Care and Place (CAPE)

Care need and housing characteristics 

Using data from 8,000 older people from the English Longitudinal Survey of Ageing (ELSA), this study explored the prevalence of housing problems (e.g., damp, condensation, noise, being too cold in winter, lack of space), and how they may co-occur. The research team identified three types of housing based on their characteristics and quality which provided an insight into how problems co-occur and do not appear in isolation. In this regard, they found that people who lived in worse housing conditions – with a greater number of housing problems – were on average likely to develop care needs at a younger age compared to those in better housing. This was still the case when they took account of socio-demographic factors (e.g. gender, employment, ethnicity). This shows that it is not only type of problem, but also the combination of housing conditions that could affect when long-term care needs start to develop. 

The study also developed a comprehensive measure of fuel poverty that encapsulates a lack of affordability and thermal comfort based on household income, electricity and gas consumption, whether a person lives in a rural or urban environment, household expectation of their ability to cover their needs, perception of accommodation being too cold in winter, and the presence of rising damp. Here they found that fuel poverty is associated with a greater risk of developing long-term care needs and worse mental health.  

Analysis of in-depth interviews with 72 people aged 65 and older living in England and/or their unpaid carers found three key aspects of housing to be perceived to be linked with care needs. These were condition of the home which included cold and damp, state of repair, and cleanliness and clutter); space and internal and external access); and housing tenure. There was variation in how and whether housing affected care needs by financial resources and type and level of care need. Care needs increased requirement for warmer, less damp homes and could be a barrier to keeping the home clean or doing repairs. In turn housing problems could precipitate or worsen care needs. Conversely, good quality housing could help play a role in preventing occurrence or worsening of care needs. 

Looking at people’s trajectories of care needs and care use, that is how care needs or care use change over time, we identified three trajectories of long-term needs (low, medium, and high care need) and three trajectories of care use (low, medium, and high care use). Both care needs and hours of care received increased with age, but the speed of increase varied. People experiencing more housing problems were more likely to follow the trajectory characterised by higher care needs and higher care intensity.  

Care use and housing characteristics  

Good quality housing is also important to optimising care use from formal care services or from family and friends (unpaid care). Using analysis of survey data and in-depth interviews, we found that overall poor quality housing increased care use but this was not even. Poor quality or unsuitable housing could increase care use for some people through increasing or precipitating care needs and thus necessitating help from another person. On the other hand, it could be a barrier to receiving care resulting in unmet need for care or could decrease some types of support and increase others. 

Increases in care use has associated costs. The research team project that, without housing interventions, unpaid care costs will increase from £55.2 billion to £90.8 billion between 2022 and 2042. In a scenario where no houses have more than two problems, formal and unpaid care costs in 2042 are project to be £0.8 billion and £2.3 billion lower, respectively, than the no intervention scenario. In a scenario where all housing problems are remedied, formal and unpaid care costs in 2042 are projected to be £1.8 billion and £7.1 billion lower, respectively, than the no intervention scenario. Good quality housing delays the progression of social care needs, resulting in lower social care costs in the long run.  

For mental health, they project that, without housing interventions, the number of older people aged 65 and over with depressive symptoms will rise from 5.93 million to 7.48 million between 2022 and 2042 in England. In the no housing problem scenario, the projected number of people with depressive symptoms will be 0.38 million lower than in the no intervention scenario. The costs of unpaid care for people with depressive symptoms are projected to rise £33.6 billion in 2022 to £59.9 billion in 2042 in the no intervention scenario. If all housing problems are remedied, the unpaid care costs are projected to be £3.5 billion lower in 2042 in comparison to the no intervention scenario. The costs of formal home care for people with depressive symptoms are projected to rise from £4.2 billion in 2022 to £8.1 billion in 2042 in the no intervention scenario. If all housing problems are remedied, the projected costs in 2042 will be £0.3 billion lower.   

Social care and housing information and barriers to information  

In the 72 in-depth interviews we explored the ways in which older people and/or their carers find information related to housing and/or care. People used a range of sources including the local council/social services, voluntary and community sector local groups and organisations, family, friends and neighbours, and the internet. They often relied on multiple sources to get the information they need. However, many older people in our study did not know where to get trusted information on housing and care, which was partly due to lack of knowledge about what is available or what they are entitled to but also due to difficulties in accessing online platforms. People who had prior knowledge about existing services and support found it much easier to find relevant information about maintenance and repairs, adaptations, care support and/or housing options. Non-English speaking older people may experience additional barriers. 

Choices, barriers, facilitators and outcomes of moving  

As in other research, the researchers found in their interviews that many older people in the study had a strong desire to remain in their own home. However, some people found that their independence had been increased by a move to more appropriate housing. They also found that some people who were in a home that was not good for their wellbeing perceived and/or experienced barriers to moving home. A preference to move was not always matched by an expectation of moving and this was borne out by descriptive analysis of survey data which found that older people with care needs were less likely to expect to move compared to those without care needs but that preferences were not significantly different. For those we interviewed that had moved home, moving to a different type of housing could enhance wellbeing, improve access to social interactions, and make it easier to maintain the home. Barriers to fulfilling preferences to move included lack of availability or affordability of the desired type of housing (such as bungalows), lack of knowledge of available options, concerns about a move resulting in a worse situation, and expected difficulty of moving. 

Limitations 

Possible limitations to these findings include that, whilst present in both the survey and interview data samples, there may be underrepresentation of older people living in the poorest quality housing in our interview sample and of older people living in rural areas. Future research could investigate the extent to which the factors found to be important to people’s care and housing in our interviews apply to other populations. Future research could also further explore the housing and care situation for non-English speaking older people in England; the interviews with a small number of non-English speaking older people suggests they may face additional housing and care challenges.

This was a mixed methods study comprising secondary analysis of quantitative data from the four most recent waves of a large representative sample, the English Longitudinal Study of Ageing, ELSA covering the period 2012/2013 to 2018/2019; semi-structured in-depth interviews with 66 people aged 65 and older with care needs and/or their unpaid carers living in five localities in England; and simulation modelling using Markov modelling and macrosimulation approaches. 

Our study shows that improving the condition and suitability of non-specialised housing for older people with care needs may have benefits in terms of delaying the onset of care needs and reducing number of difficulties and the steepness of their trajectory. As poor housing is concentrated among people with less financial resources, improving housing also has equity implications. In addition, improving housing has potential to optimise care use – reducing the need for care services and unpaid care for people who would not need them if their housing problems were remedied, and enabling support for people whose poor housing is a barrier to receiving care. There are potential savings of billions of pounds to government in social care costs, adding economic incentive to the imperative to improve social care and the lives of people who use it. Improving housing would also increase choice over current and future housing and care needs. However, there are other barriers to actualising choice such as a lack of accessible, joined-up and personalised information.  

Specific implications for adult social care practice include working more closely with housing to find joint solutions to benefit older people with care needs. Given differences observed by housing tenure, this may include targeting of people with care needs in the private rented sector, for example, where legal protection and requirements to improve homes are weak or absent. Legislative levers are the other part of this picture. Adult social care could help provide or link people to information about housing as well as care, and housing professionals could do likewise. Given the relationships between housing and care, joint information that takes both into account as well as the financial implications is essential. Information could also helpfully be provided about repair services, home improvement grants including those related to insulation, and types, entitlements, and costs of adaptations. This includes information about the Disabled Facilities Grant (DFG). Criteria for the DFG could also be expanded to include small repairs to, for example, remediate damp and cold. Where the limits of adaptability and improvement of a home are reached, there may be a role for social care in helping people manage a move to a more suitable, warmer, safer home. Outside of social care practice, there are also implications for policy and practice in other spheres and for integrated care systems.