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Chapter eight Moving Forward
8.1. This chapter aims to draw together the key issues arising from the literature review that might benefit from further consideration or research by the Scottish Executive, by identifying gaps in research or identifying a need for follow-up or evaluative research that would update the body of knowledge in this field and facilitate more informed political decision-making. It will broadly follow the structure of previous chapters for ease of referencing.
Gaps in the body of existing research
8.2. Demographics (pages 16-18)
The statistics of ageing are well covered in the literature. However, there has been less investigation as to what impact these will have in terms of absolute demand for different forms of housing, tenure and care in Scotland. In particular a clearer understanding of changes in healthy life expectancy would help to predict future changes in demand for age specific services.
8.3. The demographic changes suggest that there will be a change to the gender balance among older people in Scotland. The lack of existing evidence relating to gender differences in housing preferences and access means that it is difficult at present to predict what impacts this change will have on the demand for and provision of housing for older people.
8.4. Housing Preferences (pages 18-19)
There is considerable evidence relating to the housing preferences of older people, including some research in Scotland, and much of the research undertaken in England is likely to be applicable to Scotland. It may, however be instructive to investigate if there are any differences between the preferences of older people in urban and rural areas.
8.5. Deciding to move (pages 20-21)
The evidence relating to the decisions of older people is an area that has been thoroughly investigated in the literature in England, and investigations by local authorities in Scotland are likely to provide a local context for this evidence. In taking this area of research forward in Scotland it may be interesting to consider the pathways approach to housing decisions, as described by Clapham (2005). This provides an interesting tool in understanding the longer-term implications of peoples' housing decisions. In particular this could be a means of investigating the longer term impact of the significant recent changes in tenure.
8.6. Poverty (page 22)
The research that has looked into the financial circumstances of older people is unanimous in identifying the link between older age and lower incomes. However, there has been a significant input from central government to reduce the difficulties that older people face in relation to fuel poverty and care and repair. It may be instructive to follow up the recipients of this programme, to investigate the impact it has on them over the longer term, in particular in their housing choices. This would help to identify the overall impact of these schemes in facilitating older people to remain in their own homes.
8.7. Older people in rural areas (pages 22-23)
Provision of services in rural areas face particular challenges. The evidence to date comes from both England and Scotland, with research at the local authority level in Scotland providing some interesting recommendations. Williams (2001) suggests that improvements to home based services would be more effective than the provision of specialist housing in meeting the needs of older people in rural areas. However, he does not investigate the logistical implications of this suggestion, or the viability of expanding these kinds of services to enable older people to stay at home. This proposal would have significant challenges in terms of delivery and staffing arrangements across wide areas. This is an area that the Scottish Executive or specific local authorities may be interested in exploring.
8.8. Poor private sector housing conditions are a particular problem in rural areas. These areas may therefore be appropriate for focusing efforts to inform older people of the services available to them in relation to care and repair, equipment and adaptations and improved heating provision. While the Scottish Executive has made significant improvements in these areas, there are still likely to be some 'hard to reach' older people who are unaware of the opportunities available to them. A focused approach to disseminating this information may assist the Scottish Executive in meeting its longer-term aims.
8.9. Minority groups (pages 23-26)
There has been relatively little research on the housing options and associated care services available to older people from ethnic minority groups in Scotland. Evidence from elsewhere in the UK and from Europe indicates that this is an area in which there is still a perception of information gaps, and lack of a clear policy framework that spans all relevant policy areas and all levels of government. European research also suggests that there is work still to be done on improving relationships between local authorities and representative bodies at local level.
8.10. The literature to date has also not considered the impact of rural issues on older people from ethnic minority groups in Scotland. The limited evidence in relation to this group may warrant further investigation, including the anticipated growth in this group over the next few decades.
8.11. If there has been little research on the housing options and associated care services available to elders from ethnic minority communities in Scotland, there has been even less in relation to other minority groups such as lesbian, gay, bisexual and transgender (' LGBT') older people. The ODS / Stonewall Scotland report (Communities Scotland, 2005) raised a number of substantive issues regarding housing and care options for this group, and it is not yet clear to what extent, or by what mechanism, they are being addressed.
8.12. Care at home (pages 28-31)
The provision of care at home is highly dependent on Supporting People and free personal and nursing care funding and organisation. There have been calls for increased direct payment of these funds, to enable older people to have a greater say in the services they receive, and who provides them. However, this has associated difficulties for the older person, taking on the role of care co-ordinator and employer. This is an area which warrants further investigation in relation to whether older people in Scotland would like to have improved access to this form of delivery, what the barriers are in terms of accessing services and delivery, and how do these vary across Scotland, what regulation could be developed to reduce possible abuse of this system, and what are the experiences of those who have already used direct payments. This is an area where research could benefit a wide range of service users, with older people being a key group.
8.13. Another area for possible future investigation lies in the provision of low intensity support, and its role in preventing dependency. The statistics suggest there have been changes in this form of provision in recent years in Scotland. The introduction of Supporting People is likely to have had an impact on this, and local Supporting People reviews may reveal qualitative as well as quantitative changes to delivery and impacts.
8.14. Property Based Services (pages 31-33)
There has been substantial progress made in relation to the improvement and adaptation of homes for older people. The key question that remains is how to identify those properties still in need of improvement, and how to target information at those who would most benefit. This is closely linked to the issue of information dissemination for rural areas.
Sheltered housing (pages 33-36)
8.15. Our review of the research into sheltered housing identified the difficulties that these schemes have experienced, as well as the various options that have been identified to deal with some of them. One issue that has been identified in relation to sheltered, extra-care, and alternative models of housing provision, is the need for a mix of residents in terms of their age and ability. Beneficial research could investigate how best to achieve this mix, what level of mix is required to achieve increased social interest, and an assessment of whether this is realistic.
Private sheltered and retirement housing (pages 37-38)
8.16. The increase in the provision of private sheltered accommodation in Scotland raises a number of issues. There has been no research done into who is choosing to move into this form of accommodation in Scotland, and whether the provision of services meets their needs and expectations.
8.17. Concerns over private renting in private schemes following the introduction of the Title Conditions (Scotland) Act 2003 appear to be unfounded. However, this is an issue which may be worth re-visiting or monitoring as private provision increases. Also of concern for the future may be how planning policies relating to the provision of affordable housing are implemented within sheltered housing development. This may require local authorities to prove the need for affordable housing for older people and to develop policies that apply to this particular form of development.
Extra care housing (pages 38-43)
8.18. The benefits of extra-care as a form of provision for older people in need of support are clear from the wide-ranging research that has been conducted. However, the cost efficiencies of this form of care over residential care are not clear, and the findings of research to date are contradictory. This may partly be due to the differences in funding structures in England and Scotland, and the changes that have occurred in relation to Supporting People funding. Given the emphasis on this form of provision as an alternative to residential care, it may be instructive to investigate the absolute costs of extra-care, and compare these to both residential care and intensive care at home.
Assistive technologies (pages 45-46)
8.19. Our research identified only two specifically Scottish bodies of research into the application of assistive technologies in the homes of older people - the West Lothian 'Telecare' project, and the 'Home Comforts' pilot project in South Ayrshire. Both projects are being evaluated by the University of Stirling, but the results are not yet known. Given the potential benefits that such technology is capable of delivering to older people, and the costs associated with developing smarter homes, we would suggest that further evaluative research on assistive technologies in the homes of older people would be beneficial.
Delayed discharge (pages 47-50)
8.20. The issue of delayed discharge from hospital is receiving significant policy and research attention as part of the Joint Future and Essential Connections initiatives. It is also an area that has been allocated a substantial sum of money over the next few years; for this reason, we would suggest that the formative evaluation of the impact of these programmes, particularly on the effectiveness of joined up working arrangements, in reducing delayed discharges from NHS care in Scotland would be a useful research focus.
Dementia care (pages 50-52)
8.21. Our literature search has revealed a relative lack of research into the housing options available to dementia sufferers in Scotland. There is new research covering operational aspects and good practice in providing housing and care services for dementia sufferers; however it is likely that there is a complex interplay of factors involved in the process of making decisions regarding housing and care in this situation, and this aspect is still relatively under-researched. The existing body of research appears to suggest that the organisation of services for sufferers and their carers, particularly an ongoing lack of integration of health and social care services, combined with funding issues, all play a role in that decision. We would suggest that this would be an appropriate area for further research to elucidate the interplay of factors influencing the decision, in order to better meet the housing needs and preferences of dementia sufferers.
Co-housing models (pages 53-54) and continuing care retirement communities (pages 54-55)
8.22. These two models of provision are beginning to play a role in the housing options available to older people in Scotland. While the take up of these models is likely to be limited in scale, the development of these options provides a clear means of expanding the choices open to older people. In this regard, there may be scope for identifying guidance for those wishing to develop such schemes. This would be particularly important for groups thinking of developing co-housing communities. However, an initial consultation with the group working in Fife would be instructive, to identify the barriers they have encountered, and the possible scope of the guidance.
Flexible tenure (pages 55-56)
8.23. The various different tenures available to older people are an important means of providing choices, particularly for those older home owners who want to move to sheltered or extra-care housing. The availability of shared ownership and shared equity schemes may be a means of attracting a greater mix into sheltered and extra-care schemes. Research may be useful to identify the scope for increasing provision of these tenure options, including consultation with providers to identify any barriers from their perspective.
Intermediate and respite care (pages 57-58)
8.24. The recent focus on delayed discharge has led to the improvement of intermediate care in England. There are suggestions that the provision of both intermediate and respite care are receiving attention at the local authority level in Scotland. However, there has been limited research done into provision at a national level, and the development of benchmarks may provide a measure against which local authorities could compare their levels of provision.
Local Authorities (pages 59-61)
8.25. The work at local authority level is at present focused on reviews of home care, sheltered and extra-care provision under the Supporting People programme. These will feed into strategy reviews, and may provide a link between the existing community care plans and local housing strategies. However, there is a need to draw together the strategic issues relating to older people, to ensure that different forms of provision are working to the same goals. Following on from the present consultation exercise, the development of a national strategy for older people will be a useful step towards more localised strategic integration.
8.26. In developing these strategies, a more complete understanding of the housing needs of older people would also be informative. This is an issue which could be addressed through guidance relating to the housing needs assessments which are already carried out by local authorities as part of the local plan development process.
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