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Chapter six Alternative Models of Delivery

6.1. This chapter provides an overview of some alternative forms of delivery that have been developed in England and abroad. Initially we consider two forms of housing provision for older people that are just emerging in Scotland: co-housing schemes and retirement communities. We then discuss the role that tenure can play in the delivery of specialist housing for older people, and the various options that are evident in the literature. Finally we consider two forms of provision that provide an extension to existing sheltered and extra-care schemes: intermediate care and respite services.

Co-housing Models

6.2. Co-housing models of living have developed since the 1970s in Denmark and the Netherlands, in communities of all ages, as well as those developed by and for older people (aged 50+). They have more recently emerged in the UK, with the development of a scattering of communities, mostly in England, one of which is for older people: the Older Women's Co-Housing Group in London. This group was established in 1998 and is still in the process of developing its housing. It is the focus of research for the Joseph Rowntree Foundation, which aims to identify the transferability of this model to the UK (Brenton, 1999). There is also a group of older people in Fife who are exploring the possibility of developing a co-housing community for older people in North East Fife ⁷.

6.3. The research relating to these forms of development (Brenton, 2001; 2002) draws on the experiences of communities that have developed in the Netherlands, where there are now 200 co-housing communities. The concept behind co-housing is that of independent living within private space, but alongside others within a community that promotes active engagement with others, in communal spaces and around common interests. The key features of co-housing are:

• Common facilities
• Private dwellings
• Resident-structured routines
• Resident management
• Design for social contact
• Resident participation in the development process
• Pragmatic social objectives

6.4. The communities develop around shared interests, and either develop through personal contacts, from a few individuals advertising and gathering others into a group, or through active enrolment by an existing housing association. They do not provide formal care or support, but 'buddying' and other systems evolve within the community, to check on the older members of the community, or those who are unwell.

6.5. These groups take on the process of finding a site, developing or converting buildings according to the specific needs of the group, and developing skills as a group. This process takes an average of four years in the Netherlands, though it is likely to take longer in the UK, due to the limited experience of housing associations and participants. (The Older Women's Co-Housing Group has so far taken eight years, and the older people have not yet moved into their new homes) During this process some group members will choose to leave, while others join. The optimum number for an older people's co-housing scheme has been identified as 30-40 people, with the provision of 24 units. As with other age-segregated housing provision, there is a need to ensure that there is a mixed age-range, so that the community is able to maintain its vitality and renew its membership.

6.6. In some respects this form of housing could be considered to be in line with UK government's aim of providing 'integrated, holistic, inclusive, involving and preventative' housing for older people ( DETR, 2001). However, the regulation and established practices of housing associations make it more difficult to implement this form of community in the UK. In particular there are issues over allocation policies, and the identification of suitable tenants to move into schemes when residents die or choose to move. Another issue that makes the provision of these communities more difficult in the UK is the much higher level of owner occupation, and the requirement for mixed tenure schemes in order to meet the needs of all members of the group.

6.7. There may also be a cultural reluctance in the UK to live in co-housing communities in general, including communities for older people and those for all ages. However, Brenton suggests that changes in demography and culture in the UK may mean that the 'soon-to-be-old' in the UK will have different expectations of later life, and may find this concept more appealing than the prospect of sheltered or extra-care schemes, where they would have no control over their neighbours or the environment in which they live.

Continuing Care Retirement Communities

6.8. The concept of continuing care retirement communities has largely been introduced from the USA, though there are forms of this provision elsewhere in Europe (Phillips et al, 2001). There are a limited number of such communities in the UK, with one well-known community near Aberdeen: Inchmarlo ⁸. In the UK they have been developed both by not-for-profit organisations (such as the Joseph Rowntree Foundation at Hartrigg Oaks near York), and by the private sector, such as at Inchmarlo. While private developments are generally more exclusive, due to the costs of entry, the concept and facilities appear to be similar.

6.9. The main feature of these developments that makes them different from other forms of age-specific housing provision is that they tend to be geographically distinct communities. They are also generally larger in scale than other housing schemes for older people: in the USA these communities can vary in population from several hundred to several thousand (Phillips et al, 2001). However, in the UK they are more limited in size, ranging from 120 to 320 units (Shipley, 2003).

6.10. These communities provide a 'home for life', with all buildings designed for wheelchair access, a range of care and support provided on site, as well as residential care for those in need. However, limitations were identified with this principle in the evaluation of Hartrigg Oaks, (Croucher et al, 2003), which noted that some residents with dementia type illnesses moved to more specialist provision outside the community. Depending on the size of the community, they also offer a wide range of community facilities such as café, library, gym, meeting and activity rooms, as well as health care facilities. Communal grounds can be extensive, providing a high quality setting for the community, maintained through management fees.

6.11. The segregation of these communities from the wider community, in terms of geography, age and income (due to the cost of living in such communities) has led many to criticise them (Phillips et al, 2001). In the USA residents in these communities tend to be white, well-educated, middle-class people, generally in the older end of the age spectrum at 75+ years (Croucher et al, 2006).

6.12. The exclusivity that is associated with this form of development was confirmed by the evaluation of Hartrigg Oaks (Croucher et al, 2003). Fees for care services were based on findings from research by the Joseph Rowntree Foundation (Garrido, 2004), as well as from existing models in America. A fee-pool (similar to a 'rent-pool' approach) was used. This pooled the resources of all residents, so that whatever the individual's future care needs become, they can be met without any additional charge. However, this flat-rate payment system (unique in the UK) assumes that residents are paying for their own care, as state funding would not match these fees for those with low intensity support needs. It found that one in five residents were struggling to meet the cost of living there, and concluded that the community would only be affordable to one in four of the UK population.

6.13. Nonetheless, the evaluation of the development at Hartrigg Oaks found that the residents were in general very satisfied with the community. The privacy, on-hand assistance, independence, facilities, and lack of crime were identified as being the best aspects of living there (Croucher et al, 2003). The neighbourliness, security and sense of community have also been identified as significant benefits of living in retirement communities (Phillips et al, 2001).

Flexible Tenure

6.14. The vast majority of specialist housing for older people is within the social rented sector. However, this pattern is changing with the increase in owner occupied sheltered housing, as described in Chapter Four. There have also been moves to increase the range of different tenure options open to older people. This has been most effectively achieved by housing associations, the voluntary sector and not-for-profit sector.

6.15. The Joseph Rowntree Foundation ( JRF) has played a major part in developing a range of different forms of tenure available to older people in a range of settings. They have also advocated an increase in the provision of private specialist housing, and have urged local authorities to include housing for sale in their provision strategies (Joseph Rowntree Foundation, 2004).

6.16. The Joseph Rowntree Memorial Housing Trust won the right to sell their properties for older people in 1982. Since then they have developed a scheme in York where properties can be bought on a shared equity basis, with the equity share ranging from 0% to 99%. There is also the option of staircasing up and (more importantly for older people) down, so that they can release equity if they need to. This is facilitated by the development of a 'float' fund, which can be used to purchase equity shares back from residents, and which can be supplemented by those wishing to buy more equity. (Oldman, 1990b)

6.17. Since the inception of this scheme, shared equity tenure has become much more common in housing for general needs, but is still relatively uncommon in specialist housing developments, partly because many are still owned by local authorities. However, JRF are encouraging local authorities to stimulate the market to provide more of this forms of mixed tenure developments.

6.18. Another example of where JRF have introduced flexible tenure is at Bedford Court, a development of 34 'close care' bungalows, a care home with 34 single rooms and four apartments. This is a small version of a retirement community, though its location in a village close to Leeds means that it is not as segregated from the wider community as many other such developments are. JRF have developed a system of bonds, so that residents can either rent their property, or buy bonds which reduce their rental costs, and which provide a rate of return when they are sold. (Garrido, 2004).

6.19. There are two forms of alternative tenure that are being actively developed by Communities Scotland:

• Homestake, which is a form of shared equity, as described above, based on the buyer purchasing 60% to 80% of the property, and a housing association owning the remainder of the equity. ⁹
• Mortgage to Rent, which provides a safety net for those at risk of repossession; a housing association buys the property, and rents it back to the owner(s) at a social rent. ¹⁰

Both these schemes were under development at the time of writing, and there was no additional literature or evaluation available.

6.20. Another alternative for older people living in their own homes is provided through equity release mechanisms. These enable older people in owner occupied properties to release some of the equity in the property to provide either a supplement to their income, or as a lump sum (for example, to pay for improvements to the property) (Leather and Terry, 2000). The research in 2000 found that there were just under 30,000 older people in Scotland for whom this form of tenure could provide funds that would cover the costs of improvements required to their home. However, given the substantial increases in property prices across Scotland since then, it is likely that this number will have increased.

6.21. This shift in ownership for those in need of additional income is only appropriate for those in their later years (80+); although they are generally available to people aged 65+, the level of income that is achieved after fees is generally not high enough to make it worth the expense ( FSA, 2005). There has not been any evaluation of the take up of equity release in Scotland or of the impact of the changing property market on its viability for older people.

Short-Term Provision Within Long-Term Facilities

Intermediate Care

6.22. The government focus on the issue of delayed discharge has led to the introduction of intermediate care and rehabilitation provided within existing sheltered or extra-care facilities. These services can also be extended to other older people in the community who may be in need of additional support for a short period, to overcome illness or other crisis, or to avoid admission to hospital or residential care (Parry and Thompson, 2005). There is some suggestion that the focus on delayed discharge has been at the expense of the very important preventative aspects of intermediate care, which can reduce the need for hospital admissions (Department of Health, 2005b).

6.23. These services are generally based on principles which encourage and enable clients to meet their potential for independence, rather than a task-based approach where staff do the jobs on behalf of the client. This is most effective if home care staff can also be involved in the approach, not just those in the intermediate care team, so that this approach can be continued following the return home (Parry and Thompson, 2005).

6.24. A case study of the implementation of such a service has been undertaken in the Royal Borough of Windsor and Maidenhead (Department of Health, 2005b). This provides an interesting model, with the intermediate care service using six flats within a mixed scheme of sheltered and extra-care housing. This flexible service provides a bridge between hospital and home, and an access route to other services. Some of the key features of this model include:

• The intermediate care service is part of a wider rapid response and rehabilitation team, with a range of multi-disciplinary staff. (They also provide short-term rehabilitation for people in their own homes);
• The eligibility criterion has been set at the need for at least 10 hours of support a week;
• Referrals come from GPs, hospital and community teams; there has been an ongoing process of educating professionals about the service and the appropriate client group.
• The service is integrated with the generic home care team, to facilitate a smooth transition for older people moving back home;
• The length of stay is normally around 6 weeks, though if a need for longer term provision is identified, clients can transfer to being long-stay residents of either the sheltered or extra-care service, or to an alternative local scheme;
• In particular, the service offers clients the opportunity to test their skills and abilities, test various kinds of equipment and adaptations that they can then use at home, allow time for home adaptations to be made, and also find out what it is like to live in sheltered accommodation.
• An initial 6 month pilot provided positive results, and allowed the confidence for the team to expand and develop.

6.25. A national review of intermediate care services (for all age groups) in England has been undertaken by the Department of Health (2005b). The full report for this research was not available at the time of writing (March 2006), but the summary of findings suggests that, while these services can take time to implement, there have been significant changes in the structure of service delivery and commissioning. This is combined with commitment from operational staff that has improved patient advocacy, needs analysis and inter-disciplinary working. Service users said that the service had made a significant difference to their lives, though the longer term outcomes varied significantly between individuals.

6.26. This research identified the core components that are required for a comprehensive intermediate care system:

• Service type, content and location specific to the needs of people in transition
• Mechanisms in place for referrals to on-going services at home or in the community
• Mechanisms in place for appropriate referrals to the service
• Skilled, multi-disciplinary team

A particular concern that was highlighted by this research was a lack of capacity and skills in this enabling approach in mainstream home support services, to follow on from the intermediate care. This issue of insufficient capacity also extended to the provision of equipment and adaptations and the provision of social support for older people.

Respite Services

6.27. Respite care has traditionally been provided in a residential setting, either in a nursing home, hospital or care home. It has been used to provide carers with a break, or in response to a crisis (Care Development Group Report, 2001). However, with the closure of residential care homes, this form of provision is becoming more difficult to provide.

6.28. There have been calls to increase the level of respite care provided, though there is also evidence that where this has been offered, it has not always been taken up. This may be because the service being offered does not provide the flexibility that carers require (Care Development Group Report, 2001).

6.29. As with intermediate care, there is a growing recognition that extra-care facilities can also be used to provide respite services. This, combined with increased funding from the Scottish Executive (Care Development Group Report, 2001), may expand the availability of this form of support, and the range of respite care available.

6.30. The provision of respite facilities does not directly impact on the provision of housing for older people, and is therefore rarely mentioned in the literature. However, it has two indirect impacts:

• Residential or extra-care places used for respite care are not available for long-term provision;
• Improved availability in respite care is likely to enable people to stay in their own homes longer.

6.31. With this in mind, the provision of respite care should be included in strategic housing and support service reviews, though at present the evidence that this aspect of provisioning is taken into account is limited.

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