Official Report (Hansard)

Committee for Health, Social Services and Public Safety

PDF version of this report (255.65 kb)

The Chairperson: Professor Tinker, you are very welcome.  I will give you a minute to gather yourself.  You are here on behalf of the Department of Social Science, Health and Medicine at King's College, London.  The normal procedure is that we ask you to make a 10-minute presentation, and then we will invite comments, questions or queries from members.  So, I will hand over to you.

Professor Anthea Tinker (King’s College London): Thank you very much for asking me to come here; I am very honoured to do this.  You have asked me to discuss specifically best practice, particularly in relation to Europe, lessons about supported housing where perhaps Northern Ireland might learn.  I will draw mainly on research that was done for the Technology Strategy Board on long-term care.  We were looking specifically at Europe, but we also had a case study from the Netherlands.  You can ask me about that, and I will refer to it.  I am doing it on behalf of my fellow researchers, Professor Jay Ginn, Professor Leonie Kellaher and  Eloi Ribe .  There were four of us involved in the specific piece of research, but I will draw on other research as well. 

I have produced some notes for your Clerk, including headings that I will go through.  I will make a short introduction, and then you may want to focus on some more than others. I thought that it would be sensible for me to say a few words about where we are starting from so that we all agree.  Secondly, what do we know?  Thirdly, what can we learn from Europe?  Fourthly, some of the findings from the main study and from the Netherlands, what wider issues come out of the research, and a note of caution about drawing conclusions from the Netherlands.  We have done that, but there are reasons why it might be advisable to have some hesitancy about it.  I start by saying — and this will all be very familiar to you — that the numbers of old people will increase dramatically, particularly very old people.  I am sure that you know that, in Northern Ireland, the number of people who are 85-plus will almost double by 2025.  Therefore not only do we have more old people but we have more very old people.  Specifically, this will mean not just a need for more services, particularly housing, but that there will be a drop in the number of people of working age to provide those services.  I suppose that the most challenging thing that we all have to face all over the world is the percentage of pensioners who will have dementia:   about one in five people aged 85 and over.  If you think about how many people are in this room and how many of us will end up with dementia, it is pretty frightening. That is the main thing that we have to bear in mind. 

What do we know?  I will just say something about that and then we can go on to what we can learn from elsewhere.  The first thing that we know from research abroad, particularly from the EU and the Organisation for Economic Co-operation and Development (OECD) is that housing, which is one of the main foci of your Committee, is increasingly recognised as being the key ingredient, if not the only one, in well-being.  It is not just health, which we tend to think about, but housing. 

The second thing is the growth in solitary living.  When you are planning supported housing, we all have to be aware of that.  It is not just that people are surviving more into old age, often it will be a spouse, but people are also choosing to live alone.  They may be older people.  People are divorcing much more in old age, but there is also an increase in solitary living in middle age.  Whoever is involved with housing later on will be faced with more and more people living alone.  That is not necessarily a bad thing because living alone does not necessarily mean that you will be lonely. 

The third thing is the growing evidence, which we have known for a long time and a lot of my research when I was in the Department of the Environment and, subsequently, as an academic, is that people want to remain in a home of their own.  In our research, we do not dismiss institutional care.  In fact, we say that there is a demand for it and a case for it, but there is growing evidence that people want to remain in a home of their own and not in an institution, although that may have to come afterwards. 

Fourthly, housing is increasingly being bound up with the environment.  We are not just talking specifically about the bricks and mortar of housing; we are talking about the environment.  The work that I did for the World Health Organization on age-friendly cities showed that.  It is often the little things in the environment that, when you are looking at supported housing, you need to link in with, such as the need for loos, which is very mundane, but that is what older people said to us.  Work that we are doing on a big new grant with the University of Edinburgh is on mobility, mood and place.  One of the ingredients of that, which is quite novel, is called co-design, where groups of architectural students — we are catching them early — are working with older people to co-design housing.  They have done the first part in Manchester where architects and older people work together to think about the sensible thing to do about that area.  It is the link with housing and the environment. 

The final thing is the shortage of housing.  It is a mundane thing to say, but perhaps we can discuss how to get over it.  Those are the four ingredients that we need to think about — where we are and what we know.  I do not know whether you want to start with learning from Europe or whether you want me to say anything by way of introduction.

The Chairperson: Go ahead.

Professor Tinker: With regard to the context of what we did when we looked at Europe — I have to say that the research is based on evaluated schemes — you can read about all sorts of things, including people writing to the press, journals and so on saying, "We have this fantastic scheme.  It is a pilot or whatever", and you do not know whether it really is good or not.  So, in Europe, with the exception of the Netherlands, where we looked at pilot studies, we are looking at evaluated schemes.  That is a word of caution.  People are very keen to show what they are doing, particularly in supported housing.  They say, "This is what we are doing.  It's fantastic."  However, we were looking at evaluated schemes, whether they were on costings or on the views of older people or staff. 

Our starting point was that we realised that certain things provided the context.  I mentioned the growing numbers of very old people; we knew that.  We also realised that there is an increased prevalence of long-term conditions.  If you survive into old age, you are likely to have some measure of disability.  Although women live longer, they will be more disabled in old age than men.  We do not know the reason for that, but they will be.  There are rising expectations, and we all expect more.  There are more older people in employment, and I am an example of that. Some people will choose to retire in their fifties or sixties, but many older people will want to, or will have to, work because of income.  That is a lesson for us as well.  We all know that the numbers in institutions and the associated cost will have a knock-on effect; we know that there is very poor care in institutions; we know that there are financial constraints; and we also know about the key role of informal carers and the complexities of funding.  That is the background.

How do we crack this problem, which is, I imagine, at the heart of what we want to discuss?  The first thing that I said — perhaps we can have a discussion on this now — was about the lessons that we learned from Europe, the most important of which was putting older people at the heart of provision.  I do not know whether you would like to comment or ask questions on that.

The Chairperson: We can come back to it if members want to reflect on it when you are finished.

Professor Tinker: Do you want me to finish?

The Chairperson: Go on with your presentation if you are happy enough, and we will come back to it.

Professor Tinker: Absolutely.  It is about putting older people at the heart of services and ensuring that we do not just pay lip-service to that.  We are all very different.  Men and women are different, as are black and ethnic minorities.  We should not generalise about the over-65s, the over-70s or very old people.  We are all very different.

When we did our work in London on age-friendly cities, we found that older people knew very much what they wanted.  They knew that they wanted to be involved in the design of housing, where it was placed, whether it was a one-bedroom or two-bedroom flat, and so on.  Part of that involves the scenario of reablement, which is the technical term, whereby we start with older people and find out what advantages and skills they have and how we can use and involve them.  So I say this:  let us start with older people, and let us involve them. 

I chaired the Technology Strategy Board work, which was carried out by the Design Council.  That work was not evaluated, but I mention it just to spark things off, because older people were highly involved in it. 

Another example is a cooking club where older people teach younger people.  Another one is where older men in a neighbourhood felt that they were not being listened to, so they set up a scheme to work together to do all sorts of things.  Another example is where an older person shares their home with a younger person and has a say in who comes to stay with them.  We can talk more about those schemes later.  The older person can choose, through a properly vetted scheme, to have someone live with them, particularly an intern.  The young person pays very little or no rent, and in return for staying with the older person, they will say, "I will guarantee that I will sleep here seven days a week and that I will give you a little bit of help".  There are all sorts of things that we need to do to put older people at the heart of services. 

Before schemes are designed, and, in fact, during the research now, some researchers will say, as disabled people do, "Nothing about us without us".  That should always be the case.  It is a hard lesson for some of us researchers:  start with the older people.  I do not know whether you agree with that or if you have examples.

The Chairperson: Do you want to continue?

Professor Tinker: It is entirely up to you.  I do not want to talk at you all the time.

The Chairperson: We will just finish your presentation, and then we will come back to it.

Professor Tinker: The second lesson is about the importance of housing and the key role that it plays.  That fits in with objective 3.2 in your Northern Ireland Active Ageing strategy.

Being at home and staying at home is incredibly important, because you are familiar with it and it has a role in prevention, such as preventing falls and so on and, in particular, the key role of adaptations, which I know that you stress as well.  Therefore, if you turn to ways in which older people can stay in their own homes, the first thing is that we need newbuilds.  There is newbuild; however, it is expensive.  Ideally, it should be a lifetime design so that it is there from day one.  If you design for a lifetime, you are designing for children, pregnant women, people with buggies, people who happen to break their leg for a short time and so on. 

I thought that it was ironic when I was preparing this that I saw an article in 'The Sunday Times' that said:

"After the bombs comes the buzz of Belfast"

That attracted me, as I was coming here.  On the other side was a fascinating article.  Home sweet home.  Shed:  all mod cons for £30,000.  You may think that that is a jocular thing to say, but if you provide a very inexpensive pod for younger people, then that will also help older people.  Indeed, you could have a group of them, if possible.  Perhaps that is at the ridiculous end of the scale, but I do not think that newbuild should be ruled out. 

The second way is home modifications.  Sadly, money has often been withdrawn for them, but clear research has shown that it is cost-effective to provide modifications — aids and adaptations.  There are one or two schemes developing in the UK, which have not been evaluated, where people — a doctor or care worker — can phone in to a central point and get something modified that very day, such as a loo changed or grab rails.  That is also the case in the Netherlands.  It can happen the very day they have been assessed, and that prevents someone having to move.  Those schemes need evaluating, but it sounds as though it is a good idea to have them.  We have a lot of well-evaluated handy person schemes in the UK.  Somebody can come in, obviously properly supervised, and do something small to the home.  It may be something larger, and they may enable someone to get a grant.  They will help with all the cost and the things that come from the firms, such as the tenders, evaluate them, make sure that the work is done properly, and make sure that the person is safe back in the home.  We can learn a lot about the ways in which people can stay in their own home.

You may not think that sharing a home with a family is supported housing, but it is a way for someone to stay in their own home.  It can be the family moving in with the older person if the older person's home is too big, and that is being encouraged with the bedroom tax in the UK.  However, think about the reverse, where the family builds a granny flat.  That was actually my PhD.  Granny flats are very cost-effective, and it can be very helpful when the older person can give help to the younger person, and that can work in reverse.  I do not know whether any of you have experience of granny flats.  It is not particularly good in the public sector, because what happens when granny dies?  Do you move another granny in?  Actually, it worked quite well in the social housing schemes that I looked at.  What happens if the family moves?  However, granny flats are one way of enabling an older person with a large property to move in with a family, and you have saved on that kind of housing. 

What about fostering, which is developing in the UK and across Europe, shared lives and adult placements, in much the same way as it is done for children?  Provided that it is properly vetted, that is another way of saving accommodation where an older person may give up their home and move in with the family, although it has to be very carefully vetted. 

Do you want me to carry on?

The Chairperson: Yes, sure.

Professor Tinker: One of the interesting things from Europe, which we hardly do here at all, is called co-housing.  It is most widely practised in Denmark, where there are 350 schemes.  It started with younger people, but now it involves older people and some mixed communities.  A group of 10, 20 or 30 people come together and decide to live together in old age.  They have separate apartments but with some shared facilities, such as a club or a laundry room.  This model has been very well evaluated, particularly in Scandinavia and the Netherlands, and a scheme has just started in north London where a group of older women have decided, "why not?"  If people are going to save accommodation, they can group together.  The evaluation in the Netherlands showed that a scheme has to be very clear in order to cope with conflicts.  This did happen; people have to have a sense of responsibility and there were some conflicts, but co-housing is something that we might possibly want to foster.

I have mentioned home sharing, where an older person shares their home.  One of my own students did this; she lived in a lovely big house, which she could not have afforded to rent.  In return, she had a very close link with the older person and she went far beyond what she was bound to do, which was to sleep there and give a little bit of help, although she did not provide personal care such as bathing.  This is another thing if you are thinking about supported housing — you can think widely.

Then there is specialist housing.  Do you want me to pause here for questions?

The Chairperson: No, no, go ahead if you are comfortable.

Professor Tinker: You do not want to discuss co-housing or any of the other options?  No?

The Chairperson: We will come back to the individual issues.

Professor Tinker: OK.  I will move onto specialist housing.  It is interesting:  if people come from abroad to the UK, the thing that they always want to see is sheltered or very sheltered housing.  It is completely bizarre, given that less than 10% of people live in it, but it is the one thing that people from abroad always want to see.  I am sure that you are familiar with sheltered housing.  The Commissioner for Older People for Northern Ireland, from whom you heard evidence — I have done my homework — said that there is confusion about terminology.  I suggest that we do not get hung up on terminology; it is called assisted living and all sorts of things.  I would prefer to talk about sheltered housing and extra-care housing.

Let us think about sheltered housing first.  It was the best thing since sliced bread in the 1960s; it was developed in the UK.  Although I say that we are learning from Europe, there are some things that England and Wales were very good at, including sheltered housing, in the past.  These schemes developed, and groups of people were together in bungalows or flats with communal facilities and a warden.  Everybody thought that they were wonderful, but they are not.  They are no good for frail older people.  Why would you move to one of these if, in fact, you could stay in your own home?  Sheltered housing does not offer you very much, apart from being grouped with other old people.

The research on it discovered that most schemes, whether they were social housing or private, were difficult to let.  People could not believe it:  how could a scheme like this be difficult to let?  What seems more promising is where you add on to these schemes and either call them very sheltered or extra-care housing.  This is where you provide one meal a day, 24-hour care and extra communal facilities where, in fact, a frail older person can be supported quite well.  Amazingly, however, some of these are difficult to let, too.  I have provided the Committee Clerk with a summary of the research that I did, which was called remodelling.  This may or may not resonate with you, but we looked at sheltered housing, extra-care housing and residential care homes, which are very unpopular, to see how they could be remodelled to provide extra-care housing.  How could all these, particularly the residential care homes, be remodelled?

We found that it was difficult to do if you have a listed building.  In nearly every scheme, they ran into problems, quite often asbestos; it is not necessarily cheaper to remodel than to provide from scratch.  Of course, you do not want to knock down all those schemes mostly, but subsequent research into extra-care housing by Ann Netten and colleagues at the University of Kent showed that extra-care housing is one of the ways forward.  It is certainly one of the things that the Government are giving money for because it does seem to provide at least care and ways in which people can join together.

Subsequent research by Richard Best and Jeremy Porteus suggests that it may not be economic to have all the range of communal facilities.  I am sure that you have such schemes, but it is a positive way forward.

The more trendy thing is retirement villages, which they have a lot of in Australia and the States.  Caution about these, particularly where they are private:  in the States, they found that, according to their terms, people can be turned out when they become frail.  Some have gone bankrupt.  We have had them in England for a long time, such as Licensed Victuallers.  Imagine it, spending the rest of your life with fellow pub owners.  However, there has been very little evaluation.

Two famous ones have been evaluated in the UK, one at York and one at Berryhill, in the Midlands.  Retirement communities might be popular and research has shown that, so that is a possibility.  We have an example from the Netherlands where they have villages, but they have been unusual.  One, for example, is called a care co-operative village, where they have pooled out a lot of the facilities.  They have one care co-ordinator for everybody in the little village.  They pool their personal budgets.  The gardens are done by workers in the area who are in sheltered employment, so it is giving employment to people.

They use volunteers, so there is a lot of social interaction.  They loan out motorised scooters.  A care co-operative village is a possibility.  You may have an existing village where you can do this, but it is bringing in resources, volunteers and people who need employment.

Do you want me to talk about some really radical alternatives?  Do you want to go on to the cruise ships and hotels?

The Chairperson: Yes, we like radical.

Professor Tinker: You do?  OK.  You probably read about the couple who went to a Travelodge and stayed for 22 years.  They found that they had everything in the Travelodge that they wanted.  They did move out after 22 years.  That is not being evaluated and was a one-off.

More seriously, there are cruise ships.  There has been an evaluation and a cost/benefit analysis by a geriatrician.  If you have a lot of money, it is very cost-effective to go on a cruise because you have all the facilities there.  You are not far from a loo at any time.  You have fantastic medical backup, and you will be very popular when your grandchildren and children want to visit because they have all the facilities.

I joke, but I had a friend, who, sadly, has since died, who had terminal cancer.  One of the things that she did at the end was to go on a cruise because everything was to hand.  They are much cheaper now.  We need to think not just about the very poor but about people with a bit of money.  Now, of course, you can spend all your money when you get your pension, although perhaps we should not go down that route.  However, there are radical options. Of course, people in the 1930s went to boarding houses on the south coast of England, and that is where they lived.  Who is to say that you sell your home and go to a hotel — would you like that?

Mr Dunne: No, thanks.

The Chairperson: I do not think that our constituents would.

Professor Tinker: You would not like to stay in a hotel for the rest of your life?  No response from anybody who wants to live on a cruise ship or in a hotel. Shall we move on to technology?

The Chairperson: Yes, sure.

Professor Tinker: We are incredibly hung-up on words.  Nearly every time I look at anything to do with technology, it is called something different.  It is telecare or telehealth or whatever, so we should not get hung up on that, but the use of technology in supported housing is important.

Telecare provides simple personal alarms, like a pendant to press, through to smart homes, which I will develop on in a moment.  They can do a whole lot of things, including reminding people to take their medication.  They can press a button, and it will alert someone.

Telehealth is delivering healthcare at a distance.  You assume that there is a health professional at either end of the technology.  So, a carer in your home could say, "Put your hand under the camera", and someone at a distance can make an observation.

Vital signs and monitoring:  I am sure that you are going to have to have that installed in supported housing in the future, where someone does not have to go and have their heart monitored or blood glucose and weight checked.  It can all be done at a distance.  I am in a longitudinal study and wore one of these for seven days.  Everything that I did went through to a central point.  That is incredibly useful, so I am sure that has to be built into things.  I gather that you have an extensive telehealth programme, supported by the Centre for Connected Health and Social Care, although I do not know an awful lot about it.

It has great potential, but there is a word of warning about technology and the hype.  The findings of the only randomised control trial of telehealth in the world was paid for by the Department of Health in England.  It was called the whole system demonstrator.  The trial was with 6,000 people in Kent, Cornwall and Newham who had certain conditions.  It was about the transmission of data between patients and professionals.  Early findings came out about lowering mortality and emergency admission rates, which was fine as far as it went.  However, a word of caution:  the response rate to the study was not high and the sample included people at very low risk.  One has got to be aware of that.

The thing that has come out of all research on technology is the value of simple gadgets.  Make it simple.  We got together a group of engineering students and a group of older people.  We had asked the older people what were their major problems, and they said walking up and down stairs.  They worked with the students to devise a simple rod that ratchets up the stairs.  They said that they loved that it was shiny wood and not plastic, which a lot of things are, and simple.

I think that greater use of mobile phones is the way forward.  You may or may not have noticed that I carry my phone — which is, of course, switched off [Laughter.] — everywhere.  I do that because my children told me that I need to be accessible at all times.  They need to contact me, and I may need to contact them.  I carry my phone the whole time.  Mobile phones, smart tablets and so on have an enormous impact on people.  I do not know whether you feel that.

There are ethical issues to do with surveillance.  How would you feel if you were in a home, had a lot of equipment around you and knew that someone was monitoring you and could see you?  Parents can now see the childminder or the nanny looking after the child 24 hours a day.  How would you feel about that?

The Internet is extremely important.  Here is an example of older people working with Internet companies, and here again is the potential for investment:  in Almere, they got together a group of older people and Internet companies and set up and invested in a high-speed broadband network.  That enabled older people to do what they wanted to do:  to join in exercise classes and to be involved in art, music, theatre and so on.  The evaluation reported not just increased social contact but stimulated economic growth.  I have given the full reports of the research to your Clerk.  You may want to look at that.  It is an interesting example of an area slightly beyond your supported housing, but it is a good lesson for stimulating the economy while involving older people.

Finally, on technology, there are smart homes, where you link everything up in one home; you have the whole lot.  Again, I pause.  Do you want to ask anything about technology?

The Chairperson: I am conscious that you have given us quite a range of themes and information.  At this point, do members want to ask any questions on what they have heard specifically?

Mr McCarthy: Thank you very much for your presentation.  It has been very interesting.  In fact, you have probably answered all the questions.  The main one was this:  how can older people have an effective say in what their requirements are?  I think that you touched on that.  What steps can be taken to better address social isolation in such provisions?

Professor Tinker: It is difficult to involve older people.  Let us make no bones about it.  You can go to the conventional groups, the well-known suspects and the people who will always say, "I speak up on behalf of older people".  It is very difficult to get hold of — this is in research as well — people who are at home and housebound.  One has to make very deliberate attempts to get hold of the people for whom there is no voice at the moment.  There is a problem of social isolation.  The most isolated people, in other research, are in southern Europe, where they have the highest rate of living with families.  The families go out, they come home and they do things.  The lowest rate of loneliness and social isolation is in Scandinavia, where they have the highest rate of solitary living.  One should not make assumptions.

Mr McCarthy: Are there any examples of best practice in a shift of resources from acute services to support the emphasis now being placed on community services?

Professor Tinker: Most countries in western Europe, because of welfare cuts, are doing that.  One way they are doing it is by giving personal budgets.  I do not know whether you want me to talk about them, because there is a word of caution.  This is slightly off what you are saying.  Research on personal budgets — giving money to people individually rather than hospitals — is very mixed about it.  The Netherlands had them for a long time, but they have now stopped them completely for new applicants, partly because of cost and partly because of abuse.  They were being abused.  So, there is a word of caution about giving the money to people individually.  It is fine in theory, but if you have the money, how do you choose yourself?  Does the older person vet the person who is going to provide the service?  Do they check references?  It is difficult.  It is part of the shift.

Mr Brady: Thanks very much for a very interesting presentation.  Kieran alluded to having older people at the centre of making policy and legislation that affects them.  We advocated having an older persons' commissioner for a long time.  Older people should be very involved in the issues that affect them.  This week, we will have the Pensioners Parliament, and the Age Sector Platform and Age NI are very effective in their advocacy roles for older people, which is very important.

Many years ago, the Housing Executive built old persons' dwellings (OPDs), but it got subsidies to do that.  When those subsidies stopped, those dwellings became single persons' dwellings.  They were one or two-bedroom bungalows, but there were not that many of them.  Initially, they were being retained for older people to move into and would not have been made available to younger people.  In my constituency, some of the housing associations have built limited numbers of lifelong houses, but you can see the benefits, such as wider doors, ramps, recyclable water and panels in the ceiling for persons who might need a floor-to-ceiling lift in future.  Those are relatively straightforward to install, and you do not have to rip ceilings out and that kind of thing.  There is a bit of foresight and forward planning involved.

You mentioned granny flats.  One of the issues that I have come across is that people find it difficult to get planning permission here in many instances.  That is something that could be looked at, because they can be effective.  You talked about social isolation and mentioned Sweden in particular, where a lot of people live alone but social isolation is not a problem.  Maybe we, as a race here, are more gregarious and we have extended families; maybe that is something, again, that we could look at.

I sit on the Committee for Social Development, which deals with housing and benefits etc.  One of the big issues for older people is the amount of money that they have to live on.  Here, and in Britain, we have one of the meanest pension schemes in the developed world.  You get paid a basic flat rate having contributed for many years and you get very little out of it, depending on how long you live.  That is an issue that affects people, but it seems to me that there is not enough interconnection between the Health Department and DSD on issues that affect older people in particular.  That is something that needs to be looked at.  Both Committees and the Assembly should be looking at having much more interaction between Departments, because a lot of the issues that affect older people are very much interconnected with the different Departments that deal with them.

I was interested in your radical stuff around cruises and so on.  With my luck, I would probably end up on a cruise ship with retired DUP members. [Laughter.]

Mr Dunne: There are very few of them about.

Mr Brady: That was just a final thought.  Thanks very much.

Professor Tinker: The older people's parliament is extremely important.

You talked about housing; the number of bedrooms is an interesting one.  Many schemes have become difficult to let because there was only one bedroom, and two bedrooms is the way forward because couples, for all sorts of reasons, may want to live separately or with a carer and so on.  Interestingly, at the last Housing Learning and Improvement Network (LIN) conference before Christmas in London, it was suggested that there may be a reversion to bedsitters for people with dementia.  We can mention dementia specifically at the end, but it may be sensible to provide a bedsitter for people with dementia.  One or two-bedroom flats may be the way forward.  Planning permission in England for granny flats has been slightly modified.

Interconnectivity is crucial; it is extremely important that government Departments speak to one another.  Pooling budgets and all sorts of things like that can do that.  A lot of it is about personalities; do the people in the Health Department get on well with people in housing?  A lot of it is about that.

Mrs Cameron: Thank you very much, Professor Tinker.  I am really enjoying this evidence session; it is fascinating.  I want to ask about the co-housing issue, with people living independently in their own accommodation as a group.  You mentioned groups of 10, 20 or 30 people, which are very large groups.  Can you tell us some more about how that works?  Is this based on them living in their own homes?

Professor Tinker: They normally buy a large building.  It might be an ex-hotel or a big Victorian house, or they might build afresh.  I think that the development in north London is being built afresh, but I am not sure.  It is possible.  There are blocks of apartments in the Netherlands.  One has about 30 people, men and women, living together in apartments, but they share a lot of things, including the cooking and laundry.  You can have all sorts of sizes.  It is an interesting concept.

Mrs Cameron: Yes, it is a very interesting concept.  Is that provided by the local council?

Professor Tinker: There can be subsidised schemes, but quite often it is provided by people chipping in their own money.

Mrs Cameron: That is interesting because we are always looking for ways in which the state will provide but a lot of the examples in your presentation are more common sense —

Professor Tinker: Of course.

Mrs Cameron: — kind of empowering people to look at what they can do themselves and decide how they want to live into the future.  I think that you mentioned — I hope that I got this right — that residential care homes in England were very unpopular.

Professor Tinker: Yes.  But you are right:  most of what I said is common sense, and a lot of things in life are common sense.  Another thing that we have not touched on and that we can learn about particularly from the Netherlands is dementia care.  As part of the village community, groups of demented people may live together.  Others are together according to their interests, so people who are maybe ex-civil servants or interested in art live together in a community but separate.

There is another village of older people living together there where they are even more creative, and which, I think, is subsidised.  Not only do they bring in volunteers but schoolchildren aged from 16 to 19 are employed in the evenings to cook meals for the older people.  Again, you are encouraging the mixture of generations but also creating employment.  The use of volunteers and people coming in is another way we can learn from the Netherlands.

Mrs Cameron: Fascinating.  Thank you.

Mr McKinney: I am just thinking back to Mickey's comments.  It is clear that, by the time Mickey retires, he does not believe that he will have a united Ireland and, in fact —

Mr Brady: I do, actually.

Mr McKinney: He might set about trying to unite the ship going round it.

I am interested in the legislative platform that can drive some of this.  Here, the absence of such legislation means that older people can be discriminated against.  What form of legislation do we need to make sure that people can demand that they get provision as opposed to earnestly pleading for it?

Professor Tinker: It is difficult in housing.  In health, there is legislation, under the national service framework originally and then it translated into legislation.  You cannot discriminate.  You cannot have, as we used to have in London, for example, a stroke unit not accepting you if you were over pension age.

There is still discrimination in employment in the UK even though there is legislation.  You may be able to legislate, but there are ways around it.  It is a change of attitude more than anything.  I am not sure how far you can go with legislation.

Mr McKinney: Are you saying that there are productive ways around it?

Professor Tinker: It is a change of attitudes that we do not treat older people as different from others and we do not discriminate just because you are a pensioner, of a particular age, gender or anything else.  I am not sure:  do you think that you could do it by legislation?

Mr McKinney: In England, for example, the Equality Act brought in the goods, facilities and services that allows for people to demand or expect certain provision.  Here, we do not have that yet.

Professor Tinker: I did not know that.  Maybe that is one way forward.  You know more about that than I do.

Mr McKinney: I have one other point, and it is down to how people are grouped.  You talked about artists.  Even among artists, some may favour music whereas others may favour a different version.  How does the individual get a voice?

Professor Tinker: It depends on —

Mr McKinney: Many of them do not have a voice because they have dementia or whatever.  How does the individual with a voice get it heard, and how does the individual without a voice get their needs catered for?

Professor Tinker: I think that this was mentioned by the first questioner.  You start with your older people's parliament, which we do not have, and then go right down to an individual scheme, a local authority, or people like me doing research involving older people from day one.  It is not easy to get groups of older people or individuals.  You can do it by research.  As a researcher, I would say that, wouldn't I?  One way of getting the views of older people is through qualitative interviews in particular.  You may find quite unexpected things.  For example, when we were doing our remodelling, we found very mixed views where older people were left in situ; in other words, they were left, and the scheme was remodelled round them.  By doing the interviews, we found that there was disruption, which we expected, but, on the other hand, they absolutely loved having electricians and all sorts of people around them who they could interact with.  There was something exciting going on all the time.  We thought, "Oh, they're not going to like it; it's all going to be incredibly disruptive and dangerous".  When we interviewed them, it was quite the opposite:  there was a buzz.  They really loved it.  Would we have found that without asking them individually?  I do not know.  It is not easy to find out views of older people.

Mr Beggs: It is interesting to hear of evidence from elsewhere.  You mentioned that there were same-day modification schemes in various parts of the country for older people living in their own homes.  Recently, I came across a constituent who needed a raised toilet and support etc to make that a safer area.  She was told that it would be five, six or even 10 weeks before someone would be out to assess whether that was what she needed.  Can you advise of particularly good schemes?  Have any of them been evaluated in terms of how much benefit it brings to the individual and how much longer it keeps them in their own home?

Professor Tinker: Yes, I have given evidence in the paper that I gave to your Clerk about staying-put schemes that have been well evaluated and are cost-effective.  The new one that I mentioned — the first contact scheme — has not.  I have details of the Derbyshire one.  That has not been evaluated.  That is where somebody — it can be the doctor — rings up and gets that adaptation immediately.  You have that in housing associations in the Netherlands.  That has not been evaluated, but it sounds like a good way forward.  There have been very good evaluations of the conventional staying-put schemes.

Mr Beggs: Is there evidence of how many accidents and costs to the health service have been avoided by that very speedy response?

Professor Tinker: Offhand, I think that there is one about the prevention of falls.  I am not sure; I cannot give you chapter and verse.

Mr Beggs: Could you perhaps come back to us?

Professor Tinker: Of course.

The Chairperson: Thank you for the presentation.  What is apparent is that you can be creative with some of the models of supported housing and living.  You said, "Don't get too hung up on definition".

Professor Tinker: Yes.

The Chairperson: That is the first time we have heard that message.  Consistently, we have found that there has not been a clear definition of "supported living" or "supported housing", particularly from the Health Department's point of view.  It has now agreed to look at what that is.  You talked about very sheltered and extra care.  Flowing from that, is there an agreed cross-departmental, cross-agency definition of "extra care facility"?  What about information on choice?  Who is responsible for — for want of another word — marketing the availability? One of the things that we are finding is that there is a real issue with choice of the types of supported housing or supported living that are available.  Who, in your experience, which might come from European models, has been responsible for marketing or providing that information?

Professor Tinker: It depends on the providers.  The Department of Health has one model, and the Department for Communities and Local Government, of course, had a series of supported housing grants.  There is no agreement, and I am not sure how you will ever get it.  Will private providers in particular not call it whatever they think will sell?  I do not know how useful it is to have one common definition.  I use mine.  I use the term "sheltered housing", as I described to you, and I use "extra care housing", but some people use "supported housing" or "assisted living".  Do you think that it is really important that we agree?

The Chairperson: I suppose that the issue concerns forecasting the population.  We know the forecast and statistics for the elderly population, and we know where we will be in 2020.  We even know some of the geographical areas where the growth will take place, so I suppose that, for us as a Committee, it has been very much about understanding that the whole strategic change in health is about care at home, care in the community or reablement, which is not always an option.  If we have this elderly population and a growth in the ageing population, this is about asking how we plan for that and what types of models or living arrangements we need.  For example, in the past number of weeks we visited what I think members will agree is an excellent supported living facility in Downpatrick.  It was interesting that there were people with different levels of need, including mild to moderate levels of dementia.  It is an excellent facility with some real characters living in it, but there are still empty places.  So, you wonder about the flow of information about choice.  How is that information relayed through the system so that our elderly people know that there is availability in these models?

Professor Tinker: Maybe by asking me to talk about supported housing, you have defined it for yourself.  I would include anything that you want under that, but it is difficult to try to explain to someone what it is.  Most people know what residential care is and what a nursing home is, but there is a whole plethora of options, some of which I described, including staying at home or in what used to be called sheltered housing.  I think that it is very difficult.  Maybe you should say what you think the definition should be.

The Chairperson: To take you up on that, the Department has come back and said that it is reviewing and looking at an agreed definition.  I am sure that the Committee will have a view on that as we move forward. 

I am conscious of time, Professor, and we probably stopped three quarters of the way through your information.  Is there anything that you want to add at this point?  We have the information, and we will, obviously, reflect on that in going forward.  Are there any other comments that you want to make as your concluding remarks?

Professor Tinker: I have given all the information.  The only other thing to add is that we have to do something about the low status of the staff who care for older people.  That is incredibly important.  They receive low pay and have low status, but they are the key, really, to the care of older people, whether they are in supported housing or wherever.  So, I think that that is probably the most important thing.  We need to change attitudes towards these people and give them training.  If they earn less than they could get in a supermarket, what does that say about us as a society?  That is really important.

The Chairperson: Thank you very much.  That has been extremely useful.  Obviously, the Committee will reflect on all that.  I think that there was a lot of common sense in your presentation.  I thank you for taking the time; it has certainly been of benefit to us.

Professor Tinker: Thank you very much.  If there is anything that your Clerk needs to get back to me on, I am sure that she will do that.

The Chairperson: I appreciate that.  Thank you, Professor.