Age, home and community: a strategy for housing for Scotland's older people 2012-2021

CHAPTER 1: INTRODUCTION

The number of people aged 75 and over is projected to increase by 23% between 2010 and 2020, and by 82% between 2010 and 2035. ^[1] In the same 25 year period, the number of people aged 60 - 74 is projected to increase by 27%. In 2010, 23% of the population was aged 60 and over. By 2035, this is likely to have increased to 30%.

1.1 The Scottish Government has a longstanding policy of 'shifting the balance of care'. This means supporting people to remain at home independently for as long as possible, rather than in care homes or hospitals.

1.2 This has been housing and community care policy under successive governments and has been given impetus by the likes of the UN Convention on the Rights of Persons with Disabilities, ^[2] where Article 19 sets out the right to independent living.

1.3 Housing and housing-related support have a key role to play in supporting a 'shift in the balance of care' and reducing the use of institutional care settings. They can also enable people to live independently, comfortably and securely. As people age, their housing needs change and, in some cases, they will also need specialised support services. If these housing and support needs are not met, it may be more difficult for people to remain in their own homes and increase the risk of accidents, undermining our aims to 'shift the balance of care'. Emergency admissions to hospital by older people cost £1.4 billion and, without change, are expected to grow. The benefits of providing the right housing and support at the right time could, therefore, be considerable, by reducing both the costs and trauma of unplanned hospital admissions.

1.4 The main ways in which the housing sector supports a reshaping of our health and social care services, 'shifting the balance of care' and independent living are:

• Ensuring an appropriate balance of housing provision, across all housing tenures, and a range of housing sizes and types, including extra care, sheltered and mainstream housing;
• Providing specialist housing with care and support, which is suitable for people with greater health and care needs, particularly those with mobility problems, and providing accommodation for respite and intermediate care, facilitating early discharge from hospital;
• Providing housing adaptations and other preventative property-related services, such as housing support, handyperson, small repairs and gardening services and telecare, which support people to remain at home comfortably and safely and reduce the risk of falls and other accidents;
• Providing information and advice on housing and support services, so that older people can make informed choices which help them to live independently at home for longer;
• Building new housing, both mainstream and specialist, which is adaptable and suits the needs of older people; and
• Supporting local communities through wider activities, such as promotion of social networks and provision of activities which help to increase community cohesion.

Demographic change

1.5 Demographic change is likely to lead to increased demand for such services, and with a more difficult financial environment, we need to change the way we provide housing and services to ensure that needs are met in ways that are sustainable.

1.6 We have not used any fixed definition of 'older person' in this strategy. Life expectancy varies quite considerably across Scotland, from 71.6 years for men in Glasgow to 82.7 years for women in East Dunbartonshire, ^[4] and older age means different things in different communities. At the moment, many people undergo a major transition in their lives between the ages of 60 and 65, when they retire from full-time work. The age at which this transition occurs will increase in the coming years, as the State Pension age rises to reach 66 for both men and women in 2020.

1.7 The age distribution and balance of Scotland's population is predicted to change considerably over the coming years. The proportion of older people will dramatically increase, with the ageing of people born in the post-war 'baby boom' and increases in life expectancy. Although all areas will see an increase in the number of older people, there will be a considerable variation in that increase, from a 23% increase in the over 75 age group in Glasgow by 2033 to 154% in Aberdeenshire, as shown in Figure 1. Overall, the bigger increases tend to be in more rural areas. The number of older people living alone is also forecast to rise, with single person households aged 75 and over projected to increase by 82% between 2008 and 2033. ^[5]

1.8 Healthy life expectancy is improving in Scotland, although not as quickly as life expectancy. Older age often brings health problems and reductions in mobility, and people are living for longer with long term medical conditions. Around 50% of men and 54% of women aged 75 and over identify themselves as having limiting long-term conditions. These may be physical or mental conditions or disabilities, which restrict daily activities. For those aged 65 - 74, 43% of men and 44% of women have such conditions. ^[6] However, in general terms, we need to look at people's needs, rather than their precise age, and we also want to increase awareness among younger people, particularly those in their fifties of the challenges they may face.

1.9 Many older people will live their lives, without a need for specialised housing or support services. This may be because they don't need such support, or because it is provided by family or friends. However, they should be aware of the support that is available. Others will need low levels of support for minor health conditions, while some will need high level intensive support to combat the effects of serious health problems.

Financial resources

1.10 At the same time as these shifts in our population, we face the most difficult economic situation since devolution. This strategy is being published at a particularly challenging time, with substantial reductions to overall public spending in the coming years. The Scottish Budget has been cut by £1.3 billion in 2011-12, from that for 2010-11, and we will see spending reductions of over 12% in real terms between 2010-11 and 2014-15. ^[7] The capital budget, which is clearly key for housing, faces a real terms reduction of over 36%.

1.11 It is widely acknowledged that demand for services is rising steeply at a time when resources are falling. It is estimated that it could take until 2025-26 for the Scottish budget to return to 2009-10 levels. Over the entire period, the cumulative amount foregone could be close to £40 billion. For local government, the funding gap is projected to continue to increase over the next Spending Review period, reaching more than £3.7 billion by 2016-17. ^[8] At the same time we face the tension of meeting existing and rising expectations about the services that local authorities deliver. The size of the reductions, and the length of time before budgets will recover, cannot be addressed only through efficiency savings or marginal changes to service provision. We will all face difficult choices in how we use the limited funding we have. Continuing with traditional service models would require massive investment in new hospitals and care homes to maintain current levels of service:

• We spend around £4.5 billion of public funding each year on health and social care for people aged over 65 in Scotland. Nearly a third of this was spent meeting the cost of emergency admissions to hospital. A further 12% was spent on care homes. Some of this could have been better used to support people at home.
• We would require an annual increase in investment in health and social care services of £1.1 billion by 2016, assuming that demand increases in line with the growth in the older population and that service models remain the same. ^[9]

1.12 Such a dramatic increase in expenditure is not possible, even if we were not subject to budget reductions. It means we need to find new ways of delivering services and of improving the effectiveness of the services we already provide, so that they are sustainable in the long term. These include working more closely with, and learning from, the private, third and voluntary sectors, developing new funding models and working more closely with the wider community.

1.13 The Christie Commission, established to consider the future delivery of public services, reported in June 2011. ^[10] It noted increasing demand for public services, partly because of demographic change. Its report advocated an urgent and sustained programme of reform, embracing a new collaborative culture, to enable Scotland to deal with a financial landscape, where budgets won't return to 2010 levels for 16 years. The report also recommended the prioritisation of preventative measures in expenditure. It highlighted the need to involve people who use services in their design, and to strengthen partnership working between service providers to deliver integrated services that meet local needs.

1.14 The outcome of Spending Review 2011, announced in September, marked a shift towards preventative spending to tackle the root causes of disadvantage and inequality, rather than the symptoms. This will help to improve outcomes for people and reduce demand for acute services over time. We believe that investment in preventative spend will also help to improve our use of resources, by reducing future costs of those acute services. As part of this approach, the Change Fund for Older People's Services is being continued and increased (see Chapter 3).

1.15 We acknowledge that there may be some up-front costs to investing in preventative services and changing the ways in which services are delivered, and that the returns may not be immediate. The extension of the Change Fund for Older People's Services is one tangible way, in which we are seeking to bridge the gap and support a shift towards a more preventative approach to support for older people. Over the long term, we are confident that there will be savings, by enabling older people to be active and independent.

Wider Planning for an Ageing Population

1.16 In view of the twin challenges of an ageing population and reduced public spending, the Scottish Government established the Reshaping Care for Older People programme ^[11] in 2009, in partnership with COSLA and the NHS, to consider the future delivery of services for older people and ensure they are sustainable. As part of the Reshaping Care programme, the Wider Planning for an Ageing Population working group was set up to review issues relating to housing and communities.

1.17 The development of a strategy for housing for older people was the main early action proposed by the Wider Planning for an Ageing Population working group in its final report, published in March 2010. ^[12] The group saw a need for the Scottish Government to set out a clear vision for housing and related support for older people, and a framework to enable delivery. This strategy sets out a framework, within which the work started by the Wider Planning for an Ageing Population working group will be taken forward.

1.18 The strategy aims to help ensure that a wide range of housing and services is provided to enable older people to live independently at home. As shown in Figure 2, the vast majority (over 96%) of people aged 65 and over live at home, including around 6% who live in housing with care or support (sheltered, retirement or extra care). Relatively small numbers of older people live in care homes (3.5%) or long stay hospital care (0.3%). 75% of people aged 60 and over are owner occupiers, including 64% who own their property outright. 21% are tenants of local authorities or housing associations, and 3% live in privately rented homes. ^[13]

1.19 The strategy fits in with a number of existing Scottish Government policies and strategies in housing, health and social care. It builds on Reshaping Care for Older People: A Programme for Change: 2011 - 2021, ^[14] which sets out the headline ambitions for the Reshaping Care programme as a whole, along with the first set of actions required for delivery. It highlights the importance of housing in meeting the programme's aspirations, including through adaptations; housing with care and support; preventative services; and building standards.

1.20 The strategy also meets one of the commitments made in Homes Fit for the 21 ^st Century, ^[15] the Scottish Government's strategy and action plan for housing for the next ten years. Homes Fit for the 21 ^st Century was the first national housing strategy document to make commitments on independent living for older people and disabled people. These include:

• The publication of a national strategy on housing for older people in 2011;
• Development of a national register of accessible housing;
• Simplification of the arrangements for the public and housing providers to access funding for housing adaptations;
• Ensuring needs of older people and disabled people are better reflected within national and local planning and housing investment processes; and
• Building on the introduction of the new Change Fund for Older People's Services and work with local authorities and the NHS to ensure the housing, health and social care needs of individuals are addressed more holistically.

This is a big step forward, but we recognise that there is some way to go until all older people and disabled people enjoy a full choice of housing and support options.

Supporting health and social care

1.21 In considering the needs of older people, there are a number of other areas, mainly relating to health and social care, where the right housing and housing-related support can help to improve the lives of both older people and their families and carers.

1.22 There are increasing numbers of people with dementia in Scotland. A familiar home environment is particularly important to people with dementia, and appropriate adaptations can help to support them to remain at home. Scotland's National Dementia Strategy ^[16] notes that most people with dementia wish to remain living at home, and that 63.5% do so. This brings benefits for them and lower costs. The Dementia Strategy highlights the importance of preventative support in enabling them to avoid crises and the potential need for expensive hospital services. It also notes the need for 're-ablement' services, including some, such as adaptations, which are 'housing' focused. 'Re-ablement' services provide intensive support to people returning home after a stay in hospital, which is then reduced as the person regains independence.

1.23 The Scottish Government operates a policy of Free Personal Care ^[17] for people aged 65 and over, who have been assessed as having substantial personal care needs that require services to be put in place. This care may be provided in a care home or in the person's own home. Around 55,300 older people (6.5%) receive home care services provided by the local authority to enable them to live independently at home. Commonly, these services may include help to get up in the morning and/or to go to bed at night, or help with food preparation.

1.24 As well as receiving care, many older people play a crucial role in keeping other older people living independently at home, through being unpaid carers for family members or friends. It is estimated that just over 3,000 people over 65 years receive more than 20 hours of paid care per week, while over 40,000 people over 65 years provide more than 20 hours of unpaid care per week. ^[18] Caring Together: The Carers' Strategy for Scotland 2010 - 2015 ^[19] recognises the contribution made by Scotland's unpaid carers. The strategy sets out a vision, whereby:

• Carers are recognised and valued as equal partners in care.
• They are supported to manage their caring responsibilities in good health and to have a life outside caring.
• They are fully engaged in planning and developing their support, and the support of those they care for.
• They are not disadvantaged, or discriminated against, by virtue of being a carer.

1.25 A key shift in current policy is towards giving people greater choice and control over the care and support they receive, through self-directed support. There is strong evidence, not just in the field of social care, that greater involvement of people in decisions about their life produces better, more sustainable and effective outcomes. People in Scotland, including older people, rightly have increased expectations about the degree of choice and control they should have over the support they receive. S elf-directed Support: A National Strategy for Scotland ^[20] sets out the Scottish Government's ten year strategy on self-directed support. It highlights the importance of informed choice, both in enabling older people to choose forms of support which reflect their lifestyles, and in securing a range of different services to support individual choice. In 2012, the Scottish Government will introduce a Bill. Together, the Bill and the strategy will support the aim of bringing self-directed support into the mainstream of social care, making it clear what options are available to people, and - critically - that it is their choice, as to how much control they want to have over their care.

1.26 This strategy for housing for older people also contributes to Independent Living - A Shared Vision. ^[21] This statement sets out an agreed vision for disabled people, based on choice, control, freedom and dignity, and was signed in December 2009 by the Scottish Government, COSLA and disabled people represented by the Independent Living in Scotland Steering Group.

Housing benefit reform

1.27 Housing benefit reform is one element of changes being made by the UK Government, as part of wider welfare reform to introduce a unified single benefit - Universal Credit. While we agree on the need to simplify the benefits system and incentivise work, the Scottish Government, along with COSLA and other stakeholders, has a number of concerns about the reforms, some of which will directly affect older people and will reduce the support available for people to cover their housing costs. In turn, this may well impact negatively on housing services.

1.28 People aged over 65 years make up the biggest group of housing benefit claimants in Scotland in terms of age distribution, with over 135,000 claimants. Around a third of these people are single pensioners, most of whom (68%) are women. ^[22] Although Universal Credit is for working age claimants only, the reforms have the potential, directly or indirectly, to affect the lives of a significant number of older people in Scotland. The exact impacts will become clear during the life of this strategy. We will work together to keep these matters under review and take whatever action we can to influence the reforms and mitigate their impact.