Expert Brief

The change in commissioning strategies and reference to policies suggesting why supported living for people with statutory care and support needs is the commissioned arrangement of choice as opposed to hospitals and care homes Supported Living has been commissioned by Local Authorities and Health Authorities in the UK since the late 1980s and the early 1990s. Whilst there has always been an anti-institution/communitarian movement in the United States, Supported Living became the manifestation of these sentiments in the UK partly as a result of the drive to accelerate the closure of the long-stay hospitals.  It was felt by many leading managers in Health and Social Services that to simply replace the larger institution with a smaller one did not provide for people who aspired to a similar life to the rest of the population. Wrestling with the difficulties of introducing a fairly rigid care system to the idea that people could have their own homes, and that their support would be separated from their accommodation tenure was truly ground-breaking, and led ultimately to the introduction of the Community Care legislation in 1990.  There followed a series of adjustments and developments, the most recent being the Care Act of 2014.  The important milestones for Supported Living were the separation of care and housing, the purchaser/provider split, assessment of need and latterly the development of individual budgets and bespoke housing arrangements. By the year 2005 the first examples of Extra-Care provision had started to appear where older tenants with support needs could develop or continue a much more autonomous and independent lifestyle with flexible support, outside of the institutional settings of the residential care system. Until quite recently the underlying policy assumption had always been that the government would provide money directly for these developments.  Initially much was achieved through the double-funding of shrinking long-stay hospitals and the development of community care however the continuous cutbacks in local authority funding, now a part of 'austerity', have tended to hollow out the ability for large programmes to be run on a command and control basis by statutory authorities. The present policy framework for Housing, Social Security and Care is perhaps best defined as benevolent tinkering.  Recent reports, including one presented in 2015 to the government by Sir Stephen Bubb, have been well-meaning and compelling appeals for effective joined-up programmes to support people beyond the institutions however there has been no realistic attempt, nor any real appetite, to follow any recommendations which involve wholesale investment in local authority and local health infrastructure. It has become clear, however, that it is possible to create and sustain very significantly improved opportunities for vulnerable people by using a wider palette of resources. The use of housing benefit, private finance initiatives and closer working between health and social services departments has finally allowed Supported Living to become the main objective for individuals, their families, and for the Commissioners of services.  The 'closed' residential homes, group homes and long stay health units have increasingly become out-dated and have been seen as the cause of much human misery following a long series of scandals where vulnerable people have been abused. It has become clear that abuse has been endemic, but has only come to light as the institutions have been replaced by more open ways of living which bring the ordinary communities we all live in, in touch with vulnerable people. The more recent of these abuses have been very well documented and exposed to the public eye by the media, however these abuses have been going on for many years.  There is now an all-party consensus that the remaining institutions need to be replaced. Because of the comparative speed of developments, assisted by early transfer funding from Health, there was a mismatch between the visionary, idealistic models for Supported Living and what could actually be achieved from existing housing stock. The rose covered cottage remains elusive. The idea that everyone should have their own home, and their own care package, whilst by now a universal aspiration, has simply not been achievable for the majority.  Far from being provided mainly for people with severe disability all people who need support rightly expect to be able to live outside of institutional care, with security of housing tenure. This was never going to be deliverable by the statutory authorities alone. The coalition government cut the budget which supported bids by Housing Associations for new capital projects by 50% at the beginning of their term of office in 2010. The pressure from vulnerable people and their families and advocates, the lack of housing grant and the massive increase in the number of applications for support by people whose needs have been assessed have led to new pragmatic commissioning strategies with Supported Living/Extra-Care the over-arching motifs. A telling point, which exemplifies the new pace of independent development, has been the use of designated 'common areas' in apartment and Extra-Care housing.  Commissioning strategies are increasingly based around the development of new forms of accommodation where the key determinant is fully self-contained accommodation with access to support staff.  Until very recently this sort of accommodation tended to have some part of the building dedicated as a common area where people could meet up and socialise.  On reflection this practice contained the ghost of the old institutional thinking.  The reality is that, once people had their own cooking facilities, bathrooms, bedrooms and lounges, as well as support staff to help them with tasks they could not do themselves, they saw no need to seek interaction with other tenants, who, after all, would often be people who they would be unlikely to know. Social interaction in this paradigm is supported to occur not in the managed environment of a communal lounge, but in the community itself. Where people do make friends with fellow tenants, which is of course very common, it is more usual to get together either in one’s own living space, or in valued venues open to all. For commissioners there are a new series of relationships which make this happen.  This includes organisations providing care, support and supervision for vulnerable people as part of a package of domiciliary care, tailored through the assessment of need. These costs are met through mainstream funding for care/health via local and health authorities managed by commissioners themselves.  Developers are now a crucial part of the mix being able to attract independent funding to acquire land to build the apartments and extra -care facilities, in the absence of any grant.  Housing Associations, registered with the Homes and Communities Agency manage the properties as landlords, and assist tenants to access the cost of the lease, the repairs and maintenance, and their management costs through the payment of Housing Benefit, as accommodation which is exempt from stringent levels of rent control. In the old system of residential care, the housing costs were effectively hidden and rolled up in the price per bed space per week.  Similarly, the care costs were part of that rolled-up price. In the system of Supported Housing, as described here, the Housing Benefit claims are intensely scrutinised by the Housing Benefit Manager and his staff to the extent that expert independent consultants are involved to ensure that the regulations are correctly observed.  Similarly, the domiciliary care provision is individually commissioned and costed, and again this is scrutinised by highly motivated budget managers.  It is therefore unsurprising that the costs of the new Supported Living services to Commissioners is no higher than the old inefficient residential care services, and is often somewhat less costly. A further more recent innovation is now in place whereby highly sophisticated electronic and physical adaptations are being built in to the requirement for every apartment/extra-care dwelling for people with a high level of need for support.  This is extremely attractive to Commissioners as it is claimed that permanent cost saving of up to 40% of the care costs can be secured.  A study is available from a recent development in Blackburn which shows that the saving to the Local Authority’s care budget came about as a direct result of the development of the HB Villages Supported living model, which enabled the Local Authority to make such savings given the efficiencies achieved.