Haven or Hell? A critical debate on the implications of ageing-in-place
Health, housing and social care services assume that older people prefer to age-in-place. While this may be true for many individuals, we shouldn’t assume it’s always the best option for all older people, as occupational therapist Helen Brown of Sheffield University explains.
Ageing-in-place, defined as people living largely independent lives in the community as they age, has been encouraged by policymakers from all sectors of housing, health and social care. Consequently, there are a plethora of policies promoting ageing-in-place across these services. For instance, the Care Act 2014 mantra - prevent, reduce, delay - is imprinted across adult care departments like the lettering inside a stick of Blackpool rock. Furthermore, performance measures aimed at reducing delayed transfers of care in acute health services talk of ‘Home first.’
I have never met a person who was enthusiastic about using a commode or sleeping on a hospital bed in their front room. Have you? Would you be?
In our own sector, there is ‘Housing first,’ an initiative to provide housing for people experiencing homelessness and cocoon them in services. However, a shortage of appropriate accommodation has presented challenges with this model. Policy promoting ageing-in-place has, in part, been driven by the ageing population and increasing number of people with multiple long-term conditions. As a result demand for services is growing, against a shortage of housing across all tenures, rising inequalities and reduction of statutory resources. Providers are having to be innovative in the delivery of services - but I would argue that providing fewer services is not innovation.
You might be thinking that many older people are driving this policy agenda themselves, and indeed for some people ageing-in-place is ideal. Some even say they want to remain in their home until they are “carried out in a box.”
As an occupational therapist practicing in a local authority housing department when people said this to me, shamefully, I was often relieved. Why? Because I knew we had limited suitably adapted accommodation available and accessing the stock we did have could involve a wait of months or even years. I assumed that by ageing-in-place individuals were able to preserve their identity and attachment to home and neighbourhood thereby maintaining their own wellbeing, saving scarce resources, right?
Not always… and this is the point. I have rehoused older people with complex mental and physical health needs to new, more suitable accommodation, but that has often failed to address the underlying issues. For example, a person with hoarding behaviours began collecting again immediately he was rehomed. Worst of all, a person re-housed from a care home to the community described her new adapted home as akin to being in prison as she felt lonely and isolated. These examples illustrate that while ageing-in-place is ideal for many citizens, there is a danger in assuming this is right for all older people, and for some may have serious implications, perpetuating stereotypes and embedding inequalities.
Firstly: the rise of ageing-in-place has coincided with a growing incidence of loneliness. My research colleagues will be quick to remind me that ‘correlation does not equal causation,’ however, it remains the case that social isolation is increasing across all age groups, including older people.
Secondly: globally one in six people over 65 years old experiences elder abuse, including financial abuse, physical or sexual abuse and neglect. If people are to age-in-place successfully then how can providers safeguard against abuse of all kinds?
Thirdly: if older people do have social care at home, what about those who live in the recently reported ‘care deserts,’ the one in four postcodes with not enough carers to meet demand.
Finally: a safe, physical environment is essential for wellbeing in later life. Yet some older people experience fuel poverty leading to damp, cold homes and others are at significant risk of falls due to disrepair of their home, both of which have hugely negative impacts on their wellbeing.
Consequently, a range of housing and service options to meet the housing needs, and aspirations, of older people is essential, both for those who wish to age-in-place and those who wish to relocate. As housing professionals we need to understand what older people’s housing aspirations truly are, then offer solutions based on real evidence rather than stereotypical assumptions associated with ageing-in-place.
The purpose of this blog then, is a call to action. The next time an older person tells me they want to age-in-place, I will ask why. What will you do?