Comparative perspectives Mark bevan, centre for housing policy, university of york Delivering services for older people in rural areas
Introduction I would like to focus upon delivering services for older people in rural areas. The talk draws in part upon research undertaken within the Centre for Housing Policy for the Commission for Rural Communities and the Housing Corporation looking at the housing and support needs of older people in rural areas. The research included discussions with older people in a range of different rural areas in England, about their views, experiences and aspirations. The talk also draws upon a wider literature to illustrate further points.
Plan of talk
Delivering services for older people: the rural context
A focus on housing and support
Previous speakers have noted the particular trends in their respective countries. I would briefly like to highlight demographic projections in rural areas of England. Recent research has identified a number of key trends for the future (Rural Evidence Research Centre, 2005):
Projected % Change in over 50’s 2003-2028
Major urban large 28.5
Large urban 27.2
Other urban 34.6
Significant rural 37.4
(Source: Rural Evidence Research Centre, 2005)
NOTE: Rural/urban definition for England The 354 districts in England are divided into 6 groups to reflect the structure of districts:
Major Urban: districts with either 100,000 people or 50 percent of their population in urban areas with a population of more than 750,000; there are 76 districts in this group.
Large Urban: districts with either 50,000 people or 25 percent of their population in one of 17 urban areas with a population between 250,000 and 750,000; there are 45 districts in this group.
Other Urban: districts with fewer than 40,000 people or less than 25 percent of their population in rural settlements: there are 55 districts in this group.
Significant Rural: districts with at least 40,000 people or at least 25 percent of their population in rural settlements; there are 53 districts in this group.
Rural- 50: districts with at least 50 percent but less than 80 percent of their population in rural settlements (including urban areas with between 10,000 and 30,000 population which are of rural functional importance); there are 52 districts in this group.
Rural- 80: districts with at least 80 percent of their population in rural settlements (including urban areas with between 10,000 and 30,000 population which are of rural functional importance); there are 73 districts in this group.
The starting point for how services should be configured and developed into the future is the priorities and views of older people themselves – how can services fit together to meet their priorities and aspirations.
Age Concern (2006) has reviewed a range of research that has sought to identify key dimensions of older people’s lives who live in rural areas. These include:
2. Being heard
3. Interdependence and reciprocity
4. An active life – keeping busy
5. Receiving help not care
6. Feeling safe
7. Continuity of place.
Delivering services for older people: the rural context There can be a number of features of operating in a rural environment that can affect the delivery services. I would like to note that there can be opportunities and positive aspects to working in rural areas, just as much as barriers and constraints.
There is often a higher cost attached to providing services in many rural areas.
Increasing centralisation of services, particularly of health care.
Limited transport options may restrict mobility and access, increasing dependency and exclusion.
Time required to develop local community trust and confidence in new initiatives where past change and opportunities have been limited.
Achieving economies of scale
Models of service delivery Overlaying these specific features of providing services in rural areas is the diversity of rural areas themselves. A number of research projects have focused attention on the particular features of models of service delivery that perhaps work better in some types of rural areas compared with others, or are attempting to identify aspects of models of delivery that can replicated in other rural environments.
Just to give a couple of examples of what I mean from Scotland. A recent research report in Scotland has noted a distinction between remote and accessible rural areas in terms of the way that services might be configured – and this is where broader strategic planning would need to come into play across different types of service in terms of designing and evaluating the effectiveness of services. This research suggested that in more accessible rural areas a focus on transport to services in towns may be the most cost effective approach. In contrast, remote communities may need the provision of services on the ground (Accent Scotland and Mauthner, 2006).
There a number of ways that services can be configured to undertake that role in remoter areas such as mobile services going out to communities. Another suggested approach is the way that staff are trained up. In urban areas you can afford to have staff trained in very specialised roles. In remoter rural areas an alternative approach is to have staff trained up in a different way to undertake a more generic role, in terms of either providing services and/or signposting people to other services.
An example of learning which aspects of services can be replicated elsewhere is the DESERVE project, which is funded by the European Union. This project is a collaboration between Scotland, Sweden, Iceland and Finland to test the transferability of models of service delivery to remote and rural areas. Each participating region will implement a project utilising a model previously tested by partners in their own countries. The emphasis is on the models of service delivery to remote and rural areas rather than on the specific services provided, so it may be hoped that some of the lessons may be learnt which could be applied in the context of housing and support, even if projects have not directly been involved in this type of service.
There is also an issue of the diversity of older people themselves. What might work well for some people won’t work for others. One issue is the way that services engage with ‘hard to reach’ groups of older people. There is a geographical dimension to this issue in terms of the physical remoteness and isolation of some people in very sparsely populated areas because of remoteness. There may also be an unwillingness to engage with service providers. For some people there is a lack of trust towards statutory services and a feeling that they will lose control over their own lives. There is also often reference to a culture in rural areas of ‘making do’ and not articulating needs. How far that culture will continue across future generations is perhaps a question for future research.
A focus on housing and support Specifically I would like to focus the rest of the talk on how delivering housing and support services in rural areas can impact upon continuity of place for older people. By support services I mean statutory services that deliver personal care to people, but also much wider formal and informal help that can be delivered not only by statutory services, but also the voluntary sector and by friends and relatives. There are two issues here. The first is how housing and support services can enable older people to continue living in their current homes. The second is how these services can help to facilitate positive moves to different locations, if these are required or desired by older people.
Part of policy response to ageing has been developments around combating age discrimination. The Housing and Older Persons Development Group have stressed that planning for older peoples’ housing needs to go beyond equating accommodation requirements for older people with specialised accommodation.
The majority of older people live in their own home and are owners occupiers. The 2001 Census showed that of households in Britain with one person of pensionable age - 90% lived in mainstream housing. The remainder either lived in sheltered accommodation or a registered nursing home.
Research has highlighted that that most older people want to remain living in their own home. Discussions with respondents in rural areas also emphasised this point.
One challenge for spatial planning to enable people to continue living in their own homes, linking together issues such housing, health, transport and access to services, the preventative agenda, and access to advice and information. These issues were reflected in discussions with older people in rural areas as part of research. Successful housing solutions often linked with other factors such as transport and access to services. Time and again, respondents discussed what would happen when they had to give up driving, and the impact of this upon housing decisions.
There is also an important role for planning to play in providing viable and attractive alternatives for people if they need or want to move to alternative settings such as housing with care. One issue on rural areas which perhaps could be examined further by research is how far people say they want to remain in their homes because there isn’t an attractive option available to them within a reasonable distance. Further a recent paper by Robin Means has highlighted groups of older people who lack the choices open to older people generally such as people with dementia.
Housing with care, or extra care, has been put forward as a model for increasing independence and can have a preventative function for those who need housing-led personal care and support care. In rural areas it can also provide a base for other services, such as Intermediate Care, that might otherwise be absent from a rural area and from which outreach services can be delivered to a wider area. However, there are major hurdles to be overcome in providing this type of service in rural areas. The costs of providing this type of service in smaller communities can be prohibitive, and it is more often associated with market towns to achieve economies of scale. One scheme in Suffolk had been built in a village, and provided very valuable range of services to surrounding community. However, revenue costs were such that housing manager stated that would be unable to replicate this model in other areas.
The main issue is how far housing that meets high standards of design with regard to access and flexibility in use can be made part of the mainstream, general housing stock. The aim is to make a home easier to use and also adapt as a household’s needs change over time. The wider intention is to provide accommodation which can provide flexibility in use across different occupants over time, and across as wide a range of the population as possible.
The Lifetime Homes standard provides an example of one model for accessible housing. The lifetime homes standard is based on 16 principles such as adequate space for wheelchair access; potential to adapt a stairway for a stair-lift; one point to make is that Lifetime Homes as a model is contested. One issue is space for storage.
The Department of Communities and Local Government is currently consulting on whether to include lifetime homes standards as an essential element of the Code for Sustainable Homes, to encourage the adoption of lifetime homes standards by the housebuilding industry. It is already intended that most government funded new build housing schemes will adopt the Lifetime Homes standards from 2010.
The Department of Communities and Local Government has estimated that by 2050, about one third of the housing stock will have been built between now and then. However, what is not clear is how that figure of one third will vary geographically. In areas of traditional planning constraint in many rural areas, including areas such as National Parks that figure could well be much lower.
What this suggests is that there are very limited opportunities for diversifying the housing stock in many rural areas in relation to the proportion of new build accessible housing. So is there an argument for saying that any new build going into rural communities – both public and private - should at least meet lifetime homes standards. Given the fuss that the private sector made over the last changes in 1999 to part M of the Building Regulations, one can imagine intense lobbying around this issue.
Another conclusion to draw is that if new build is likely to have a limited impact in many rural communities, the focus of attention in these areas should then be on improving the existing housing stock. And that suggests a greater emphasis on for example, Care & Repair, Staying Put services. Worryingly, these types of service tend to operate at a lower level that found in urban areas (Molineux and Appleton – Learning and Improvement Network).
A further problem affecting urban and rural areas alike is the current pressure on personal care services provided to older people on a statutory basis by social care services. There is an intense level of needs relative to resources that is affecting how statutory services can respond. This problem is reflected in the fact that many local authorities are having to target higher levels of care needs only, and cannot cater for people with lower levels of need. One example of the pressure on social care services in a rural area in the research we conducted was illustrated in the following quote by a practitioner in social care services:
About five years ago five per cent of people supported by social services were self-funders who had run out of money. But now 25-30 per cent of the purchasing budget for nursing and residential care is for self-funders who have run out of money. What this quote reveals is not only the increasing pressure on social services budgets, but also a very particular trajectory of ageing – people who have run out of money.
Instead, preventative services also have a key role to play in enabling people to continue living in their own homes. Preventative services as those that:
promote the quality of life of older people and engagement with the community
Research has demonstrated the high value that older people place on services that help them small tasks around the home, or enable them to socialise and get out of their homes. The context in rural areas of limited housing options, and also poor access to transport services means that low level support and preventative services can play a particularly crucial role in rural areas in helping people to sustain their lifestyles in the own homes.