'looking out, not in'; the chance to choose whether to eat together with neighbors and family; a focus on activities to keep people healthy. There are likely to be many more, but these serve as reminders of an overall intention to create a place that widens rather than limits horizons, with people around who support that intention.
It was also pointed out that one of the original features of 'extra care' was a mixed and balanced community, with 33% of tenants requiring substantial care and support, 33% requiring limited support and 33% requiring no care and support at all. As tenants and owners grow older, the balance changes or possibly disappears. At the same time, commissioners expect 'extra care' to be able to provide for and respond to increasing numbers of older people with complex conditions and increasing frailty.
It was also discussed that there is a need for a 'whole system approach', easily tripping off our tongues, but an approach that acknowledges that people lead lives that have multi-faceted components, e.g. family, neighborhood, faith, work, hobbies and health. We often refer to it as a 'rich tapestry' and it remains essential that we do not deny older people the chance to continue to develop that tapestry for themselves.
The private sector was represented at the table and it allowed for an interesting conversation about the advantages and disadvantages of mixed-tenure schemes, with a majority view that the advantages are greater, bringing diversity into people's lives and into the settings. It was highlighted that sales bring in much needed capital that create the opportunity for cross-subsidies and the development of a wider range of facilities and activities.
At their best, extra care housing schemes are part and at the heart of a neighborhood and community, with traffic going both ways, tenants and owners using local shops, services and facilities and local people making use of the facilities that the housing scheme has to offer, e.g. gym, restaurant and coffee shop. In addition, there was recognition that the scale/size of a scheme becomes an important determinant of the range of facilities on offer.
Research can be a real aid in thinking about what works best and we considered the findings from Aston University's research into the model of support offered by ExtraCare Charitable Trust. This has some encouraging signs about reducing unplanned hospital stays and cost savings on social care (available from ExtraCare Charitable Trust at: www.extracare.org.uk/research/findings). There was a view that Wales needs some bespoke research, to mirror that undertaken by Aston University, so that we can develop an understanding of what works for older people and the benefits for those agencies that have to make decisions about what to commission.
Commissioners of services may see 'extra care' as a simple solution but it is far from that, since it also reflects a step away from the majority of people continuing to express a wish to stay in their own homes, even when planners may judge their accommodation to be too large for their current needs. These are important, yet difficult discussions to hold with older people, but if the citizen is going to be central in all future planning in Wales, staying amongst your friends and family and in a familiar environment will always be a first choice and any alternative has to aim for features that capture some of those key ingredients.
There was no sense of a counsel of despair in what are difficult economic and political times. Those present were convinced of the need for the development of a whole system approach, combined with conversations with older people about what matters to them and what can make a difference to their lives.
Extra care housing also has to be more visible so that more people can exercise a choice about their housing needs and wishes in their later life, with the potential for Government to make it clear that it believes extra care housing is a preferred environmental planning option now and for the future.
The hope and ambition that surrounds 'extra care' is reflected in the Social Services and Well-Being (Wales) Act 2015 and therefore the potential for realising that is probably increased, with the backing of legislation and political determination for the Act to fundamentally change the offer made to the people of Wales.
And finally, it was noted that work is now taking place through the Housing LIN (Learning and Improvement Network) Cymru to consider the 'state of the nation' in both residential care and housing with support for older people.
The journey and the conversation have to continue.
A list of those who attended the round-table discussion can be found at: www.practicesolutions-ltd.co.uk/blog/post/2015/07/20/a-round-table-discussion-on-extra-care-housing-that-may-just-be-part-of-something-bigger
Published by the Housing LIN on 11 August 2015