This chapter considers how housing and, more especially housing associations, are a key partner in delivering the new approach to health in Wales set out in the principles of prudent healthcare. We will expand on the conventional understanding of housing, highlighting how the housing association sector is adapting to meet need in a preventative way. The chapter will also explore contemporary ideas of how innovation involving housing associations can complement, drive and sustain the prudent healthcare approach.
Housing has been recognised as a determinant of health since early efforts to improve public health in the 19th Century. Poor housing which can’t retain heat is in disrepair or can’t be adapted to meet current or future mobility needs can have a huge impact on people’s ability to enjoy their desired quality of life as well as protect their own mental and physical wellbeing.
We all know our lives usually revolve around the home – from everyday routines to special celebrations. The implications of not having a home or access to the right home can have profound and long-lasting consequences.
As well as recognising the impact of poor housing and homelessness, we also know that improving the quality of housing and delivering the right interventions at the right time for residents has a positive impact on health outcomes.
First it is important to understand what we mean by housing. “Housing” can refer to residential property in relation to housing associations, the private sector or local authorities. Looking closely at the housing association sector in Wales, the challenges and opportunities in working with the different types of housing sector are distinct. Therefore, it’s important that we’re not too quick to make generalisations when we think about housing.
More than bricks and mortar
The impact of cold housing is profound. Cold homes deteriorate health and impact on people’s respiration, circulation and mental health. Housing associations know the importance of building high-quality homes. They build to meet environmental standards and can be easily adapted as necessary. Housing associations are also doing much more to offset the impact of fuel poverty, including:
Improving the energy efficiency of homes through the Welsh Housing Quality Standard and energy programmes such as Arbed.
Helping tenants to maximise their income through employment opportunities, as well as projects such as the Your Benefits Are Changing (YBAC) campaign. This project helps tenants to claim benefits they are entitled to. One area of success has been the identification of the Warm Home Discount – last year, YBAC successfully helped more than 900 people to claim a rebate, which together brought in a sum of £127,960 for the year.
Helping to try to negate energy price increases through actions such as behavioural change for energy use.
Looking beyond the physical
To fully realise the possibilities, we must look beyond the impact and opportunities to intervene in the physical environment alone. As this chapter will highlight, the opportunities for housing to fully deliver on the prudent healthcare agenda will lie in our ability to look beyond housing as simply part of the physical environment. We will need to extend our understanding of the potential of housing, to encompass social, cultural and economic aspects of housing as well.
Housing Associations are some of the organisations most deeply involved in some of the most deprived communities in Wales. Their roles go far beyond what we might understand as traditional landlords, for example many Housing Associations are now offering:
- A range of diverse, flexible care services
- Supported housing working with and serving potentially vulnerable groups
- Community engagement
- Digital inclusion
- Money advice
- Employment and skills initiatives
Prudent healthcare drives us to think more profoundly about the factors impacting on an individual’s life outside the hospital door, post treatment. Many of the common forces driving change across the public sector in Wales in terms of increasing demand, dwindling resources and public expectations are equally those impacting housing associations.
Our tenants, patients, service users, customers…
The challenges facing tenants and housing associations in Wales will certainly have an impact on both the NHS and social services. The UK Government’s welfare reforms have had significant impacts on social landlords and tenants alike. We anticipate that these will only place further pressures on many family and individual finances.
The removal of the spare room subsidy has meant that many tenants have had to downsize to smaller properties, sometimes having to move from the social to the private rented sector. Housing associations have traditionally built family housing, which in the current environment has meant a lack of one and two-bedroom properties, although Welsh Government have invested in this provision. The introduction of direct payments, where the tenant receives their housing benefit directly rather than the money going straight to the landlord, is having its own implications on how individuals manage their money and pay their rent with the consequence that some risk falling into rent arrears.
We know that there is a growing need for advice and support with welfare reforms intensifying financial worries and anxieties. Although the Your Benefits Are Changing Campaign and housing associations individually, continue to provide independent advice to tenants who have been adversely affected by the policy, there have been – and will continue to be – implications for mental health services, GP surgeries and A&E departments as the financial pressures on individuals and families leads to prolonged periods of crisis.
Welfare reform is the thin end of the wedge
Welfare reform is just one of several factors which together are intensifying what has become for many communities across Wales, an entrenchment in prolonged poverty. We know that poverty cannot solely be solved through meeting a housing need. Employment, health, and social inclusion are just some of the other elements which must be addressed… This is why it remains so vital that across public services, and evermore increasingly between health boards and housing associations, needs are served at the right time. It is essential that we make best use of resources and the opportunities to support people in the right way, at the right time.
The Supporting People programme in Wales delivers a wide range of support services such as homelessness, domestic abuse and substance misuse. Housing associations are among the providers delivering these services which are designed to prevent individuals needing more intensive, longer-term interventions. These services work together with individuals to identify and address challenges and barriers, find and make the most of opportunities to meet their goals and aspirations and support people to move on and sustain independent living.
However, cuts to the programme’s funding, raise questions about how the programme can continue to meet demand in a preventative and prudent manner. The opportunities which lie outside the narrative around the Supporting People budget are also well worth considering. These will also help us to go some way towards supporting people in the right way at the right time:
- Linking with housing providers to ensure that end of life care can be received at home
- Working with housing associations to look at how excess capacity in extra care and sheltered housing can provide step-down accommodation
- Finding innovative new ways to release capacity in respective frontline workforces – for example, medicine prompting could be done by non-medical professionals
- Making full use of money advice services to ensure that health issues resulting from financial hardship are addressed
- Building resources within communities – combining community facilities with pharmacies, GP surgeries etc., and working with and using housing association and health resources
- Using a collaborative approach to meet housing needs strategically, to avoid placing people away from their family or local community.
Our joint workforce
Employing more than 8,000 full time people in Wales during 2013-14, housing associations consistently report high levels of staff satisfaction. If you were to view any tenant satisfaction survey from the most current, to years gone by, it is no surprise that this has translated into high levels of satisfaction from those receiving services.
Housing association staff – from tenancy officers to specialist nurses – should be considered as an extension of the healthcare workforce in Wales. There are excellent opportunities to serve our communities through a focused approach which makes the most of our knowledgeable, versatile workforce. Prudent healthcare rightly encourages healthcare staff to only do what they are skilled and able to do to ensure expertise is being used in the right way for the right people. However, we also need to consider what other staff, across the public sector can do in partnership with the health service.
Working with and for communities
The combination of poverty, welfare reform, cuts to public services, demand for housing, the need for tenancy support and the broader role of the sector in supporting health, employment and independence has led to a situation where housing associations, like the NHS and other public services, have no option but to become prudent.
The prudent healthcare principles and underpinning message of collaboration with the public resonate strongly with housing associations in Wales. It opens the door to a common approach, a common language between housing and healthcare that will produce consistent, high quality outcomes for those we work with.
Individual contributions count
To make prudent healthcare work, it is vital that we, together with the people of Wales, become experts in nurturing the potential in people to fully realise their value, ambition and role within society. In the housing association sector in Wales, we have seen the massive value that tenant scrutiny, focus groups and volunteers can bring. Used in business improvement, developing stronger communities and personal development shows that this approach can have high value outcomes for all involved.
Understanding this value, housing associations in Wales work with communities to support ongoing activities that ensure voice and control in how housing associations operate, as well as improving health and wellbeing through involvement in community activity.
Timebanking, first conceived by Edgar Cahn, when he was in hospital recovering from a heart attack, is a method of engaging communities and rewarding people for investing their time, skills and expertise between each other and with organisations. This is an approach that has been successfully adopted by many housing associations in Wales.
Timebanking is very simple. For each hour a person gives they receive a time credit which can be redeemed against a range of activities provided by large national organisations as well as local independent providers. The benefits could include trips to the cinema, access to leisure facilities and a variety of day trips.
What timebanking demonstrates is that grass-roots driven support in communities is, in many instances, alive and well. It is precisely this type of activity that prudent healthcare and co-production encourages us all, as organisations and as individuals, to tap into. Re-defining the relationship with the public must include a push towards fully valuing what people can and already are offering in their own locality.
In a recent, wide ranging data collection exercise completed by Spice , a social enterprise that works with organisations and communities to develop timebanks, it found that timebanking had benefited respondents in the following ways:
- 45 per cent reported feeling healthier
- 95 people reported being incentivised to start a community group
- 19 per cent said they had visited the doctor less since earning and using time credits
- 76 per cent felt they could contribute more time.
The Scottish approach
In Scotland, progress is being made linking primary care and community activity. The approach complements the role of frontline services to offer long lasting interventions, making the best use of resources that are driven by people at grass-roots level.
A Local Information System for Scotland (ALISS), uses a large database which people can feed activities into and any user can then view and search the database as required. This can be done independently, or through a visit with their GP. Mapping out community activities, the ALISS system allows a person to discuss options with their GP which will improve their wellbeing and decrease their need for medication or further healthcare services.
The “Improving Links in Primary Care Project” report reflects how the ALISS system has benefited patients from their perspective. These views capture the potential of this approach:
“Although the anti-depressant drugs did help stabilise me I was still depressed, but then I was told about the local Women’s Aid group and the community group that could help with child support because I was struggling with bringing up two young boys on my own. I see my friends much more, we meet up without the kids. It’s also helped give me time to look at going to college which I’m going to do – I want to train to be a paramedic and that’s given me a real goal in life. I was on quite a high dose of anti-depressants but it’s a lot lower now.” Patient using ALISS 
“I had never really spoken with the GP about the problems I had financially because of time off work, but it did bother me and probably wasn’t helping the way I was feeling emotionally. It was only when it was pointed out that I was entitled to financial assistance and certain benefits that I looked into it and sure enough I got help with this. I even got help to complete the form which was a nightmare. It really helped me and took the pressure off financially.” Patient using ALISS 
With considerable pressure on primary care services, it is vital that we also seek to make the right links. The socio-economic conditions lying beneath deteriorations in health must be addressed in a holistic way.
Housing associations, local authorities and the voluntary sector can all support communities in developing mutually-beneficial activities and also be beneficiaries of community engagement themselves. When used in practice with professionals like GPs, a resource like this can be a hugely powerful tool to reduce reliance on core health services, increase individual impact on their own health and the health of those around them.
Examples of innovative practise
In One Place – Gwent Collaborative
In One Place is the formal collaboration between Aneurin Bevan University Health Board, five local authorities and nine housing associations.
The collaboration is underpinned by a legally binding collaboration agreement which was endorsed through the scrutiny processes of each partner organisation and formally signed on January 23, 2014. It is supported by the Welsh Government through the Regional Collaboration Fund and the Intermediate Care Fund.
The In One Place collaborative agreement enables partners to:
Establish a special purpose vehicle which facilitates a collaborative approach to dealing with the accommodation requirements of people with complex health and social care needs in one place, thereby enabling partners to streamline procurement procedures where they are applicable.
Agree to separate accommodation and care support requirements in the future, wherever possible.
Align health, social care and housing planning processes to ensure that current and future accommodation (and care and support) needs are addressed at the earliest opportunity.
In addition to better outcomes for service users and their support networks, the In One Place model has the potential to realise considerable savings across agencies by minimising accommodation costs through the effective use of housing benefit, capital assets and grant funding.
Working collaboratively, the model could also be used to maintain efficiencies in care costs without any negative impact on the quality of care and support. The In One Place team expects that by using a person’s home as the basis for all care and support, service quality will be enhanced and better outcomes will be achieved for all stakeholders.
Some early financial modelling has demonstrated potential savings in excess of £80k per continuing NHS healthcare case shared across accommodation (£9k) and care and support (£71k). The In One Place programme team anticipates reviewing all current cases (78), including in particular out-of-county placements (24) against the In One Place model. In addition to existing cases, the In One Place team is aware of 29 transition cases from children’s services over the next two to three years.
Reducing delayed transfers of care – Taff Housing Association
The Lighthouse Project, is directly managed by Taff Housing Association, working in partnership with Newport City Council’s Supporting People team. Newport city Council funds the project to provide floating support – a service that provides housing-related support to vulnerable adults to enable them to maintain their independence in their own home.
The Lighthouse Project created a hospital tenant support worker placement, as the project realised support was being delayed for patients leaving the Royal Gwent Hospital because of third party referrals and unnecessary paperwork and liaison. The request for a tenant support worker to be placed in the hospital came from the hospital social work team in Newport.
The social work team had experience of referring patients for support from the Lighthouse Project and appreciated the value of housing related support. There were, however, unnecessary delays in starting support and it was agreed by the Lighthouse Project, the Supporting People team and the hospital social work team that there would be a potential advantage in having a dedicated worker based within the hospital social work team. The tenant support worker could expedite a safe discharge from hospital and offer a more comprehensive support package, working in partnership with the hospital social workers and health professionals.
The outcomes of this project included:
Faster and more responsive service for those awaiting discharge
Ongoing floating support arranged where appropriate so that independence can be maintained and individual goals achieved
Reduced re-admission to hospital due to safety checks, tenancy related support and signposting to other agencies or more appropriate accommodation
Cost savings for health and social services.
Closer to Home – First Choice Housing Association
First Choice Housing Association provides housing throughout Wales and Shropshire to enable adults with a learning disability to live independently, with support in the community.
Closer to Home is a positive step towards reducing the number of institutional placements of people with a learning disability who also have challenging behaviour. It is especially important in light of the scandal at Winterbourne View in England.
The initiative aims to enable people with a learning disability and challenging behaviour who are living out of their home county to move back to their local area in Bridgend, Neath and Swansea. This prevents further out of area placements and reduces admissions to acute services.
First Choice gives the landlord function as part of the initiatives, and sources and develops the type of accommodation needed. The benefit of supported living accommodation is the promotion of an individual’s right and independence to live in an ordinary home in the community. In addition, it provides certain individuals, as a tenant with a legal right to live in their home, with appropriate care and support and a property that is adapted to meet their needs.
Based on this case study an example of the savings (per annum) that could be achieved are:
Out of area placement cost £311,000 per person
Closer to Home £90,000 per person
Savings £221,000 per person
Additional properties for this scheme will be delivered by First Choice Housing Association in the Swansea area in this partnership during 2014-15.
Prudent healthcare will not only change the way healthcare services are delivered, but will also change the way public services, the voluntary and private sectors work together. In the housing association sector, we are increasingly aware of challenges facing the NHS, local authorities and the independent sector and recognise these challenges are shared across services. Having a shared narrative around these issues will help us use common terms to discuss our challenges and implement solutions while being more able to fully involve the public in problem solving and discovering solutions.
Prudent healthcare stamps our collective commitment to consistency. Many of the examples we highlight here are unique to a certain setting or region. But we must, through the prudent healthcare approach, move to a situation where we no longer consider any of this best practice but more common practice.
Housing associations are seeing first-hand the impact that poverty, welfare reform and cuts to public services and key budgets are having on individuals and families. These tough conditions are driving people to need a wide variety of services and it has never been so important to consider how we best serve this growing demand. At the same time we need to be people in back in control of improving their own wellbeing offering support rather than creating reliance on our services.
The aim of this chapter is to highlight some of the links that have already been made and the opportunities to create value in the future. By recognising opportunities, taking action and building on the contributions highlighted in this chapter together we can pave the way, using housing associations as agents for change, for the principles of prudent healthcare to benefit people in the home and beyond.
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- Local Action on Health Inequalities: Fuel poverty and cold home-related health problems” UCL Institute of Health Equity 2014
- Year 7: The Socio-Economic Impact of the Welsh HA & Community Mutual Sector. http://chcymru.org.uk/uploads/events_attachments/WERU_Full_report_FINAL.pdf [accessed 8 December 2014]
- Edgar Cahn http://www.timebanking.org.uk/edgar_cahn.asp [accessed 2 December 2014]
- United Welsh Housing Association – Welcome to the World of Timebanking. http://www.uwha.co.uk/tenant/Time%20Banking%20%28Welcome%20to%20the%20World%29.html [accessed 8 December 2014]
- An Evaluation of Spice Time Credits. http://www.justaddspice.org/images/stories/downloads//article/103/xSpice%20Apteligen%20Report_Electronic_Dec2014.pdf [accessed 7 December 2014]
- Improving Links in Primary Care. http://www.alliance-scotland.org.uk/news-and-events/news/2014/09/improving-links-in-primary-care-report-launched/#.VIXFhzGsVyx [accessed 27 November 2014]