In societies the world over, the population of older people is growing. More people are living longer, including those living with multiple chronic conditions. In older adults, a chronic condition may cause issues with functional ability, and this may worsen over time. The older person's housing needs may, therefore, change. The UK has a robust housing scheme whereby those who are at most risk or most vulnerable are prioritised first, but essentially anyone can apply, although they may be on a waiting list for a long time if they are not considered to be a priority. For older people living in the UK, there is an increased risk due to their age and any medical issues, as well as vulnerability if living alone. If they are receiving long-term support from community nurses and social care for chronic conditions, they would be considered a priority over an able-bodied person. If someone has dementia with symptoms, they are considered highly vulnerable as the disease progresses, and a housing application on their behalf would be prioritised. The system is complex, but allows a chance for a multitude of people in all sorts of situations to access housing.
There are numerous social housing options, and Age UK can help support the application (Age UK, 2021). It is important that nurses are also aware of signposting where they recognise a need for a change in housing. They may have noticed that the patient is struggling with day-to-day tasks due to their decreasing level of independence and may not have a disability-friendly environment with the right equipment or adjustments that would enable them to carry out their wellbeing tasks. A person may avoid eating or washing due to a decrease in their typical day-to-day functioning. More suitable housing may include adjustments and have no steps, so as to avoid falls risks, and may be in an environment that feels safer and is less lonely. It may be that the older person's partner is their carer and needs respite through a more helpful living environment. Challenges can make it difficult to navigate the social housing system and, therefore, signposting to Age UK can be a good idea. Referrals to social service or occupational therapy may be necessary. The Government has worked on solutions to the housing difficulties older people face by ensuring there is a better provision of appropriate housing, but only time will reveal statistics regarding waiting times and other difficulties older people face, such as provision of inappropriate housing. Ultimately, a person's level of independence can increase, mental wellbeing can improve, physical function can improve and falls risk can reduce if they live in an environment where they feel safer and perhaps less lonely.
This article provides a general overview of social housing, Government policy on housing for older people, functional issues that indicate a change in housing is required and solutions. Through timely signposting and knowledge empowerment to support the older patient in their care, nurses can truly help support the older person with moving towards a better future with the right housing and their needs being met.
Social housing
The Hyde Housing Association Ltd (2021) stated that anyone can apply for housing, but eligibility criteria would need to be met for the range of housing available. Eligibility would be based on need, and applicants would be placed on a waiting list held by their local authority. Priority would be usually given to the homeless, those living in overcrowded or unsuitable housing, people with welfare or medical issues, victims of domestic violence or racial and sexual abuse and those who have been referred by social services, the national probation service and refugees. Housing associations work with local authorities to meet housing needs. They provide millions of homes and have anywhere between 10 homes and 50 000 properties to let, sell or manage. They provide affordable tenancies and landlord services and individual support and encourage community projects to help tenancies work and people to integrate into the environment in which they have been placed. They are sometimes referred to as registered providers and, in England, are regulated by Homes England. There are various types of social housing. Social rented homes are low rent, typically making up 50–60% of market rent, which are prioritised by need. Affordable rent housing is social housing but with a higher rent of up to 80% market value, and is less secure than social rented homes, again being prioritised by need. Shared ownership allows people to part-buy and part-rent, and buyers must meet a certain income criteria. Intermediate rent homes provide housing at 80% of the market rate. Supported housing, which may be what older people supported by community nurses require, is for those with additional needs, and includes care homes. There are various types of tenancy but this is not necessarily relevant for this article.
Housing options for older people
Age UK (2021) provides information of their local branches according to the patient's postcode. They have a wealth of information on their website regarding housing for older people. This includes applying for social housing and specialist housing. Housing applications can be made with the support of Age UK, and, if a nurse finds that the patient requires help with housing, they can always call Age UK on the patient's behalf or provide the details of their local Age UK branch, so an advisor can get in touch and assist with the process. A social worker may also be involved in the case, so they should also be contacted or referred to in the case of a patient requiring social housing. Housing includes almshouses, retirement homes, care homes, sheltered accommodation, advice on moving in with relatives, older person's application for shared ownership, assisted living and extra care housing. Age UK (2014) explains the housing process in more detail.
Government publications relating to housing for older people
The Government's Secretary of State for Housing, Communities and Local Government responded to the Second Report of Session 2017–19 of the Housing, Communities and Local Government Select Committee inquiry into housing for older people (HC 370) in 2018. The document had made numerous recommendations relating to housing for older people. The inquiry had asked whether a national strategy was required for housing provision for older people, given the rapidly ageing population. The vast majority in Government agreed that there should be a national strategy for this group of people. The report stated that it is a well-known fact that UK society is ageing, with 18% of people aged 65 years and over and 2.4% aged 85 years and over in 2016, and the proportion of people aged 85 years projected to double over the next 25 years. Although this is essentially a positive thing, it presents challenges, as when people get older, their housing needs and preferences change, and they may need to make changes to the way they live. Additionally, older people's housing needs and options are diverse in terms of tenure, geographical location, income, equity and individual choice. As the number of issues presented in the government response report shows, the topic is broad and complex when considering policy. Therefore, the Government has set out a strategy to ensure that the housing market works and that it can work for all sectors of the community, which includes older people. The white paper ‘Fixing our broken housing market’ (UK Government, 2017a) recognised a significant need to do more to ensure more homes are suitable for older people and are being built as part of their overall ambition to increase housing supply.
The Government also laid out plans aimed at tackling the lack of affordability for housing, and to increase choice, as well as to make the housing market fairer for renters and home owners. They have provided £44 billion of financial support for housing since 2018, covering 5 years, and consulted on reforms to the planning system through a revised National Planning Policy Framework, which states that local planning authorities should have clear policies that address the housing needs of groups such as older people. The Government has stated that there is a need to provide more of the right types of homes for older people in order to help support an ageing population. By accommodating older people with a better choice of housing, they can live more independently for longer, which can improve their quality of life and free up more family homes for other buyers. This would also be important for falls risk reductions and other appropriate needs that are recognised, so that the older person can be at a lower risk of falls and accidents, increasing their quality of life, freeing up hospital beds and reducing financial pressures at the same time.
The Government four ‘grand challenges’ in announced in its industrial strategy white paper in 2017 (UK Government, 2017b), one of which was the ageing society. In May 2018, the Prime Minister announced that the first goal of the grand challenge would be to ensure that people can enjoy at least 5 extra healthy, independent years of life by 2035, while narrowing the gap between the experience of the richest and poorest. Housing plays a significant role in supporting the delivery of this mission. Home adaptations are recognised as critical in helping older people to remain safely and more independently in their homes for longer. The Government decided to also review how the disabled facilities grant works and how it can work in the future, whereby a range of matters such as the means test for assessing eligibility, the allocation methodology for distributing the grant to local authorities and the grant upper limit would be looked at. The link between adaptations and health and social care services was also recognised, and the paper looked at how the disabled facilities grant might adapt to better support the adoption of new innovations and technology in the future.
Difficulties for older people applying for housing
The difficulties at present for older people when accessing social housing can be varied. They may be very isolated and lonely, with depression and a lack of motivation to tackle something as big as changing in their housing need, or they may be physically disabled and unable to cope in the home they are in, due to the number of steps in the house and other factors, meaning they are at risk of falls and serious injuries from such falls if they are to stay. Housing that can be provided can be on the ground floor with wheelchair access, ramps, stools, bars to hold onto to aid mobility and an alarm system if a fall were to happen, and it can include a range of other adaptations. Alternatively, an occupational therapist may be able to assess the patient and suggest numerous aids and appliances that could dramatically increase the person's quality of life. The person may benefit from being in a community of other older people where they are less lonely. They may want to sell their house and not know how, being unfamiliar with the internet, and possibly with eyesight problems or confusion stopping them from being able to do this by themselves. It may be that one older person cares for their partner and adaptations are required to aid them and for respite to be provided by applying for residential care or sheltered accommodation. It can be difficult to determine what can be applied for through the local council and waiting times can be lengthy, which causes problems for the older person. For instance, their condition can deteriorate in this time and they could require a hospital stay, as they cannot cope or manage their health at home any longer; the wait time can also cause problems with stress and anxiety.
What conditions cause a change in housing requirements?
There are many conditions that affect someone's health when they are older and may cause a requirement for a change of housing. As people get older and live for longer, the chance of someone living with a chronic condition increases. In the past, the condition may have shortened their lifespan, but, now, such beneficial treatment is available that people are able to live with the condition with a far longer prognosis. However, this means someone may progressively deteriorate over time, losing their mobility and ability to perform activities of daily living. Household tasks may become difficult as they are increasingly at falls risks, fatigued, breathless, or unable to perform tasks such as cooking or even eating due to problems with manual dexterity, reaching, lifting. Other conditions associated with symptoms such as breathlessness, fatigue, or chronic pain may make using the stairs in their home impossible. Chronic obstructive pulmonary disease (COPD) progressively worsens and causes significant breathlessness and fatigue, making it hard in the end to do the smallest of tasks. Arthritis and other painful conditions and associated complications may cause pain, which means that the person walks in an unsafe way and avoids tasks.
If someone with such conditions is provided a wheelchair-accessible ground floor home with no steps/stairs, and they have adaptations fitted, they may be far happier in that the stress and physical exertion is reduced, and they feel safer with walking around their flat, washing and dressing, and cooking, eating and drinking. This, in turn, increases their chance of a healthier and happier life, and avoids hospital admissions/emergency callouts. When speaking with the patient about their needs, it is good to have a general idea of their conditions, likely prognoses and their level of functional activity with all essential day-to-day tasks regardless of their diagnoses, as this is the likely indicator that they require a change in their housing. Their level of function is crucial to consider, as this can vary widely among various patients who have the same diagnosis.
Patients may also have conditions that cause confusion, where they are unable to complete the documentation required and would need significant support. In such instances, someone may be in charge of their documents and would be present for any meetings, with significantly more support from Age UK and healthcare staff with completing any necessary documentation. Conditions causing this type of difficulty include dementia, Alzheimer's disease, Parkinson's disease and brain injuries, and many of these in advanced stages also cause significant physical difficulties. Conditions such as multiple sclerosis (MS) and motor neurone disease (MND) would cause the patient's needs to change over time, and in the case of MND, this condition may instead require transfer to an allocated hospice bed, rather than residential care. Those with MS may simply require a ground floor property with adaptations. Assessment should consider the likely deterioration and prognoses for each individual.
Someone who is morbidly obese may also fit the criteria for an adapted living environment and a transfer to an alternative more suitable social housing allocation, as they may be very breathless and fatigued, with significant problems associated with their condition, for example, their size making it difficult for them to care for themselves or function, and they may have heart disease and arthritis, for example, as conditions linked to their weight. Someone with uncontrolled diabetes may require sheltered accommodation where they are able to access an alarm for help if they become very dizzy or have a fall related to their condition.
A person with significant deterioration in their eyesight would also potentially require a change in accommodation and would need full support in the management of the transfer. Such conditions include diabetic retinopathy or retinitis pigmentosa.
Potential solutions
A timely discussion with the patient about their housing is useful, and, as necessary, nurses should refer to the local Age UK branch and social services. Patients may require a change in their housing, such as moving or having adaptations fitted. Their functional needs should be met, and future functional needs should be assessed in a timely way, to establish what the likelihood is that they require adaptations, or when the best time would be and whether they meet eligibility criteria to be referred for residential care, sheltered accommodation, or a house that is more suitable for their needs with various adaptations. Age UK can help give plenty of advice on tailored solutions depending on the needs of the individual.
Conclusion
The housing market is a difficult area to navigate for an older person. Older people vary in their level of function, diagnoses and symptoms, what the prognoses are for each condition, and how these conditions are likely to affect function now and in the future. Many conditions that progressively deteriorate now involve a longer lifespan, meaning that more people than ever are living longer, yet requiring multiple interventions in their healthcare and in their housing needs. Age UK is a brilliant charity that can help navigate the local council available housing options. A social worker may be able to help, or an occupational therapist may be needed to help make temporary adjustments to their present accommodation through provision of equipment, such as aids or appliances, depending on the person's functional capabilities. Older person should also be assisted with the transition from their home to a new home or type of housing/adaptations to their housing, bearing in mind their physical level of functional need, so falls risk can be reduced, possible loneliness can be mitigated and their physical and mental wellbeing can be at an optimal level.
The Government aims to help people live an extra 5 healthy years, and has recognised the need to implement appropriate systems to aid older people in accessing the right type of housing in a timely fashion, with the right support. Such difficulties that may lead to a change in housing needs would be long-term chronic or acute conditions that impair a person's level of functioning to an extent they may be safer and happier, and more able, if supported with housing adaptations. A nurse visiting the patient can signpost patients appropriately and support them with these issues.
KEY POINTS
- Housing requirements for older people can be complex but housing conditions have a considerable impact on people's health and wellbeing
- Types of social housing include sheltered accommodation, residential care, equipment installation, wheelchair accessible/disability-friendly living and others
- Appropriate housing can reduce risk of falls, increase wellbeing, avoid loneliness, and reduce likelihood of hospitalisation or other conditions arising from poor self-care
- Appropriate housing can also increase a person's level of independence
- Solutions lie in meeting a person's functional needs physically and addressing mental wellbeing needs, and providing the appropriate living conditions through correct choice of housing
CPD REFLECTIVE QUESTIONS
- When visiting a patient, what are the typical functional issues you might look out for that indicate a change in housing is required, and typically what conditions and prognoses relate to a deterioration in function?
- What types of social housing options are available to older people and what services might you signpost the older person to and support them with in order to start the process of changes in their housing?
- Reflect on how you may approach the subject that someone may need extra support with their daily living/housing requirements, if the person finds change very difficult and is independent despite their deteriorating level of function?
- What are the challenges and solutions in the social housing process and allocation?