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Committee for Health, Social Services and Public Safety

Review of Transforming Your Care and Older People: Age NI

The Chairperson: I welcome, from Age NI, Ms Judith Cross, strategic policy adviser in health and social care, and Mr Duane Farrell, director of policy.  You are very welcome.  Let me advise you, as witnesses, that the Committee has read your briefing paper, and we thank you for it.  We note that it is very broad in scope and that a lot of detail is provided on important issues, such as domiciliary care, community meals and so on.  However, we want to be very clear that the focus of our review is supported living for older people within the context of Transforming Your Care (TYC).  We want to maximise the time we have with you as best we can.  Normal procedure is that we ask you to make a 10-minute presentation, and then I will invite questions from members.

Mr Duane Farrell (Age NI): I hope that we can do better than 10 minutes for you and move to the substantive business of questions and answers.  The first thing I want to say is thanks to the Chair and Committee members for inviting us here.  We welcome the opportunity to give evidence to the Committee on cases for older people and Transforming Your Care, particularly around enabling older people to remain at home.  We understand that the Committee is looking at the scope of this in its review of assisted living and we are happy to provide evidence.

Let me just quickly say something about Age NI.  It is a regional organisation which, over the past year, has had about 125,000 engagements with older people across domiciliary care, day care and residential care, as well as the work we do with older people's groups and networks across Northern Ireland and the advice we provide through our advice line.  Our comments, and the evidence we provide, is on that basis.

Older people have been clear that they want to remain at home, and die at home where possible.  Given that this is Dying Matters Awareness Week, it is probably quite an important point to make.  We have engaged with many of you as individuals, Committee members and through your political parties.  Many people have given support for Age NI's vision of social care.  We talk about:

“quality integrated social care that recognises the rights, aspirations and diversity of us all, and is based on the right to live with dignity, independence, security and choice.”

We welcomed the vision of Transforming Your Care.  Home as the hub of care is what older people want for themselves, and we have been very active throughout the process of Transforming Your Care and have made a series of recommendations to enable that to happen.  Home as a hub, as a concept, like everything else, does not happen in a vacuum, and housing is a vital component in enabling older people to remain at home and is central to the Transforming Your Care vision.

It is probably important to say, at this stage, that we are not a specialist housing group provider, but our evidence highlights how the importance of services and housing options for older people are pivotal if we are to realise the vision in Transforming Your Care to enable older people to remain at home for as long as possible.

Just by way of establishing some context, the arguments are probably well rehearsed, but it is always important to point out demographics.  We are living in an ageing population that is not as healthy as we would like it to be, and levels of disability significantly increase with age.  Poverty and fuel poverty are rising; levels of pensioner poverty are stabilising, but we have a view that that is about broader issues.  We have high levels of owner-occupying and higher levels of older people in nursing and residential accommodation when compared to England.

We also highlight the current situation with regard to how social care is provided across Northern Ireland, and it is probably important to flag up our concerns about how services are potentially being rationed on the basis of meeting only high, critical and substantial levels of needs.  We know that enabling older people to remain at home does not happen in a vacuum and is the responsibility of more than health and social services.  DSD and housing are significant factors.  However the capacity for Health and Social Care to deliver on a range of social care services to enable older people to remain at home or in a supported housing environment is seriously called into question as, we believe, the evidence in our paper shows.

Age NI makes no apology that any discussion of future housing options must include older people as part of that debate.  It is about choice.

In order to live at home, and for home to be the hub of care, people need a decent suitable home in which to live.  We believe that this aspect receives little or scant attention in public policy.  The evidence is clear that bad housing has a knock-on effect for the NHS and other areas of public policy.  Many of the chronic conditions experienced by older people have a causal link to, or are exacerbated by, particular housing conditions.

The context section that we included our paper shows that a great number of old people are living in fuel poverty.  Increasing numbers of the older old-age cohort are likely to need care and support.  Increasing levels of ill-health and chronic conditions amongst older people — coupled with restrictions in care packages and calls for the reform of funding of adult social care through the Who Cares?  The Future of Adult Care and Support in Northern Ireland consultation — potentially make for a perfect storm.

The Committee is aware of Age NI's call for a regional prevention strategy led by the Department of Health, as we believe that prevention, in many instances, is the key to the promotion of good health and reducing health inequalities.  For older people, investment in preventative social care services is cost-effective and can increase their quality of life.  Housing needs and solutions should be part of any regional strategy.  Age NI believes that a regional prevention strategy can reduce the need for the provision of social care, both at home and in a care home setting.  It can reduce attendances and admissions at emergency departments and enable older people to remain at home where they want to be.

A regional preventive strategy, driven by the DHSSPS but including Departments such as the DSD, has the added advantage of bringing together the key elements so that we can ensure provision of supported housing in all its forms.  That is what older people want and desire for themselves.  I made the point earlier that the voices, experiences and desires of older people must be central to any discussions on supported housing options.

I think that those are probably the useful key points to start off on, Chair.

The Chairperson: OK.  Thank you, Duane.  Let me just pick up on the overall message:  it is about the voice of older people in issues such as supported living.  One of the issues that we have been confronted with through this inquiry is that of choice.  We learnt very recently about vacancies in facilities.  We visited one of the facilities last week, Cedar Court in Downpatrick, and I think we all agreed that it was a modern, vibrant facility with quite a number of characters as tenants as well.  They seemed to really benefit from that particular model of care.  The staff seemed to be very enthusiastic about the model that they were delivering, but there were still vacancies in the facility.  My question is this:  do you think that there is a general lack of awareness among older people about supported living as an option?  Are you coming across that?

Mr Farrell: Anecdotally, that is a fair comment.  There is a lack of awareness.  The Committee has also discussed how we use language and the terminology of "supported housing" and "sheltered accommodation" and the confusion between those models.  Very clearly, I think that there is a greater awareness of fold and sheltered accommodation, but of the more specialist housing models, housing-with-care models, there is probably not huge awareness among older people.

The Chairperson: OK.  One of the things in your paper that jumped out at me was the number of care assessments.  I put this in the context of supported living and I am staying on that as an issue, but the number has actually been decreasing.  Is there a rationale for that?

Ms Judith Cross (Age NI): We asked the Health and Social Care Board to explain that and it was unable to do so.  Our view is that there is an increasing number of older people but, as you can see from the chart, the number of domiciliary care assessments is actually going down.  We know from evidence, as Duane said, from anecdotal evidence, that trusts are meeting only critical and substantial need.  Those people who, in the past, would have been entitled to some form of low-level help are not even being assessed.  Our advice line also has evidence that older people are being told that that type of service is not being provided any more — services that they are supposed to be providing.  Trusts seem to be cutting back on the number of packages.

The Chairperson: Should issues such as supported living be factored into those care assessments?

Ms Cross: Yes.  The Northern Ireland single assessment tool should capture the need for some sort of supported living if the older person is in a house that is not suitable.  It should capture that, yes.

The Chairperson: One of the things that the Committee has been discovering throughout this process is the more strategic issue around the ageing population.  In her evidence session, the Commissioner for Older People said that there were no clear plans or projections.  There was not even, in essence, a clear definition of supported living, but there were certainly no clear plans or projections available from the Department.  Would that be your sense?

Mr Farrell: Absolutely.  I would go back to the start of the Assembly term.  We believe that population ageing is a brilliant success but requires policy planning, housing and health and the interface between housing and health is one of those areas.  We asked at that time that ageing should be seen as a key driver for the Programme for Government to drive the types of culture changes that were needed in policy and services.  Population ageing is to be seen as a success, but what does that mean in policy terms and for the challenges that are faced in our society?  The interface between housing and health is one of the areas that we have to see coming through in policy planning and service planning.

The Chairperson: Is there any sign that that is now shifting or that organisations such as yours are in the room when it comes to projections or planning?

Mr Farrell: We are, in different spaces.  We have been very heavily involved in health and social care and in the Department's work on Who Cares? The Future of Adult Care and Support in Northern Ireland and the Health and Social Care Board's consultation on Transforming Your Care.  We are probably less involved in the spaces relating to housing, but that is not a surprise to us; housing is not a particular or discrete focus for Age NI.

The Chairperson: OK.  Finally, in Transforming Your Care and the implementation plan, it was suggested that the whole notion of supported living and its development would reduce the need for statutory residential provision.  What is your sense of that?

Ms Cross: I suppose there is a view that a lot of people in residential care could be easily cared for in some sort of supported living environment.  However, for Age NI it is about choice for older people.  Our view is that there will always be a need for some sort of residential model and that there is a need for different models across the age spectrum.  No one model will do it all; there have to be different models of housing need for older people just as there are different levels of housing options for the whole community.  It can reduce the need for residential care, but I would be concerned that they would say that there is no longer a need for the residential model of care.

The Chairperson: OK, thank you.

Mr McCarthy: Thanks very much for your presentation.  How effective is the collaboration between the Department, the board and housing associations in planning for the future for supported housing?  Duane, you said that it is important that senior citizens have a very strong input into the type of supported accommodation they require.  How would you assess those?

Mr Farrell: There are two questions there, Kieran.  I suppose, in light of what I said, which was that housing is not a specialist area for Age NI, I probably feel slightly ill-equipped to comment authoritatively on your question about collaboration with the Housing Executive and housing agencies.

I feel a lot more equipped to answer your question about participation.  We have a significant journey to travel with respect to how we enable the effective participation of older people.  Age NI operates an initiative called Peer Facilitators, which are groups of older people who we have trained in facilitation, listening and reporting skills.  They engage with older people in the community and feed back to us on the issues that are there.  They have spent the first four months of this year in residential and nursing homes across Northern Ireland listening to the voices of older people in those facilities.

It is not a straightforward process; there are people with complex needs or cognitive impairments, and the communication skills required are significant.  In addition, when we are potentially running consultations, the questions we ask on policy consultations are complex and not the easiest for older people to engage with.  I do not think that there is a strong culture of participating with people, particularly those with complex needs, in a way that allows them to participate effectively.  Age NI and others are looking at innovative ways to bridge that gap, but a lot more work has to be done if we are serious about the meaningful engagement and participation of older people in service design and policy development.

Mr McCarthy: Do you agree that it is important that senior citizens are consulted as far as possible so that provision can be made?

Mr Farrell: We believe that it is a fundamental element of a rights-based approach.

Ms Cross: It is also a significant part of section 75 of the Northern Ireland Act.  They have to consult; it is a legal duty.

Mr McCarthy: OK, thanks very much.

Mr Brady: Thanks for the presentation.  You said that the type of housing involved can impact on a person's health.  Part of the difficulty is that a lot of older people live in rural areas, where housing is not fit for purpose.  I am a member of the Committee for Social Development, which deals with housing.  Not as much supported housing is being built as should be built, so there is a dearth there.

When the Commissioner for Older People was appointed, the argument was that she would be at the heart of policymaking for older people.  That does not seem to have happened, and people such as you should be an integral part of policy decision-making affecting older people, or senior citizens as Sam refers to them.

Irrespective of the type of housing people have, they need enough money to live on.  At the moment, there are people on £145 a week, which falls about £30 short of what was projected three or four years ago that they would need to live on to have a reasonable quality of life.  Therein lies part of the problem.  You could have the nicest house in the world, but, when we talk about fuel poverty, it is about poverty.  It does not matter what sort of heating system you have, if you cannot afford to put oil or gas into that system, forget about it.  That is an inherent part of the difficulties that older people face.

Very few housing associations look to lifelong housing when they build houses.  Those types of houses have wider doors, facilities for ramps and lifts, walk-in showers, and all that.  Forward planning is very much lacking, but ultimately it is about the amount of money that people have.  We have one of the meanest, if not the meanest, pension systems in the developed world, and that is the reality.  People need to be aware of this, because one can provide all the services, but people do not have the income that provides the quality of life that they need and deserve.  If you have enough money to live on, that creates independence and reduces social isolation; it helps quality of life, helps people to live longer and gives them a better quality of life, which is important.  Would you like to comment on some of that?

Mr Farrell: There are a couple of areas there.  From Age NI's perspective, more people campaigning, advocating and bringing the voice of older people to the fore, whether that is the Older People's Commissioner, age sector organisations or specialists in housing, with a focus on older people, is to be welcomed.  There is a huge interface, and I appreciate that the Committee has a very specific focus on supported housing and on this issue.  Some of your points are valid and important.  The ageing strategy that the Office of the First Minister and deputy First Minister has out for consultation indicates that, for one in every 230 older people, the house that they live in fails to meet decent homes standards.  Obviously, that will have a knock-on impact on their health, their ability to live independently and their ability to have a decent quality of life.  There are interfaces, and I suppose that, as the Committee takes forward its role and looks at those broader interfaces with the Department for Social Development, it is quite important that it looks at a range of policies.

Mr Beggs: Thank you for your presentation.  You indicated that you have facilitated engagement with older people over the past number of months.  Did you pick up their level of knowledge about supported living?

Ms Cross: We did not consult them on the concept of supported living.  We were working with older people in the statutory residential homes and we also worked with older people who lived in nursing homes, because the Department is looking at reviewing the standards for nursing homes.  That was why we were in those facilities.

Mr Beggs: Have you had any wider discussions beyond what exactly supported living is?

Mr Farrell: Not on supported living.  We have had conversations with older people about what their home is to them.  It is important to flag that up.  For some older people, it is the home that they are currently in.  However, for a larger swath of older people, a home is a more nebulous concept.  It is about their links into the community, and their ability to live independently and engage with the resources around them.  That indicates a more flexible approach — to a spectrum from the building they are in to a place where they feel valued, safe and secure.

Mr Beggs: One of the aspects of supported living, where it exists in Northern Ireland, is the very limited geographical locations involved.  How important is it for older people who need supported living to be able to continue living in their home, to have access to their local community, friends and family and to issues down the street etc?

Mr Farrell: It is hugely important in our work with older people living in residential care, although I do not think that it is unique to supported living.  In a world in which our families are becoming a bit more geographically diverse, the ability to have people in close contact, with regard to the point that I made a minute ago, is essential to them feeling safe and secure.  On a broader level, Age NI believes that access to certain services should not be a postcode lottery.  If we are serious about supported living being a means to enable older people to remain at home, there should be an ability to access that wherever they are.

Mr Beggs: With regard to planning for the future, do you accept that it is also important to consult those who are still in their own homes?

Mr Farrell: That brings us to the point we made earlier, which is that the voice of older people should, absolutely, be central, whether their own home is currently residential, a nursing home or whether it is their family home that they have been living in for a number of years.  That provides a challenge to policymakers and service developers, because I do not think that we have good mechanisms to do it.

Mr Beggs: As representatives of older people, and as people who, to a degree, are involved in policymaking, do you have a clear definition of what supported living is and what is just an older person's home?

Ms Cross: No.

Mr Farrell: No, is the straight answer to that.  We do not have a very clear definition.  We feel that terms are used interchangeably to describe a fold or sheltered accommodation, through to the Mullan Mews/Sydenham Court type of model, which is probably what we are more fully —

Mr Beggs: As do some others.

Ms Cross: I think that that is probably part of the problem.

The Chairperson: No other members have indicated that they wish to ask a question.  I think that you are right and that that is part of the issue.  How are we supposed to plan, project and forecast for types and models of accommodation that we have not properly defined?  That is the real challenge to come out of this.

I want to thank you for that —

Mr Brady: I have just one final question.  With regard to the definition of supported housing, I attend the Pensioners' Parliaments, and supported living does not really feature as a major topic.  That is indicative of the lack of understanding of what it actually is.  People talk about fuel, money etc, but they seldom talk about supported living and supported housing, which is such an important issue for them as they go forward into the future.  Maybe that indicates a lack of understanding of the definition of what it actually is.  Maybe it is time that a more definitive assessment was done of what it actually means and what it is for people.

Ms Cross: It is probably similar to the whole issue of care and residential homes and domiciliary care.  You tend to deal with it only when it is your own personal circumstances.  Our advice line gets lots of calls from people who just find the whole situation baffling.  They find that what they are entitled to with regard to social care and domiciliary care is confusing.  My instinct tells me that the situation with supported housing is exactly the same.  You deal with it only when you know that you have to do so.

Mr Brady: It is a challenge for all of us to get that message out, because there are so many types.  It is about trying to tailor individual needs to the individual type of supported living or supported housing that the person needs.  I do not think that that diversity is clear to people.  I have spoken to people who are in sheltered accommodation, with a warden, or who are in fold-type accommodation.  We visited Cedar Court last week, and it is such a refreshing place.  However, there is so little of that available, and therein lies the problem.  Then again, it is underoccupied, and why is that?  You do wonder.  It is a challenge for all of us.

The Chairperson: Thank you both.  That was very informative for us.  The first message that we take out of this is the need to have a clear definition of supported living.  The second message is that the voice of the older population should be included in processes and that there is a need to forecast and plan.  Thank you for your time.