Editorial

Citation

Johnson, R. (2013), "Editorial", Housing, Care and Support, Vol. 16 No. 3/4. https://doi.org/10.1108/HCS-09-2013-0015

Editorial

Article Type: Editorial From: Housing, Care and Support, Volume 16, Issue 3/4.

Cross threads

It's hardly news to say that we are living in a world of change. Housing, health and social care are constantly going through rapid evolutions, whether led by technological or demographic change, or by new policy directions. Broad changes in society, including the impact of new technologies, and shifts in the Zeitgeist of modernity, all equally impact on the way we live in and see our own homes – what we look for from, and in, our housing.

We see then the responses of the housing sector to the challenges and opportunities this poses. These responses are often especially visible in public or not-for-profit housing, where the mixture of public purpose and accountability ensures that these developments and discussions are explicit. Yet this apparently simple distinction between the public and the personal is becoming increasingly hard to define.

In news and journal publishing too, we see rapid change, with the explosion of on-line news and analysis, blogging, and in more academic publishing, the on-set of Open Access. In this double issue of the journal, we are experimenting, with a larger volume of paper content, which allows us to explore a particularly rich interweaving of many of the themes that this journal had covered, over many years. Here, as ever, we are tracing the multi-layered links between housing and community, and the role of housing in creating, maintaining and even re-building, that sense of belonging and active participation which is so necessary for a healthy population, and a healthy body politic.

Whilst central governments and their various funding regimes may set the framework to encourage a new style of integration, and new technologies make possible new and more flexible connectivity, much of this new integration operates, we note, at locality level. Yet every locality is different – its contours, its challenges, its opportunities. Giving an account of this creativity which is true to the subject itself then creates challenges for more formal and academic styles of research.

Here therefore we have a typically wide range of writing styles, which is the hallmark of this journal – an eclectic mixture of original research, literature review, policy analysis, commentary and personal narratives. This breadth of style reflects not just the multi-layered-ness of the subject area, and the breadth of the readership, but also the inclusiveness and pluralism of the evidence base that we must consider, when looking at the impact of health on housing, and housing on health.

Balancing principles

We begin by exploring a range of ways in which ordinary housing can be made more "accessible" to those more vulnerable individuals – which is all of us, after all, if we live long enough. Making ordinary housing "accessible" will often entail adaptations to the building itself, to which the housing and support sector has responded. The healthcare market, too, has recognised the business opportunity, so that the aids and adaptations sector has seen healthy growth in recent years.

Amidst such enthusiasm, Colin Jones's paper on the actual long-term gain from adaptations in social housing, to allow more vulnerable and disabled people to sustain their independence in their own home, then makes challenging reading. It is sobering to then hear that, for example, in the UK in 2009 only 22 per cent of vacant wheel-chair accessible housing was actually let to wheelchair users. There is clearly something amiss here.

In this context Jones then explores one promising approach, as a first step to managing this adapted housing stock more efficiently, via the production of a local register of adapted housing – an AHR. Using three potential different models of AHR, based on a local area case study of 100,000 homes, Jones assesses the extent to which they can improve the matching of tenants to properties. Jones’ findings suggest that although a full-scale AHR is an expensive undertaking, the costs would be easily covered by the savings, were the AHR to lead to a better match between future tenants and existing adapted homes.

Nevertheless, this aspiration – the "matching prowess" of an AHR – is constrained in practice by the preference for extending customer choice, In the UK, the allocation of social housing homes is no longer managed on behalf of tenants by the housing provider but, under the "Choice-Based Lettings" approach, is now opened up to tenants, who "bid" for all vacant homes from a common register of properties. These bidders may well consider a wide range of features, such as location, size and type, state of repairs, etc. This must inevitably limit the extent to which the cost savings of better matching can be realised in practice, if this is not the sole criterion for choice.

Squaring this circle – as Jones puts it, balancing need and choice with resource efficiency – is a challenge for policy makers and for social care and social housing in particular, partly because of the higher proportion of older or disabled living in social purpose housing, and partly due to the constant pressure to demonstrate cost efficiency – an expectation that, perhaps unfairly, does not seem to apply to private sector housing. Nevertheless, if in the UK and elsewhere we are to devote an ever larger share of both public and private funds to managing physical disability, we must aim to ensure that the publicly funded resources at least are used to maximum benefit.

As Jones also notes, "The cost effectiveness argument is also a powerful narrative for the international transmission of policy adoption". The hardware for adaptation, to maintain independence and quality of life, is not necessarily more efficient, we now realise, unless supported by management systems for re-allocation of adapted properties, and this is work that must be done at locality level. Meanwhile, the demand for adapted housing can be expected to grow. This assessment of the cost effectiveness of the AHR itself should be a useful aid to local and national decision making.

Further practicalities

Remaining for the moment with the practicalities of independence, Jill Manthorpe and Jo Moriarty then focus on a useful parallel example, in their literature review of the evaluation of handy persons (HP) schemes. Recently much promoted by the UK government, and taken up with some enthusiasm both by local authorities, provider agencies and indeed tenants, there is still the need to assess their impact; and this has raised a raft of difficulties for researchers, in evaluating such schemes in a climate of devolved governance.

One of the key issues in this paper is the extent to which, despite government ambitions to promote HP, and now the rights-based universalist implications of the recent "Equality Act", introduction of such schemes have been dependent in practice on a patchwork of transient and/or primarily local or devolved and localised funding streams. This renders systematic research and evaluation more difficult.

We often hear calls that policy-making needs to be more evidence based, reflecting the growth of "evidence-based medicine" in particular. In actual fact, even evidence-based medicine has not been without its critics; there are those now who argue that it gives too little weight to clinical experience, etc. But Manthorpe et al. study suggests that there are real difficulties in interpreting research for the benefit of evidence-based social policy, when development is devolved to local level, with wide variations in what may be actually done, and even what is meant by the same terms.

Tools for analysis

If the AHR can be seen as a kind of communications technology, a means to improve local co-ordination of scarce resources, this is a useful reminder that not all tools are things that you hold in your hand. In Part 2 of her series of papers exploring the value of business models and management training concepts as applicable to the social housing world, Patricia Dearnaley has been examining the adequacy of current business planning approaches, for those considering entering the fray of the new social care market, as care providers.

In the first in this short series, Dearnaley analysed the restrictions and distortions in the "market" for care services, deriving from the widespread adoption of the practices of new public management (NPM). This is the same Zeitgeist shift that had led to local authorities hiving off their housing stock to be managed by formally separate organisations, and to social services farming out care services to private and voluntary sector "providers". We are of course seeing the same thinking now permeating the healthcare sector – albeit with strong resistance, in the UK, where the central state is still largely popular and trusted as a provider.

As Dearnaley shows, the result of NPM's purchaser/provider splitting reforms is nevertheless a "contrived" market, which means that, for potential providers, basing future service planning ventures on a pure market model is misleading here. For example, regulators’ or commissioners’ expectations of "best practice" are in effect a constraint on provider options and customer choice. As a policy dilemma, it is directly comparable to the issues Jones has highlighted in his observations on balancing need, choice and efficiency in our use of adapted homes.

In this the second of the trilogy, Dearnaley turns to marketing models such as contingency planning – the hypothesis that competitive advantage derives not from "best practice" but rather from "best fit" with consumer's wishes. She concludes that pure or free market concepts nevertheless still need some modification here. Turning then to the greater complexity of stakeholder involvement – not just with tenants as consumers, but with commissioners, other care services, and crucially, the organisation's own staff, Dearnaley advocates becoming more focused on on-going market analysis and updating, arguing the need for all staff to be seen as part of "a learning organisation".

Finally, she warns, with the still relatively limited take-up of self-funding so far, the social housing sector in the UK is not fully geared up for the demographic and funding changes on the horizon. Her analysis suggests some of the key features and issues that new business managers will need to attend to. In the third and final paper in this series, Dearnaley will be outlining an alternative model for market analysis that has arisen, from her earlier research with a social housing agency.

One consistent thread in recent Zeitgeist shifts has been the trend away from centralised provision to more devolved approaches; and governments now aim to foster integration and decision-making over the deployment of scant public funds for the vulnerable to locality level. But over the past decade or so, in countries with established welfare systems on the post-war European model, we have seen increasing interest in taking devolution one step further, to the individuals themselves.

If new communication channels and business planning models are all part of the software of delivery, then the practicalities of personalisation, with individualised budgets and self-directed support (SDS), can be seen as part of the emerging "soft technology" of governance. Part of the "choice" agenda, this is as much a political philosophy of empowerment as an economic model of delivery. Yet despite strong support from government, and the endorsement of many professional and provider sector support agencies, the progress of SDS in the UK has been – as Dearnaley had noted – stubbornly patchy.

Personalisation and other borders

In our next paper, Rosengard and colleagues have explored the roots and the nature of this current patchiness. Once again, although the national political will and in most cases the financial procedures were in place, and in all three areas senior managers and politicians all expressed their support. it is the more human element that accounts for the variance between localities in the area they studied. Their analysis highlights turnover of key staff, IT problems, staff training, which were identified as frequent causes of delay.

Linked with this, perhaps, was a marked differential take up, with certain client groups in the lead, and others far behind. To what extent this difference reflects the wishes (or anxieties) of the respective user groups, or the commitment of the particular groups of care staff to personalisation via budgets, is harder to discern. Mental health, for example, seems to have lagged behind; and yet this is one area where personalisation in inter-agency care planning is relatively well established, across the UK.

More systemic problems, however, are suggested in the fact that it seems neither housing services, nor the health service, had been involved in planning and developing the Test Site programme. Nevertheless, what emerged clearly was that issues that come under the general rubric of housing-related support were highly relevant to the needs found; and of course, all these services involve managing care needs at home, in ordinary housing stock.

Meanwhile, Rosengard and colleagues point to the growing divergence between Scotland and England – since decentralisation, and a change of political control in the Scottish parliament at Edinburgh, there are increasingly distinct policy priorities between the two countries – as currently posing a difficulty for evaluative research, since the same approaches are implemented differently across the borders. Yet also, having started with the same baseline and known changes between these two diverging jurisdictions, the differences might be seen as a potential resource for comparative study.

One recurrent theme in this journal of late has been the need for better recognition of the lessons to be learned from comparisons between the ways that different countries conceive and manage these issues. We have argued that "[…] whereas we may be entitled to think that health issues may be fairly international – the human body being much the same the world over – the social organisation of these social determinants varies widely from country to country".

"How far, then", we have asked, "can we really understand the nature, roots and life course of ageing, for example, or of homelessness, if we do not seriously explore how these issues are played out in other countries, with different GDP or funding streams, welfare philosophies or machinery of government, and different climate or culture and beliefs, which may throw up problems in different ways?" (Johnson, 2013). It is especially interesting therefore to note that Rosengard and colleagues also suggest homelessness resettlement as a promising area for individual budgets and SDS, and one where the differing politics of the two countries may start to show the broader impact of wider social policies of austerity on the outcomes of support, with equally relevant opportunities for research.

Homelessness and exclusion

In his paper, Serdar Arslan looks at the issues of provision for homeless people from the point of view of the worker, grappling with the demands of working with individuals with often hugely complex psychological and emotional needs, yet who are often poorly served by the more conventional healthcare services of the country. Here Arslan explores the very human side of offering support – even simple safe containment – to those often excluded from other help agencies by virtue of their complex needs and challenging behaviour. In the UK, in the past few years, there has been growing interest – with endorsement from government – in recognising and meeting the psychological and emotional needs of people who are homeless; and this has lead to some welcome increased focus on training and support for hostel staff (and volunteers).

In an earlier issue of this journal, Nick Maguire wrote (Maguire, 2012) of the ethical dilemmas this kind of work may pose for staff; and in the special issue of HC&S (Volume 15 Issue 2) devoted to the notion of a psychologically informed environment or PIE, Scanlon and Adlam (2012) wrote on their observations on the culture of staff teams, when such emotional challenges are not adequately addressed. But this new study, conducted by a frontline service worker with support from research psychology colleagues, is relatively rare – indeed, it may possibly be the first research study of its kind – in examining closely the impact on workers, as experienced by the worker, via interview.

This was inevitably a very small study, from which to attempt to draw large conclusions; but it is certainly consistent with earlier studies. Many of the same themes appear, in this in-depth qualitative analysis approach, as are found in the policy documents and in more clinical or epidemiological studies. This paper is therefore a useful contribution to the growing literature calling for better recognition of the needs and the challenges in this area of work. It also serves as an introduction to a research methodology, interpretative phenomenological analysis, with which many in the housing world will be unfamiliar, though this is now quite common in more social psychology, when the experience of the individual subject is seen to matter.

There are, certainly, some very different traditions as to what constitutes research, and even what constitutes understanding. One long-standing divergence is between the Anglo-Saxon empiricist school, and the more interpretative approach associated with continental philosophy. Before, then, we move on from homelessness, we include here a brief observation – there will be more in future issues – from Claude Chevrier, Director of the new Rosa Luxemburg Group in Paris, writing on the therapeutic/philosophical stance now being adopted in homelessness reception and resettlement services there.

In other countries, these issues may be articulated and recognised to different degree, and perhaps in different ways; and here they are conveyed in language drawn from a rather more philosophically oriented psychology, psychiatry and psychoanalysis, of the Lacanian school – a therapeutic orientation that is not often seen or heard in the Anglo-Saxon world. Nevertheless, the fact that, in homelessness services in Paris, we are now seeing attempts to look again at the nature of resettlement work, and of the working relationships, is a timely reminder that these issues of exclusion, emotional challenge and person-hood are everywhere.

In future issues, we will be exploring in more depth both the psychoanalytic traditions of France, now impacting upon homelessness; and also the parallel evolution of more humanitarian practice, which we have seen in religious communities and the services they have developed, starting from a more spiritual or values-based practice.

Seniors housing

The reminder that this business is primarily about how people feel also chimes well with the concluding comments of Eileen Thompson, in her final paper of observations from a study trip to North America on seniors housing: "But let’s not be mistaken, housing is really about people, and it will be people, individually and collectively, who will make the real difference on this issue".

In her first instalment paper, in the previous issue of this journal Thompson (2013), described what she had seen of peer self-help in retirement village communities with, again, some use of telecare, here called "Remote Monitoring". In this, her second paper, Thompson continues her explorations of the contrast in development of seniors housing, between the UK – in this case, more specifically Northern Ireland – and the UK and Canada.

Here, she looks at the different funding models which underpin development in the USA especially, where we might expect different approaches to personalised investment in a more consumer-driven market economy. With more self-funders in the care system and/or greater roll out of individual budgets and "SDS", and more people approaching retirement with some capital to invest in a future home, we are certainly seeing the introduction of a greater consumer focus in health and social care, to parallel that in housing. So how are the integration issues played out there: and how much of this could happen here?

We have probably all heard of Medicare; but here, Thompson looks first at what they there call the "Money Follows the Person" programme, for the transition for hospital to housing in the community. It is salutary therefore to find that, despite the differences in principle between more paternalistic public provision and a more insurance-based approach, it seems that the same issues of joining up IT, developing a shared language, information and advocacy emerge.

Thompson acknowledges that differences in scale, too, and different "naturally occurring retirement communities" reaching the critical mass for focused services, may account for some of the different possibilities that the USA and Canada can develop. Yet the growing concentration in all our cities, towns and villages of both the "young elderly" – those fit and active, with time to offer – and the "old elderly" of the frail and vulnerable, some of this self-help thinking must soon rub off on our vision of ageing and housing, across the old and new worlds.

For housing developers in the old world, where large scale new build is constrained by existing development, and in-fill building is more the norm, the notion of "mingle apartments", for example, may be worth exploring; and the development of "Life Lease" schemes, though evidently still new even in the States, will certainly be worth watching. But the idea of an "inter-generational lens" for all new build development may yet take the concept of mixed tenure housing to a new level. We are already seeing housing estates designed so that traffic is slowed, and children will play in the streets. Will we soon see new estates consciously designed so that the grandparent generation can also keep an eye on them, as happened and still happens in more traditional communities?

Connecting spaces

Finally, then, we come to the spaces around our homes which, like white space on a page, framing our words, are equally crucial for a sense of community, of belonging. In this journal, our principal focus is on the role of housing in sustaining or even re-building a sense of well-being, resilience and community, whether for the more vulnerable and/or excluded, or for the population as a whole. As other ways to confirm a sense of who we are – our work and workplaces, ethnicity, religious faith, etc. – are less prominent in our interactions with others, we now want our homes to express our personalities, to embody our desire to belong.

It is certainly true that a sense of being at home is about more than just the design and condition, the size and suitability to needs, of the actual domicile. We know that location and neighbourhood are also crucial factors in housing satisfaction. Indeed, social epidemiologists, such as Michael Marmot in his recent influential report on health inequality, have tended to lump housing and neighbourhoods together, in a broader category called "the built environment", or simply "place". We may tend to thing of housing per se as being made up of discrete units, and community as something broader that binds, or fails to bind. But there are also other, more intermediate structures.

For Jayne Phenton, the bits between our homes are not just the loose social threads of informal communities, or the ligaments of organisational structures, but the actual physical streets and what we now call – perhaps tellingly? – the "street furniture". In her paper here, Phenton argues that we have paid too heavy a price for the apparent convenience of the automobile, and it is telling to see that the sacrificing of informal social supports has hit the poor and more vulnerable the hardest.

If good fences make good neighbours, good pathways make strong communities. With increasing interest in "dementia friendly" towns and cities, and as "housing and neighbourhoods" becomes part of a spatial strategy to be addressed in public health terms, we can expect to hear more of the growing need to shape our buildings, and the spaces they offer us, in psycho-social as well as financial terms.

I can re-arrange the furniture in my own home. I can sometimes even buy new. But to re-arrange the street furniture, benches, street lighting, pedestrian access, etc., requires me talking to my neighbours, to the planners in the local authority, perhaps the owners of the block or the developers. For some, such a degree of involvement with others may seem insuperable.

Phenton's paper returns us, then, to that broader picture of housing, neighbourhoods, communities and health – just the area where strategic overview of public and preventive health begins to now turn. The place of housing, in this view of community health, both the broader role of community housing, and all the intermediate services and tools with which housing services may work, can extend the scope public health far further than simple health promotion programmes. Support services, admin processes, business models and philosophies of care and support all serve in their different ways to connect us, like cross-threads, in the new tapestry of community in the emerging modern world.

Robin Johnson

References

Johnson, R. (2013), "The wide-angled lens", Housing, Care and Support, Vol. 16 No. 2, p. 55

Maguire, N. (2012), "Training for front-line homeless workers: practicalities and ethics of teaching cognitive behavioural and dialectical behavioural psychological therapeutic techniques", Housing, Care and Support, Vol. 15 No. 4, pp. 177-85

Scanlon, C. and Adlam, J. (2012), "The (dis)stressing effects of working in (dis)stressed homelessness organisations", Housing, Care and Support, Vol. 15 No. 2, pp. 74-82

Thompson, E. (2013), "From Canada to Kircubbin: learning from North America on housing an ageing population – Part 1", Housing, Care and Support, Vol. 16 No. 2, pp. 58-63