Martin Knapp PSSRU, Social Policy Department London School of Economics and Political Science

1. Housing LIN 17 February 2015 What price care? Research reflections Martin Knapp PSSRU, Social Policy Department London School of Economics and Political Science NIHR School for Social Care Research

2. What price care? Research reflections • Mixed economy of care • Personalisation & choice • Neighbourhoods • Design & technology • Concluding comments

3. NIHR School for Social Care Research Mission: to develop the evidence base for adult social care practice in England by commissioning and conducting world-class research • LSE, KCL, Universities of Kent, Manchester, York • £30 million funding over 10 years (since May 2009) • Both ‘intramural’ and ‘extramural’ commissioned research • Conduct and commission high-quality research • Provide focus for social care research within NIHR; strategic leadership • Develop methodological rigour and broaden repertoire • Consult widely on research priorities • Help to build social care research capacity & awareness • Support knowledge exchange and impact

4. SSCR: activity since 2009 70+ commissioned projects completed or underway. The research questions follow wide consultation. Active engagement with all stakeholders Aim to span today’s (and tomorrow’s) leading social care practice issues. Findings available on many topics 40+ methods & scoping reviews commissioned – promoting understanding and research skills and capacity. Annual conference Full programme of seminars & workshops on leading practice topics. We are very keen to engage as widely as possible

5. Personal Social Services Research Unit @ LSE (February 2015) • Dementia • Outcome / performance meas’t • Children & young people • Unpaid care Research areas • Social care service evaluation • Systems / policy analysis • Modelling needs, funding & LTC • Mental health economics & policy Overarching emphases • Improving user, carer involvement • Supporting staff development • Impact & knowledge exchange • Policy engagement • Practice relevance • Academic contributions • International collaboration All work/staff externally funded: 40+ staff; 0.2 HEFCE Project lengths range from 2 weeks to 4 years

6. The Social Care Elf (launched 26 Nov 2014) Aim: to get the best available evidence to those who need it Scanning >70 journals, databases & websites Identifying relevant & reliable evidence Blogs on days that start with T Short summaries (<1,000 words) Critical appraisal and commentary Written by researchers, social care workers, others

7. A Mixed economy of care

8. Provider types • Public sector: the state - national, regional or local • Voluntary (Third) sector: organisations independent of the state which cannot distribute any surpluses (profits) to owners • Private (for-profit) sector: also independent of the state, but surpluses (profits) can be distributed • Informal sector: individuals, families and groups without formal rules / structure / governance

9. Purchasing routes • Public sector: ‘coerced’, collective. Public sector acts on behalf of citizens, mandated by democratic processes, funded mainly by taxation. • Charitable: uncoerced, collective. Voluntary organisations use voluntarily-donated funds to finance their own or other services • Corporate: private-sector companies funding services or insurance for employees or families. • Individual (own use): payment for goods or services by the individual using them • Individual transfers: payment for goods or services by one person for use by another person

10. The mixed economy of care matrix Martin Knapp, The Economics of Social Care, 1984

11. Policy options in the mixed economy Martin Knapp, The Economics of Social Care, 1984

12. B Personalisation and choice

13. Why this policy/practice emphasis? (1) • Long-standing social work commitment to self-determination for (under-privileged) individuals and families – i.e. empowerment … • (Also to encourage personal responsibility for health e.g. for lifestyle, diet, exercise, alcohol…) • Empowerment could encourage services to be more responsive to individual needs & preferences. • Social care, public health (and health care?) emphases on the roles of families & communities • … particularly benefits of social capital (trust etc.) • And over-arching belief that individual, family & social outcomes will be better; and/or costs will be lower

14. Why this policy/practice emphasis? (2) • Citizenship agenda – ground-level politics, participation • Rights-based advocacy by / for service users • Flexibility: personalisation potentially offers different levels of independence & control • ‘Collectivization of welfare’ – encourages informal pooling of budgets. • Political support: • from Right – encourages personal responsibility; accountability; market-like allocations (e.g. PBs) • from Centre Left – encourages public confidence, social inclusion, personal rights

15. Personalisation in practice in social care • Services tailored to the needsof the individual, rather than ‘one size fits all’ • Services tailored to the preferencesof the individual Hence actions could include: • Better information & advice on care & support • Promotion of independence & self-reliance among individuals & communities (includes social capital) • Prevention / risk-reduction strategies that emphasise personal strengths & responsibilities • Direct payments and personal budgets (with appropriate brokerage & support)

16. Evaluating personal budgets (IBSEN) CORE QUESTION Do individual (personal) budgets offer a better way to support disabled adults and older people than conventional methods of resource allocation and service delivery? If so, which models work best and for whom? Evaluation dimensions User experience Carer impact Workforce Care management Provider impact Risk & protection Commissioning Outcomes Costs Cost-effectiveness Glendinning et al (2008) Evaluation of the Individual Budget Pilots + numerous journal

17. Outcomes and costs (IBSEN evaluation) * IBs offered more ‘felt control’ when analysed for the overall sample and the learning disability group

18. Positive effects of Personal Budgets (IBs) Quality of life, social care outcomes and satisfaction Outcomes linked to level of support Overall - cost-effective use of public resources But much less positive for older people Concerns about managing budgets Concerns about employing PAs and similar Individuals needed more preparation & support Carers much more positive, however Overall conclusions from IBSEN

19. Adult Social Care Environments & Settings • The ASSET study explored views and experiences of people commissioning, delivering and receiving adult social care services in extra care housing and retirement villages. • For some older people a move to housing with care improved quality of life compared with living in mainstream housing. • Local authority commissioning approaches vary considerably • Urgent need to provide better financial information to current and prospective residents and their families - including information on personal budgets, direct payments and charging arrangements. • The housing with care model can support residents who are very diverse in terms of abilities, needs and care packages. Simon Evans (Univ of Worcester) et al. Funding NIHR School for Social Care Research

20. C Neighbourhoods

21. Neighbourhood effects Social capital  socially cohesive  better health and wellbeing, reduced level of (perceived) crime, higher educational achievement, economic growth Volunteering intrinsic motivation and benefits, health and wellbeing, pathway to employment Social support  reduced social isolation, loneliness and depression, and risk of death Community capacity-building  can be effective and cost-effective Age-friendly involve older people as participants, respond to local conditions, including (e.g.) neighbourhood hubs to ease access to healthcare, social care, local services and facilities. Halpern (2009), Ironmonger (2006), Steptoe et al (2013), Knapp et al (2013), Foresight

22. Age-friendly neighbourhoods Neighbourhoods that are valuable resources for older people are: • age-friendly • safe • changeable in response to preferences of people who live there They should: • … not stop people getting to outdoor spaces • … have a minimum of physical barriers and the right kinds of facilitator (e.g. longer time intervals for pedestrian crossings) • … have good and accessible community transport, particularly for those older people no longer able to drive or be driven • … have safe spaces to allow full community participation • … support implementation of community contributions to health and social care support. Chris Phillipson (Univ of Manchester) for Age UK volume, 2015

23. Isolation and loneliness • Social isolation among older people is growing. • Isolation is a risk factor for loneliness and poor health (including depression, cardiovascular problems and cognitive decline). • Interventions such as structured befriending programmes and time banks – that build social capital – may help to tackle the problem, although evidence in support of their benefits is not yet overwhelmingly clear. Probably cost-effective. • Services are acquainted with emerging evidence on social isolation and loneliness-associated risks, but less clear about what to commission. • Neighbourhoods and communities can help to combat negative effects of isolation. Emilie Courtin & Martin Knapp (LSE) scoping review for SSCR Anna Goodman (Campaign), Adrian Adams, Hannah Swift (Univ of Kent) for SSCR

24. Economic pay-offs from community resources Time banks • Cost per time bank member = £607 p.a. • Economic pay-offs = c.£1300 per member • … of which £187 = short-term cashable to govt. Befriending • Cost per older person = £90 over 12 weeks • Economic pay-offs = £490 including QOL gains • … of which £38 = short-term cashable to govt. Community navigators (benefit & debt advice) • Cost per ‘hard-to-reach’ person = £611 • Economic pay-offs = £360 (or £1200 including QOL gains) Knapp, Bauer, Perkins, Snell, Community Development Journal 2013

25. D Design and technology

26. Mismatch in housing • Housing stock mismatched with needs of older people: 35% of households consist of 1 or 2 older people, but most homes are designed for families, with three bedrooms. • How much housing more appropriate for families is being occupied by older people? • Many older people want to move to ‘appropriate’ properties but they are not available: specialist housing commonly provides 1-bedroom units, whereas most people prefer 2-bedroom. • Changes in mainstream housing provision have generally been slow. Foresight Ageing programme; evidence reviews, 2014-15

27. Design & technology • Much research into design requirements of housing for older people • Support for well-being, accessibility, sensory contact and support, health and safety. More attention now to design for dementia. • Adaptations: grab rails, better lighting and other home improvements • As individual needs (and preferences) change, can housing respond? Jeremy Porteus (Housing LIN) for Age UK volume, 2015; Foresight Ageing programme

28. Support in the home • ‘Handyperson’ services; support for ‘low-level’ needs • Home care services – changing, but not always for the better • Better support for carers (e.g. START) • E-inclusion of older people? Challenges? • Telecare – acceptable? adapted to individual preferences and needs? • Robotics (e.g. for dementia)? Sanders et al; Henderson et al for WSD trial; MonAMI results; SSCR on home care

29. E Concluding comments

30. Policy and research • Policy often moves ahead of research evidence – sometimes good, sometimes bad • Changing demographics mean that growing (and changing?) needs of an older population should not be a surprise • Research can continue to feed information into the sector to support better provision and more-informed commissioning

31. Changes in attitude / approach over 70yrs (Borrowed from a presentation by Robin Murray-Neill)

32. Funding, disclaimer, conflicts of interest Some of the work presented here was supported from: • the Department of Health (DH) for England • the National Institute for Health Research (NIHR) School for Social Care Research • the Economic and Social Research Council • the Alzheimer’s Society. All views expressed in this presentation are those of the presenter, and are not necessarily those of the DH, NIHR, ESRC or Alzheimer’s Society. I have no conflicts of interest to report that are relevant to this presentation. Thank you for your attention m.knapp@lse.ac.uk