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Committee for Health, Social Services and Public Safety

Review of Transforming Your Care and Older People: DHSSPS and Health and Social Care Board

The Chairperson: You are all very welcome.  We have Seán Holland, deputy secretary of the Department's social services policy group; Mr Dean Looney, from the community care directive at the Department; Pamela McCreedy, director of Transforming Your Care (TYC) at the Health and Social Care Board (HSCB); and Kevin Keenan, assistant director of social services, older people and adults at the Health and Social Care Board.

This is the Committee's first evidence session on the review of supported living, which is obviously specifically for older people, in the wider context of Transforming Your Care.  Our purpose today is to gather the facts and figures around the Department's approach to supported living.  I ask you to keep your answers concise and to try to keep on the topic of supported living, because we do not want to engage in a general discussion around this today.  We will have an opportunity to come back to this.  We are keen to get to the facts and figures.  As you know well, it is a 10-minute presentation, and then it will be opened up to members.  I assume that you are leading, Seán.

Mr Seán Holland (Department of Health, Social Services and Public Safety): Absolutely, Chair.  I will try to take those comments on board and whizz through an opening statement.  First, thanks, as always, to the Committee for giving us this opportunity to speak to you regarding older people in supported living.

You mentioned facts, so I will start with a few facts.  Older people in Northern Ireland receive care and support from a broad range of social care services, including residential care, nursing home care and domiciliary care.  Since 2008, the number of residential care home packages for older people has decreased by 5%; the number of nursing home packages has increased by 7%; and the number of people receiving domiciliary care has increased by 10%.  That obviously has to be viewed in the context of the changes in demographics.  Northern Ireland, like the rest of the UK, has an ageing population.  People are living longer.  A point that the Committee has previously made about that is that it is of course something to be celebrated, but it is significant in respect of planning.

By 2022, we estimate that the population will rise by 11%, and that, within that, the number of people aged over 65 will increase by approximately 26%.  That represents 344,000 people.  The most significant figure in the demographic is probably those whom we call the "old old" — those over 85.  That is anticipated to increase by 50%.  Obviously, as I said, that is something to be celebrated.  I will not dwell on it, but I think that it is important that we set the context that having an older population is something that enriches our community and adds to life in many ways, but it presents challenges in providing services.

Rates of ill health and disability increase dramatically the older we get.  The rate of disability amongst those over 85 is 67%, compared with only 5% amongst young adults.  Dementia, of course, is one of the most significant issues with an older population growing.  It is projected that 60,000 people will be suffering from the condition by 2051.  In addition, the profile of older people requiring recurring care is becoming more complex, with many people now living with chronic conditions.

Within that context, 'Transforming Your Care: Vision to Action' sets out a number of service changes that are proposed.  They are aimed at promoting independence and reducing reliance on traditional institutional care.  They include the likes of fall-prevention programmes, reablement programmes, which promote rehabilitation in independence — I know the Committee has heard about that — and the use of telehealth and telecare programmes for remote monitoring.

As set out in the paper that we provided, supported living provides an environment for people who cannot live independently in their own home but who may not yet require the additional support of residential nursing home care.  The Supporting People programme helps fund supported living in Northern Ireland.  DSD, the Housing Executive and Health and Social Care all play an important role in the provision of supported living for older people.

The Supporting People commissioning body is chaired by the Housing Executive but includes representation from the board, the Regulation and Quality Improvement Authority (RQIA) and two Departments:  DSD and DHSSPS.  The commissioning body assesses and prioritises proposals for supported living developments.  Those proposals are generated by five area Supporting People partnerships:  northern; southern; western; Belfast; and south eastern.  All of those include representation from the relevant trusts.

Once a commissioning body approves the scheme, a housing association is selected to take forward the development.  While DSD commits capital funding for development and revenue funding for housing with support services, such as befriending services or help with security, Health and Social Care provides the funding for personal care and support to tenants on the basis of their assessed needs.

The paper we provided sets out the number of supported living facilities and tenancies for older people:  414 facilities covering some 9,081 tenancies.  Those represent just over 14% of the overall Supporting People budget and just under 60% of supported living units.  Obviously, other groups that utilise supported living include those with learning disabilities, people with mental health needs and those with physical disabilities.

At this point, the Department has not established a specific target for supported living for older people.  However, an indicator of performance to measure the number of older people living in supported living facilities has been established for the first time within the set of performance indicators that HSC uses.  Primarily, our objective is to offer choice to older people.  Choice means a range of different options, and supported living needs to be one of those options.

Supported living is provided in the context of a range of other services.  I will briefly cover some of them.  Domiciliary care, which I mentioned, was provided to over 25,000 over the course of a survey week in September 2013.  The regional social care procurement group has initiated a project that will undertake a regional audit of domiciliary care.

Reablement services, which I also mentioned, aim to maximise a person's capacity for independent living by supporting and enabling people to do things independently rather than simply doing things for people and fostering long-term reliance on care and support.  Reablement has been rolled out in three of the five trusts, and plans are in place for a full roll-out across the region.

Self-directed support aims to give service users even greater choice and control over how their needs are met.  As a first step, it is intended that, by March 2015, 100% of those who are eligible for an adult social care service will be made aware of the amount of money that has been set aside to meet their needs.

Assistive technology also plays a role, and Northern Ireland has been recognised by the European innovation partnership as one of the leading regions in Europe for addressing the health and social care needs of the older population through innovation.  For example, the telemonitoring service referred to in the briefing paper provided over 274,000 telehealth-monitored patient days and 432,000 telecare-monitored patient days in the first eight months of this financial year.

Housing adaptations are also significant, and DHSSPS and DSD have worked collaboratively on the issue for many years.  They produced a review report, which was consulted on from February to May last year.  The review report's recommendations, which include closer working and more creative approaches to adaptation, have been welcomed in the consultation, and officials are drafting a final report and an associated action plan to take forward the recommendations.

Members will be aware that the strategic implementation plan for TYC indicates that the effect of this broad range of community-based alternatives to residential care will most likely lead to a decline in the demand for places in residential care.  To that end, the HSC Board has published a programme initiation document on improving services for older people, which involves a new process for consulting, engaging and implementing change.  That was published on 21 August. 

The first of two public consultations is under way.  It relates to the HSC Board's consultation document 'Making Choices: Meeting the current and future accommodation needs of older people'.  It recognises that, in some circumstances, it may be better to develop a new supported living facility rather than making piecemeal changes to statutory residential homes.  That consultation document sets out four criteria that are proposed will be used to assess the future role and viability of individual statutory residential homes.  The Committee is well aware of the detail of that, so I will not go through each of them.  The consultation runs until 7 March 2014.  At the end of the consultation, it is hoped to agree final criteria that may be used in future exercises to determine the viability of individual specific homes.

In closing, it is fair to say that supported living has a role to play in enabling the implementation of service reform proposals.  It is an important alternative service to residential care for some people while, for others, different community-based alternatives such as reablement may be more appropriate.  However, it is important to stress that assessed need and service-user choice have to remain the key determinants of how and where care supports are met.

The Chairperson: Thank you, Seán.  As I said, we want to focus specifically on the supported living issue.  If I picked you up right, you said that there are now performance indicators in the Health and Social Care Board.

Mr Holland: They are being developed, yes.

The Chairperson: You said that there was no target yet for supported housing.  Why is that?

Mr Holland: The first thing to say is that we do not believe that older people should necessarily live in any one particular setting.  The important thing is that people have choice, and that, combined with an assessed need, should determine where they live.  It is not a case of us having an exact view and saying that there must be x number of facilities.  The important thing is that there is choice, and supported living should form part of that choice.  The indicator that has been developed will give us a better idea of the number of places available and the number of people who are using supported living, and that would give us an indication, if we felt that we needed a target, to create a sufficient marketplace of choice.  Currently, we do not have a target.

The Chairperson: I do not think that anybody would have any difficulty with choice, or should not have any difficulty with choice.  However, we know the demographics, and we know that there is an ageing population.  You have given us the figures for up to 2020 and the percentage of the population that will be over 80 at that stage.  So, we know the projected forecast.  Why, therefore, are we not setting targets that address the need?

Mr Holland: It is difficult to set a target for choices that people will make in the future because you do not know what choices people will make, which is one issue.  It may well be that we will set targets if the current exercise indicates that there is not sufficient provision.  Equally, you do not want to have overcapacity.  These facilities are increasingly bespoke and designed to meet particular needs.  You certainly do not want to have a target that is driving you to build facilities that people may not choose to live in. 

I will offer this to my colleagues to see whether they have anything more to add about the process.

Mr Kevin Keenan (Health and Social Care Board): Supported housing is only one of the options that we need to develop to meet the needs of older people in the future.  It is not the only option available to us.  With regard to numbers and targets, we work very closely with the DSD on the three-year funding cycle.  We had many meetings with it at the beginning of the current cycle, and it asked us what we wanted to develop across a range of programmes of care.  We jointly made the submission to the Department for the funding.  The current target that the DSD side of the house is working to is somewhere in the region of 850 units, but that covers a range of programmes and geographies.  We are on target to achieve probably 650 to 700 of those.

The Chairperson: First, I think there is an issue about how many of those are for older people.

 Do you have a figure for that?

Mr Keenan: Most of the proposals that we put forward in the funding cycle that I am talking about were linked to existing residential provision.  Most of the projects on which we have worked closely with DSD and the Housing Executive have concerned re-providing statutory residential facilities around the country.  I think that 10 homes have closed over the past five years.  To date, the majority of those have been re-provided for by supported housing facilities.

The Chairperson: We are not honestly saying that, of the 414 facilities with, I think, 10,000 tenancies, what we have across the North is anywhere near addressing the need.  I go back to Seán's point about choice.  Of course there should be choice; that is a must.  However, there is clearly an identified need here.  What ratio is being applied to forecasting the elderly population?  There does not seem to be one.

Mr Holland: I am not sure that those numbers necessarily indicate that we have a current deficit in provision.  I am not aware of significant numbers of people wanting to live in supported living arrangements and not being able to avail themselves of them because of a lack of capacity.

The Chairperson: I am sorry, Seán, but my point is that you do not need to be a statistician to work it out.  With such an increase in our ageing population over the coming years, and we have 414 facilities, surely that is not —

Mr Holland: Not necessarily.  I will ask colleagues to come in in a moment, but I think that older people's expectations of where and how they lead their life are changing fairly significantly.  Particularly with the provision of domiciliary care and reablement services, a lot of people are choosing to carry on living in their own home in circumstances that, 10 years ago, were not available to them.  So, an increase in population does not clearly equate to a demand for certain types of provision.  Pamela, would you like to come in?

Ms Pamela McCreedy (Health and Social Care Board): That is exactly the point that I was going to make.  There has been a significant increase of investment in domiciliary care.  I am sure that you find that, when you are out in public, that is what they voice.  In the main, they want to stay at home.  It takes you into different fields of supported living, whereby people have individual needs that it helps them meet in a more robust way than would be the case in their own home.  As we know, it is a continuum.  That is where the residential care/nursing home care element comes in.  However, there has been significant change in investment in domiciliary care over the past couple of years.  So —

The Chairperson: With respect, I think that is a separate issue.  There is a big issue there around investment in domiciliary care and adopting a regional approach to how some of the domiciliary care packages are agreed.  We need to park that.  We are talking specifically about the facts and figures around supported living.  To come at this slightly differently:  the implementation plan for Transforming Your Care talked about improved availability of supported living places.  In his opening comments, Seán said that the demand for residential care places will decrease.  Can you quantify that expected shift?

Mr Holland: I referred to the most recent decline in demand for residential places.  It is important to realise that, although I mentioned a range of services, it does not equate to a journey that one individual older person will make through those services.  So, for example, one older person may choose to stay at home until they go into a nursing home, whereas another older person in similar circumstances will make the choice to bridge those journeys by going into supported living.  Or, indeed, it may not be a bridge and they may end their days in supported living.  So, an increase in the population cannot simply be worked up into a ratio for increases of all these different types of care.  The important point is that we have a range available and people are able to make choices.  If we discover that people are not able to make a particular choice because of a shortage of provision, a target, at that point, comes into play and you stimulate the market in one way or another to make sure that that gap is filled.  At the moment, though, that is certainly not the situation; demand for supported living is not outstripping supply.

The Chairperson: Seán, I am trying to ascertain here what seems to me to be a presumption around the notion that a decrease in demand for residential care is a view.  I am not hearing anything scientific. The TYC implementation plan said:

"Due to improved availability of community-based alternatives, it is expected that demand for statutory residential homes will further decline."

Can you quantify that expected shift?

Mr Keenan: We work very closely with the Housing Executive under the auspices of the Supporting People programme.  We have a planned programme of developments across all of the programmes of care on a rolling three-year basis.  As things stand, there are six proposals in the pipeline for older-people developments, amounting to 155 placements.  Those are based on submissions that come to the commissioning body from the trusts.  They are based on business plans, and those business plans are interrogated by us to make sure that they are based on assessed need.

The Chairperson: I appreciate that, because we are getting facts and figures.  You said 150 —

Mr Keenan: The six concrete proposals that we have been considering at the commissioning body amount to about 155 places.  There are a couple of other slightly more tentative proposals that have not quite reached business case yet or have not been approved.

The Chairperson: I appreciate that.  Page 18 of your document talked about the number of intended developments.  Where are the intended developments?  What stage are they at?  Where will they be located?  How will they be funded?  Is that the 155?

Mr Keenan: Yes.

The Chairperson: So, they are at various stages of business planning.

Mr Keenan: They are at various stages, yes.

The Chairperson: I assume that they are site specific?

Mr Keenan: Yes.

The Chairperson: Therefore, some ratio is being applied around the needs of the increasing elderly population.

Mr Dean Looney (Department of Health, Social Services and Public Safety): At this point in the process, the demand is considered at a local level through the area Supporting People partnerships.  The issue for us with the indicator of performance is whether a central target established by the Department might be necessary to drive further expansion.  That is something that we will consider when the indicator of performance starts reporting back to us with data.

The Chairperson: Finally — I know that a number of members have indicated that they have questions — as this develops, it would be very useful to have the specifics around those 155 places.  We are accepting that they are at various stages of their business cases and planning.  However, the Committee would seek to be informed as that process develops.

Mr Holland: We can get that information from the commissioning body and supply it to you.

Mr Brady: Thank you for the presentation.  Seán, you said that the fact that people are living longer is to be celebrated, and that is certainly true for older people.  However, that goes hand in hand with a quality of life and an expectation that people will have an enhanced quality of life rather than having to go into residential care.  Our research people have told us that the Supporting People budget was £8·9 million for 2012-13.  Could you give us some idea of what it was in 2013-14 through to 2016?  It would not seem unreasonable to assume that, if you are going to put in place a situation where people want to remain at home, the budget should increase.  That does not seem unreasonable in the circumstances. 

I sit on the Social Development Committee, so I am aware that there is not as close a working relationship as you have pointed out.  For instance, it is not that long since the Minister for Social Development stood up in the Assembly and admitted that he had failed to reach his Supporting People housing targets.  To date, and we are not even at the end of the financial year, almost £70 million has been handed back.  That includes maintenance etc.  You could build a lot of supported housing and a lot of social housing for £70 million.  There seems to be a disconnect there.  I am not sure how close the interdepartmental relationship is.  Sitting on both Committees, it seems to me that it is not obvious, and that is my point. 

With regard to the budget, it would be useful to find that out.  DSD is very heavily involved — I will qualify that by saying that it should be very heavily involved — in building houses.  You mentioned choices and said that people would make the choice to stay at home; but, if a lot of older people knew what was in store for them with the infrastructure that is provided, they may well make other choices.  In my experience — I deal with it daily, and I am sure that we all do at a constituency level — the infrastructure and the support is simply not there.  I have been dealing with people for a long time.  We have been through Customer First and all of that, and the bottom line is that it is all about money.  That needs to be addressed, the systems need to be addressed, and proper procedures and proper infrastructure need to be put in place. 

To me, it is a great principle that people should remain at home, and most people want to do that, but they can only do that if there is a proper and supportive infrastructure to ensure not only that they can stay at home but that their quality of life in doing that is enhanced as they grow older.  It has been admitted on many occasions that people are living longer, because of modern medicines and all of that, but not necessarily more healthily.  People need to be treated as people and not as commodities.  Unfortunately, we have moved away from treating people as human beings and to treating them as commodities, because you can now make money out of them if they live in residential care in the private sector.  That is just a personal observation over many years, and I think that that is something that needs to be addressed.  However, it would be helpful if we could get the budgets through, because £8·9 million is not really that much in the scheme of things.

Mr Holland: Specifically, what budget figures are you looking for, Mickey, because we can supply you with —

Mr Brady: The Supporting People budget for older people.  That spend was £8·9 million —

Mr Holland: That is the Housing Executive's Supporting People budget.

Mr Brady: That is the figure that we got from our research people, and that is for 2012-13, so I am looking for figures for 2013-14, 2014-15 and 2015-16, if that is possible.  I am sure that it is.

Mr Holland: It is a Housing Executive budget, but we can certainly get that information for you.

Mr Brady: Again, with this close working relationship, it should not be any problem.

The Chairperson: I want to come in to clarify on that.  The briefing paper that we have states that, in 2012-13, the trust spent £3·7 million on providing support in supported living settings.  Was that all older people in supported living?

Mr Looney: Yes, it is.

The Chairperson: So, is that £3·7 million out of the overall £8·9 million?

Mr Looney: No, that is in addition.  The £8·9 million is separate; it is the Housing Executive's funding that goes into supported living.  The £3·7 million is from health and social care trusts.

The Chairperson: I am sorry, Mickey, thank you for letting me come in on this.  I think that it is important.  The trusts spent £3·7 million in 2012-13 on older people in supported living.  Is that accurate?

Mr Looney: They did, yes.

The Chairperson: OK.  Do we have an expected spend for 2013-14?

Mr Looney: I do not have those figures to hand, but I can check them with finance colleagues when we return to the Department.  I should also say that the expenditure on supported living for older people is not reported in the same way by each trust, so £3·7 million represents the expenditure of some trusts.  Some trusts report the expenditure on supported living through their domiciliary care budget, and that is why, I think, your research paper also refers to expenditure on domiciliary care for older people, which is around £160 million.

The Chairperson: With respect, I find it difficult that we cannot get access to the budget and projected budget when we are having an evidence session on supported living.

Mr Looney: As I said, we can check that for you with finance colleagues when we return.

The Chairperson: Seán, is that not something that the Department should bring to us?

Mr Holland: I apologise if you feel that we have not brought you information that you required.  We have given you the budget that we have spent.  It is, as my colleague said, a budget that is made up of different components.  There is the personal social care component, which the HSC provides.  There is also the Housing Executive budget, which itself has different components.  There is both a capital and a housing support component.  If you want us to supply projected figures, we can certainly go back and bring those to you.

The Chairperson: We need to get clarity on the £3·7 million, because we are now hearing that it goes through different trusts differently and it might be part of the domiciliary care package.  We are talking specifically about supported living here, so I think that we need to get a breakdown of that and clarification on whether that is all for older people in supported living.  As Mickey Brady has asked, how much do we expect to spend this year and next on supported living?  If we can get that information, it would be very useful.

Mr Brady: Is the figure of £8·9 million, which we got from our research people, just for supported housing?

Mr Looney: That is my understanding of it, yes.

Mr Brady: Yet we have been told by the Minister for Social Development that the targets have not been reached.  Is that something that there is a discussion about?

Mr Holland: Yes.

Mr Brady: Can we be assured that targets will be reached next year or the year after?  This is supported housing, which is, obviously, separate from social housing, which is a huge issue in its own right.  Again, targets are failing to be met there.  I assume that the £8·9 million was not used, or that only part of it was used, if they failed to reach the supported housing targets.

Mr Keenan: As you have suggested, the development of this model of care depends on different funding streams coming from two Departments:  DSD and DHSSPS.  Both of those Departments are very clear about what they have currently invested in supported housing.  Our contribution at this point in time is £3·7 million.  If the projects that I have told you about come to fruition, we have business cases and projected costs in there.  If and when those facilities are built and funded from the housing side of the house, the trust will be providing the resources and the money to make sure that the care costs are met.

Mr McKinney: What are your projections?

Mr Keenan: We do not know exactly when all of these facilities are going to open.

Mr McKinney: But you should have a ceiling projection vis-à-vis the concept of them, surely.

Mr Keenan: Yes, we will.

Mr McKinney: What is it?

Mr Keenan: I do not have the figures from the composite business cases here.

Mr McKinney: In broad generality, is it a 10% figure?  Is it a 20% figure?  What is it?

Mr Keenan: Sorry, a 10% —

Mr McKinney: Increase.

Mr Keenan: Increase on the £3·7 million?

Mr McKinney: Yes, generally.  Give us a ballpark even.

Mr Keenan: I think that there could be a couple of facilities open in the next 12 months.  That is what we have got in front of us.  I am not going to give you a percentage or a figure today on what that might add to the Health and Social Care budget, because I would not be confident about standing over it.  We can go and find out for you, but I am not able to give you a figure here today.

Mr Holland: I reiterate my apology to the Chair that we do not have information that you were hoping to have today.  We will endeavour to get that to you as quickly as possible in written response.

The Chairperson: Go ahead, Fearghal.

Mr McKinney: No, I will leave it until I see how the rest of the evidence proceeds.

Mr Beggs: Earlier, the point was made about choices.  My experience is that supported living accommodation, where there is a mixture of Health Department and DSD support, is full.  There are vacancies in sheltered housing, but what is commonly known as supported housing, where there is a bit more supervision, is full.  As they are full, how is there choice?  Furthermore, there is the proposed closure of the limited supported housing that there is in certain areas, such as Lisgarel in Larne.  It is proposed that that be closed, without any proposal for replacement, so there will be no choice.  How do you say that there is a choice?

Mr Holland: There are vacancies in some supported living facilities, and they are available to be filled.  With regard to the planning for any local area, I go back, again, to the process that Kevin described.  There is a commissioning process in each of the health and social care trust areas, and it identifies the need and commissions and develops schemes accordingly.

Mr Keenan: Two new schemes have opened in the past, I think, 12 months.  There is one in Belfast and one in the South Eastern Trust.  They are state-of-the-art facilities.  They are taking a little bit of time to fill up, but you do not move 30 people into a new facility in one day.  There is a planning and transition process, and the trusts are very confident that they will fill those facilities in due course. 

As regards your geography — I know that you are preoccupied with Larne and the needs of the good people of Larne — we have been down to Lisgarel to talk to the people, their carers and their relatives.  There are no plans currently in place for any supported housing developments in the Larne council area.

Mr Beggs: Are there other areas in which there is, similarly, no choice for supported living?

Mr Keenan: I have told you that there are six proposals in the pipeline and that there are four tentative proposals.  Those are all significant developments.  There are somewhere in the region of 28 to 30 places.  It takes time.  There is a lot of planning involved, and it is an extraordinarily complex process.  We are not developing homes in every council area at the one time.  This has to be a planned process over a period.  It is a rolling programme. 

Of the last two that opened, as I said, one is in Belfast and the other in the South Eastern Trust.  We would like to think that the next geography that may benefit from a good supported housing development could possibly be the Northern Trust.  However, we cannot move on all fronts at the same time.

Mr McCarthy: You will be glad to know that I am after more figures and facts.  If the Committee is to do its job right, it needs to have precise figures.  Those are what we are hoping that you will be able to provide.  Indeed, we need to see evidence that the Department has concrete projections for how many tenancies are needed in the future.

Your paper refers to 414 facilities for older people and nearly 10,000 tenancies.  I think, you said a few minutes ago, Seán, that there are unoccupied places at your facilities.  If so, how many?  Would you know?

Mr Holland: No, I do not have the exact figures for the voids.

Mr Looney: We are aware that housing associations have concerns about voids in their portfolio of properties.  The housing associations' view would be that they are not sitting at 100% occupancy.

Mr McCarthy: You did say, Seán, that there are unoccupied places.

Mr Holland: There are some, yes.

Mr McCarthy: Can you get those figures for the Committee?

Mr Holland: We can approach the Housing Executive.  It is important to realise that these are not Health and Social Care facilities.  They are owned by housing associations and their building was funded by the Housing Executive.  We can certainly request the information, but these are not things that we directly run.

Mr McCarthy: What is the rate of turnover of places in supported living facilities?  Can you give us a figure there?

Mr Looney: That is something that we would also have to check with the Housing Executive.

Mr McCarthy: How many tenancies does the Department intend to create for older people over the next three years?  I think that you disappointed us by saying that you had no target.

Mr Holland: I think that Kevin has already addressed that.

Mr Keenan: But that is not to say that that figure cannot be added to as more business cases come through the system or as need is identified at local level.  This is not a static programme.  This is not the last figure that we could offer up.

Mr McCarthy: In 10 years' time, how many older people would the Department wish to see housed in supported living?

Mr Holland: I would have to come back to my starting point:  that depends on how many people want to live in supported living.  It is not for us to tell people where they are going to live.

Mr McCarthy: Is that why you said in your introduction that you did not have targets for that?

Mr Holland: Yes.

Mr McCarthy: You do not have targets because you do not know what the choice will be at that time.  Is there no way that that can be looked at?  That is something that the Committee really needs to find out.

Mr Holland: That is why we are looking at the indicator to get a baseline as to how many people are making that choice, but, ultimately, it is an individual choice.  If you were to roll the clock back to 15 years ago, we could have given you a projection as to how many residential nursing home beds were going to be in place and how many people would be in them, because that was the only choice available.  It is not as exact as that any more.

Mr Beggs: In your paper, you mention the 414 facilities for older people and nearly 10,000 tenancies.  How many facilities is the Department of Health involved in, and how many tenancies are you involved in?  There is sheltered housing that is just the Housing Executive, but how many involve the Department of Health in supporting people?

Mr Holland: The indicator that we propose will assist us in giving you that exact answer.  We do not have the exact answer at the moment.  That is one of the reasons for the development of the new indicator.

Mr Beggs: I am astonished that the Department of Health does not know how many supported living accommodations it is contributing towards and the number of tenancies.

The Chairperson: I share that view.  The Department was very quick to make calculations on residential care, for example, and to target the closure of 50% of residential care facilities.  Thankfully, that is not now a reality and a proper consultation is taking place.  However, if that had been a reality, where would those people be expected to go if you are saying that you do not have targets?  How do you calculate 155 places as fitting a need, if we are serious about enabling people to stay at home or to live in supported housing?  I find it irregular that the Department cannot give us those statistics.

Mr Holland: In relation to the closure of statutory residential care homes, it was not a target; it was thought that possibly up to 50% of statutory homes may close.  Each home has to be considered on its own merits.  The criteria that are currently being developed to assess whether any individual home will or will not close include the availability of alternative provision in the area.  So, at a local level, it is proposed to be done on a planned basis.  Currently, not a single home has closed or will close.

The Chairperson: I do not want to open the debate on residential care, but, with respect, Seán, 50% was in black and white.

Mr Holland: What was in black and white was "up to 50%".

The Chairperson: I think that the rest of the world, looking on, would say that that is a target.  It was not just something that somebody decided to put on paper for no reason.  Let us park that, because there are a number of members who want to speak.

Mr Beggs: With the mix of provision in the Supporting People programme, there could be a variety of providers, including statutory housing associations and, indeed, the voluntary sector.  Which sector does the Department see as having the most potential to provide increased capacity in the near future?

Mr Holland: On future developments, again, I look to Kevin, who is involved in the commissioning.  He can identify the people who have been identified to bring forward proposals.

Mr Keenan: Most of the facilities for older people in Northern Ireland are developed collaboratively, as I said earlier.  It is usually the housing association that provides the bricks and mortar, and, in most of the older people's developments, the trust provides the staffing, although the new Moylinney development in east Antrim may involve a voluntary sector provider.

Mr Beggs: What are the advantages and disadvantages of each different mix?  If you are always going for the housing associations, what advantage do you see them having over others?  What other options have you considered for staffing?

Mr Keenan: The Supporting People model, as I said earlier, is based on collaboration between two major Departments and the alignment of funding.  We benefit from the fact that the money is provided for the bricks and mortar to provide state-of-the-art, modern facilities into which people can be appropriately placed, following assessment.  It is then our obligation to make sure that they are provided with the appropriate support and care so that they can live there securely.  When it works well, it is a very good alliance, in terms of both funding and methodology of support.

Mr Beggs: I am aware of Barn Halt in my constituency, and there are many other developments like that.  Have you detected a high level of satisfaction with that model elsewhere in Northern Ireland?

Mr Keenan: I am not sure if it was contained in the papers that you received, but a piece of work has been done in relation to Barn Halt specifically.  It is a follow-up piece of work in the form of a user satisfaction study, which was very thorough, and the message was very positive indeed.  There are other facilities around the country, such as Mullan Mews in the east, Sydenham Court and Seven Oaks up in the west.  We are getting reports of a high level of resident satisfaction with that model of care.

Mr Beggs: Are they all housing association-led developments for bricks and mortar, with provision of support by the trust?

Mr Keenan: Yes, they are.  I would like to emphasise that.  It is a model that, when it works well, is very highly regarded by the residents.

The Chairperson: I do not think that anybody is disputing that.  Gordon is next.

Mr Dunne: Thanks very much for coming in this afternoon.  What evidence is there that the private sector is keen to get involved in the provision of, say, retirement villages for folk who can manage to buy or, perhaps, to rent in the village?  What sort of engagement do you have with the private sector on that?

Mr Keenan: I talked to Housing Executive colleagues a few days ago, and there is currently nowhere in Northern Ireland that could be described as a retirement village per se.  However, we and the Housing Executive have been approached by private developers who were thinking of building this model of care in Northern Ireland.  Nobody has yet put their money where their mouth is and developed retirement villages.

The model in the rest of the UK tends to be in the south-east of England, but it is not a model that has been widely promoted and progressed across the whole of the UK; it tends to be in certain pockets, and, I have to say, generally affluent pockets.

Mr Holland: That is also the experience internationally.  That kind of model tends to thrive in areas with high personal net wealth.

Mr Dunne: Are we doing anything to encourage and incentivise private developers to come on board?

Mr Keenan: No.  Although I do not want to digress, with investment from the private sector, and as part of the wider residential care debate, we have significant over-capacity of residential and nursing home care in certain parts of Northern Ireland.  That is because private individuals have invested, at risk, and built facilities.  At this time, we have an over-provision.

Mr Dunne: I was thinking more about what you said about retirement villages and the opportunity to rent or, in many cases, purchase in a quality development, where there would be space, and people would have amenities rather than living in confined areas.  Such villages would have standards similar to what people are used to.  Surely that needs to be encouraged and developed.

Mr Keenan: As I said, a number of people have thought about introducing and promoting such a model here.  I am quite sure that those people have also done some marketing intelligence.  At this point, the indicators may be that Northern Ireland is not ready for this model of provision just yet or that, in the current housing market, people are not prepared to take the risk to develop such a model of care to that scale, as you probably appreciate.

Mr Dunne: I am aware of some recent newbuilds for dementia care homes.  Have you been engaged with any of those providers, or are you doing anything further to provide for those with dementia?  It is certainly a big issue.  We have just come from an Alzheimer's Society presentation, which was attended by number of MLAs.  It made us very much aware of the problem, which needs to be addressed and funded.  Will the Department provide any incentive to the private sector to engage and to provide quality developments, as I have certainly seen in north Down, in response to what is sadly a growing need?  I feel that there is a role for the private sector.  What is being done to encourage that?

Mr Keenan: We are working on two fronts.  You are absolutely right:  some private sector providers are looking at the market and the need.  They have, quite rightly, identified that dementia is a huge challenge for us to which we have to rise.  In some cases, they have reconfigured their services to point them in the direction of dementia care.  In north Down, there have been a number of quite significant new developments.  My understanding is that the trust is working closely with those developers because it sees the need for that type of care.  Some of the more recent supported housing projects that have gone into the system under the umbrella of what we are talking about have also been targeted to meet the needs of people with dementia.  Cedar Court, in the South Eastern Trust —

Mr Dunne: Sorry, where is that?

Mr Keenan: It is in Comber.  There is also a new facility, Hemsworth Court, in the lower Shankill.  The people who developed that have tried to ensure that it can rise to meet the needs of people with dementia as well.  New facilities that are being planned take the dementia factor into account.

Mr Dunne: They do?

Mr Keenan: Yes.

Mr Dunne: These are joint ventures that the trust runs.

Mr Keenan: Yes.  People with dementia will test this model severely, because it is premised on the tenancy model and a reasonable level of independence.  This is the next tier down from residential nursing home care, in which people are very dependent.  People with dementia will test the model to destruction; it will be very challenging.

Mr McKinney: This goes back to your point about choice.  Transforming Your Care states that there is a need to ensure that the availability of supported living is more widely known about and promoted.  How is that being done, and what is the budget?

Ms McCreedy: That touches on a few of our earlier points.  Without digressing from supported living and supported housing per se, I have noted that part of the statutory residential review is to look at the needs in each area by geography.  A significant amount of work has already been developed and been done.

I go back to the Chairperson's point.  What provision do we have for people at home in domiciliary care?  Do we have a clearer articulation of who is in supported living, who is in residential care and who is in elderly mentally infirm (EMI) care, and so on, across the spectrum?  We need to layer growth on that and the age of the population and build in assumptions around anticipated choices that people may make.  It goes back to Seán's point that people will have choice, and you can but best anticipate where that will take you.  That will start to tell us about any potential gaps and where they are.

It is known in part, and that will be part of the outworking of the consultation on the statutory residential review of what is currently available, but it is more about making sure that, as we move and change the model, we have the building blocks in place to make sure that people can avail themselves of that choice.

Mr McKinney: Specifically, how is the supported living aspect being promoted?

Ms McCreedy: We have been discussing people's awareness of it — the Committee has touched on that — how older people understand where it is, what it is like and how they can see, feel and touch it to know that it would be an option for them.  At the moment, not everyone would rise up to understand that.

Mr McKinney: What evidence can you point to that it is being promoted?  Can you tell me about the promotion campaigns and the types of budgets that are attached to that?

Mr Keenan: I would come at it from a different direction.  As people get to a stage at which they need or want to move into a different model or configuration of care, they come into the system that we are talking about in two ways.  They can come in from the housing side:  they want to move, but they are not quite sure about the options, so they may get advice about what is available.  Our Housing Executive colleagues promote that very strongly.  Under the supported housing umbrella, there is a spectrum of accommodation models.  On our side, if someone became more frail, more dependent or experienced disability and had to move, he or she might talk to his or her social worker, who would know about the availability of different models of care in that locality.

Mr McKinney: In that latter category, it is a crisis that introduces them —

Mr Keenan: Sometimes it can be as a result of advance planning.  If someone is in the early stages of dementia —

Mr McKinney: Can you tell me about the promotion campaigns and the information flows?  Where are the information flows for what people need to know?  Are they available in advance or at the time?

Mr Keenan: It is usually on the basis of the assessment.

Mr McKinney: Are they available at that time and not prior to that?

Mr Keenan: Yes.

Mr McKinney: So there is no promotion campaign.

Mr Keenan: Information about the availability of resources in any given area is on a trust website, for example.  People can access that through the Housing Executive website.  That type of information is available, but it does not mean that it is promoted on a daily basis.

Mr McKinney: Yes, but Seán was talking about informed choices.  What are you doing to inform the choices?

Mr Holland: At the point when people are having their needs assessed, they sit down with a social worker or a care manager, who will take them through the range of available options.  In the past, those options may have been restricted to residential homes or nursing homes.  Now, when a person is taken through the options, they include domiciliary care, reablement, supported living, residential care and nursing home care.  It is not about having a public awareness campaign on which we would spend tens of thousands of pounds on television advertising or something like that.  It is about the relationship with the social worker, working with individuals and their family to assess need, establish circumstances and present some of the available options.  That is how the choice is being promoted on an individual basis.

Mr McKinney: For the record, I am not talking about expensive advertising campaigns.  I am talking about information through the Pensioners Parliament and other mechanisms such as Age NI.  What is being done in advance to prepare people for the choices that they will inevitably have to make, and not just at that time?

Mr Holland: With supported living, individual housing associations undertake campaigns in which they try to raise awareness about the range of services that they offer, including supported living.

Mr McKinney: Are you not doing that?

Mr Holland: We do it through individual assessments and by making sure that individuals are made aware of the available options and are supported in making a choice.

Mr McKinney: You referred to social work issues, but in other areas, how are people assessed as being suitable for a place in a supported living context?  Are only social workers involved?

Mr Holland: It will be part of an assessment whereby an elderly or community care team will respond either to a request from an individual or a family member.  Frequently, a GP initiates the process.  Kevin, you previously managed that area of service.  Is that a fair description?

Mr Keenan: It goes back to what I said earlier:  people come into the system in two ways.  They may come in through the housing route.  They may be living in a Housing Executive house that is too big for them and may say to a housing officer, "This place is too big for me" or "I have a disability and can no longer use upstairs.  What other options are there?"  If people are in that situation, the housing side will work very closely with a social worker to do what Seán is talking about — namely, assess their needs and make sure that, wherever they end up, the service there is appropriately tailored for their needs, both in care support from a trust and the physical fabric of a building.

Mr McKinney: This can often be a traumatic period for people who find themselves moving from one side to another.  What we have been talking about is people moving out of home.  What information is provided on exiting when it comes to financial advice on renting or selling a home?  Is there anything being done about easing the journey on the exit as opposed to just the entry?

Mr Keenan: Those are two sides of the same coin.  If people reach a stage, either individually or with their family, whereby they feel the need to move, I would expect the housing side and the health and social care side to offer assistance.  It is not just about their physical needs, and that is very important given what Seán said.  Any move of this sort will have a financial dimension, so you would sit down with people and assess their financial means, because, in some cases, people do not have to pay a penny, but, in others, people have to contribute to their care.  So there are physical, emotional and financial aspects.

Mr Holland: I can illustrate that with personal experience.  We went through this process with my mother, who has passed away.  We were visited by a social worker, who as well as undertaking an assessment, which involved the GP and an occupational therapist (OT), talked us through various issues.  She said, for example, "You need to tell us about your money so that we can do a financial assessment", and she told us how much my mother was allowed to retain without having to make a contribution.  The legal implications of that were talked through with us.  That was my experience of the process.

Mr McKinney: I do not want to drill down into personal experiences, because I have my own, and they were not good.

What are the usual triggers that result in someone moving into supported living?

Mr Keenan: People could get an early diagnosis of dementia and would not be as able to live on their own, or, if they are living with somebody who goes out to work, that person is afraid to leave them there.

Another trigger could be the onset of physical disability.  Somebody could become wheelchair-bound and be living in a home in which the doorways are not wide enough and that does not have an appropriate bathroom.  In some cases, an OT might come to the house and do an assessment, and the property might have an adaptation.  However, if the person feels the needs to move out, it could be the disability that triggers that.

Mr McKinney: Can people self-refer?

Mr Keenan: Yes, they can.

Mr McKinney: How many people self-refer?

Mr Keenan: We do not have that figure with us.  I will go back to a point that Seán made earlier about the numbers that we are talking about this afternoon.  The health and social care system does not have unique responsibility for or total oversight of all entrants to that system.  In fact, most facilities are the responsibility of the Housing Executive.

Mr McKinney: I am sorry to interrupt.  Given the generality of our discussion, is that a failure?

Mr Holland: Do you mean a failure because we cannot identify the number of self-referrals?

Mr McKinney: It is not only the number of self-referrals.  You have been unable to bring a lot of other information to the table, and that concerns me.  Kevin spoke about self-referrals, but he also mentioned not having oversight.  Is that a systemic failing as to how we move forward?

Mr Looney: It is recognised that the system can work better and that the two Departments can work more closely together.  At the beginning of the year, both Ministers asked officials to have conversations with each other and to have a series of meetings to identify issues in the planning and implementation process and to consider a way forward that would address those.  The exchange of information between the two Departments is one of those issues.  We had a meeting last week that included representatives from the housing associations, and there was a helpful discussion from the perspective of the health and social care trusts, the Federation of Housing Associations, the Housing Executive and DSD.  The forum that has been established will be the means through which we can address many of the issues and many of the improvements that can be made.

DSD made a commitment to review the Supporting People programme by March 2015.  That mechanism also exists, and we will look at how the programme works and where improvements can be made.

Mr McKinney: Can we ask for that to be shared?

The Chairperson: Yes, absolutely.

Mr Holland: With any complex social issue, there is always a dilemma over whether you try to bring it all within the remit of one Department or group or whether you try to approach it on a partnership basis.  You could end up with one massive Department doing everything.

Mr McKinney: I was struck by the graphic at the very start of the TYC document, on which all this is predicated, which is about a growing older population and increased pressures.  With respect, we are not hearing enough evidence or information that you are putting in enough resource or that you are considering the issue in the context of its importance.

Are there waiting lists for supported living facilities?

Mr Holland: I am not aware of —

Mr Keenan: I do not have the numbers.

Mr McKinney: With respect, I am holding my hands up because there is an awful lot of information that we are not getting today.  I will not make any assumptions about it, Chair.  We are simply not getting the information.  The homework has not been done.  Maybe we should revisit the issue, Chair.

The Chairperson: Members have raised a number of issues that have not been answered.  It is irregular that we are holding an evidence session specifically on this issue and that we do not have the detail.  However, I know that Jim has been waiting.  Have you finished, Fearghal?

Mr McKinney: I had one more question, but I will pass.  I am not sure that I will get the information.

Mr Wells: This has been interesting.  The session has covered some of the points that I wished to raise, but I am trying to tease out the commitment of the trusts, using that awful Americanism "going forward".  I cannot think of any other phrase, so I will use it anyway.  You gave us some idea about 2013-14.  What is the commitment to funding, through the trusts, for the next few years for sheltered accommodation?

Mr Holland: It is impossible for me to give a detailed breakdown beyond the comprehensive spending review programme.  The commitment from the trusts will be to respond to demand as it presents itself on the basis of assessed need.  Kevin referenced the schemes that are coming on line, which reflect a commitment from the trusts to fund those schemes.  That is the process through which I see that commitment being taken forward over the next few years.

Mr Keenan: Dean said that we are coming to the end of a cycle, and Mickey talked about the money that has not been spent in the current cycle.  Hopefully, we will address some of the issues that you raised about the alignment of information, but we are moving into a new phase in which we will have to develop a new joint bid, look up the road and try to estimate the types of needs and the number of developments that we need to put into the system for the next three years.  As for the horizon that we are working towards, we are not looking much further forward than 2015-16.

Mr Wells: I must say that, listening to these answers to questions on such a crucial issue, which, frankly, almost derailed Transforming Your Care because of the whole controversy, my impression is that there does not seem to be much concrete thinking.  I would have expected a definitive plan as to where we were going and what we wanted to achieve, rather than reacting to proposals by some private entrepreneurs and housing associations.  I am not content that you have grasped just how difficult an issue this will be.  Unless the public are reassured that there will definitely be proper provision, the residential home issue will, unfortunately, come back to bite us.  I am just wondering why the answers are not more definitive.

Mr Keenan: Most of the action proposals in the programme are aligned with the re-provision of statutory residential care in the relevant geographies.  So it is not a random choice.  Most of the proposals are about the straightforward re-provision of residential care facilities.  There are plans in the pipeline for Greenisland, for example, where the home closed last year.  This is a proposal to re-provide and put in place supported housing.  We have concrete plans in the system for Moylinney Care Home, which also closed last year.  Most of the proposals on the schedule relate to current statutory homes and the re-provision thereof.

Mr Wells: I wonder whether you sold that well enough.  What disappointed me about all the controversy that erupted was that, when you dug a bit deeper, there were often concrete proposals for alternative provision.  In Limavady, for instance, there was great controversy over Thackeray Place, but I learned that there was a proposal for a bigger, more modern unit to be built in Limavady a few miles away.  However, that did not seem to be known by the residents, staff or local politicians.  Have you been doing enough to make it clear to residents that there are attractive options out there?

Mr Keenan: I had two sessions yesterday with elected members of Ballymena Borough Council and the northern group of councils.  I reiterated John Compton's acknowledgement that communication at the front end of this process could have been significantly better.  However, we have worked hard at trying to get the broad message back on track.  There was quite a bit of acknowledgement yesterday, at both sessions that I attended, that we have worked hard and are communicating the message a little bit better than previously.  People are starting to learn that, behind all the headlines, some reasonably well-thought-through plans are in train and in the process of development in different parts of Northern Ireland that will soak up and address the needs to which you refer.

Mr Wells: Were the residents of the existing residential homes and their carers aware of that?  I listened, obviously with a mixture of horror and shock, to all the media coverage and certain irresponsible BBC journalists, who remain utterly nameless, going around residential homes and interviewing very vulnerable old folk.  Nowhere in that conversation did they show the slightest indication that they knew that there were realistic alternatives to their homes.

Mr Keenan: I will use two examples to give the story behind the headlines.  I use the example of Greenisland, because it is in my geography.  Plans for Greenisland were well advanced, residents were on board, had been kept in the loop and were well briefed.  When the media firestorm broke, the people of Greenisland kept their heads down and worked with the trust to ensure that the home moved towards closure and people were able to move.  The same applies to Rathmoyle Residential Care Home in Ballycastle.  The people in Ballycastle want to keep on working with the Northern Trust to make the changes that have been proposed.  So there were proposals in the pipeline, and there were good examples of people working with the trust.  Unfortunately, as I said, the firestorm erupted in April and May last year and was not helpful.  It caused a serious amount of distress.

Mr Wells: Let us take another example.  Roy slipped in a constituency issue of his own, and one of mine is in Kilkeel, where there is a good residential home and a planning application has been submitted for sheltered accommodation that would more than replace what Slieve Roe House presently provides.  However, that application is stuck in the planning system and there are objections from local residents, and so on.  A commitment that there would be no change to that residential home, or any other residential home, until the replacement was built, would have allayed a lot of fears.  There was a concern that a lot of people felt that the residential home would be closed, and the alternative would not be there. ·Is that a way forward to try to allay the public's concerns?

Mr Holland: That is exactly the work that Fionnuala McAndrew has been doing.  She has been consulting on the criteria that will be used.  Availability and accessibility of alternative services is one of the criteria that she has been consulting on, so that will now be a criteria.  Unless that can be satisfied, suitable availability and accessibility of alternative services —

Mr Keenan: Kilkeel is a good example of what I was speaking about.  A business case was done, and the proposal went through the appropriate local mechanisms in the Southern Trust area.  I believe that all the parties bought into that concept.  This has been held up by a very technical issue — the surrounding land, ownership and access — over which we in health and social care have no control.

Mr Wells: Slieve Roe was offered up by the Southern Trust, with all its residential homes, for closure, and it had not even put in the planning application for the alternative.  That is what caused a lot of concern.

Mr Keenan: I do not want to broaden out this debate, but, as part of the revisiting of the residential care issue, we have said to the trusts that perhaps a more considered look is required at the possible sequencing and the choices that need to be made in each locality.  We have moved away completely from the idea of a total closure programme.  We are not consulting on that at present.

Mr Holland: The Minister made it very clear, Jim, that he was not happy with how some of the issues were handled at trust level.  That is why this new process has been commenced.

The Chairperson: Thank you for that.  I think that we will want to return to the issue.  Certainly, from my perspective, which I think is shared, we did not get any sense today that there is a strategic approach that is based on the needs of the population.  It is frustrating, Seán, that we could not be told today how many of the 414 facilities, for example, are actually funded by the Department of Health.  Equally, we could not be told today of the breakdown of the £3·2 million budget and how much of that is directed towards supported living.  Neither have we been told how 155 places will meet demand, or even how those calculations are made.  The Committee, obviously, takes these issues very seriously.  I suggest to you that it is a key component of Transforming Your Care that requires, at the very least, accurate data and statistics and, equally, a strategic plan on how it is taken forward.  We did not hear that today.

I have no doubt that we will be writing to you with a number of questions and queries.  We will await the answers to those, but I expect that we will have further engagement.

Mr Holland: Thank you, Chair.  Chair, you know that I appear before the Committee not infrequently, and although it is often a robust exchange, I always endeavour to have available the information that I anticipate that the Committee will require.  Occasionally, we have to say that we will come back to you with a written response.  Today, the number of issues on which we have had to do that is, obviously, greater than I am happy with and, clearly, what you are happy with.  However, it probably reflects the complexity of the issue in that this is not solely the preserve of the Health Department, the HSCB or the trusts.  The issue involves several partners:  different Departments, housing associations, and what have you.  However, we will certainly do our utmost to respond to your requests for information.

The Chairperson: I accept that, Seán, but the Department of Health has a key role in Transforming Your Care.  Therefore, at a very basic level, you should be in a position to come to a Committee with a budget.  I will leave it at that and not reopen the discussion.  We look forward to getting the information from you and continuing the conversation.  Thank you for your time today.