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Chapter Five Further Considerations
Assistive technologies
5.1. The application of assistive technologies in the home is another key issue that will impact on the housing options open to older people. Assistive technology has been defined by the Kings Fund as 'any product or service designed to enable independence for disabled and older people' (Kings Fund Consultation, 2001, quoted in Assistive Technology Forum, 2004). Given this broad definition, assistive technologies have relevance to a wide number of people (Department of Health, 2004), including older people wanting to leave hospital on time and remain in their own home (whichever type of housing they live in).
5.2. Each year, the Department of Health publishes a summary of research and development work that is underway in relation to assistive technology. Their 2005 report contains details of a number of initiatives that will have implications for both future research, and for the delivery of assistive technology services to older people in Scotland. For example, it noted that the Research Councils, particularly the Engineering and Physical Sciences Research Council (' EPSRC') and Medical Research Council (' MRC') both provide substantial funding annually for assistive technology related research projects. Moreover, EPSRC and the Biotechnology and Biological Sciences Research Council (' BBSRC') have recently launched a multi-disciplinary network - the Strategic Promotion of Ageing Research Capacity (' SPARC') - which provides support for ageing-related research projects including consumer product design and care home design (Department of Health, 2005a).
5.3. Evidence submitted in 2005 by the Royal Society of Edinburgh to the House of Lords Science and Technology Committee emphasised the importance of health-related assistive technology to older people and their housing options. They quoted an example of technology that allowed an older person who was unable to travel to hospital or their doctor to use a digital thermometer or blood pressure monitor, and to communicate with a doctor who could interpret those measurements, without having to leave their home (House of Lords, 2005).
5.4. In the light of a recommendation in the Report of the Joint Future Group (Scottish Executive, 2000), the Scottish Executive established a Strategy Forum on Equipment and Adaptations. Their report (Scottish Executive, 2003d) was supported by research that gave an overview of the legal position in Scotland regarding equipment and adaptations, which was designed to give professionals a better understanding of the framework in which they work (Scottish Executive, 2003f). The report exposed an intricate and multifaceted picture of provision of equipment and adaptations in Scotland, which they believed was hampering provision of assistive technologies to those who would benefit from it. They concluded that there was significant scope for improvement in the management and organisation of resources.
5.5. The report set out a fourfold strategic vision for provision of equipment and adaptations in the home:
- The promotion of social justice by mainstreaming equipment and adaptations into everyday life
- Extending and sharing knowledge by improving the information available and how it is provided
- A joint future in which equipment and adaptations are integrated with one another, integrated within community care, and across care groups through joint resourcing and joint service management, single shared assessment and care management.
- Assuring quality and innovation: by auditing and improving service standards, improving the knowledge base by evidencing and evaluating the impact on people's lives and the impact on other care services, and by encouraging and supporting innovation.
5.6. Our literature search revealed some evidence of other Scottish research into the costs and benefits, and prevalence of assistive technologies. West Lothian Council has made 'telecare' - a combination of sensors and detectors installed in the home, which alerts West Lothian Careline if anything appears unusual - available to all people in the area aged over 60 who are assessed as needing it due to illness, vulnerability, or other risk factors. There are presently 1900 service users, and Stirling University is currently undertaking a series of evaluations on the system. Initial indications are that telecare solutions have reduced the burden on the local health authority by reducing the length of time its users stay in hospital, and facilitating timely discharge from NHS care (Scottish Executive, 2006c).
5.7. Most people interviewed by Dundee University as part of an earlier study of the West Lothian 'Telecare' programme (Gillies, 2001, quoted in Scottish Executive, 2004c) reported that assistive technologies were helping people to continue living in their own homes, and that users had become accustomed to the technology and appreciated the benefits it afforded them. Some minor technical difficulties were reported with the technology. Carers were also satisfied with the technology implemented, although it was unclear whether they were experiencing any actual reduction in their care burden.
5.8. Other research has reiterated general satisfaction with services but suggested that introduction of the technology into people's homes can lead to worry that it might go wrong, or that it might cause undue concern to relatives, carers and service providers if it does (Bowes & McColgan, 2002). An evaluation of a smart homes project undertaken by the Joseph Rowntree Foundation and Edinvar Housing Association in Edinburgh has also pointed to people's scepticism about introducing new technologies into their homes, and to the fact that the pace of technological change may cause rapid obsolescence and issues with upgrading (Gann et al, 1999).
5.9. Researchers from the University of Stirling have evaluated the Home Comforts pilot project in South Ayrshire, in which smart home technologies were provided to 22 people. There is evidence in this study that the use of smart technology had some positive effects. By comparing the care provided to users of the assistive technology package with the care provided to a control group, the researchers showed that the control group were more likely to have received increasing hours of home care, been admitted to care homes or hospitals, or visited their GP more frequently than those using the assistive technology care package (Bowes and McColgan 2003).
5.10. The process of designing assistive technologies and 'smart homes' that will benefit older people and help them to live more independently has been discussed by researchers from Robert Gordon University. They note that while "smart homes can be useful, enhancing the quality of life for those whose life is limited by their domestic environment" (p133), it is also important to consider what the assistive technology will do for other stakeholders (including the potential for lightening of the care burden on carers, family, and providers of other health and social care services), and the need to ensure that systems - particularly those concerned with home security - cannot be hacked into (Dewsbury et al, 2001).
Delayed discharge
5.11. The issue of delayed discharge from NHS care has received significant attention in the past decade, for the most part because of the knock-on impact it has on other parts of the health service by causing 'bed blocking'. The Scottish Executive has developed targets for the reduction of delayed discharge. However, with delays of over a year still featuring in the statistics, this is an issue which is still receiving noticeable policy attention.
5.12. As of January 2006, there were a total of 1,488 patients ready for discharge in Scotland, compared with 1,576 in October 2005, and 1,668 in January 2005. This represents a drop of 10.8% over the past year ( ISD Scotland, 2006). The chart below indicates the number of patients affected by, and reasons behind, delayed discharge in Scotland since September 2000.
Figure 2 - Patients ready for discharge outwith the 6 week period, by reason for delay, since Sep 2000 (source: ISD Scotland 2006)
5.13. According to Shelter, "many older people remain in hospital when they are well enough to leave because care is simply not available to them either to help them in their own homes, or because of problems in availability of care home placements. This can significantly affect a patient's physical and mental well being" (Shelter, 2005, p4). The issue of delayed discharge from NHS care is clearly a significant issue for older people in Scotland, and one which affects - and is affected by - their housing choices. The chart below illustrates the number of patients affected by, and reasons behind delayed discharge, analysed by age. As at January 2006, just under 75% of patients awaiting discharge beyond the 6 week discharge planning period were age 75 or older ( ISD Scotland 2006).
Figure 3 - Patients awaiting discharge beyond the 6 week period, analysed by age group (source: ISD Scotland 2006)
5.14. The Scottish Executive has already commissioned and published a review of existing research on the issue of tackling delayed discharge from NHS care (Scottish Executive, 2004b). While we do not wish to reproduce the full findings of that report here, the research identified a number of key points surrounding the issue of delayed discharge (ibid. p14-15) which it would be useful to note, such as:
- Issues regarding consistency in the criteria by which a patient's readiness for discharge is assessed.
- Older people, those with multiple pathology, and those with some specific conditions (such as neurological deficit and stroke) are most at risk of delayed discharge. Studies suggest that patients waiting for a place in their first choice of care home to become available, and patients who did not have a companion to escort them home were also likely to be delayed.
- Some medical conditions appear more likely to lead to a delayed discharge for all age groups and that this is often because there is a lack of alternative care facilities available for these particular people. In other words, it is not the clinical condition per se, which causes the delay, but how organisations are managing services to care for these particular clinical groups.
- Problems within both health and social care organisations have been attributed with causing delayed discharges. Organisational factors associated with delay include: (i) lack of home support, (ii) unavailability of convalescent or rehabilitation facilities, (iii) waits for community care needs assessments or home care packages. Some patients admitted as an emergency were more likely to have a delayed discharge compared to elective admissions, and that people with severe mental illness admitted for planned short hospital stays were less likely to have a delayed discharge compared to those who were admitted as long hospital stays and in receipt of standard care.
- Whilst the Joint Action Plans of most Scottish Partnerships focussed on older people, they were not explicit about targeting particular groups of older people most at risk. Nor were they specific about which high risk groups of the population, besides older people, were being targeted to tackle delayed discharges. This may be because Joint Action Plans did not specifically request this information. However, it would be useful to know whether Partnerships were targeting high risk groups and what initiatives they were developing to facilitate their discharge.
- A lack of clarity regarding the relationship between causes of delayed discharges and the initiatives being introduced at Partnership level to combat them.
5.15. Subsequent to that research review, work undertaken in 2005 by Audit Scotland (Audit Scotland, 2005a; Audit Scotland, 2005b) has reiterated that older people are at increased risk of delayed discharge, and that an interplay of factors is responsible. The research pointed to three factors as causing delayed discharges: (1) the assessment of a patient's ongoing care needs, (2) putting in place community care services such as home care arrangements, and (3) arranging funding for a care home place if this is necessary. The research indicated that at any one time, around 8% of hospital beds are 'blocked' by patients awaiting discharge, and that most patients delayed in hospital are aged 75 or older. Given the projected increase in Scotland's older population over the next 20 years, Audit Scotland warn that the problem of delayed discharge is likely to increase unless action is taken to plan and co-ordinate services more effectively.
5.16. To this end, £30 million has been allocated per year until 2007/08 to Scotland's 15 delayed discharge partnerships to help alleviate the problem (Scottish Executive, 2002c). The Essential Connections initiative also sees dealing with delayed discharge as a priority, quoting the objective of working "To avoid unnecessary admissions to, and to facilitate timely discharge from, hospital by providing the right services organised to coincide with patients' needs and circumstances" (Joint Improvement Team, 2005, p7).
5.17. Furthermore, in a project which may address some of the organisational factors that contribute to delayed discharges, NHS Quality Improvement Scotland is currently drafting a set of standards relating to healthcare services used by older people in Scotland. Standard 8 in particular deals with management of transfers between care providers dealing with discharges, based on the overall objective that "Co-ordinated and multi-disciplinary teams involving acute, primary care and social work staff are responsive and available rapidly to support older people returning from hospital as part of an agreed pre-transfer / pre-discharge assessment" (Expert Group on Healthcare of Older People, 2002, quoted in NHS Quality Improvement Scotland, 2004, p49).
5.18. Under this standard, relevant local agencies will be required to demonstrate a co-ordinated approach to service provision for older people returning from hospital, and that the effectiveness of discharge services is monitored in terms of patient impact and service outcomes ( NHS Quality Improvement Scotland, 2004). The finalised standards are expected to be published later this year.
5.19. Many factors contribute to reduced delayed discharge, including care and repair already noted above (paragraph 4.23) and falls prevention, where a number of partnerships or collaborations are achieving good results in Scotland (Scottish Executive, 2006d).
Housing options of those requiring dementia care
5.20. There are around 63,000 people in Scotland with dementia, and around 30% of them live in care homes (Alzheimer Scotland, 2005). The number of sufferers is expected to reach 192,000 by 2040 (figures from the Dementia Services Development Centre, University of Stirling, quoted in Grant, 2004 p45). While the decision to move into a care home can be a huge step for a sufferer, Alzheimer Scotland report that making this move can have a positive impact on the sufferer's well being if good quality of care is provided in the care home. However, Alzheimer Scotland have concerns about the quality of care provided in care homes, and note that there are a number of challenges to providing good quality care. These challenges span the whole journey of care from the choice of care home through to end of life care, and encompass issues such as health, behaviour, stimulation, relationships, spirituality and religion (Alzheimer Scotland, 2005).
5.21. Research evidence from 2003 suggests that as community-based services for older people have expanded, the number of NHS Old Age Psychiatry beds has reduced. Although there is significant local variation in the reductions, the overall reduction between 1990 and 2003 was 2,500 beds. This was matched by an increase of 3,060 care home beds for the same period - this being the net increase resulting from a much larger increase in nursing home beds, offset by a reduction in residential home beds over the period (Grant, 2004). The housing choices being exercised by older people leaving NHS Old Age Psychiatric wards is illustrated by statistics published by ISD Scotland: in 2002, 7,051 older people were discharged from NHS Old Age Psychiatry inpatient services (both acute and continuing care). 52% were able to return home, 14% transferred elsewhere in the NHS, 22% went into care homes, and the remaining 12% died (quoted in Grant, 2004 p45).
5.22. The Dementia Services Development Centre recently launched Home Solutions 2 - a good practice guide on housing, care and support for people with dementia and their families. (This complements Home Solutions published in 1998). This report looks at development and operational aspects of a range of housing and care services affecting people with dementia and draws on 10 case studies in order to identify emerging themes. 6
5.23. 5.23. As noted above on page 43, consultation with service users is considered good practice in provision of housing services to older people. While there may be an active network of researchers in Scotland applying new techniques to 'hearing the voice' of dementia sufferers (Scottish Executive, 2004c) one literature review carried out in 2005 has pointed to the relative lack of consideration of housing options for older people in general, and more so for older people with dementia (O'Malley & Croucher, 2005). They argue that this is explained in part by the treatment of ageing, dementia, and housing as separate entities in social policy initiatives (ibid. p570), and that there is little in the policy guidance available to guide practitioners, service planners, or relatives in housing related choices for people with dementia (ibid. p571). They also note that between 60% and 80% of people with dementia live in the community, and that although research has been undertaken that focuses on specific services available that allow people with dementia to live in their own homes, there has been no large scale, multi-site or comparative study of the relative effectiveness of those services (ibid. p572).
5.24. The study indicates that some commentators believe that sheltered housing is playing an increasing role in providing care for dementia sufferers (although this may be due to existing residents developing the condition rather than people with a pre-existing condition choosing to live in sheltered housing). However, there has been limited UK research exploring this issue, and no UK research exploring the existing population of people with dementia in sheltered housing and their future housing options and preferences (ibid. p573). The study did observe a trend of transitions from home to formal care settings as people grow older, and that behavioural problems, cognitive decline, and the increasing care burden are all associated with an increased likelihood of moving into some form of care (ibid. p574).
5.25. Research which is due to be published in April by Housing 21 appears to reiterate these findings. It finds that suffering from dementia may not be the only reason why older people choose to enter residential care. Despite moves in 2004 to join up the planning, organisation, and delivery of services for dementia sufferers and their carers (Scottish Executive, 2004d) the Housing 21 research notes that an ongoing lack of integration between health and social care for dementia sufferers is still a key reason for making the decision to enter residential care (Hocking, 2006). Research undertaken in relation to implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003 has also emphasised the need for "robust inter-agency working" when dealing with older people with mental health problems (Grant, 2004, p44), and the ongoing need to 'close the gap' between health and social services for dementia sufferers has also been commented on by Andrews, 2006.
5.26. A qualitative study undertaken in 2005 discusses issues for the development of dementia care services in rural Scotland (Innes et al, 2005) which might impact on the housing choices made by dementia sufferers in rural areas. It notes that there is a "marked lack of [research] information about dementia care generally" in contrast with other countries such as the U.S., Australia, and Ireland and Sweden in which users perceptions of dementia care services in rural settings have been studied more extensively (ibid. p354).
5.27. The same study indicated that 35 out of 45 participants highlighted gaps in service provision, although experiences of the services available were generally positive. The main gaps in service provision noted relate mainly to the rural location of the service user, for example, due to lack of transport; the availability of respite, day and home care was also reported as problematic due to location issues (ibid. p359). The social aspects of care provision were noted as a positive aspect of services, as was the stimulation provided through participation in games and activities (ibid. p360). Carers in particular felt they benefited from a sympathetic and informed listener, from the respite from care-giving (ibid, p361) and from peace of mind they had from knowing that their relatives were safe and content while receiving services (ibid, p362).
5.28. One Scottish housing-with-care initiative aimed at people with memory problems and dementia has been underway in South Ayrshire since 2004 (Quality Homes and Places, 2005). The Gemmell Crescent development was funded jointly by Communities Scotland, South Ayrshire Council and Hanover Housing Association. The development was designed specifically in order to help residents orientate themselves, and features 'smart technology' that contributes to providing a safer environment for tenants. Sylvia Cox, of the Dementia Services Development Centre at Stirling University has outlined some housing choice issues facing dementia sufferers while being interviewed about this development:
"Ideally people prefer to stay in familiar surroundings, but if the family carers wish to go on caring it is important that they can do so knowing that the right kind of help is on hand and that the design of the housing will maintain and often improve the person's quality of life. Quite often the current housing is just not suitable. The challenge is to provide a dementia-friendly environment within ordinary domestic housing in a way that better supports people." (ibid. p20)
5.29. These design challenges have been addressed by the Dementia Services Development Centre in the design of the 'Iris Murdoch Centre', which may be the first building in the world to have been specifically designed in a 'dementia-friendly' way (Hopkins, 2003).
5.30. Research by Alzheimer Scotland outlines the difficulties faced by the 29,000 carers of people with dementia in Scotland (Alzheimer Scotland, 2003), including a high level of unmet need for mainstream medical services and domiciliary support. This research notes that service objectives are best defined in terms of both delayed entry into long-term care and of improved quality of life for both the dementia sufferer and their carer.
5.31. Alzheimer Scotland also see short breaks as playing a part in allowing dementia sufferers to remain in their own home for longer (Alzheimer Scotland, 2004). However, not all carers are able to make use of existing short break services due to transport issues, quality concerns, or because the dementia sufferer does not want to attend. This report highlights some practical issues that could improve short break services, such as flexible hours of operation, and continuity of care workers.
5.32. The need to provide culturally aware services for people with dementia has been touched upon in some research (Kerr et al, 2005), since the confusion experienced by dementia sufferers is exacerbated by a lack of cultural awareness in services dealing with minority ethnic groups.
5.33. Finally, the issue of free personal care for dementia sufferers is being examined as part of the current Scottish Parliament Health Committee Care for the Elderly Inquiry. Oral evidence submitted to the inquiry has indicated that free personal care has improved conditions for people with dementia, that it affords person-centred care and support to informal carers (often providing care in the sufferer's own home), and that it improves the quality of life of people with dementia (Alzheimer Scotland, 2006).
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