Care and Place study (CAPE): The relationship between older people’s housing characteristics and social care needs, care use and care costs
Nicola Brimblecombe, Javiera Cartagena-Farias, Bo Hu, Madeleine Stevens, and Jayeeta Rajagopalan
Care Policy and Evaluation Centre, London School of Economics and Political Science (LSE)
22/05/2024
Correspondence to: n.s.brimblecombe@lse.ac.uk
Funded by National Institute for Health and Care Research School for Social Care Research (NIHR SSCR). The views expressed are those of the authors and not necessarily those of the NIHR School for Social Care Research or the Department of Health and Social Care, NIHR or NHS.
1 Aim
The Care and Place study (CAPE) toolkit is an interactive resource based on the main results of the CAPE study. The main aim for the toolkit is to support practitioners in their role, providing details on the role that housing conditions could be playing in the development of care needs and level of service use among older people. It includes information on housing quality, fuel poverty, how much financial resources could be saved if housing problems could be solved, and a summary of the experiences, worries and aspirations of older people.
Throughout the CAPE toolkit you will also find a few questions to test your knowledge!
Our results are based on data from 8,000 adults aged 50 years or
older living in England (The English Longitudinal Survey of Ageing,
ELSA) and qualitative interviews with 72 older people and their
carers.
2 Terminology
This section lays out some of the terminology we
have used throughout this toolkit.
2.1 Glossary
| Variable/Methodology/Terminology | Description |
|---|---|
| ADLs | Activities of Daily Living: Personal hygiene or grooming, dressing, toileting, eating |
| IADLs | Instrumental Activities of Daily Living: Cooking, cleaning, transportation, laundry, and managing finances |
| Housing conditions | Damp, condensation, noise, pest infestation, accommodation is too cold, among other housing problems. |
| Fuel poverty | Includes individual-level factors (such as income and energy bills) and structural condition (e.g. fuel prices and the weather) |
| EPC | Energy Performance Certificate |
| Decent homes standard | Technical standard which has played a key role in setting the minimum standards that homes are required to meet since the early 2000s. A decent home is defined as being free from most serious health and safety hazards, such as fall risks, fire risks, or carbon monoxide poisoning. The Decent Homes Standard is currently only applicable to the social rented sector. A consultation to apply the Decent Homes Standard to the private rented sector was published on 2 September 2022. |
For more information on the Decent Homes Standard, see here.
3 Background
Housing has the potential to play a key role in promoting independence, delaying and/or preventing the onset of care needs and in influencing the level and type of care provision required. However, many older people (50+) live in homes that are not suitable for their comfort and needs.
The Care and Place study (CAPE) aimed to investigate the association
between characteristics and conditions of non-specialist housing (where
the majority of older people live) and people’s social care needs and
use. For instance, we looked at how poor housing conditions (e.g., damp,
condensation) co-occur and are associated with an early development of
care needs (measured as the number of Activities of Daily Living (ADLs)
and Instrumental Activities of Daily Living (IADLs)). Please find more
details on this study at https://www.sscr.nihr.ac.uk/projects/p191/ or contact
its Principal Investigator Nicola Brimblecombe (N.S.Brimblecombe@lse.ac.uk).
4 Housing conditions
In the context of an ageing population, many countries have promoted strategies that encourage older people to remain in their own homes. This is based on the understanding that people wish to maintain their independence, preserve their self-esteem and self-identity, and to stay close to friends, family, and familiar places.
Older people may also prefer to remain at home as they age because it is a familiar environment, to avoid the stress of relocation, for financial reasons, and/or to prevent expensive institutionalisation costs, the latter also being an important concern among policy makers. ‘Ageing in place’ has become, therefore, an underlying principle in current ageing policy in many countries, and has arguably become a central part of policy and advocacy discussions in England. However, access to satisfactory housing conditions cannot be taken for granted. For instance, housing quality varies by geographical area and housing tenure. Test your knowledge!4.1 Housing conditions co-occur
Using data from 8,000 older people from the English
Longitudinal Survey of Ageing (ELSA), we 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 CAPE study
identified three typologies of housing based on their characteristics
and quality:
4.1.1 Type 1: Good housing conditions
Type 1 (21.4% of the homes analysed) were most
likely to be larger homes (ie., with a larger number of rooms), and in a
better condition, with relatively fewer issues than other homes.
However, noise, pollution, and infestations are some of the most
important problems among the homes included in this group.
4.1.2 Type 2: Worse housing conditions
Type 2 (10.4% of the homes analysed) were found to
be smaller homes and with several housing issues. That is, in addition
to problems with noise, they also present issues with damp, cold, and
condensation; they are also dark, and have general rotting.
4.1.3 Type 3: With some issues
Type 3 (68.2% of the sample analysed) were found to
be medium-sized homes, with some housing issues (in particular, problems
associated with their roof, as well as damp and cold).
4.1.4 More information on housing typologies
A larger proportion of homes with worse housing
conditions (those in Type 2) are privately rented (7% compared to 2% and
5% in Types 1 and 3, respectively), but also a larger proportion of
homes in Type 3 are social housing (28% of homes in Type 2, compared to
less than 10% in the other two types). On the other hand, but as
expected, a higher proportion of Type 1 (good housing conditions) are
owner occupied (91%).
The types identified provide an insight into how housing characteristics co-occur and do not appear in isolation.
Test your
knowledge!
4.2 Housing conditions and early onset of care needs
The total number of housing conditions and the identified typology of housing were both found to be associated with having an earlier onset of care needs (that is developing care needs at a younger age). That is, 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 we took account of socio-demographic factors (e.g. gender, employment, ethnicity, etc.). This shows that not only is the type of problem, but also the combination of housing conditions that could affect when long-term care needs start to develop.
The following tabs show the age of development of care needs (ADLs) by:
4.2.1 Number of housing problems
In the graph below, the median age of onset of care needs (please follow the red lines on the graph below) was 89 years old for those living in a dwelling without any housing problem, but 81 for those with 3 or more housing problems: total number of housing conditions was found to be associated with having an earlier onset of care needs. This is true even when we compare people with similar socio-demographic characteristics.
4.2.2 Housing typology
Homes in worse conditions (Type 2) were found to be associated with an earlier onset of care needs. The median age of onset of care (please follow the red lines on the graph below) was 78 years old for those living in Type 2 and 87 years old for those living in Types 1 and 3. This is true even when controlling for other housing related factors and socio-demographic characteristics.
4.2.3 Housing tenure
Those privately renting or in social housing, are more likely to have an early onset of care needs. The median age of onset of care (please follow the red lines on the graph below) was 79 years old for those living in social housing compared to 84 years old and 89 years old for those living in rented accommodation and those that are home owners, respectively. This is true even when controlling for other housing related factors and socio-demographic characteristics.
The findings show an inequality in development of care needs based on the type and condition of the housing people live in. There is additional cause for concern when we consider that there has been a significant increase in the number of older people expected to rent rather than own their own home in later life (Centre for Ageing Better, 2022), and also since a substantial proportion of older households (approximately 15% in England) are in the social rented housing sector (Ministry of Housing, Communities and Local Government, 2020; OECD 2020).
What do these findings mean in practice?
The number of housing problem matter for the development and level of care needs so a holistic approach to improving housing may be needed.
Housing problems co-occur, so it is likely that homes with condensation problems, will also be too cold in winter.
People living in social housing or privately rented homes are living with worse quality housing on average when compared with owner occupiers.
5 Fuel poverty
Tackling fuel poverty - a measure of a household’s ability to keep warm has become a priority in many countries, as it may reflect both poorly insulated and energy-inefficient housing conditions as well as household financial disadvantage.
The official measure of fuel poverty in England is the Low Income Low Energy Efficiency (LILEE) indicator. Under this measure, a household is considered to be fuel poor if their required energy costs are above the national median, their income minus energy costs falls below the income poverty line, and if the property where they live has a low energy efficiency rating (Department for Business, Energy and Industrial Strategy, 2022).
However, this official measure of fuel poverty may also mask some important factors. It has been suggested that more subjective indicators capturing perceptions of whether individuals are able to keep their house warm should be included. In addition, poor housing conditions may be considered, as they are understood as a catalyst for energy poverty when interacting with low income and high energy prices.
Therefore, the CAPE study used a comprehensive measure of fuel poverty that encapsulates a lack of affordability and thermal comfort based on household income, electricity and gas consumption, location (rurality), household expectation of their ability to cover their needs, perception of accommodation being too cold in winter, and the presence of rising damp.
We found that fuel poverty is associated with a greater risk of developing long-term care needs and worse mental health. We also found that fuel poverty is multidimensional and as such, influences the development of care needs from many fronts.
The map below shows the relative levels of fuel poverty across areas in England. Test your knowledge!In our analysis, we found that fuel poverty comprises individual factors (e.g., household income), but also structural factors (poorer housing conditions). Therefore, we did not make use of the LILEE indicator, but measured fuel poverty using a comprehensive measure which encapsulates income, energy consumption, but also lack of affordability and thermal comfort. We found that fuel poverty is associated with a greater risk of developing long-term care needs and worse mental health.