ACTION PLAN
Building an effective interface between housing and integrated health & social care (IHSC)
Introduction
- It is widely recognised that housing has a vital part to play in assisting the new Integration Authorities (or ‘Partnerships’) to achieve their desired outcomes:-
- “People, including those with disabilities or long term conditions or who are frail are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community” (National Health & Wellbeing Outcome 2, our emphasis)
- “The housing sector already makes a very significant contribution to national outcomes on health and social well-being… The integration of adult health and social care is recognised as bringing opportunities to strengthen the connections between housing and health and social care … to support the shift to prevention” (Strategic Commissioning Plans Guidance, December 2014)
- Nevertheless, there are challenges and constraints which will make it harder to realise the potential benefits from improved and more responsive housing services. Among these are:
- Most aspects of housing services will remain outwith the scope of the Partnerships; consequently, collaboration between housing and the partnershipswill not be underpinned by a legislative framework, but will instead rely on cohesive choices by local leaders in both sectors. This will require both leadership and willingness by the Partnerships to welcome and include a housing input, and a matching commitment by “housing” to maximise its contribution.
- Housing itself is a diversified and multi-faceted sector, provided by councils, housing associations, private sector landlords, a variety of third sector support organisations and private house builders. While this diversity is part of the sector’s overall strength and vitality, it will make it harder for leaders of the Partnerships to broker agreements with “housing”.
- Housing association and council housing budgets are under great pressure, with the need to create further capacity for independent living competing with other pressures – such as to increase overall supply, to improve energy efficiency and to improve the physical quality of the housing stock[1].
- A high proportion of older people are owner occupiers, without any pre-existing links to public sector agencies for housing or social care.
- This paper identifies 7 core prerequisites for effective interfaces between “housing” and IHSC. Many of them are already being worked on by the Joint Improvement Team and others; but this important work may need to be supported by a governance structure within the SG to make the necessary connections within Government, including to Ministers, and to ensure these prerequisites are delivered.
- The prerequisites are:
- A. Clarity on how indicators reflecting the housing contribution will be included within the national suite for IHSC and will be interpreted and used.
- Bi. Effective housing representation in the strategic commissioning process at partnership level and in locality planning.
- Bii. Strategic local coordination of housing organisations so that these housing representatives can speak collectively on behalf of the housing organisations in their locality.
- C. Housing to raise its game, with the 2015 revisions to the Housing Contribution Statements and the next round of local housing strategies setting out specific plans to provide better support to IHSC, backed by the commitment of councils and housing associations locally.
- D. Partnerships to consider increasing the budget for housing services within their functions.
- E. Clarity on how innovative solutions may be implemented and funded by Partnerships and the housing sector; and a clearer evidence base to demonstrate what can be achieved.
- F. Significant improvements in day to day processes for coordinating the care for individual people between IHSC, housing organisations and the individuals themselves.
- There are many other relevant workstreams being taken forward by JIT and others[2], which will also contribute to the effective coordination of housing and IHSC. But this paper focuses on these 7, which are arguably fundamental. The common theme is to identify where specific authority lies, to increase investment and make improvements in services related to housing, in order to improve wellbeing.
A. Indicators
The issue:
EachPartnership will report annually on its progress on the basis of the agreed indicators. They are therefore of vital importance to ensure thePartnerships are focussed on the right objectives.
The suite of indicators to measure progress towards the national outcomes has now been finalised. It includes global measures such as “rate of emergency inpatient days for adults” and measures of delayed discharge, and also a number of measures that will specifically pick up the housing contribution:
- “percentage of adults with intensive needs receiving care at home” (to check the extent of care at home, an important overall summary measure of the housing contribution)
- “percentage of adults supported at home who agree that they are supported to live as independently as possible” (to check the quality of care for those who are supported at home)
- “proportion of last 6 months of life spent at home or in community setting” (an alternative measure on extent, which could also be affected by changing trends in morbidity in the last months of life).
Action:
Ensure that Ministers and health, social care and housing leaders emphasise the importance of seeing real progress on these indicators, and in general on supporting independent living at home.
Timescale: ongoing
Description of success: indicators recognised as being accurate and meaningful; Partnerships being assessed by their achievement of them; annual results showing successive increases in percentage of adults with intensive needs being cared for at home.
Bi. Housing representation in strategic commissioning
The issue:
The SG published Strategic Commissioning Plans Guidance on 19 December 2014. It includes the definition of strategic commissioning as ‘the term used for all the activities involved in assessing and forecasting needs, linking investment to agreed outcomes, considering options, planning the nature, range and quality of future services and working in partnership to put these in place’. In short, Strategic Commissioning (including locality planning) is the principalprocess whereby integration will take effect.
However, this will be a complex process. The task is inherently complex, and in addition it is effectively split between partnership level and locality level. The guidance makes clear that it is the responsibility of eachPartnershipto “produce a strategic commissioning plan that sets out how they will plan and deliver services for their area over the medium term, using the integrated budgets under their control”. But their decisions will be informed by the views of their localities, because “localities, and locality planning, provide a key mechanism for strong local clinical, professional and community leadership, ensuring that services and planned and led locally in a way that is engaged with the community”.
It is therefore essential for a strong housing voice to be represented both in the Strategic Planning Group which advises the Partnership, and in each locality. Provision for this representation has already been made in the IHSC legislation and guidance. The implication is that there couldbe over 100 housing representatives engaged with the Strategic Planning Groups or the localities.
Actions:
1. Clarify the arrangements for setting up the Strategic Planning Groups and locality planning in each council/locality area, and the housing input to them.
2. Consult with all councils and housing associations about who will fill these rolesand what their representative role will be.
3. Policy and practice discussions within housing so that the housing representatives on these groups learn from each other’s ideas and are helped to play a strong role.
Timescale: Action 1: April2015;
Actions 2&3: 3-9 months
Description of success: In due course, once the arrangements have bedded in, housing representatives on theStrategic Planning Groupsand in the localities report that they are able to contribute powerfully and effectively to the processes.
Bii. Strategic local coordination of housing organisations
The issue:
The housing representatives on theStrategic Planning Groupsand the localities will wish to explore the potential for housing to increase its contribution to IHSC outcomes, for example by enhanced housing support for frail residents, a more responsive provision of adaptations, or more specialist housing provision. They may be able to engage in debate about increasing investment into these areas. However, they will need to take into account the plurality of housing organisations who would need to be involved in delivering an increased housing contribution.
To cope with this, there will need to be clear channels of communication locally between all key players in housing and housing support, so that the representatives on the planning groups will be able to speak realistically and authoritatively about what the local housing system can deliver. In most authorities there is a well-established housing partnership group or LHS group which should be well placed to take this forward.
Action:
Strengthen as necessary the local communication arrangements among housing organisations in each council area, with existing coordination groups asked to ensure their members can work together robustly, are able to take a joint strategic position on key issues and can make joint commitments where necessary.
Timescale: 3-6 months
Description of success: In due course, housing representatives on theStrategicPlanning Groups and in the localities report that they are able to represent the whole of the local housing and housing support system, and are backed by engagement with housing partners to address the health and social care challenges being faced locally.
C. Housing Contribution Statements and Local Housing Strategies
The issue:
Successful achievement of the IHSC outcomes will depend, among other things, on housing organisations improving their services in respect of adaptations, housing support and the provision of specialist housing. The ways in which they will do this should be set out by council housing departments in their Housing Contribution Statements (expected in 2015) and in the next round of their Local Housing Strategies (expected between 2015 and 2018).
The SG’s LHS guidance, published in August 2014, included the following:
9.12 The LHS should be clear on what the integration of health and social care means in terms of providing suitable accommodation and the care and support required to fully support this agenda, whilst enabling people to live independently within their own home for as long as possible. Having the right amount of care and/or support in place can help prevent unplanned hospital admissions and allows people to leave hospital more quickly, benefitting both the individual and the hospital system.
9.13 A Housing Contribution Statement (HCS) is required from each local authority. The initial HCS (2013) will need to be revised, potentially in April 2015, to cover a period of at least 3 years. The HCS should be completed by local authority housing practitioners working in close collaboration with social work colleagues and local health professionals to ensure the statement is inclusive and fully supports the integration of housing with health and social care. Joint working will help to build consensus and a wider understanding and appreciation of each other's needs, issues and resources.
In early 2015 the SG will issue guidance on the form and content of Housing Contribution Statements. While the HCSs produced in 2013 set out some important principles, these documents now need to be significantly enhanced, setting out specific and realistic plans rather than merely general policy intentions or lists of relevant housing stock, and fully addressing the roles of groups such as housing associations and Care and Repair, as well as councils. Housing Contribution Statements need to set out the functions that housing organisations provide (to assist Partnerships in establishing relationships with them); and they then need to set out how their investment plans will enhance this contribution. The LHSs in the subsequent two years must expand on the latter and make it more specific.
There is also a role for the SG Housing Regeneration & Welfare Directorate to encourage and support increased collaboration and a stronger contribution by the housing sector. For example, HRW invests directly in affordable housing supply and also in adaptations to RSL properties. The SG will ensure that guidance continues to promote the role that housing can play in supporting people to live independently.
Actions:
1. Partnerships and LAs to revise and update their Housing Contribution Statements
2. LAs to develop concrete proposals for investment to support IHSC outcomes, and to publish these in their local housing strategies, if not before. Partnerships and housing organisations (including councils) to work together to agree plans for coordinated delivery of their respective responsibilities.
3. SG to continue with work to implement the recommendations of the independent adaptations working group.
4. SG to reaffirm the importance of local authorities continuing to fully consider the requirements for specialist housing locally.
Timescale:
Actions 1, 3, 4: by September 2015
Action 2: 2015-2016
Description of success: Partnerships recognise an increase in the ability of the housing system to help people to remain at home for longer despite support and care needs.
D. Budget for integrated housing functions
The issue:
There are a few local authority housing functions which the legislation specifies must be delegated to the Partnerships, the main ones being assisting with the provision of housing adaptations (except for housing association tenants); and the housing support aspects of social care services. There are other housing functions which may be delegated with local agreement, including homelessness services and many aspects of housing support.
Partnerships will have a direct responsibility to decide the investment in these services, so the priority they give to them will signal the extent to which housing is seen as critical to their plans.
Action:
Housing representatives on strategic planning groups and in the localities to be clear on the importance of these integrated services and to ensure their importance is recognised.
Timescale: 2015-16
Description of success: Partnerships use investment in housing adaptations and in housing support to improve IHSC outcomes, and demonstrate a shift towards preventative care. An increase in investment in these services is made in several authorities,where the HCS/LHS/Strategic Plan highlights this is necessary in order to meet local needs.
E. Implementation and funding of innovative solutions
The issue:
There is scope for housing organisations to play a stronger role in enabling Partnerships to achieve their outcomes. For example, short term respite care can be provided in a homely setting by housing associations as an alternative to care home provision; and preventative action by social landlords can help prevent avoidable hospital admissions. Joint planning of the care pathway should help identify how services can be better joined up from the point of view of the service user, and where innovative approaches can deliver better outcomes.
Where innovative solutions are brought forward, how they are implemented and funded will need to be agreed between the Partnership, its constituent health board and social work department, and other partners such as housing organisations. It is open to the Partnership to reshape the deployment of its joint budget (but only within its delegated functions[3]). Therefore, where Partnerships recognise that housing organisations can play a stronger role in delivering the Partnership’s health and social care functions in new or different ways, it is open to them, working with health boards and/or local authorities, to commission such services from the housing organisations. Equally, it is open to councils and housing associations, consistently with their statutory and other responsibilities, to use their housing resources in different ways to help achieve better wellbeing outcomes.
The role of the Chief Officer will be key: the Chief Officer is accountable to the Partnership Board for strategic planning, and reports to the Chief Executives of the Health Board and Local Authority in his/her role as joint director of delivery of integrated health and social care provision. The Chief Officer must maintain a number of highly effective relationships with colleagues across the Health Board and Local Authority, and indeed the Community Planning Partnership.
Innovativeapproacheshave potential to improve wellbeing and in many cases may represent an efficient and effective use of resources. However, Partnerships considering financing innovative activity in the housing sector will wish to be assured of:-
- who in the housing sector can make commitments to deliver agreed levels of services;
- in each case, what those specific commitments are; and
- wherever possible, the evidence that the new way of working, including preventative action, will bring benefits in a cost-effective way.
Actions:
1. SG to publish some principles about how Partnerships can make agreements with housing organisations, to (a) ensure that Partnerships, health boards and local authorities know that it is permissible for them to work with housing organisations to deliver delegated functions and (b) to exemplify the type of commitment that would be expected from a housing organisation.
2. Establishsome exemplar funded projects between Health and Housing which secure increased housing provision to be available for discharged patients (or to reduce predictable unplanned admissions); establish the protocols under which this provision would be operated; and share good practice.
3. Bring together the evidence for the efficacy and practicality of housing interventions to support IHSC, and present this to Partnership Chief Officers.
4. In the medium term, analyse further the potential advantages and risks of delegating to the Partnerships the ‘may-be-delegated’ housing functions such as homelessness and housing support.
Timescale:
Actions 1,3: by Summer 2015
Action 2: Immediately, ie commencing Spring2015
Action 4: 2016-17
Description of success: AllPartnerships are aware of the role thathousing organisations can play in delivering a range of integrated functions; and housing associations are clear how they may negotiate such deals if they wish.
F. Day to day processes
The issue:
Separately from the question of investment, there are a number of issues in the way that health, social care and housing services communicate with and co-ordinate with each other, to deal with the care and support needs of individuals. The IHSC reform process rightly emphasises the delivery of person centred services as the objective of reform. Although outwith the integration authorities, housing needs to embrace the same principle and develop joined up services despite the variant governance and accountability structures.
Work under the auspices of the Delayed Discharge Task Force has already identified a number of important aspects of this, and work on them is ongoing, including:
- A locally-agreed single point of contact - i.e. a local ‘housing broker’ - for discharge teams/hubs/intermediate care teams, who would coordinate access to suitable accommodation (whether short-term or on a permanent basis) for those unable to return to their current home.
- A fast-track one-stop shop to coordinate housing adaptations as required to a person’s home, to prevent avoidable admissions to hospital or (if admitted) to prevent delay to their discharge
- Housing options advice and information for people who may need additional support to continue (or resume) independent living; to be available both to those in hospital preparing for discharge; and also preventatively, for those at risk of avoidable emergency admission.
Actions:
1. Establish trial arrangements for each of the above services.
2. Monitor closely how they perform, and in particular what organisational issues, financial constraints or other difficulties they encounter
3. Draw lessons about how these services need to be structured and can be supported across Scotland.
4. Roll out.
Timescale: 2015-2017, with substantial progress early in 2015
Description of success: Continuous improvement in the ability of housing and IHSC to deliver joined up, person-centred responses to people’s needs.
Housing Support & Homelessness Unit