Home Improvement Agency
Health and Housing
The right home environment is essential to health and wellbeing. It is a wider determinant of health.
There are risks to an individual’s physical and mental health associated with living in:
- a cold, damp, or otherwise hazardous home (an unhealthy home)
- a home that poses risks such as being overcrowded or inaccessible to a disabled or older person (an unsuitable home)
- a home that does not provide a sense of safety and security including precarious living circumstances and/or homelessness (an unstable home)
The right home environment protects and improves health and wellbeing and supports physical and mental ill health. It also enables people to:
- manage their own health and care needs, including long term conditions
- live independently and safely in their own home for as long as they choose
- complete treatment and recover from substance misuse, respiratory illness or other ill-health
- move on successfully from homelessness or other traumatic life event
- access and sustain education, training and employment
- participate and contribute to society
- delay and reduce the need for primary care and social care
- prevent hospital admissions
- enable timely discharge from hospital, and prevent re-admissions
Removal of hazards in the home not only supports the occupier, but also acts a stimulus to the local economy, promoting employment and supply chains.
Health and Housing MoU
Under the Care Act there is a requirement for closer cooperation of services that support the health and wellbeing of those who may be in need of care and support. An emphasis is placed on greater integration between health and social services to deliver more person-centred outcomes.
As part of a drive for more integration, a pioneering Health and Housing Memorandum of Understanding (MoU) between government departments, its agencies such as NHS England, Public Health England and the Homes and Communities Agency, was signed in 2015 by sector professional and trade bodies, including Foundations. Three years on, a new MoU was published in 2018.
Foundations provides the secretariat for the MoU - arranging and minuting meeting and providing the impetus for ingoing collaboration.
The MoU details areas of improvement where organisations will work together to:
- Establish and support national and local dialogue;
- Exchange information to support decision-making across government, health, social care and housing sectors;
- Coordinate health, social care, and housing policy;
- Enable improved collaboration and integration of healthcare and housing in the planning, commissioning and delivery of homes and services;
- Promote the housing sector contribution to addressing the wider determinants of health; health equity; improvements to patient experience; and
- Develop the workforce across sectors so that they are confident and skilled in understanding the relationship between where people live and their health and wellbeing and are able to identify suitable solutions to improve outcomes
Health & Housing Memorandum of Understanding 2018 (opens a new window) (Opens in a new window)
In May 2015, the Care Act passed into English law, and fundamentally changed the way in which social care is to be delivered. It replaces and amends a number of existing Acts, and enshrines the new statutory principle of wellbeing: a move away from providing specific services according to eligibility criteria, to a broader approach designed to meet an individual’s needs based their own circumstances. The wellbeing principle is rooted in keeping people independent for as long as possible, and in control of their own care pathway where it is appropriate for them to do so.
The Act is very much geared towards preventative services, and is clear that housing and housing related support is a key element of this.
Key changes include:
The principle of wellbeing
That a person’s needs may be influenced by a number of factors including their housing situation, financial arrangements, or links to their community. Local Authorities have a duty to promote wellbeing when carrying out their assessments, and there is an assumption that people know best what they need in order to live well. There are eight elements listed as contributing to a person’s wellbeing, all of which can be assisted through appropriate housing services: personal dignity, including respect; physical and mental health, and emotional wellbeing; protection from abuse and neglect; control over day to day life; participation in work, education, training or recreation; social and economic wellbeing; domestic, family and personal relationships; and suitability of living accommodation.
Assessment, including carers’ assessments
Local authorities have a duty to assess any person who appears to have any level of need for care and support. This is irrespective of whether the authority considers that the person may be eligible for help from them, and must assess their needs regardless of any assistance provided by an existing care arrangement (whether informal or paid for). A significant change is that this duty now also extends to carers, many of whom have needs of their own which have not been recognised previously. Reducing the mental stress and physical demands of caring for someone in their own home can have significant benefits to the carer’s ability to maintain their own wellbeing. Housing needs, therefore, including the need for repairs, adaptations, overcrowding, safety (including hoarding and cleanliness) and other aspects of the home environment, should be included in the assessment process.
National eligibility criteria
New eligibility criteria, which applies across the country, replaces the Fairer Access to Care Services (FACS) criteria under which care services were allocated previously. These are arranged around the person’s ability to meet a range of defined outcomes. Many of these outcomes are linked to the home environment. Some of these, such as maintaining personal hygiene, managing toilet needs, being able to make use of the home safely and maintaining a habitable home environment are clearly linked to Disabled Facilities Grants and adaptations, but others could also be improved through home based interventions: ensuring a kitchen is safe and hygienic for example, can help with preparing and eating nutritious food, and encourage improved relationships as people can cook for friends and family and will be less anxious about inviting people into their home.
Care planning and review
Where a local authority has a duty to meet eligible needs, then a care and support plan must be put in place (or a support plan for carers). This may include housing support or adaptations, and authorities are not expected to hold lists of ‘prescribed providers’. Everyone should have a personal budget as part of their care plan, some of which may be paid through direct payment, and people should be allowed to choose their own forms of support as they wish. This could allow local providers to develop new ways of meeting people’s needs outside the traditional routes funded through social care.
Care plan reviews must take place within 12 months, but can be carried out by the person themselves, their carer, a provider or another authorised professional. They are then signed off by the local authority. Caseworkers, for example, could be well placed to undertake this role if suitably trained. The review should be person-centred, should be used as an opportunity to ensure outcomes, needs and aspirations are being achieved, and to make adjustment where they are not.
This scheme allows people to move into residential care, without having to sell their home to contribute to the cost of the care they receive. The costs will, instead, be recouped when they decide to sell their home themselves, or will be realised from their estate when they die. The local authority will need to satisfy itself that there is sufficient equity in the home when the deferment agreement is made, so maintenance and repairs could be an important aspect of this calculation. If there is a spouse or partner remaining in the home, they may also find maintaining the home more difficult on their own, and Handyperson services, in particular, could offer a lifeline in these circumstances.
The Act outlines a radical reform of the way social care will be paid for in the future. The most important of these are the changes to the way people contribute to their care costs, including local authorities being able to charge self-funders going into care homes for their care costs (although this cannot be more than the local authority would pay), a strengthening of ‘top-up’ fees rules so that these must be arranged through the local authority, and from 2016/17, increasing the upper capital limit for care cost to £118,000, and imposing a cap on the amount someone has to pay towards their care costs of £72,000 (for people over retirement age). The second phase of the reforms has, however, currently been delayed due to concerns about the ability to implement them while the overall condition of the social care system is unstable.
Aids and minor adaptions up to the value of £1,000 should continue to be arranged and paid for by social care for eligible people.
The Care Act requires that local welfare authorities (County or Unitary authorities) co-operate and work with local housing authorities (district councils in two tier authorities), housing providers, third sector providers and private companies to produce a range of services to meet their obligations and help people stay well and independent in their own homes. Market shaping and commissioning is a major part of this duty. Promotion of innovation, quality and value for money are key to developing services which provide choice for customers while emphasising prevention, reducing isolation and enabling independence.
Commissioners should be aware of the market in their local area, and the business challenges faced by their providers. They must have an understanding of the financial implications of delivering quality services, and legislative demands on providers (for example, the introduction of the new Living Wage and pension reforms) taking care not to set fee regimes that are not sustainable for long term service provision, and which can lead to disruptive and costly reprovisioning and disruption to services.
The Department of Health and Social Care estimates that in England approximately 676,000 people are living with dementia Prime Minister’s Challenge on Dementia 2020 (2015) (opens a new window), and the numbers are set to double over the next 30 years.
The term dementia covers a range of symptoms and behaviours which are linked to a degeneration of the brain tissue and death of brain cells through disease. The main forms are Alzheimer’s disease, dementia with lewy bodies and vascular dementia. There are many other forms of dementia, however, and some other conditions and diseases may also lead to dementia, for example, Huntingdon’s and Parkinson’s diseases. Frontotemporal dementia (including Pick’s disease) is less well known but can affect people in their 40s and 50s.
Dementia is commonly understood to affect memory, but can also impair behaviour and emotional stability, affect language and understanding, and have a physical impact on other senses such as sight and taste. Some people can become aggressive or overly affectionate, or they can withdraw from friends and family, and regress into the past – perceiving carers or family members as strangers (because they don’t remember meeting them) or mistaking them for other people such as deceased parents or spouses.
Although the condition is currently irreversible, many people can stay at home and undertake everyday tasks for some time after diagnosis. Indeed, for some, attempting to move people from their home environment may increase anxiety. Home Improvement Agencies are well placed to help people stay at home for as long as possible, and adaptations to the home can reduce risk and anxiety for the person affected and their carers and families.
The Alzheimer's Society has published a booklet that describes ways to create or adapt the home environment so that it remains a safe and familiar place. Download (opens a new window)) Making your home dementia friendly. They have also produced a fact sheet (opens a new window) that looks at various pieces of equipment and parts of the home that can be adapted for people with dementia.
Age UK Scotland have produced a guide for carers of people living with early stage dementia, on how to create a dementia-friendly home.
Dementia Dwelling Grant
A number of local authorities have introduced new grants into their Housing Assistance Policy to support people with a diagnosis of dementia. A great example is the Dementia Dwelling Grant (opens a new window) which was introduced across Worcestershire and externally assessed by the University of Worcester.
Evaluation of the Dementia Dwelling Grant (Opens in a new window)
Dementia does still have a stigma attached to it, although that is now changing. However, special care should be taken when dealing with people with dementia, and Dementia Friends training (opens a new window) can help Caseworkers, Technical Officers and contractors who come into contact with people with dementia understand some of the challenges that they may face.
Enabling People with Dementia to Remain at Home: A Housing Perspective
Published to coincide with World Alzheimer’s Month , this report has been produced on behalf of the Dementia and Housing Working Group (opens a new window) and Housing LIN (opens a new window), and supported by Homeless Link (opens a new window), Foundations and the Life Story Network (opens a new window).
The full report (opens a new window) and the accompanying executive summary (opens a new window) set out the key role housing providers, and in particular social housing providers, can play in supporting people living with dementia to stay independent in the home of their choice for as long as possible. Its findings are divided into ones directly relevant to those working in the housing sector and those that provide a platform for wider application; for example, to become more dementia-friendly.