Official Report (Hansard)
Date: Wednesday, 11 June 2014
Committee for Health, Social Services and Public Safety
Review of Transforming Your Care and Older People: Department of Health, Social Services and Public Safety, Department for Social Development, Health and Social Care Board and Northern Ireland Housing Executive
The Chairperson: Folks, you are all very welcome. We have Seán Holland, deputy secretary of the Department of Health, Social Services and Public Safety; Michael Sweeney, acting director of mental health, disability and older people's policy; Fionnuala McAndrew, acting chief executive of the Health and Social Care Board (HSCB); Stephen Martin, deputy director of housing policy delivery in the Department for Social Development; and Brian O'Kane, acting assistant director of strategic partnerships in the Housing Executive. Again, you are very welcome.
The Committee wants to discuss some key areas and issues with you today; we want to work through each issue in turn. We want to use this as an opportunity to understand the position of the Health Department, and indeed the Department for Social Development, on the issue before we make any recommendations in our report. We would welcome open and constructive debate, which we normally have.
I ask you to make a short opening statement. Then, we will open it up to members.
Mr Seán Holland (Department of Health, Social Services and Public Safety): Thank you, Chair, for the opportunity to give evidence on supported living for older people. I am aware that the Committee was disappointed that we were unable to give you answers to some of your questions in the previous session on 26 February. You have subsequently written to the Department, and we have provided you with further information on a few occasions. Today, I am joined by Michael Sweeney, Fionnuala McAndrew, Stephen Martin and Brian O'Kane. I think that the number of witnesses whom we have brought today reflects the range of roles and responsibilities across government with regard to supported living.
I am aware that one of the main issues for the Committee to date has been a definition of supported living. The Minister's letter to the Committee dated 28 April advised that the definition was under review. The DHSSPS, the Health and Social Care Board and the Housing Executive met in April to discuss the scope of the definition. As members will be aware from Professor Tinker's evidence, there is no agreed, fixed definition in UK law, but we are trying to reach a common understanding as to what would be a useful definition of supported living.
As set out in the briefing paper that we shared with you at the end of last week, we consider "supported living" to encompass a range of health and care provision, health-related adaptations, housing accommodation and housing support services that are designed to help vulnerable people to retain their independence in their community.
Supported housing is one key supported living option. It relates to accommodation that is provided for vulnerable people who require housing support and/or an element of care, and is intended to help individuals to lead as independent a life as possible in their own homes. Supported housing can vary in type and nature and can be designed to meet very different levels of need. I believe that that might have been the cause of confusion in our previous evidence session regarding the extent of provision of supported housing. The Committee was advised that there were 414 schemes for older people, while the health and social care trusts, at a subsequent session, indicated a much smaller number. If I may, I will take the opportunity to clarify that those 414 schemes represent the entirety of supported housing schemes for older people in the social rented sector.
Sheltered housing, which is managed by the Housing Executive and housing associations, makes up the majority of the 414 schemes and is intended for people who remain relatively independent but who may, from time to time, need to avail themselves of support, which is normally available from a scheme supervisor or — some people might be familiar with this term — a warden associated with such a scheme. It should be noted that there have not been any new developments in sheltered housing for some time.
In recent years, trusts have identified a need that is more specialist in nature. Given that, the focus for newbuild social housing for older people has been on frail elderly schemes. The facilities, which the trusts report on, are designed for people who need greater levels of support to remain independent. That includes help with personal care and tasks such as dressing, eating and bathing, all of which are provided or arranged by Health and Social Care (HSC).
There are 18 schemes in Northern Ireland, two of which — Cedar Court in Downpatrick and Hemsworth Court in Belfast — have been completed during the comprehensive spending review period. Planning for such supported housing schemes takes place within three- to five-year periods, with the current period ending in March 2016. The number of proposed developments is driven by trust assessment of demand as part of ongoing service delivery. In the current planning period, there are plans for a further seven facilities, one of which is Cuan Court in Ards, which is scheduled to be ready at the end of this month. We believe that the process has worked well over the last number of years, but we recognise that there may be the potential for a centrally established target to drive the number of future developments, and that is why we have established an indicator of performance for supported living for older people this year.
Notwithstanding the need for an agreed definition, we contend that the central purpose of supported living is commonly understood. Similarly, we are of the view that the roles of respective stakeholders in the Supporting People programme are understood, as outlined in your paper. To summarise, trusts have a responsibility for identifying need for new supported housing and developing business cases, which are then considered through the Supporting People commissioning arrangements. Trusts also provide funding for any social care required for tenants of supported housing schemes.
DSD, through the Housing Executive, provides grant funding of up to 70% of the build cost to housing associations. Housing associations then project-manage the construction of supported housing schemes for social rent and become the landlord of the scheme once it has been built. Housing associations then either manage directly the housing support services to tenants or contract those out to specialist support providers, usually in the voluntary or community sectors.
The Housing Executive, through the Supporting People programme, provides funding for housing support services, including those using supported housing. Those services are designed to help people to develop the skills and confidence necessary to live independently without support or to maintain independent living with ongoing support.
At the beginning of the year, the Minister of Health and the Minister for Social Development met officials and the Northern Ireland Federation of Housing Associations (NIFHA) to discuss the future of supported living for older people and other client groups. The Minister subsequently asked officials to arrange a workshop in February with key stakeholders, including both Departments, the HSC Board, each trust, the Housing Executive and representatives from the Federation of Housing Associations. The workshop was very helpful in identifying a number of areas where improvements could be made, some of which are listed in your briefing paper.
Both Departments are in discussions with potential funders. We are driving a number of projects on supported living for older people, although we are not in a position to discuss the detail of the funding arrangements at this time. However, if we can secure the funding, the work would include a project to identify and develop appropriate future models of supported living for older people, including those with dementia, and people with physical disabilities. That work would take into account factors such as geography, needs, including care, affordability and assistive technologies. It would also include an assessment of whether existing models, particularly sheltered housing, are being used effectively and for the purposes intended. The study would also highlight situations or client needs for which supported living is not appropriate.
There would also be a project to identify any lessons learned from legacy or existing supported living schemes. A small number of such schemes have run into financial difficulties due to places being unfilled; "void" is the common term for an unfilled place over a sustained period.
The purpose of the project will be to identify and share lessons learned from the commissioning, design, construction and operation of these schemes with a view to identifying how they can be made sustainable over the medium term and pinpointing lessons for future development. Finally, we will be piloting a supported living champion to promote the benefits of supported living.
Success in securing funding for these projects will enable us to address many of the concerns raised by stakeholders throughout the process initiated by Ministers as well as build on learning from the Committee's investigation.
The Chairperson: Thank you for that, Seán.
Mr Gardiner: Thank you for your presentation. How many, in your words, "older people", although I prefer the term "senior citizens", can live in a supported living environment and how many are too frail or too much in need of constant medical care to do so? Does that vary between board areas?
Mr Holland: The number of people in supported living varies between trust areas, but I would not say that the definition is purely on the basis of frailty. As we said when we attended last time, two components will determine where someone lives in these schemes: the first is an assessment of their need; the second, and most important, is choice. It is a combination of those two factors, which is why exact projections can be difficult. You have to account for those whose needs could be met by supported living as well as the number of people who would chose to live in supported housing. Obviously, that varies from person to person.
Mr Gardiner: So, can you not give me the figures? Does the number of senior citizens vary between board areas?
Mr Holland: There is a variation in the numbers of people in supported living —
Mr Gardiner: Do you have those numbers?
Mrs Fionnuala McAndrew (Health and Social Care Board): The number of people in a supported housing —
Mr Gardiner: — environments. How many are too frail or too much in need of constant medical care?
Mrs McAndrew: It is important to say that a range of services is provided, so those who need constant medical or nursing care would be assessed as needing nursing-home care. We have roughly, off the top of my head, 5,000 places in nursing homes across Northern Ireland. I would need to add up the number of places in supported housing in order to give you the number of people living there, but I think that the number of supported housing places that we have was given in your briefing paper.
It is down to the definition of need, and, overlaying that, the number of older people who might be living in a locality, a ward area or trust area, and the projected shift in the number of people who might live there in future. There is a continuum of care need that needs to be addressed, and that is the purpose of the planning process: to make sure that we have that range of services available.
To briefly pick up on Seán's point, one of the key issues about community care over recent years is that we discuss their care needs with people and they have some choice in how their care needs are met and delivered, where possible. There has been a trend where people prefer to stay in their own home or they prefer to live in an environment such as a fold where they have their own front door and self-contained accommodation. However, knowing that there is a shifting and ageing population and that long-term conditions are increasing, the likelihood is that that cohort of people will mean that we need to have 5,000 nursing care places to be available in the future.
Mr Gardiner: You cannot tell me how many are in each bracket, that are living in —
Mrs McAndrew: I can tell you, but I do not have the cumulative figures in front of me
Mr Gardiner: Maybe you could send them.
Mrs McAndrew: I can send that to you.
Mr Gardiner: Thank you.
The Chairperson: Specific themes came out of the work that the Committee was doing. One of the key issues, which you mentioned, was definition. I think that Roy wants to lead on that.
Mr Beggs: The trusts and the Northern Ireland Federation of Housing Associations (NIFHA) indicated that they believe that there is a very clear definition of supported housing.
The definition in common use was that such housing was where there were supported living facilities for older people whose facilities were commissioned on the Supporting People programme. It is very clear. I am just trying to understand how that definition has suddenly changed.
Mr Holland: I do not think that it has "suddenly changed". It is important to bear in mind that there are different types of definitions. You can have a very strict definition set out in legislation, which would clearly define entitlement or a legal description. There is no such definition relating to supported living or supported housing. I think that the other kinds of definitions are what people generally understand to be the case to describe it. What you have given is a definition that they believe clearly describes it. I would not question that. I think that there are other elements that you could include or exclude from that definition, and that is what the current discussions are around: what is a good, working definition that everyone could commonly agree on? Substantively, we have provided you with this in the briefing material. There is agreement on what the core elements of supported living and supported housing are. Would my colleagues from DSD like to add to that?
Mr Stephen Martin (Department for Social Development): Yes. In the housing strategy, 'Facing the Future', the definition that we have given you is the definition that we use. "Supported living" is an umbrella term for a range of services aimed at supporting people to live independent lives. One element is supported housing, but there are others, as Seán mentioned, such as adaptations and so on, which support people to remain in their own home. I do not think that the definition that we have given is at odds with the definition that the Federation of Housing Associations has given or the trusts or, indeed, with that of Professor Tinker who, I believe, gave evidence to you fairly recently on what she calls "extra care" schemes or what we have referred to as "the frail elderly" schemes, because that is what we call them, and sheltered housing is for those with lower support needs. Different terms are sometimes used, but we are all talking about the same thing, and we have a common understanding across our Departments and organisations. I do not think that it is at odds with what you have been told before today.
Mr Beggs: When you change the definition it starts to cause confusion. That is my view, and I think the view of the public, certainly locally. You are aware that Barn Halt is a major supported housing scheme in my constituency, there is other supported housing at Lisgarel, and there are a number of sheltered housing accommodations. That terminology will be all mixed up if this is put into play and bought into. What was the purpose of changing the definition? How can the Committee have confidence in the Department? How can the Department give trusts a clear policy direction in the area when, before the review began, it was working to a completely different definition of supported living than they were?
Mr Holland: I do not think that we are changing the definition, and I do not think that there has been a fixed definition prior to this point. As I said, there are some situations where you have a fixed legal definition, and sometimes those mirror phrases that are in common usage. I will give you an example. If I were to use the phrase "children in need" to you, I am sure that you would have an understanding of that; most people would. There is also a very strict legal definition of a "child in need". The position with "supported living" and "supported housing" is that there is not a strict legal definition; there is a common understanding of what they mean.
The work under way is to see whether we can make sure that we can reach an accepted definition that everyone finds useful, but I do not think that there is any significant evidence that the absence of a fixed definition is causing any difficulties. Indeed, Professor Tinker made that very point when she gave evidence to you.
Mr Beggs: It gives me the impression that you are trying to change what is commonly known "supported housing" to a new definition "frail elderly" schemes. How easy do you think —
Mr Holland: No.
Mr Beggs: You are now referring to what people commonly know. Under the supported housing programme, you are now referring to them as "frail elderly" schemes. Is that correct?
Mr Holland: We would consider "frail elderly" schemes to be one possible expression —
Mr Beggs: Right
Mr Holland: — for supported living.
Mr Beggs: So what was previously known is "supported housing" will be relabelled "frail elderly" schemes. Is that correct?
Mr Martin: May I clarify? There are many types of supported housing, and for older people there are two main types. There is sheltered housing that many people know as folds, which have been around since the 1970s.
Mr Beggs: Sorry, I contacted the Housing Executive and asked whether there was any supported housing in Larne, and it tells me "no". It told me that there is sheltered housing in Larne, but there are vacancies; we have no supported living in Larne. So how can you say what you have just said? Please explain.
Mr Brian O'Kane (Northern Ireland Housing Executive): Stephen was making the point that there are two main types of supported accommodation. There is sheltered accommodation, which most people tend to refer to and understand as folds. So, there is provision of sheltered accommodation in the Larne area.
In terms of supported accommodation and the frail elderly, there is not a service or project in Larne like Barn Halt and what will hopefully happen in Greenisland in the near future. I do not want to speak for staff in the Larne area, but my sense is that they are referring to what they understand to be sheltered accommodation. There is common parlance for, as John said, what they understand that to be. It would commonly be referred to as "a fold", even though there may be other housing associations delivering sheltered accommodation.
The issue for us is defining and understanding what the frail elderly service is, because Barn Halt, and, hopefully, the services at Greenisland that we plan to develop in the near future, will be different from sheltered accommodation.
Mr Beggs: Surely, in the past that would have been referred to as "supported housing"; that seems to be being relabelled as a "frail elderly scheme". How easy will it be to convince an older relative to go into a frail elderly scheme as opposed to a supported living scheme? How easy do you think it will be with that label?
Mr Martin: It is probably an unfortunate term.
Mr Beggs: It is a very unfortunate term.
Mr Martin: It is an unfortunate term. It is common parlance in the housing world among housing professionals, but I take your point. We thought that Professor Tinker's definition of extra care housing was quite useful. We are talking about the same thing, but the terminology is probably unfortunate.
Mr Beggs: Finally, a number of older people in supported living facilities are treated and contained under the HSC's 2014 indicators of performance direction. What exactly are the trusts measuring?
Mr Holland: The trusts know the number of schemes.
Mr Beggs: Which schemes? I am trying to be clear about what are they measuring at present.
Mrs McAndrew: We will be measuring the 18 supported living schemes.
Mr Beggs: OK. So, that is different from what you are actually talking about with this new definition. Is that correct?
Mr Holland: The new definition includes those schemes. We have not actually arrived at a new definition. As reflected by the difficulty that you found when you contacted the Larne Housing Executive, we are trying to work up a definition that everyone would agree on and understand.
Mr Michael Sweeney (Department of Health, Social Services and Public Safety): We had hoped that the definition that we provided in the briefing would have been helpful, but, as was said earlier, "supported living" is a generic or umbrella term. In the briefing, we detail underneath the various types of support provided by the frail elderly schemes. It is just a good working definition in the absence of an academic or legal or one.
Mr Beggs: It will cause problems for those who wish to use the service. Under future projections for supported living places, you have included those listed in the three-year Supporting People programme. Are there no sheltered housing programmes planned within the three years if you have come up with this new definition?
Mr O'Kane: In the briefing, reference was made to the current comprehensive spending review (CSR) period. The focus, despite the definition issues referred to, has been on the frail elderly, Barn Halt and the Greenisland service. We have not planned to commission any new sheltered accommodation, but it is something that we are talking to the federation about.
We are looking at the future planning cycles coming out of it and some of the work that we referred to and that Seán referred to. We want to look again at the future role of sheltered housing.
The important thing from a service perspective, and I take your point about the customer — the older people themselves — needing clarity about the offer. So, we take your point about the confusion of the other issues, but we have been focusing on developing Barn Halt and the higher level of delivery that goes with those services that you would not get in a traditional sheltered scheme.
Mr Beggs: Can you understand why I am getting confused when you do not even apply your own new definition in the document that you provided us with?
The Chairperson: Just on that, for clarity, are you saying that the definition is still being reviewed, Seán?
Mr Holland: Yes, there is work ongoing. People are coming together to ask, "What do we commonly understand to be supported living and supported housing, and can we agree a definition that encompasses it?"
Meanwhile, it is worth noting that in the Departments and agencies, the absence of a fixed definition has not arisen as a difficulty in working together.
The Chairperson: Do you not accept that it becomes a difficulty when we hear evidence from the trusts about 18 facilities and evidence from yourselves about 414 facilities?
Mr Holland: I do not see that as a difficulty. The trusts are reflecting the schemes that are likely to require intensive personal care services because of the needs of the individuals living in them. The broader definition includes housing schemes that, although they provide a degree of support, do not require intensive support for people requiring personal care.
The Chairperson: Let me put it a different way. In the absence of an agreed definition, there is a performance direction that has been issued by the Department. That is a legal document.
Mr Holland: That is a performance indicator that relates specifically to that part of the supported housing market that we are heavily involved in, which are schemes where people require intensive personal care. We have no need or interest in issuing a performance indicator related to supported living situations where the support is not provided by —
The Chairperson: Sorry. Fionnuala just outlined, in answer to Roy's question, what is being measured in the 18 facilities.
Mrs McAndrew: Under that performance indicator.
The Chairperson: What about the 414?
Mrs McAndrew: I think, Chair, that it is about how care is provided. In the 18 supported housing arrangements, or whatever we call them in future, we make direct care provision. It is part of the design of the service that the trust is providing the care hours into that facility. Under the sheltered accommodation, which is the old fold definition, any care that is required — not everybody living in a fold will require care services — is provided in a different way. That would be provided as a domiciliary care service if it is required into the individual living in fold or sheltered accommodation. So, from our purposes when we are counting, and I know that it is just about how we count things, there is a clear difference in how we provide the care that leads us to separate out the 18 supported living arrangements under the performance indicator that we have from the Department from any domiciliary care service that we might provide into sheltered accommodation. That is covered in our overall domiciliary care figures.
Mr Holland: Indeed, there are people living in sheltered schemes where the only support that they receive will be from the on-site supervisor or warden, so we will not be performance-managing that at all. That is a service that we are not directly inputting to.
The Chairperson: I suggest that, if the Committee cannot have confidence in the Department's policy direction on the area when before the review began it was working under a completely different definition of supported living than where we are at now. I suggest to you that we will come back to this. It is certainly causing confusion. If we do not have an agreed definition, across both Departments, what hope is there for forecasting planning, strategic direction and the wider community with all the issues that you raise about choice?
I want to move on to the theme of awareness and the promotion of supported living. Pam and Gordon indicated that they wanted to lead on this.
Mrs Cameron: Thank you for your presentation today. As a Committee, we have obtained evidence that there is a lack of awareness of the option of supported living for older people, both among older people themselves and the public at large. When departmental officials were questioned about the promotion aspect of supported living, they stated that people become aware of it once they come into the system, either via the Housing Executive for people already in social housing or through a social worker. For people who are having their health needs assessed, the Department did not seem to see the need to promote the concept of supported living more generally and to the public at large. I am sure that you will agree that it really is much better for our older population to be prepared for those later years and to have the knowledge and awareness of any schemes that are or will be available to them for that time of life. On the back of that, I have a few questions. The Committee has also spoken to key stakeholders in the age sector such as the Older People’s Commissioner and Age NI. They told the Committee that there is not a wide awareness of what supported living is among older people. What can the Health Department or other Departments do to change that?
The Northern Ireland Federation of Housing Associations stated that there is a lack of awareness and suggested a champion for supported living. What are your views on that suggestion?
Mr Holland: The evidence that was presented the last time still holds, in that, for many people, the point at which they will want to know about supported living is the point at which their needs are being assessed. My expectation is that, when that is happening with a social worker or a housing officer, all options will be discussed, including supported living.
I am aware of the federation's proposal for a champion for supported living, and, as I said in my opening statement, we have taken that into account, along with comments from our last appearance at the Committee, and we have now identified that as a proposal for which we are seeking funding. We are in the process of trying to negotiate funding across the range of projects that I outlined, one of which is to establish a champion for supported living who could take on that broader role of publicising the option and benefits of supported living, both to the community and to other stakeholders.
Mr Martin: Research was done on two cohorts by the Housing Executive, which the Committee might find useful. The University of Ulster did research a couple of years ago that focused on the housing needs and aspirations of the current older generation or senior citizens. That focused on the fact that people said that they wanted to live in their own homes for as long as possible.
We then commissioned, along with Housing Executive colleagues, a piece that looked at the next generation, those who are currently in their 50s or early 60s — the so-called baby boom generation — many more of whom are homeowners than the current generation of senior citizens. That fairly small survey — the sample was of only around 400 people — showed that people had not thought about housing options for their older years. They were not particularly interested in advice at this point, but, as Seán said, they wanted advice closer to the point at which they had to think about it. Many more of them wanted to stay in their own homes for longer. If it would be helpful, we can send links to that research to the Committee, but it reaffirms some of Seán's comments.
The work that our organisations led resulted in the proposal from the Federation of Housing Associations for a champion for supported living, and we are now working together to try to secure the funding to make that happen.
Mrs McAndrew: From a health and social care perspective, I believe that the older population should be fully informed about the range of opportunities as they move through different periods of their life into old age. As a consequence of that, work has been ongoing in the health and social care trusts to get more information. We have developed DVDs setting out the range of services that people might expect to find if they are living in a particular area. That includes the Supporting People programme. Some of our residents who live in Supporting People units are also involved in that process.
Mrs Cameron: It strikes me that, just as we are all much more aware of pensions and taking more responsibility for ourselves in the later years of life, this issue needs to come up earlier. Awareness needs to be put out there.
We recently visited the Pavilions in Lisburn, and, although it is for a limited market of people who would provide for themselves, it still generated a lot of thought and discussion about how people are going to live out the next number of years of their life. It is a good idea to impart the information to people and even to give them ideas of how they could provide for themselves, especially given the increased burden on the health service in particular, which will increase in the future because of the growing number of elderly people in society.
The Committee has been made aware that there are vacancies in supported living facilities across the trusts. Is that a concern for the Department?
Mr Holland: Yes, I think that it is a concern for both Departments, but it needs to be kept in perspective. In any local scheme, there may be some vacancies and some people on a waiting list, but if you step back and look at it regionally, you see that the number of voids is not significant, and nor is the number of people waiting, as far as I am aware. Retaining the confidence of housing associations for future builds is an issue, because, while the numbers might be small and the number of voids is not significant in the overall planning, for an individual housing association or individual scheme, the voids are significant.
Mr O'Kane: It reflects a number of the Committee's points about getting education awareness out there. It relates to the proposals that we are looking at on the scale and size of models, particularly outside large urban areas. It is also reflects Fionnuala's point about giving people choices. We need to be smarter going forward in informing older people so that they can make choices for their future.
By and large, the 18 schemes that we recognise as supported living for older people are working well and have a high level of occupancy. Some new schemes tend to take a while to get up to full occupancy, but they do so for valid reasons. One or two services in Fermanagh — I think that this is well documented and we have had reference to it before — have a large number of unfilled places. We are looking at that and are actively working with the housing association and the Western Trust to find a positive solution.
We recognise that we need to do more work on the three proposals that we set out in the briefing about what we want to do. We want to learn from the lessons of those legacy schemes, what went wrong and what we can do better. Some of that is about providing information and education, and promoting the service. It is also about looking at what is the right model when we get into more remote areas or areas where there is a large mix of urban and rural communities and how you serve that population. So, we recognise that, and we need to do more. However, the majority of services are working well and are at high occupancy levels, and they do not cause us any concern. There are challenges in one or two services, and we are working with those agencies to find a solution. It impacts the sector's confidence about getting the model right and understanding what that is.
Mrs Cameron: We have looked at different accommodation and supported living models and been really impressed with them, and many members and I are pretty astounded that there is not a big long waiting list of people wanting to get into them. So, I think that awareness is definitely a big issue. If people are not aware, I do not think that they have the full range of choice. If they wait until they get to crisis point in their life, they are limiting their choices as well.
Mr Holland: The point about raising awareness among people planning for their old age is very well made. We have taken that on board from the Committee and will hopefully address it. The federation's proposal will be part of the response to that. Individual people who require some care to meet their assessed need, and are assessed as having needs, will be made aware of available supported living schemes in their area, but people are making different choices. That is what often leads to a situation in which there is a void.
The schemes were built in the belief that there would be a demand, but people have chosen to have their care needs met in other kinds of ways. That is not fixed; it is changing significantly. From the first point at which there is an idea to have a scheme, with people looking at the assessment of need, through to the front door being opened, the lead-in time for building a scheme lasts a number of years.
Over the past five years, for example, there has been a significant change in the range of services available to people, which might result in their choosing not to go into a supported living scheme. It is fair to say that, five years ago, reablement services, for example, were very limited, whereas we now have fairly significant reablement schemes in all five trusts. Were those schemes not there, a number of the people going through them might have opted to go into a supported living scheme, but now they are maybe fit to, able to and want to stay in their own home.
Mrs Cameron: One theory for there being vacancies is the lack of a shared understanding between trusts and housing associations about which types of older people are suitable for supported living. What is the Department's view on who supported living is aimed at?
Mr Holland: Fionnuala will come in on this in a moment, but it is based on the individual. As I said, there are two factors: the assessment of need and how that need can be met; and the choice that someone wants to exercise. There will be situations of very high dependency when it is not practical to provide for someone's needs in a supported living scheme, so a nursing home would be more appropriate. However, I think that the boundaries as to where that difference exists have been pushed significantly in recent years.
Mrs McAndrew: In a nutshell, the people who are suitable are those who need care and support. Some of that is housing-based support to allow them to be able to live in their own accommodation, and some of it is care. I do not think that we have ever made any secret of the fact that the easiest correlation are those who would previously have gone into residential care. Maybe 20 years ago, much younger, fitter people moved into residential care than in the last five years. It is that cohort of people who cannot live, or chose not to live, on their own for any longer and need a level of care and support. They do not need medical or nursing care. They are not ill as such, and they can make a choice that they want that companionship. If you visited some of the facilities, you will have seen that there is provision for communal space and that they can have friendships and so on, but the key point is that they do not need medical or nursing care because, if they did, they would be in a nursing home.
The Chairperson: I will pick up on that point. When the trusts were before the Committee, they told us that supported living is a very specialised model of care that is suitable only for a small minority of older people. In contrast, the housing associations told the Committee that the model is suitable for a significant proportion of older people. How does the Department respond to that?
Mr Martin: I think that that is because we are talking about two different things. When housing professionals talk about supported housing, we mean both extra care schemes for what we call the frail elderly — an unfortunate term — such as Cedar Court, which I think that you have seen, Hemsworth Court, Gnangara and Seven Oaks, and sheltered housing schemes, which are the traditional fold schemes. When housing professionals talk about supported housing, we mean both.
The Chairperson: We have been specific about the concept of supported living in the inquiry. We are not talking about the overall package. We have been very clear and knew exactly what we were requesting, and that is the response that we got.
Mr Holland: If you are talking about people with significant care needs, they are by definition a minority of the elderly population. The majority of older people are fit, well, independent and active, and a significant number of older people are able to manage what limitations they have because of their health or through disabilities with minimal support. The people whom we consider to be suitable for the 18 schemes are not those people; they are people with significant care needs. That is a very small group of the overall over-65 population.
The Chairperson: Gordon, you wanted to come in on this issue.
Mr Dunne: Thanks, Chair. Thanks, folks, for coming in this afternoon.
I want further clarification on some points that have been made. Does the Department believe that it is possible that there are vacancies in such facilities because the trusts are under-referring, as the models are only for those with complex needs? Is there a risk that that is happening?
Mr Holland: I cannot see any possible motivation for the trusts to under-refer. When you are trying to respond to someone who has care needs and, as a result, requires assistance, it is in your interest to consider all the available resources. There is no motivation for a trust to try to withhold information about a supported living scheme from someone who is presenting as needing one.
Mrs McAndrew: I will go back to the assessment. People are referred to social services, and we undertake an assessment and look at what the needs are and how they can be met. In some cases, the family or individual may think that they would like to go into supported living, or they would like to stay at home, but the assessment of their care needs indicate that that is not feasible and that they need an alternative type of care. I have no evidence to suggest that we are under-referring.
To go back to Seán's earlier point, a lot of this concerns confidence in the style of the delivery of the service. It is about choice: people are making choices, and, significantly, people are making choices to stay at home if at all possible.
Mr Dunne: Is cost an issue?
Mrs McAndrew: It should not be. The care is provided by a trust. If people are on housing benefit, they are entitled to benefits that help them with costs. I am aware, having visited some of the facilities and talked to the staff, that some individuals who would have alternatively gone to residential care are better off in supported living because of their income status. It should not be a prohibitive factor.
Mr Holland: If you stay at home or go into supported living, the care costs are met either way; there is no difference.
The Chairperson: Is cost not an issue for the trusts?
Mr Holland: I am saying that a trust will meet the costs whether you are at home or in a supported living scheme. In Northern Ireland, we do not means-test domiciliary care. If you are in a supported living situation, that is non-means-tested. That is different to the rest of the UK where you would be means-tested, but here, we do not.
Mr Dunne: Are there no top-up fees?
Mr Holland: People encounter top-up fees if they choose an enhancement that is not to meet a basic need. Someone might want Sky Sports, for example, and we do not pay for that. People will sometimes pay a top-up fee for a "better-than" service.
Mrs McAndrew: To be clear: there is no top-up fee on the care element. Rental or maintenance charges may be applied in Supporting People schemes, but balancing that out with the cost of alternative care in residential care, it should not be prohibitive in making a choice.
The Chairperson: Is a cost analysis done? I assume that it costs a trust more to facilitate someone through supported living accommodation than at home.
Mr Holland: No, not necessarily.
The Chairperson: Not necessarily for domiciliary care.
Mr Holland: No. They will need domiciliary care if they are at home —
The Chairperson: There is no additional cost to accommodate.
Mrs McAndrew: Not necessarily.
Mr Holland: If you are in supported living, additional support is provided through the DSD supported living fund.
Mr Dunne: Surely buildings and services have a cost, which is not the case when someone lives at home.
Mr Martin: There are two sets of costs. Brian can talk a bit more on this. There are care costs, which are a matter for health and social care, and there are the costs of rent, service charges and housing support. There are housing support services as well as care services. Housing support services help people to live independently, so it will provide them with advice and support that we take for granted — paying bills, things to support their tenancy and so on. If someone is on housing benefit, those support costs will be paid; if a person is not on housing benefit, there will be a cost to them for those services. Our services are not necessarily free. They are free if you are on housing benefit or at a lower cost band.
Mr Holland: Either way, those costs do not fall to us in the health and social care sector.
Mr Dunne: Can you clarify, for my own interest, how people are selected for accommodation? Do they go onto the common selection scheme and come off the list?
Mr Martin: There are two separate processes, and Health colleagues can talk about the complex cases who go into the 18 extra care schemes. For sheltered housing schemes, people are allocated from the housing selection scheme — the common waiting list.
Mr Dunne: Is that done through the Housing Executive?
Mr Martin: Yes, for around 400; for the other 18, it is a different process.
Mr Dunne: Is it assessed on need?
Mrs McAndrew: Yes, it is assessed on need.
Mr Dunne: In areas like north Down, where there is limited Housing Executive stock, your options for this type of accommodation are even fewer. How are you going to address that? How are you going to address those needs and demands that are, as my colleague said, increasing as the population gets older? In some estates, just 25% is left, and the rest have been bought, leaving a mix of houses and a loss of accommodation.
Mr Martin: Those are separate issues. Trusts do the assessment of need in the 18 extra care schemes. For general and sheltered housing, there is a top-down and bottom-up system for assessing need. There is a demographic projection called the net stock model that looks at projections of future need for general and sheltered housing. The bottom-up system looks at waiting lists and the needs of an area. An assessment is then done by the Housing Executive, which has statutory responsibility for that, and that will inform a newbuild programme. That is how it is done for general and sheltered housing. The extra care schemes come through the board and the trusts.
Mr Dunne: Is there no tie-up between both? Are you not the main driver for housing, no matter what?
Mr Martin: We are not the main driver for those that are based on care. We work jointly.
Mr Holland: There is an arrangement for us to work jointly in the commissioning of those extra care or frail elderly housing schemes.
Mrs McAndrew: I will talk a little about how we are planning and assessing need. We have developed a GIS system. It is not fully fledged yet, but we are building it up. Remember that our planning cycle is between three and five years, and that is normally what we work on.
The map goes down to ward level across Northern Ireland. It will show us what health and social care services are available in each ward. At the minute, we have residential, nursing, supported housing and sheltered accommodation. We can overlay community-based services on that, so we know what community-based services are being provided in a ward.
Our ambition — our next step — is to overlay that with demographic information. We will be able to see where the demographic growth will be. We will have to make some assumptions about demographic shifts, because sometimes people choose to live in different places. Members will know that at one time a lot of older people went to the north coast in retirement. There is evidence that, in the future, older people may congregate more in cities rather than going out to more rural areas. We will overlay that on our mapping system so that we will be able to look at where the potential gaps are, based on some planning assumptions.
That is exciting. We have not had the benefit of that kind of visual information before, and we will be able to bring that forward. We have joint arrangements on supported housing with our housing colleagues. We can bring their information on housing need together with our information about care need and be able to plan for the future.
Mr Dunne: Given the regional differences between the trusts, what is the Department doing to make sure that trusts are not at variance with one another?
Mr Holland: It is not be an ambition of ours to make sure that there is no variation across trusts. Populations will be different in different areas, so there will be variations. The ambition is that we plan effectively for the needs in each trust area. Those needs will not be the same across the trusts.
Mr Dunne: How will you allocate? A point was made earlier about voids and how important it is that allocations are consistent.
Mr Holland: It is important that we try to plan to make sure that there are no voids. However, I suspect that we would have a far greater number of voids if we were to try to plan for consistency by simply saying that we would have the same number of places in each trust area.
Mr Dunne: What I am getting at is the need to apply policy and guidelines consistently across the trusts. What are you doing to ensure that that happens?
Mr Holland: I have no evidence to suggest that the policy or guidelines are not being applied consistently across the trusts.
Mr Dunne: We will see. It is early days.
The Chairperson: Roy, you wanted to ask about awareness.
Mr Beggs: Earlier, Seán, you indicated that you thought that the reablement programme may have contributed to the voids. I notice that, in your evidence to the Committee on 26 February, you said:
"Reablement has been rolled out in three of the five trusts, and plans are in place for a full roll-out across the region."
I am curious —
Mr Holland: I think that we now have schemes operating in all five trusts.
Mr Beggs: Yes, but I am trying to ascertain how reablement may have contributed to the voids. Can you tell us, or come back and tell us, when reablement was fully rolled out to all the trusts, and, in particular, when reablement was operating in the Enniskillen area, where there are a significant number of voids?
Mr Holland: I do not think that reablement is a significant feature in the Enniskillen example. I was saying that reablement is an example as to how the picture can change. I do not think that I would attribute any voids today to the existence of a reablement service. I am sure that there are circumstances in which that is true, but I could not identify those. I am saying that services are developing all the time, and that is having an impact on the choices that people make. Some of these have had very long lead-in times, and some are new services that are changing.
Mr Beggs: You said that reablement was a feature.
Mr Holland: Reablement is a feature and will become a more significant feature. Generally, domiciliary care and the growth of domiciliary care over the past number of years has been a more significant feature. Another feature that we have not discussed so far, which is probably starting to affect the choices that people make, is that, since 1997 in Northern Ireland, all social housing has been built to a standard that is called a "lifetime standard" — colleagues may correct me on that. The idea is that you build a house that can easily be adapted to different needs, so that the house that you live in and bring your children up in, and the house that you live in through your middle years, can be adapted to be the house that you grow old in and may end your days in. I imagine that, as people living in those homes have been approaching their old age, a growing number have been able to stay in those houses, which has probably contributed to people choosing not to go into supported housing.
The Chairperson: Seán, we are mindful of that and aware of it. That is not what we are looking at with the supported living issue.
Mr Holland: Madam Chair, the point is that it is probably not helpful to look at supported living in isolation. Supported living is one way in which we can respond to the wishes, desires and needs of older people for their accommodation and care.
The Chairperson: That is the remit of this inquiry.
Mr Holland: What I am saying is that, when we provide that care, we do it in the context of a range of services, and people make choices between them.
The Chairperson: Roy, are you finished on that point?
Mr Beggs: Yes, thank you.
The Chairperson: Before we move off the awareness issue, it is important to make this point. Costs have been raised, and both of you indicated that there is no additional cost. The Belfast Trust said:
"This model of care is very specialised. It is very expensive on the capital and revenue side, and it needs to be targeted at people who most need, and could most benefit from, the model ... So, from the Department's and the trusts' point of view, it is very targeted at those who would most benefit from it, because it is expensive for the state".
Mr Holland: The capital cost is expensive, but the care package is the care package, whether you stay at home or are in one of these schemes.
Mrs McAndrew: We have given you a breakdown of the costs of each scheme.
The Chairperson: I am sorry, Fionnuala and Seán. A few minutes ago, we were trying to tease out the cost to a trust for a supported living model. The response was that there is no additional cost. That is contrary to the Belfast Trust's comments. Who is right? What is accurate?
Mr Holland: Could they have been referring to resettlement?
Mrs McAndrew: I possibly misinterpreted the question. I hope that I am not misleading the Committee. I was focused on the cost to the individual, because I thought that part of the question was about the cost to the individual.
The Chairperson: Sorry, Fionnuala, with respect, we asked specifically about the trust.
Mrs McAndrew: I probably misinterpreted. There certainly is a cost to the trust, and some of the Belfast provision is for people with dementia, which necessarily will have a higher cost than some of the other schemes, because the annual care costs are quite varied. It depends on the layout of the building, the nature of the residents, the people who are going to live there, and so on. Are you asking me whether it is additional, above and beyond what other service might be provided? There has to be an additional cost. It is a new facility, so we have to put some money in to provide the care. We are increasingly providing additional amounts of care to individuals every year, so the cost to the health and social care trusts is increasing generally.
The Chairperson: There is an additional cost.
Mr Holland: There will be a cost to caring for people wherever they are.
The Chairperson: There is an additional cost to the trust.
Mrs McAndrew: Yes, there is.
The Chairperson: Will that impact —
Mrs McAndrew: On its decisions to place people? I do not believe so, because in setting up the facilities, we have a business case. We develop the business case, aligning the Supporting People income that is available for the facility and the care income available. Therefore, there is a commitment to that care income for the number of places in the facility. If there are vacancies, you could say that that is costing us money because we are not getting the full value of the care costs that we are putting in, so I think that it is the reverse: we would encourage people to move in, because, that way, the unit costs for the facility are lower. I do not believe that it is a reason that trusts would not be referring or admitting people to sheltered accommodation.
The Chairperson: OK. We will move on.
One of the other themes was the issue about housing associations being cautious about building any new supported living units. Mickey and Roy have indicated that they want to lead on this.
Mr Brady: Thanks for your presentation. It is encouraging — unique, almost — to see people from DSD and DHSSPS sitting together giving evidence. It certainly does not happen often enough, and, as someone who sits on both Committees, these are the type of overarching issues that should be addressed by both sets of officials.
Seán, I take issue with one thing that you said about there being lifelong housing since 1998. In my constituency, around four years ago, Trinity Housing built five houses to provide for lifelong housing. They were hailed as being wonderful, and they are. They are very well-built houses, but I do not accept that housing associations are doing that regularly. There is a wider issue, and I know, Stephen, that you are very familiar with the whole social housing issue. The reality is that we have a public housing body that does not build public housing. Government policy on borrowing means that we rely on housing associations, and that is the issue.
In the Enniskillen example, Fold has lost something in the region of £1 million in revenue. That is being replicated in places such as Glasgow because of the bedroom tax. There, there are huge swathes of houses that people will not move into, so housing associations have been going out of business. It can be a wider issue. Enniskillen may be a different example, because I know that, in Newry in my constituency, people are queuing to get into Fold, so that void issue does not exist. If flats or whatever are vacated, people are moving in on referral from the trust, but it may be just in that area. Obviously, the issue has been made people more aware.
The difficulty that we have is that Fold has said that it is not going to invest in newbuilds for this kind of facility. If housing associations are not going to build them, it does not matter what you plan to put into them, because they will not be there. That matter needs to be addressed urgently. You can have the best plans in the world for what is available, but if the actual physical housing is not there, that is the difficulty. It will increasingly become a problem, because we have 30-odd housing associations here — some quite large and some smaller ones — in a relatively small area, and there is all kind of competition. Houses are being built to the Decent Homes Standard. The Savills report from 2009 stated that we had some of the best housing in western Europe, but we do not any more, because planned maintenance does not happen. There are all sorts of issues around that. Housing associations need to keep the houses up to a particular standard. What happens if, like Fold, they say, "We are not going to build any more because of the voids, and it is costing us money"? They rely on housing benefit and rental to service their loans.
Mr Martin: I will deal with the lifetime homes issue first. All housing associations have to build to the housing association guide, which has a Lifetime Homes Standard, and there is an incentive for that. Therefore, all housing that they build is built to the Lifetime Homes Standard. During the downturn, housing associations did buy some properties off the shelf and took opportunities, and those would not necessarily be built to the Lifetime Homes Standard.
I can give you an example, and I think that this does exemplify it. The adaptation costs in housing association properties for older people who want to age in place are significantly lower than those for Housing Executive properties. Around £11 million a year is spent on adaptations in executive properties. Around £1 million a year is spent on adaptations in housing association properties to support people to age in place. That forward thinking that we have shown by putting the Lifetime Homes Standard into the design guide allows people to age in place. That is really positive.
On the point about risk, we jointly managed, on behalf of the Ministers, the session that Seán referred to with housing associations and trusts back in February. The housing associations came to us with two issues. The specialist nature of some of the schemes means that it takes quite a long time to fill the places. Hemsworth Court in Belfast is a good example. The Belfast Trust is taking about 18 months to fill the places. While the places are being filled, the money from the trust follows the person. If there is no person there, there is no money. The Ministers have asked our colleagues to look at a risk-sharing arrangement, and colleagues in DHSSPS can update you more on that. There is a loss being sustained by housing associations in the period during which full occupancy is being achieved.
The Enniskillen example is a particularly challenging one. One of the things that we want to look at in the piece of research that Seán referred to is that model of very specialised housing. To make the schemes stack up, there has to be a certain number of places. Small schemes with specialist services do not stack up economically. They do not work financially. As such, it is questionable whether a very specialised housing model will work everywhere in Northern Ireland. In some places it will work, while in other places it will not. Therefore, we want to do two pieces of work. First, we want to look at the model and look at what will work where. A lot of financial stress-testing will be needed, and, hopefully, that will help give housing associations the confidence that they need to re-engage with the work.
The second piece of work is to look specifically at Gnangara and Hemsworth Court to see what went well, what did not go well and what we can do to fix what did not go well. We are very aware of the problems.
Some associations are continuing to develop schemes, but more are becoming more cautious, because there is considerable risk involved. There needs to be some element of risk-sharing, and that is something that we are looking at.
Mr Brady: Going back a number of years, old persons' dwellings were built because, at that time, the Housing Executive was building houses and got a subsidy to do so. As time went on, they then became single persons' dwellings, so they were one- or two-bedroom bungalows. Initially, the executive did not sell them because they were being retained, and supported living and supported housing took over in a sense.
In the Enniskillen example, or, indeed, if there are voids, because you are talking about 18 months, has there been any rethink about the facilities being used as social housing? It seems to me that you have very specialised facilities but that they are not being used. You have mentioned perhaps sharing the risk factor with the housing associations. If people were living in them, irrespective of their health or disability, at least revenue would be generated through housing benefit or rent. How long can you leave them sitting there?
Mr Holland: My understanding is that the Western Trust is working with the housing association to look at how those void units can be used.
Mrs McAndrew: I have been involved in meetings with Fold about Gnangara. I am aware that we have taken quite a number of measures to look at extending the scope of what the facilities could be used for.
Mr Brady: By changing the criteria, in a sense.
Mrs McAndrew: By changing some of the criteria. A particular need has been highlighted for people with physical disability, so we are looking at whether the chalets or the flats would lend themselves to housing people with physical disability. To be honest, there is a lesson to be learned from the design, because it is on-site with a residential care home. We need to think about that in future as well. We need to get the design flexible and right so that we can accommodate a range of needs, if and when those needs arise. One of the things that we are saying to you is that people make choices, so there is a level of unpredictability about how quickly the facilities might fill up, but the point is well made, and we have been in discussions with Fold and the Western Trust on that. As a result, I think that the occupancy had increased, but there are still a number of voids that we need to consider.
Mr Dunne: I have done a bit of research and understand that half of the units were for dementia patients, is that right?
Mrs McAndrew: In the residential sector?
Mr Dunne: Yes.
Mrs McAndrew: That is right.
Mr Dunne: Is that not an issue? I take it that the Department tasked the housing association with tendering and competing for the work to build the units, is that correct?
Mr Holland: The Department does not directly. It is the commissioning process.
Mrs McAndrew: We have a joint arrangement with the Housing Executive and the Health and Social Care family, if you like — the trusts and the board. There is a Supporting People commissioning body, which is chaired by the Housing Executive. The purpose of that is to identify the need and then commission those kinds of developments. I am not sure whether Brian will agree, but we have got more sophisticated as the years have gone on with the needs assessment and the commissioning arrangements. When I look at the voids and the vacancies, Gnangara obviously stands out as being a particular issue.
Mr Dunne: The housing associations are now shying away from such projects because of the mistake that has been made here on the assessment of need. Is that where it went wrong? Earlier, you clarified that people were allocated on the basis of need and that you build where there is a demand. Where was the mistake made? Did you get it wrong on demand? Was the wrong assessment made by DHSSPS and transferred to DSD?
Mrs McAndrew: I think that, at a point in time, we felt that our assessment of need was accurate. Things have happened in that time that mean that people have different options. You could say —
Mr Dunne: What time are we talking about? Three years?
Mrs McAndrew: No, Gnangara has been open since —
Mr O'Kane: Gnangara has been open for close to four years, but, if you take the point that Seán made, the planning and commissioning process probably started two or three years before that to get it on-site. We work very closely with the Health and Social Care family across the five trusts. There are lessons to be learned from the Gnangara experience. We know that the demographics tell us about the growth in the number of older people in an area and also the growth in the number of people with dementia, so the planning assumption was that need and demand would follow.
On the point made by the member who spoke previously, we are working very hard. There is a meeting next Tuesday with the Western Trust to try to find a solution, because there is good quality housing sitting there empty. I take your point. It is something that, from a housing professional's point of view, we find easy to take.
Throughout the process, we have continued engagement with the trust, because, at the same time, as the Committee knows from the demographics and the stats, there is an issue to plan for more and to develop more. Some of the lessons to be learned are around the promotion work and understanding, which the Committee mentioned a number of times. We are looking at alternative uses of accommodation to address those issues and to give confidence back to the sector. I think that Fold's experience has been particular. It is a potential outlier, but we know that it has an impact on the confidence of the rest of the sector. However, you will have seen in your briefing that seven schemes are being planned. A new service has just opened taking in people in Newtownards this month, and there are plans to develop a service in your constituency in Bangor. The associations are on board, and you heard from the chief executive of the federation, who said that it is what the sector wants to do. The sector has talked to us about what it needs from us to reassure them about the future of the services, and we are trying our best to respond to that.
The Committee has been to Cedar Court. From a housing perspective, we are very proud of the quality of the work there and what you saw. We need to make sure that those services are delivered elsewhere, so we are doing a lot of work with our partner organisations. There are lessons to be learned about needs assessment and planning. Part of that is reflected in talking to people about what they want, and Committee members have made that point today. We need to be smarter at asking older people what their preferences are. They will have choices, and they will want to make choices. Older people will want to make informed choices about whether they stay at home or move and about what sorts of services will come to see them. We recognise that and are doing that.
As Stephen pointed out, the other three projects that we put forward in the briefing all have an impact: dealing with the design; making sure that the project is sustainable; and providing reassurance to the sector. Hemsworth Court, which is just off the Shankill Road, is an interesting project. It comprises 35 self-contained units and is a very worthy project. The association is making an application to a design award competition. It is 35 units of high-quality accommodation. As of today, there are 24 tenancies in place, and a further seven people are being assessed. There is a balance to be struck on the health side in working with individuals and their family and carers about making a planned and appropriate transition from where they are now into Hemsworth Court. We have to be conscious about working with individuals. There are a further seven people in assessment. There are lessons to be learned there about how we make sure the assessment processes are sensitive to the needs of families and individuals. We and the trusts are confident that the project at Hemsworth Court will be fully occupied by September or October this year. From a housing association point of view, that is probably a bit too long, because it was opened last July. We are looking to reassure the associations on those issues.
Mr Dunne: Is there a lesson to be learned about the mixed use of accommodation for supported living and for people with dementia?
Mrs McAndrew: It is about how we adapt the accommodation. The fact that there is a residential unit and supported living on the same site is an issue. Brian will agree that, if we had built in a bit more flexibility around the design, it might have meant more take-up earlier. As I say, we have learnt those lessons and are taking them forward into our planning processes.
Mr Beggs: If I picked it up correctly earlier, someone spoke about the deadline for the business case from the housing side and the health side and that there would be a commitment to care income. Can you explain the commissioning process for such a new development, which is what we now know as supported housing?
Mr O'Kane: When Supporting People started in 2003, we talked to our colleagues about what the right kind of commissioning structures would be. There is a regional commissioning body that is chaired by the Housing Executive's director of regional services and made up of representatives from five local Supporting People partnership groups based on the trust boundaries. The trusts use those structures to identify their need for supported housing in future from across a number of programmes, including programmes for older people and for people with dementia.
If a need is identified, a business case is produced at a local level that comes through the commissioning process. That business case is to bring forward and align the capital and the revenue from the Supporting People side and from the care side for the need for and type of services. That translates to the housing side, where, once we get to a certain point, we bring in the housing associations and nominate names so that they can bring forward the development process and find a site suitable for development. Through the lifetime of the business case, we engage with our colleagues in the trusts and with the housing associations and other agencies around the project planning of each service. In that structure, we have an opportunity to learn lessons and reflect on what has worked well elsewhere.
We are looking at restructuring and reforming some of that commissioning process so that it has a more regional structure, whereby we bring the five trusts, the board and us together more regularly to look at lessons learned going forward. The process is a bottom-up one, informed by local commissioning decisions by the trusts, which will then bring forward a business case for the Supporting People programme, while we look to align the capital and revenue — capital from DSD to fund the building and, from the revenue side, from Supporting People and the care side — so that all the bits of the funding jigsaw are in place. By doing that and by having the housing associations involved earlier — that is another lesson for us — gives added confidence to the sector that we were keen on that working. There are things that we can do better. The business case is to provide a reassurance that there is a need and that the various bits of the funding pot are together to make the schemes happen. It can perhaps take too long because the site search and the planning can, as you probably know from your own experience, be a lengthy process.
Mr Beggs: I have followed the progress of the Greenisland House development, which has still to commence on the ground after four or five years. Having gone through a planning process, my understanding was that the trusts would OK the business case for what they thought was required in the area. As I understand it, the business case is to service the Carrickfergus and Newtownabbey area, which is quite a wide geographical area. I am curious as to what the care commitment — the income — is if the numbers do not hit what the trusts say is needed in the area. What care commitment is made by the trusts so that what they say is needed actually comes about?
Mrs McAndrew: The business case would identify the allocation of funding that the trusts would be making to that facility to cover the care costs. Therefore, it is based on the number of people and an assumption and by aligning it with the Supporting People revenue that might be available. It is all worked out on the income that has to be set aside as a commitment from the trusts to the building assuming full occupancy. Our colleagues in DSD and the Housing Executive are saying to you that, where there is not full occupancy, that becomes problematic for the trusts, because they have to pay for the person somewhere else, as the money follows the person.
Mr Beggs: If that were the case in Enniskillen, the housing trust would not be losing money. Is the health trust paying for those vacancies in Enniskillen?
Mrs McAndrew: No, it is not currently, and that is the point that was being made about coming to a position in which there is more risk-sharing between the housing association —
Mr Beggs: Have you changed your policy so that you will commit to pay for vacancies on the caring side?
Mr Holland: It is currently under discussion, but if we were to pay for those voids, that would be money that would otherwise be paying for the care of older people. We are keen to make sure that, when we spend money on the care of older people, it is delivering care for older people, as opposed to paying for a void.
Mr Beggs: Has there been a policy change made by the trusts to support people with care packages in their home rather than care packages in another establishment?
Mr Holland: If I understand your question correctly, no.
Mr Beggs: I was picking up on comments that some personnel may have changed in the planning process and that that may be a contributory factor.
Mrs McAndrew: I am not aware of that, but I will take your comment away.
Mr Beggs: I dealt with some constituents a couple of weeks ago who are in rented accommodation. They explained that they could get only a one-year tenancy agreement, as that was all that was on offer from various landlords. If the properties are sitting vacant, can you not at least allow a temporary tenancy arrangement to be utilised so that income could be generated for the housing trust, rather than it suffering the expenditure without getting any income whatsoever?
Mr Holland: Do you mean for them to be used for general housing purposes?
Mr Beggs: On a purely temporary basis.
Mr Martin: If it were a highly specialised scheme, as Fionnuala mentioned earlier, we would need advice from the health and social care professionals around that. Putting people with different needs together in a facility with a lot of common spaces might be problematic. Although allocations of sheltered housing are done through a housing selection scheme, if there are longer-term voids, there are opportunities for housing associations to advertise those outwith the selection scheme. The specialist schemes are a bit more difficult, and a discussion between us and the housing associations would be needed.
Mr Beggs: Frequently, frail elderly people are awaiting bungalow accommodation or something similar. Have the trusts and the housing side considered short-term, temporary tenancies so that there will be mutual benefit for tenants who are in unsuitable accommodation and Fold, which is having to suffer loss because there are no tenants whatsoever in their brand new housing? Have you considered the flexibility of a temporary arrangement?
Mr O'Kane: Your point is well made, and I think that we need to be mindful, particularly of the experience of Fold in Enniskillen, as, generally, most of the other Fold schemes are sitting at over 95% occupancy. There is a particular set of issues around one project in Enniskillen.
We are exploring all options, and a number of Committee members have made the point that we need to find a solution to letting the housing in Enniskillen.
On the short-term let, I would say that asking someone to move in for six months is not necessarily always a good thing for the longer term to have older people move a number of times, but we are doing some hard work to try to resolve and recover the position for Fold and the trust. It is in none of our interests — by "our", I mean the board, the Western Trust, the Housing Executive and Fold — to have a property in Enniskillen that does not work. We are looking at that. Whether there are short-term options, I am not too sure, but we are looking at making better use of the project.
Mrs McAndrew: It is fair to say that we have not done it as yet, but it is certainly an issue that we can take away and look at.
Mr Beggs: I am conscious that, if it were a private sector operation, you would not have the property sitting vacant for the long term. That would not happen. Choices and decisions would have to be made quickly.
Mrs McAndrew: I refer Committee members to the paper, in which you will see that many of our supported housing arrangements have full or 99% occupancy. I just want to draw your attention to the fact that we are talking about two of the 18 facilities. By and large, the others are well used, and there are not significant occupancy problems.
The Chairperson: Thank you. We will move to the issue of long-term planning. Seán, bluntly, is the Department taking a strategic approach to the need for supported living?
Mr Holland: The Department is taking a strategic approach to the care of older people by identifying a general shift in how we provide services. That is in response to what older people have told us when they have been consulted, which is, primarily, that they want to live in their own home and remain as independent as possible. That is the strategic direction that we have set. I think that there is a difference between setting a strategic direction and having a detailed plan as to how many units of what particular kind of accommodation you will deliver in any specific year. That has to be a much more short-term activity.
Fionnuala has described the current planning cycle as following a three- to five-year pattern. The discussion that we have had around voids in particular schemes and the fact that we do not generally have significant waiting lists or voids around supported housing as a whole suggests that having a three- to five-year cycle is probably working quite effectively. I think that there would be significant risks if we were to try to extend a planning frame linked to specific units much beyond that.
The Chairperson: What you are telling me is that you have a strategic approach to general care for the elderly, but you do not have a strategic approach to supported living?
Mr Holland: No, I did not say that. I said that we have a strategic approach to the care of the elderly, and that includes a range of options that we recognise need to be developed, including supported living. I think that there is a difference between strategically identifying the direction in which you need to go and then making operational plans for how you deliver on that direction. The time frames are different. Strategically, we are looking 20 years hence, saying that we need to have a shift in direction, whereas operationally, we are looking at three to five years hence.
The Chairperson: If the general strategic approach in supported living is seen within the general care of the elderly, have we done work to forecast how many older people in the North would be suitable for supported living or actually want or need it?
Mr Holland: That is the work that is done on a three- to five-year framework. Fionnuala took you through how that work is done currently and the plans that there are to improve it, but that is done on a three- to five-year framework. I do not think that it is very wise to try to make those kinds of projections beyond that kind of time frame. There have been a number of experiences in sectors where, for example, people have tried to do very long-term planning based on demographics. Unfortunately, it has gone badly. I remember being involved in a planning exercise about 10 or 12 years ago that looked at the future healthcare needs of the population in Northern Ireland. At that stage, we anticipated a decline in the number of children based on demographic projections. It turned out to be completely wrong. Things happened — and this has happened across the UK — and actual demographic projections turned out to be very misleading. The further you go out, the greater risk there is. In the case of children, we had significant inward migration. That population of inward migrants turned out to be far more fertile than the regular population. So, we have significant pressure on maternity and birth services. If we had planned purely on demographic projections, you would have committed resources in a way that would not have actually reflected the change in the population.
The Chairperson: Seán, a few minutes ago, we heard about a GIS that will be brought into health and social care, which will take it down by ward.
Mr Holland: Yes, but the time frame that that will operate on is not 10 or 15 years to the future.
The Chairperson: Whilst I accept that forecasting in terms of population and even per location may not be 100% foolproof, we know the statistics for the ageing population. We know that there will be an additional 344,000 over-65s by 2020. We know that. A lot of the evidence that the Committee has heard to date is that there does not seem to be that strategic approach not only to the operational side of it but to setting policy. That is the key question. What I am hearing from you today is that, as it stands even for that forecast, if we have supported living as a concept in the general care of the elderly, you have not, as a Department, even forecast in your calculation the need that would exist for supported living.
Mr Holland: While people talk often about the demographic time bomb, you need to be cautious. To continue the analogy: it is a bomb that goes off very slowly. If you look at the changes in population year on year, you see that they are not significant. Given the time frame to plan for supported housing, making adjustments to meet demand is better done on a three- to five-year basis.
If we are looking at the population of older people — I am not quite sure that I recognise the figure that you quoted for the increase in the number of older people — I would have thought that —
The Chairperson: Well, it is a figure that has been identified and has been given directly by trusts, Age NI and the Older People's Commissioner. I hope that you are not saying now that we do not have an ageing infrastructure and ageing population.
Mr Holland: No, we definitely have an ageing population. However, the expectancy that I am looking at is that, over the next 50 years, the population of over-65s will increase from 244,000 to just under half a million. I do not think that that is the figure that you quoted.
The Chairperson: Well, look, there is a sizeable shift in the population of over-65s. That is a fact. What I am trying to ask here is this: what strategic approach is the Department using in setting policy to address that need?
Mr Holland: I think that the approach is to plan on a three- to five-year cycle to respond to that need. If we tried to plan on a much longer basis, there would be a risk of greatly exaggerating the kinds of problems that we currently have a very small reflection of, for example, the voids situation.
The Chairperson: I accept the three- to five-year cycle. Has that strategic planning started?
Mr Holland: Yes, that is an ongoing rolling process.
The Chairperson: Can we have sight of it at some point?
Mr Holland: You do have sight of it, in that the current plan is for seven new schemes to come online. That is on a base of rolling planning for demand. The assessment is ongoing. Schemes are identified as being possibilities. Business cases are prepared. They are taken forward. That is being done on a rolling basis.
The Chairperson: Again, we are talking about seven schemes in the overall calculation of whatever the figures are by 2020, which we accept is a huge increase in the population of over-65s, but even seven schemes seems very few.
Mrs McAndrew: Of course, there will be other things that will have to be developed to respond to the overall population increase, so it is not just relying on supported living. What I described earlier was a progression from our planning arrangements around Supporting People, which was very local, to looking at the need for supporting people much more broadly. I am just describing a mapping system — a visual representation of what is available, what the population is in a locality and what the population growth might be — so that we can then make some assumptions about the percentage of the population that might need more domiciliary care, more supported housing and more or less nursing home beds.
Mr Holland: To put the number in context: over the past 10 years, the elderly population — those aged between 60 and 84 — has risen by 20%, while the number of those aged over 85 has risen by 38%. In that time, we have developed the supported living schemes. We have no evidence to suggest that we got that significantly wrong, with the exception of one or two schemes where there are voids, and I do not think that that is down to us miscalculating the population projection. We seem to be getting it right. So, you say that seven schemes does not sound like very many, but based on the increases that we have had in the past 10 years, the schemes have responded to the demand.
The Chairperson: OK. I am going to go back to the point about forecasting, and Fearghal wants in on this as well. You are saying that there is a three- to five-year cycle in strategic planning, and that is accepted. Did that start when the concept of Transforming Your Care was initiated?
Mr Martin: The comprehensive spending review period mirrors the Assembly period. In formulating the bid, officials from my Department and the Health Department worked jointly with the Housing Executive and the board. The numbers that you have in the briefing were our joint assessment of what was needed, and a bid went forward for capital and revenue funding on that basis. We will do the same for the next comprehensive spending review period, which is from 2016 on.
The Chairperson: I appreciate that, Stephen. The point I am putting specifically, Seán, is that a major plank of Transforming Your Care was the shift left, obviously, the £83 million shift, a big focus on reablement and recognition of the ageing population. Did that strategic planning, in the context of supported living, align itself with the origins of TYC, because the CSR was before that?
Mr Holland: The planning process has been evolving since the introduction of Supporting People, so it predates TYC significantly.
The Chairperson: But is there not a planning piece attached to TYC stating where we will be in x number of years and where the need will be?
Mr Holland: We have a planning process. TYC has identified overall the policy direction, which is, as you said, the shift left. If we have a planning process within that that is fit for purpose to deliver TYC, why would we change it?
The Chairperson: We are not sure that there is a planning process there.
Mr Sweeney: Chair, maybe I can help. I think that you are looking for something solid about the planning process and modelling for the provision of services. During Seán's introduction, he talked about three particular little projects that are getting under way at the minute. One of them is to look at alternative models to see whether there are shortcomings in the way that we work and whether we can learn lessons. That is what we meant by modelling in that framework. We are not being complacent about the three to five years, but, given the difficulties that you have acknowledged in long-term planning demographics, we think, first, that what we have is not perfect but it works, and, secondly, we are not so complacent that we would not look at alternative models. That is what we are looking to do in conjunction with our colleagues over the next month.
The Chairperson: So, we are only starting to look at those alternative modelling processes now.
Mr Holland: No. I think it would be fair to say that the model of joint commissioning has been evolving continuously.
The Chairperson: I think —
Mr Holland: We have some specific proposals that we shared with you today.
The Chairperson: Sorry for interrupting you, Seán.
Mrs McAndrew: I think it would be fair — sorry.
The Chairperson: Go ahead, and then I am going to bring in Fearghal.
Mrs McAndrew: I think it would be fair to say that it is a bit of chicken-and-egg situation, to be perfectly honest. I think that TYC was informed by the joint work that we had been doing around Supporting People. I think also that TYC is driving us to do more modelling and more predictions over the next three- to five-year period. It is a bit of chicken-and-egg situation. TYC was informed by some of the work that had already happened and sets out a vision and direction that needs to be supported by some further work that needs to be done.
The Chairperson: But it is almost three years into the process. However, I will hand over to Fearghal.
Mr McKinney: You might call it a chicken-and-egg situation, but it sounds to me, on the basis of what I am hearing today, that it is make it up as you go along.
Where are the figures that show that 155 places are needed? What figures have you predicted? How far short of 155 are you or how far beyond? What is the figure? Where is the work on projections?
Mr Martin: Those figures come from the board and the trusts.
Mr McKinney: Where are they?
Mrs McAndrew: It would have been done in the context of that three-year planning to inform the plan that we already have, which is 18 already developed and seven now in the plan for further development.
Mr McKinney: Yes, but how near is that to your projections for what is needed? Where are the projections?
Mrs McAndrew: They would have been done at local trust level.
Mr McKinney: And who collates those?
Mrs McAndrew: The trusts in terms of assessing the needs that are quite localised.
Mr McKinney: Have you got them collated here?
Mr Holland: The collation is the 155.
Mr McKinney: No, the 155 is what you are building. How is that consistent with your projections? Is it consistent with your projections?
Mr Holland: We build with a view to what we believe will be filled.
Mr McKinney: How does that give people the choice if they are filled?
Mr Holland: There is obviously a degree of churn in each of the facilities. That is a projection based on what we believe people will choose. These are not built all to individual people.
Mr McKinney: But can you point to the body of work that has been done? You are talking about another research project. Was there another research project consistent with that one that you are planning now? Where is that body of work?
Mrs McAndrew: It would have been done at local level by trusts and it would have amounted to a definition of the 155, the 18 and the seven that are now projected. That would be the extent of the modelling done thus far.
Mr McKinney: I hate to bounce this one on you, because it is literally just out — all of this is going towards homes and people living in homes — but the Older People's Commissioner said today that 70% of older carers are not receiving the carers' assessment. Do you have anything to say about that?
Mr Holland: I would really like to have the chance to look at the statement. We do recognise that older people who are entitled to a care assessment are not always taking it up. We have a target to —
Mr Sweeney: Yes, there is a target within the Department to increase the number of carers' assessments out there by 10%, I think. I will have to check that and go back to the figures, but that is the strategic direction of travel as far as carers' assessments are concerned. We have to look over detail of that.
Mr McKinney: I think it is wise to remind ourselves of the second objective of the review, which is about assessing the capacity of supported living options to meet the policy objective of Transforming Your Care in terms of reducing the need for residential home places. The Older People's Commissioner's evidence to us before was that she could not find any departmental planning or modelling data for the future demand for supported living.
Mr Holland: The modelling is not done at the Department. The modelling is an aggregate of local work, which gives us a regional picture in relation to supported housing.
Mr McKinney: Who takes the lead here?
Mr Holland: There is a joint commissioning arrangement between housing and health, which leads on modelling the demand for supported housing.
Mr McKinney: I think some assumptions are made. I refer to what you said earlier: the majority of older people are fit, well and active, and others are able to deal with little help. I am not quoting you exactly. So, is that the working assumption that you are going on?
Mr Holland: That?
Mr McKinney: That most people are fit, well and active, because TYC is based on the premise that older people are getting older and there is a greater demand for hospital and other services. Which is it to be?
Mr Holland: Both statements are correct. The older population is expanding, and, within the older population, people are remaining active to an older age, but the "old old" are also expanding. That group is much more likely to require significant levels of service.
A number of years ago, people entered into residential care and nursing home care at a significantly younger age. People now maintain their independence to a much older age, but the number of people who are in the "old old" category is also growing in actual terms and as a proportion.
Mr McKinney: I hear what you are saying about the three- to five-year plan, but is there not a need for further interrogation, given the decisions made today? You talked about the failings, and I think that you said that the assessment of need was inaccurate in the past. Is there not a need then for good work to be done to try to establish beyond a three- to five-year plan because you are in danger of making it up as you go along or falling shy of what would be reasonable expectations for the older population?
Mrs McAndrew: Just to clarify: I think that we were talking about the assessment of need in Gnangara at the time.
Mr McKinney: Yes, but you also said that those things are being developed by trusts.
Mrs McAndrew: I think we are developing and we are getting more sophisticated.
Mr McKinney: Where is the evidence that you are?
Mrs McAndrew: It is in the work that we are doing around the mapping system etc. If you are asking me whether the board has a 25-year or 20-year plan for the shift in services for older people, my answer would be that it does not at this point.
Mr McKinney: Does it have a 15-year plan?
Mrs McAndrew: No, it does not have a 15-year plan.
Mr McKinney: Does it have a 10-year plan?
Mrs McAndrew: We have Transforming Your Care as a direction of travel. The work is going on at the moment to look at what that means at local level. Committee members know that LCGs and the trusts are working very closely to translate the TYC vision into local plans for the direction of travel.
For Supporting People, we have the joint commissioning arrangement and the plan for the 18 and seven schemes. The work that I described on the mapping system gives us a level of sophistication so that we can put forward our projections of demographic shifts to make a more sophisticated needs assessment. That work is progressing as well.
Mr McKinney: What is the research project called that you referred to in your opening statement?
Mr Holland: At the moment, it is a proposal. I am not aware of the exact wording of the title of the proposal, but it is a proposal that we are seeking funding for.
Mr McKinney: What is the cost of the proposal?
Mr Martin: The proposal for all three projects is around half a million pounds over the next two to three years. We have some indications of support from an independent trust, and we have some early indications of potential government support. We are also collectively committing money to that. So, we are putting the final pieces of the jigsaw in place, but it is around half a million pounds.
Mr McKinney: How long will it take to get the proposal to some stage of maturity?
Mr Martin: The independent trust is taking it to its management board in July, and we expect the proposals for the government element of that to be signed off, hopefully, shortly thereafter, with a view to being able to start to put in place the elements that we need to procure those services by September. That is all with a view to having the researchers in place the next calendar year to begin the work.
Mr McKinney: How long will the proposal take?
Mr Martin: We anticipate the funding for the three projects to run for around two years. Not all the projects will take two years. The supported living champion element would be run as a pilot for around two years. We need to bottom out the detail of the tender for the other two projects. Once we have the funding in place and the tender bottomed out, we will have a clear idea of timescales.
From research of this type that we have been involved in before, we know that these projects typically take up to a year, from the appointment of a consultant or researcher to final report.
Mr McKinney: The timeline between the start of TYC and the conclusion of both a proposal and a pilot or project is five to six years. On one estimate, that is twice the lifetime of TYC.
Mr Holland: I think that you are linking this to TYC in a way that is not how I would have envisaged it. TYC is happening. We have a planning process that TYC was cognisant of and informed by. So, TYC was informed by the developments in supported living, which were generated by the planning arrangements that Fionnuala described. That process has evolved since 2003; it has evolved and changed over that time. Fionnuala referenced a particular change that is happening to that that is not connected to the research. So, it changed during the period in which we wrote and published TYC, and it is changing as we work towards implementing TYC. Hopefully, it is also being further refined by these projects.
Mr McKinney: That would be OK if decisions were not being made elsewhere vis-à-vis the policy objectives in TYC, which is why I read those out at the start. For example, the Northern Trust simply shut down residential homes, believing that that was consistent with TYC, yet nothing was done. So, you can see the gap and the public concern that is there. TYC says something, and the Northern Trust goes, "Well, that's OK. We will do that", but there is nothing there to support it.
Now we are hearing that there is a project that may or may not get the moneys. I know that you are saying that you are hopeful, but I have not heard you saying that it is happening. You are now beginning to try to assess this, but decisions that have been made had to be reversed.
I still do not know whether we will soon get an admissions policy announcement on this very issue and whether people will be able to remain in homes or have some vehicle for getting assisted living in the absence of alternatives. We highlighted today the absence of some of those alternatives. For example, you said that there is 99% occupancy in most of the 18 schemes that are available. So, a lot of older people do not have a choice right now, despite the churn that you say is in the system. So, you can see where our concern is. I think that I am reflecting the Committee's concern here when I say that, although the policy has started off and people have made decisions, you are only starting to write the first page on how some of this might change.
Mrs McAndrew: Chair, can I make a comment about supported living, which is really important? It might not be as sophisticated as everybody would have wanted. We have been involved in a process of needs assessment and planning for supported living for a number of years, hence the 18 and the seven. That was incorporated into the Northern Trust's thinking about the future of its residential homes. I do not want to be drawn into a discussion about residential homes, but that planning was available, and the Northern Trust was involved in that. I think that Mr Beggs referenced the fact that there are already plans for new supported living facilities in the Northern Trust area, and those have been progressed. The only point I am making is that there was a planning process. We have acknowledged that that might not have been as sophisticated as we would have hoped, but it was there, and it informed TYC and trust decisions.
Mr McKinney: Or informed by TYC. You said that local trusts were making the decisions. Of course they were going to make a decision, because they thought that they had cover to do so. Yet, they did not have a system to replace that. We are being reminded of a number of homes that were already closed.
Mrs McAndrew: There are a number —
Mr Beggs: Just for information, there was replacement supported living accommodation for the ones that were announced for closure, but there were no plans to replace others that were announced for closure.
Mr McKinney: In other words, you can see our concern. A plan, with a policy objective, exists. Things happened within that framework, but we are only now learning of frail plans, let us say, to move the situation forward, notwithstanding the fact that there has been other activity. I am not saying that nothing is happening, but we are dealing with it on a strategic and policy level, and we are only now seeing some things beginning to happen. Some of them are ideas that came to the Committee first.
Mr Holland: It is important to recognise that the planning mechanism that has been in place has been responding to a growing elderly population and has been meeting that demand fairly well.
There is a difficulty in getting the balance between creating excess capacity that would allow for immediate exercise of choice and a financially sustainable model. We have to plan for near full occupancy for these schemes and recognise that, if someone wishes to move into them, you will have some availability, but that they may also wait a short time before availability is there.
If we were to create spare capacity, say 20%, that would not be financially sustainable for the housing associations. Our planning to date has delivered that. With the exception of one or two schemes, which I do not think were failures of the planning process overall, the system that we have been using since 2003, broadly speaking, has responded to a very significant increase in the elderly population during that time. There were specific schemes where there were particular difficulties that, hands up, we want to learn from and find out exactly why that happened. We want to get better and continually refine the system, but I think that the arrangement in place is currently delivering on the shift that TYC signals.
Mr McKinney: One of the things that we have been looking for throughout is measurement. We can feel the pain of it and hear the narrative of it, but at least things can be defensible with measurement. We are not seeing sufficient measurement on assessment. For example, you have indicators of performance around the direction for 2014, but we have no idea what would be a good number or a bad number. There is a number, and you are saying 155 is good, but how do we know whether that is good or bad.
Mr Holland: I go back to the plans that we made. If it were a bad number, we would have significant voids or significant waiting lists.
Mr McKinney: Yes, but we are encouraging people to go back to their own homes; that is the third part of the choice. Before this, people lived in their own home and the choices were external to the home. You have injected a new bit into the equation, which is people living in their own homes. Of course, other people make an assessment around whether that is appropriate, and you will say that they are doing that consistent with a plan, but we are seeing from this evidence that people are not necessarily getting the care assessment. People are being encouraged to stay in their homes, but are they getting the best there? We do not know that.
So, there are a lot of things that we do not know, and there are a lot of assessments. If I were hearing it, I would be able to say that I was glad to hear it. Sometimes, what you do not hear in a meeting is as important as what you hear, and I am simply not hearing an assessment. I hear things, and judgements made on what you are saying, that it is about both, those people and older people, and the value judgements that you are making around that, but I think that we need to see some kind of measurements, research and understanding. You accept what I am saying, because you are now starting to do it, but we have to ask, within the context of what you are doing now, whether you are doing the right things, given that you have not done it.
Mr Holland: Again, I come back to the activity that has been happening since 2003, which has given us a situation where we do not have significant numbers of voids nor significant waiting lists. That would indicate that it has been a reasonably accurate way of assessing the need at 115. I think that we want to improve it, and that is what we are aiming to do, but I am not sure that the evidence is there to say that it is a bad number.
Mr McKinney: I did not say that it was a bad number. I said that we do not know whether it is a good number or a bad number.
Mr Holland: I suggest that there is evidence to say that it is not a bad number, in that we do not have large numbers of voids and we do not have large waiting lists.
Mr McKinney: Yes, but if they are not built, you will not have large voids.
Mr Holland: If they were not built and demand was exceeding capacity, we would have significant pressure for places and waiting lists. We would have trusts saying that they did not have the capacity to meet the demand that they are seeing as they assess the needs of older people, and that is not what they are saying to us.
Mr McKinney: But, if you are 99% occupied now, you cannot offer people a choice.
Mr Holland: As I said, there is some churn, and people will wait. You will sustain people in their own homes and plan for them to move into one of those dwellings or settings.
Mr McKinney: So, are you measuring how many people are being sustained in their own homes now —
Mr Holland: We know how many people are being sustained in their own homes.
Mr McKinney: — and who might otherwise need something else?
Mr Holland: I could not give you that figure.
Mr McKinney: I suggest to you that that is a very important figure. In fact, it is the most important figure.
Mrs McAndrew: Well, we will certainly have a look at it. I am not sure that there are people who are in their own homes. They may have elements of their care package that they are not receiving, but if you are saying that they are maintaining their own home because they cannot access Supporting People —
Mr McKinney: Is that a reasonable request?
Mrs McAndrew: We will certainly have a look at it. I am not sure that there is anybody in that position. We will take it away and have a look at it. It has not been drawn to my attention that we are offering the wrong sort of care to somebody in their own home because they cannot access supported living, but I am happy, Mr McKinney, to take it away and have a look at it.
The Chairperson: I think it is about suitability, and I asked about people who are currently suitable for a supported living facility and what kind of assessment has been done there.
I am moving on. What I am hearing, Seán, is the word "evolving", and that does not give me a sense that the forecasting, modelling, measurement of outcomes and planning are in place. It seems to be very much an evolving process from trusts. What more could or should the Department do in relation to this? What is the "fit"? Is the Department currently doing enough? If not, what needs to happen?
Mr Holland: My answer is that the evidence shows that, broadly, we are getting it right with the plan. The evidence in relation to the development of supported living schemes, based on the planning model that we are using, is broadly getting it right, but we are looking at ways of improving it.
The Chairperson: OK. I am going to move it on to the issue of the link between supported living places and statutory residential home places.
Mr Brady: Claire Keatinge, the Older People’s Commissioner, told us that the availability of supported living will not necessarily reduce the need for residential places, because, obviously, the older population is increasing. We have been told that by the 2020s it will have doubled. There is an assertion in Transforming Your Care that the provision of supported living accommodation will reduce the need for statutory residentials.
The difficulty I have is that there was a residential home in my constituency in which Southern Cross was involved. Obviously, Southern Cross went down the Swanee at some stage, and the trust had to step in in the interim. So, there is always going to be that requirement. They are two separate issues, in a way, yet the Department has linked them. In other words, because you are going to have supported living places ergo you do not need statutory residentials.
The waiting list and the non-admissions policy is a big issue because, in my constituency, there is really only one statutory residential home left. That is working, near enough, at full capacity and there are people waiting to get in but cannot do so because of the non-admissions policy at the moment. That happens. I am really just pointing out that one does not necessarily preclude the other. If you look back to last April or May, the trusts were queuing to see which of them could close their statutory residential homes first. The Northern Trust got in, and then the Southern Trust and the rest. They all sort of jumped in to see which of them could get in first. Maybe that is a cynical view, but I am usually not that cynical. It just seemed to be the —
Mr Dunne: You must have changed.
Mr Brady: Yes, I have. It is the company that I am in [Laughter.] Seriously, it seems that that is really what happened. There was a public reaction, a public outcry, and rightly so. That is why it was changed, but the non-admissions policy is still an issue. That is something that needs to be addressed. I am really asking why is there that linkage when, in a sense, they are two different issues.
Mrs McAndrew: I suppose that what we are talking about in TYC is not just supported living, but a range of ways in which people can be supported in the future. We know that we have had a 5% decrease in demand for residential care across all sectors, whether statutory or independent. You have heard us quote the number of vacancies that we have in residential care over a period.
I have been involved in this area of work for a long time, maybe 10 or 15 years even, and the statutory side of the house, because of provision elsewhere, has started to diversify. That happened long before TYC and long before this recent debate and discussion. Other services were introduced on the statutory residential side. We will be planning for the needs of our population for the future in the context of residential care overall. As I said, there has been a significant decrease in demand for residential care as we know it and as we provide it. It is very much communal living; if you have seen the supported living arrangement, it is very different in how it meets the accommodation expectations of the population for the future.
Seán referenced our ability through intermediate care and intensive domiciliary support to maintain people at home for a lot longer; so, in itself, it is not supported living that is making that shift, it is a range of things that has meant that the demand for residential care overall has gone down. I take your point about the independent sector market and, nationally, there is work going on to get better at market predictions and forecasting. That is a national piece of work, because, at the end of the day, we do not want to be moved into a crisis situation where a home decides to close. At the moment, the capacity in the residential sector is significant. You are looking at probably 800 vacant beds in residential care. So, we have a lot of capacity in the system and it is that situation that we have to have regard for as we are planning for the future.
Mr Brady: I accept that there are a lot of diverse issues, but, if I were a cynic, I might think that the reason that there has been a decrease in the applications for statutory residential care is because people are being steered towards the independent sector. Let us be honest; nobody will convince me at this point in time that Transforming Your Care is not a shift towards privatisation, to a greater or lesser extent, but certainly that would be part of the deal.
Mrs McAndrew: We do not believe that, in itself, it is a driver towards privatisation. There are two important things to remember: the first is that we do not have statutory residential homes in all areas across Northern Ireland, certainly, even in the Western Trust area, they are still admitting permanent residents; and secondly, there is a decrease in demand over all. It is not just in the statutory sector, it is in the private and voluntary sector as well. We have the figures to demonstrate that over a period.
As you know, I visited every one of the homes in the last consultation period and I understand that people are committed to those homes, and that the quality of care in them is highly regarded. A lot of them are vibrant hubs of service delivery. They provide a range of services that people need: step-down; step-up; intermediate care; and rehabilitation. Those are things that we are going to need in the future. I am saying that the only bit of this jigsaw is that the demand for permanent living in residential care has fallen significantly.
Mr Brady: I will finish off by saying that in my area the statutory residential care that is left is very much an integral part of the community. It provides very good care. When you say that some areas do not have them, the Belfast Trust closed its statutory residential homes, but did so in a very measured way; it did not put out statements to Stephen Nolan's show to satisfy his demand for what was happening. Again, without being too facetious about it, that is basically what happened in the Southern Trust.
Mrs McAndrew: I think the key in the movement in Belfast is that the alternatives were being developed and people were reassured that if there was a reduction in residential beds it would be consistent with demand and need and that needs could still be met in other ways. Making sure that happens is the biggest communication issue that we have moving forward.
The Chairperson: Finally, the theme that we wanted to pick up was learning from other countries and the use of the private sector. I think Fearghal wanted to raise that issue.
Mr McKinney: Has any work been done on assessing best practice elsewhere?
Mr Martin: On the housing side, a number of the schemes that have been developed have been national and international award winners. Brian can touch on that. There has been a suite of research commissioned by the Housing Executive on housing for older people, which looks at international experiences, so there has been work there. As Seán said, it is always evolving and we continue to learn, but a lot of work has already been done.
Mr O'Kane: Just to take the point that the Committee has made a number of times, over the last three to four years we have commissioned a suite of research on older people's issues. That is available and I can make it available to you. That has ranged from taking the individual senior citizens' and older peoples' views about what they want in the future to commissioned research about what is best practice across America, Australia and Europe to inform design issues around design standards, space standards and use of technology to help inform the evolving process that we have referred to a number of times in terms of the journey we have been on, together with the health and social care trusts, since 10 years ago, 2003, when the programme was introduced.
I think it is testament that, in the projects you may have seen, be it Cedar Court or Sydenham Court in east Belfast, if you talk to the staff they will say that they have had delegations from across western Europe and America looking at design and at how they have integrated into communities. In many cases, I think we fail to promote and recognise the quality of the accommodation we provide.
Part of it is also to inform some of the learning that we want to take forward in design, the role of technology and scale, so that we learn from it. It is important for us to get feedback, get the customer experience, and listen to the tenants and older people themselves about what they want for the future. This is part of that informing. There is a range of information too, from the evaluation of individual projects, to see what works and that will help us inform the process.
Some of it is about trying to speed up the process. I think that a number of Committee members made the point about how long it takes from thinking of a project to people being able to walk into it. We are looking at ways of doing that as well.
We also recognise that we have not done enough around promotion, education and information. One of the projects here is to do that increasingly at local level with trusts. At the South Eastern Trust, we have done some DVDs on Cedar Court to get the message out and promote it, but also to share good practice, because we have seen huge interest from a number of international design competitions. Cedar Court was nominated for an award. Hemsworth Court is likely to put in for the dementia gold standard. People from the dementia centre in Stirling came over and recognised that what we do here is best practice. I think that sometimes in Northern Ireland we are not very good at saying that we do things well.
I know that the Committee has characterised some of the process as evolving, and I understand why that may be a concern, because "evolving" suggests that we do not have game plan, but it is evolving in the sense of using research evaluation to inform what we do and to do it better. At a local level — to feed on what Fionnuala said earlier — in recent years we have tended to bring all five trusts and ourselves, with the associations, together in a framework. Maybe that did not happen enough in previous years. The structures we have in place now bring everybody together to share best practice and say how we learnt from things. It is still a big challenge for us. We really have not got a good handle on the role of assistive technology [Inaudible.] dementia services. We have commissioned research, but that is to help us do a lot better. I think there is a lesson for us in getting that research and that market intelligence back out to you to see that we are trying to improve what we do and to listen to what the older people want.
Mr McKinney: The last time the board was before the Committee — I think it was the last time — it talked about alternatives for assisted living. The view was that that sort of model tended to exist in affluent areas in the south of England. Has there been any more study of that, given, for example, that there are other models in the north of England? Have any more projections been done?
Mr Holland: I would need to check. I thought that the reference to the kind of provision that was popular in the south of England was actually about campus/retirement villages, as opposed to assisted living.
Mr McKinney: Sorry. Yes, I did not describe it, but I was talking about alternatives.
Mr Martin: I can come in on that. The Housing Executive commissioned research in 2007 on retirement villages, which is published as part of the suite and, if the Committee is interested, we can certainly let you have it.
At that time, the view was that while the concept was good, Northern Ireland was not quite ready for it. The concept was there; it was explored and discussed with people. I mentioned to the Committee that we did a piece of research latterly, a survey of the baby-boom generation. It was a fairly small survey, just to get a sense of what people were interested in. Retirement villages and park homes were two things that people in that age cohort said that they were interested in, so there may be a change starting to happen. Certainly, there is some research already there.
Mr O'Kane: Could I just add that, as a result of that research, we have had discussions — conversations may be a better way to put it — with some private sector developers and some voluntary sector organisations that are looking to explore this concept. A major organisation is talking to us about how it had done some quite detailed planning and conceptual work around a retirement village, one that fits and works here in Northern Ireland, rather than on the south coast or north coast. So, there is some interest from the larger private sector developers in the "For Sale" market, because some of that baby boom generation will be homeowners with equity and will want to remain homeowners.
Mr McKinney: Yes. It is 70% of older people.
Mr O'Kane: Absolutely, in that age group.
Mr Holland: Although, not all homeowners would probably be in the market for that kind of development.
Mr O'Kane: Private let is a very niche market.
Mr Holland: It is expensive.
Mr McKinney: Yes.
Mr O'Kane: From a housing perspective, we have done some research and evaluation to look at the concept and applicability of the model to here, locally, to see if it would work. One or two of the key providers are private sector developers, and some voluntary organisations have land banks. We are talking to them to see if that is a way to maybe create a niche market going forward. You will have seen that, in some parts of Belfast, some of the private developers are marketing some of their new apartment developments for people aged 55-plus, and trying to tap into that market.
One of the things that we probably have not got across to you is that, when we look at what we are doing in the Western Trust or Northern Trust areas, we try to take account of what else is happening in the marketplace, whether there is private sector development or things being done by somebody else, to inform us, because it would be imprudent of us to ignore what else is going on. Those pieces of research are a good example of showing some leadership to the sector and what is OK. It has not matured into actual happening, but one or two organisations are at the point where I think they may be testing out planning applications in the near future.
Mr Holland: Going back to your original question about international comparisons and what have you, I think that it is important that both Brian and Stephen referenced the Dementia Services Development Centre in Stirling, which is an international centre of excellence which provides advice on appropriate design and how the built environment can be adapted to meet the needs of people with dementia. That is a centre that we provide financial support to, so that Northern Ireland can access a service from the dementia centre.
The other thing is that, benchmarking internationally, there is a survey that is a few years out of date that estimated that only 1% of homes across Europe were barrier-free for older people, but countries that were in the 2% to 5% band were identified as being progressive in regard to having a good provision, and the UK is within that context. My understanding is that Northern Ireland stands well in overall UK provision. By that benchmark, we would be identified as doing quite well. There are always going to be very innovative, individual schemes in other countries which take very different approaches, and it is always worth looking at those and staying abreast of them. However, as a national benchmark, the UK is seen as doing well across Europe and Northern Ireland is doing well within the UK.
Mr McKinney: I have just one final point. Obviously, if the private sector is looking in on that, it would suggest that your figures are out. I do not want to over-labour the point, but it shows that there is some extra market there that shows a differential. That is all I will say.
Mr Holland: It is worth pointing out that, when you look at what the private sector is interested in, you find that, quite often, it is a different kind of client. They will talk about concierge services and assistive technology, and they are often targeting not only a very affluent group but actually quite an able group, that wants to live with people of similar age, but does not necessarily have the care needs that we are looking at in our 115 figures.
The Chairperson: Folks, I thank you for your time. The Committee will reflect on all this before we make any recommendations. I thank you for your robust responses today, and hopefully, our robust line of questioning too.
Mr Holland: Thank you very much. I particularly thank our colleagues from DSD for coming along with us today. I think that their contribution added value, compared with our previous appearance, which I certainly regretted because I do not like leaving here without giving you answers. I am quite happy that, sometimes, we will not give you the answers that you want, but I hate not giving you answers, and that certainly was your experience of us last time we appeared. It has been very helpful to have our colleagues from DSD here today.
The Chairperson: I appreciate that, and I appreciate your attendance. Thank you all.