A picture of health: how housing and health can work together
October 2012
Family Mosaic: an introduction
Contents
Family Mosaic is one of the largest housing providers in London, Essex and the Southeast.
Summary
3
1 Health and housing
4
2 The state of health
6
3 A new approach
11
4 Measuring impact
14
We provide affordable homes to rent and buy as well as care and support services to thousands of people who need extra support. We have around 24,000 homes for rent and serve more than 45,000 people. We provide a range of opportunities for our customers such as training, employment and access to learning. We partner local communities to make our neighbourhoods better places to live.
www.familymosaic.co.uk
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summary A picture of health Social housing has always played an important role in the health of our residents. Traditionally, this has been limited to the physical improvements we make to their homes. We also play another role we believe could be expanded: actively supporting our residents to improve their health and wellbeing.
This link between social housing and health was implicitly recognised in the Health and Social Care Act. We are also having to adapt to the changing composition of our tenant population with an increasing number of older tenants who have a greater need for health care.
We identified two health issues suffered by older people where we believe we can provide support: • arthritis or back pain – almost half of the respondents said they had one or both of these conditions; • depression or a mental health issue.
We have to change. Staying the same is not an option. We have already introduced fixed term tenancies alongside employment advice and support to address the high levels of worklessness among younger tenants.
We have designed a new service model to deliver this support to residents suffering from one or both of these issues. Our Neighbourhood Managers will be at its centre, working in tandem with our existing Social and Financial Inclusion team and a newly created Health and Wellbeing team.
For those older tenants on lifetime tenancies, we need a different approach, one that uses our experience and expertise in delivering care and support services, and makes them integral to our approach to housing management. Before we developed a new service model that supports them to improve their health and wellbeing, however, we had to understand the health needs of our customers. Researching a randomly selected group of 360 of our tenants over the age of 50, we found: • 71% said either they, or a member of their household, had a long-term health condition; • 49% of people with a long-term health condition had multiple conditions; • 25% of those with a long-term health condition also had depression or a mental health issue.
We have pledged to save the NHS £3 million every year. We believe this new service will result in a significant contribution towards this target, as well as savings for local authorities’ adult and social care budgets. First, though, we need to test this hypothesis. So we have commissioned an 18 month research project, in partnership with the London School of Economics. This will focus on our older residents in Hackney and Old Oak (Acton). Following an initial assessment, they will be split into three groups: the first will act as a control group; the second will be offered basic advice and signposting: the third group will receive full support from us. This will enable us to evidence how we can best strengthen wellbeing and support the NHS, so we can create a new picture of health for our residents.
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1
Health and housing
The link between health and housing is well documented. Most of the evidence, however, is focused on the impact of poor housing on people’s health. Less well explored is the role social housing providers can play in supporting their residents to improve their general wellbeing, to live a healthier lifestyle and to reduce the need for more intensive, and expensive, health and / or adult social care interventions in the future. Social housing providers have always played an important role in improving the lives of their tenants, whether through programmes like Decent Homes or through the aids and adaptations carried out by home improvement agencies. Last year, for example, our home improvement agencies in Kent, Sussex and Hampshire helped thousands of older people to remain in their homes. Implicit within the Health and Social Care Bill that was enacted in 2012, however, was a recognition that social housing providers also have a role to play in improving people’s health and wellbeing. They will be critical in working with the NHS as it remodels its services, making more of communitybased services like floating support. Simultaneously, health and housing is an issue because of the changing population. This is not just evident in the ageing population within the general needs stock of many social housing providers. It is also because of the fact that the composition of those entering social housing now has changed, and will continue to change. At the beginning of the 1990s, those people who moved into social housing were not as vulnerable. Now, most people who are referred to us are homeless, older or have much higher needs as a result of alcohol or drug dependency, or mental
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health issues. Social housing has to change. Staying the same is not an option. Some of the changes we’ve been making are related to the tenancies we offer our residents. In July 2012, following extensive research, we started offering new tenants fixed term tenancies, alongside support and advice to encourage them into employment. Simultaneously, we decided to retain lifetime tenancies for those most in need, including older people within five years of pensionable age, and those with long-term illnesses or disabilities who are unable to work. We will offer them additional support, particularly around initiatives to improve their health and wellbeing. We believe there are two main reasons why Family Mosaic can play this role. First, because we are foremost a care and support specialist. We have a large care and support department with a skilled workforce: over 75% of the housing staff we employ already have the necessary skills to provide this service. The evidence from our personalisation pilot has demonstrated that these skills can be made integral to our housing management service, with positive benefits to our residents and communities. And we have worked closely with health on a number of supported housing schemes,
giving us a strong platform to provide greater support for the health agenda. The second reason is because, unlike many statutory agencies, we have access to our residents. We know a lot of people don’t approach statutory agencies, particularly when they are unwell, or are needing support. They are sometimes suspicious of them or worried, for example, that they will be put into a care home or lose their rights. Family Mosaic already has a foundation of trust based on our existing relationship with them and our understanding of the communities in which they live. We already have the experience in supporting people through care and support services, and community investment initiatives. Many of our existing initiatives have links with health: whether it’s our older persons walking club, or our greening communities project that enables people to create healthier, communal spaces together. These initiatives, however, rely on people actively signing up to them. People with low level depression, or anxiety disorders, however, tend to be socially isolated. As a consequence, they won’t have the self-confidence to join in with these types of initiatives. Our existing relationship with them provides us with an opportunity to actively engage them and then use our skills to support them to lead healthier
lifestyles. This may require a lot of support initially. We believe, though, that the end results will be more than worthwhile. In September 2012, we launched a manifesto containing five key commitments: one of these states that we will save the NHS £3 million every year. We aim to achieve this in two ways: by working with GPs and hospitals to provide home-based services that take the strain off expensive health facilities. And, secondly, by promoting health initiatives among our residents, so that their health improves and they don’t have to visit their GP or be admitted to hospital in the first place. There may be an initial increase in demand for health-related services, but in the long term, we believe the savings will be substantial. There will also be benefits for local authorities, by increasing the time before people need to access adult social care, or by reducing this need completely. How, though, do we intend to achieve this? First, by making any such initiatives integral to our general needs housing management. And secondly, by using research to test which services would most benefit our residents, while maximising the savings for our health and adult social care colleagues. Before we look at the design of this service, then, we needed to determine the level of need amongst our residents.
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2
The state of health
We began by trying to understand more about the health needs of our residents aged 50 or over who were living in our general needs properties. We chose this age range as they are more likely to have long-term health conditions, and more likely to be in poor health. The Department of Health estimates that long-term health conditions account for around 70% of total health spending.1
Selecting our participants randomly from a total of 5,805 general needs tenants, we contacted 360 older people and asked them about the health of the people in their household. This sample size gives us a confidence level of 95%, with a confidence interval of +/- 5%. As can be seen in the illustrations below, the age range of our respondents closely mirrored the age range of all Family Mosaic general needs tenants.
Age range of respondents
50-60 year olds
60-70 year olds
70-80 year olds
over 80 years old
Age range of all Family Mosaic tenants over 50 years old
50-60 year olds 1 Department of Health (2010). Improving the Health and Wellbeing of People with Long-term Health Conditions. 6 | Family Mosaic
60-70 year olds
70-80 year olds
over 80 years old
Household type We asked respondents to describe the households in which they lived. Almost half were single adults living on their own. Just under 40% had children living with them, whether they were single adults, or couples. One in ten were living as a couple, while just under 5% were living with their extended family.
44%
19%
18%
11%
were single adults living on their own
were living as a couple with children
were single adults living with a child
were living as a couple
4%
were living within an extended family
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What we discovered Over 70% of our respondents said that either they, or a member of their household, had a long-term health condition. This is no surprise: those living in social housing tend to be poorer, and to have poorer health. What was more startling was that in over 20% of households consisting of two or more people, more than one household member had a long-term health condition. Nearly half of those with long-term health conditions had multiple conditions, for example, diabetes and heart disease.
Research published by the King’s Fund in 2012 indicated that 46% of people in England with a mental health issue also had a long-term health condition.2 We found that 76% of respondents who said they had depression or a mental health issue also had another long-term health condition, while a quarter of those with a long-term health condition also had depression. We asked respondents how often they visited hospital because of their condition: over half went more than once a year, while a fifth went monthly.
Most common conditions 16%
12%
20%
5%
5%
15% Other conditions included: 2% Epilepsy, Hiv/Aids, stroke, skin disease, COPD, Multiple Sclerosis 1% Glaucoma, Bronchitis, Lupus, Parkinson’s disease, Osteoporosis, loss of limbs
4%
31%
24%
2 The King’s Fund (2012). Long-term conditions and mental health: the cost of co-morbidities. 8 | Family Mosaic
Long-term health condition
71%
said that they, or a member of their household, had a long-term health condition
More than one person
20%
lived in a household where more than one person had a long-term health condition*
Multiple conditions
49%
of people with a long-term health condition said they had multiple conditions
Depression plus
76%
with depression or a mental health illness also had another long-term health condition
Multiple conditions plus
25%
with multiple long-term health conditions also had depression or another mental health illness
Hospital visits
52% *
with a long-term health condition visited hospital more than once a year
Excludes those living in single adult households.
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Living alone Three out of four people living on their own had a long-term health condition. A quarter suffered from arthritis, while 16% had depression or another mental health illness. These were the three most common conditions suffered by those living on their own. By contrast, 65% of those living as a couple had a long-term health condition. A fifth of them
had arthritis, and 15% had back pain, but far fewer – just 3% – had depression or a mental health issue. This could suggest that services targeted at those living alone would be needed more. Just under half of those living on their own visited hospital more than once per year. This compared to 58% of those living as a couple who went more than once a year.
Single adults
16%
25%
75%
47%
had a long-term health condition
ARTHRITIS
BACK PAIN16%
visited hospital more than once a year
Couples 3% DEPRESSION /MENTAL HEALTH
ARTHRITIS
20%
65%
58%
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had a long-term health condition
visited hospital more than once a year
BACK PAIN 15%
3
A new approach
Any services we develop in the future must have measurable benefits for our residents’ health and wellbeing. Having spent time talking with health professionals, we understand that partnering with the NHS means we must demonstrate the savings our services will bring to them. So what services might our residents require? As part of our research into the needs of our residents over the age of 50, we asked them about the types of services they would be interested in receiving from Family Mosaic.
Proposed service
%
Enhancement to property to improve health
29
Telephone advice service, and appointment booking service
23
Appointment reminder service
18
Medicine home delivery service
14
Regular visits from a community nurse or support worker
8
Medicine reminder service
7
Respite service for carers
4
Assistance having medicine administered at home
3
The number of people who wanted an enhancement to their home to improve their health was a surprise to us as we were up-to-date with previously identified demand. Part of the proposed pilot will include identifying why tenants have not requested enhancements to their property. We also asked respondents if they would benefit from support whilst being discharged from hospital: 37% said they would. Over 20% said an adaptation to their home would support their discharge from hospital. Targeting our services In reviewing the long-term health conditions suffered by our residents, we have identified two major issues affecting our residents where we believe we could offer support to improve their health and wellbeing. Issue 1: residents with mobility issues. According to our research, 46% said that they suffered from arthritis or back pain, or a combination of the two. By improving independence in the home through the use of aids and adaptations, encouraging physical activity, a healthy lifestyle and community engagement we hope to improve mobility. This will result in people’s health and wellbeing improving, as well as a reduction in their need to move into adult social care and fewer visits to their GP, hospital and /or accident and emergency units. Issue 2: residents with depression or mental health issues. According to our research, 15% of residents suffered from depression or mental health issues. People with two or more long-term health conditions are seven times more likely to have depression than people without a health condition.3
3 Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B (2007): ‘Depression, chronic diseases and decrements in health: results from the World Health Surveys’. The Lancet, vol 370, no 9590. pp 851-8.
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We are already an established expert in mental health services in London, Essex and the Southeast. We can support people to engage more with their local community. We would expect that this, too, would result in increased health and wellbeing, as well as reduced visits to their GP and accident and emergency departments. Delivering the service Any new service will be provided through our existing Neighbourhood Managers and our Social and Financial Inclusion team, as well as through a newly created Health and Wellbeing team. All these elements will compose a multidisciplinary hub. The service will have access to our Health and Wellbeing Centre. This provides activities and advice around health and wellbeing including yoga classes, a gardening club, smoking cessation support, drug and alcohol issues and BMI checks. Residents will also be able to access our community initiatives such as Get Connected, that provides training in computer and internet use, and employment support for residents who want to get into work. Other services can be bought in, for example, ongoing physiotherapy sessions if a need to encourage daily exercise has been established. The Neighbourhood Manager (NM) is already the main point of contact between Family Mosaic and the tenant. As a result, they will play a critical role in the proposed new service. This, however, will not just be a traditional housing management role: using our expertise in care and support, we will introduce new skill sets into their work.
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How the service will work The Health and Wellbeing team and NMs will carry out initial health assessments for all residents involved in the pilot, looking at their physical health and mobility needs, and their mental health. Mobility and physical health issues Residents will be assessed on any day-to-day mobility issues they have with their home, in, for example, getting in and out of the bath. The assessment will also cover fuel poverty, fall hazards and social isolation. Base data will also be gathered to enable a review of progress against key objectives, like, for example, number of GP visits and hospital admissions. Assistance will be given to residents with slip/ trip/ fall hazards, as well as advice for keeping warm in winter. Minor aids and adaptations will be requested with small items being bought by the team. If major works are required, the resident will be referred on to an occupational therapist, for a fuller assessment. Depression and mental health issues The team will carry out a more detailed assessment, and write a position statement relating to the resident’s current situation, for example, in terms of their hospital visits and known health issues. Critically, a health action plan will be created, based on the individual’s specific needs. This could include advice and support, engagement with social and financial inclusion programmes and / or support to attend the health and wellbeing centre. Quarterly reviews will take place for all residents to monitor and measure progress against objectives.
Proposed service design
Initial health assessment conducted by Health & Wellbeing team and NM, gathering/sharing data with GP/other health professionals
People with mobility / physical health issues
People with depression / mental health issues
Develops personal plan
Major works, referral to occupational therapist
Minor aids & adaptations, advice, small grants, etc
Full assessment, and health action plan, with referral to health service where applicable
Health checks and advice: e.g. BMI check, smoking cessation, drug & alcohol advice, sexual health advice, nutritionist
Activity programme: e.g. yoga, swimming, gardening, personal trainer
Social inclusion programme: e.g. befriending, volunteering, employment support, identification and support to join community groups
Quarterly reviews to monitor and measure progress against objectives.
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4
Measuring impact
We believe that this new service model could make substantial savings for the NHS and for local authorities adult social care budgets. Most importantly, we believe it could significantly improve the health and wellbeing of our residents over 50 years old. To find out, though, we need to pilot these services and measure the outcomes. In partnership with the London School of Economics, we will evaluate the impact of these pilot services in the London Borough of Hackney and Old Oak (Acton). These pilots will form the basis of a piece of longitudinal research to be conducted over a 12-18 month period. We have chosen Hackney because of the numbers of our general needs tenants aged over 50 who live
in our properties in the borough. We are also one of the largest providers of mental health services in Hackney, so we can use the resources we already have and that people within the local health sector already know about. We will need to work more closely with them, because there are certainly some things that we won’t do, for example, blood tests and specific health preventions. We have chosen Old Oak because it is a distinct neighbourhood with
Research process Health and Wellbeing team visit resident and conduct initial assessment, gathering baseline data and placing the resident into one of three groups
research group 1
research group 2
research group 3
No support (control group)
NM provides basic advice and support, and signposts resident to local health and wellbeing services
Health action plan developed, and resident is actively accompanied to local health and wellbeing services
Quarterly review visits to monitor and measure residents health and wellbeing against baseline data
After 18 months, pilot finishes, and results are reviewed and analysed. Liaison with local health service on what works, and what doesn’t work, before refining the service offer.
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an existing centre that offers health programmes, currently aimed at families: the pilot will enable us to extend these programmes to older people. All our tenants in Hackney and Old Oak aged 50 or over will be invited to take part in the pilot. The potential participants will then be randomly divided into three research groups: • the first group will receive no services, and will act as a control group; • the second group will receive minimal intervention and will be signposted to relevant services; • the third group will receive full support from the new team, and will, if required, be accompanied to local health services. All participants will have their health needs and current engagement with health care services assessed before and after the pilot, using measures such as how often they have needed to visit their GP or have been to A&E. These will serve as baseline data for the final analysis of the pilot. At the end of the pilot, we will work with the London School of Economics to evaluate and measure the effectiveness and cost-benefits of the different approaches. This will enable us to determine: • the optimum level of service provision; • the impact of the service for residents with different health needs; • the impact of the service for residents living in different household types; • the impact of the service for residents of different ages.
It may be that, initially, we increase the demand on health services, as we encourage people who are currently not using health services to engage with them. We believe, however, that in the longer-term, there will be substantial savings because the NHS will not be picking up people when they are in crisis. Similarly, we believe such a service can delay the time before people need adult social care services, or completely negate this demand. For Family Mosaic, the new service model will further help us to achieve our social purpose. By increasing people’s mobility and independence, we will enable them to look after their property better. And by supporting more people with low level depression or a mental health issue, we could see a reduction in anti-social behaviour. We know that poor mental health and wellbeing costs the NHS between £8 and £13 billion every year. We know that the presence of poor mental health in combination with a long-term health condition increases the average cost to the NHS by each person from £3,910 to £5,670 a year.4 As a social housing provider, we are in a privileged position to help reduce these costs. We have the expertise within our staff. And we have the access to our residents. The results of this research pilot will enable us to integrate this service into our approach to housing management across London and Essex, with the confidence that we are making a difference in improving the health and wellbeing of our residents.
4 The King’s Fund (2012). Long-term conditions and mental health: the cost of co-morbidities.
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For further information contact Joanna Birch: T 020 7089 1046 M 07960 821 007 E Joanna.Birch@familymosaic.co.uk
Credits Edited and designed by Matthew Grenier, Andrew Kingham
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