Paddock Johnson, in partnership with NHS Cheshire and Merseyside, hosted a round table debate with a network of experts who work in the delivery of housing and transforming care for people who have learning disabilities and/or autism.  Invited guests represented the NHS, a Local Authority, Registered Providers and experts working in the delivery of specialist housing.

The debate gathered thoughts and ideas around; how can we collaboratively overcome the barriers, which are causing and contributing to the problem and create a better way forward.

We know that 1 in 3 hospital beds are being taken up by people who are medically fit for discharge.  And furthermore, the Assessment of future accommodation with support needs, produced by Campbell Tickell for Cheshire and Merseyside Transforming Care Partnership, predicts that an additional 1,679 units are needed in the Cheshire and Merseyside area over the next 10 years. 

The round table session was introduced and opened by Maria Killick.  “With specialist housing we understand every person has different needs and each requires an individual approach.  But when the right type of housing and care support is not available for people outside the hospital setting, the only option seems to be to stay in hospital.”

This was echoed by Sarah Houghton-Grimshaw.  “We want to focus on creating well designed homes, that with the right support can both prevent people from going into acute hospital settings, and at the other end of the person’s journey, allow for a better discharge.”  Sarah also high-lighted, “There is also a hidden homelessness community in hospital, not for clinical reasons, but for lack of suitable housing”.

So, what is the problem? Why are people staying in hospital longer than necessary?

The NHS has a goal to support people to be discharged from hospital and to help prevent people from going into hospital in the first place.  However, there seems to be existing challenges that prevent this process from happening as smoothly as it should.  The primary barrier, even before we collectively start to think about the delivery of the homes, seems to be the lack of early planning to enable people to be discharged into appropriate housing within the community.

Brick by Brick, a publication by NHS England, contains resources to support hospital-to-home discharge, which involves social workers, occupational therapists, clinicians, Care and Treatment Review leads and commissioners to firstly identify the available housing options to enable inpatients to be discharged.  There is evidence to suggest the assessment of suitable housing is not always considered early enough in the mental health hospital discharge process.

This issue was high-lighted by Amanda Wrenn, Places for People, “We need to understand the pipeline and number of people that will need supported living as early as possible, to get plans in place for supported housing.”  And to aid the linking up of the delivery, “Tri-party agreements between funders, providers and the NHS would really help”. 

Several factors seem to be contributing to the wider problem:

• A lack of suitable housing; based on size, specification, fixtures and finishes
• The initial high cost of land
• The need for a small number of homes in a particular location; often just one or two
• Viability for potential development partners
• Availability and access to funding

All the factors above are contributing to the creation of barriers, which are preventing people with learning disabilities and/or autism being provided with the opportunity to live in a home, within a community, that is appropriate for their needs and lifestyles.  One of the biggest contributing factors is funding.  However, it is true to say that having people staying in hospital isn’t free or cheap either.  One example shows the cost of housing one medically fit person with complex needs in a hospital environment for 12 months, is costing the NHS in the region of £1M.

As a snapshot of the situation, as published in the Assessment of future accommodation with support needs, by Campbell Tickell for Cheshire and Merseyside Transforming Care Partnership (May 2023), in relation to Liverpool:-

‘There are currently 10 inpatients who need housing to be discharged, although this number does vary over time.  Bespoke accommodation is needed because of sensory needs and this may include detached accommodation that is not overlooked.  This accommodation is very difficult to source.’ 

We understand there is a need for housing which is designed in a bespoke way, and in some situations, the right type of dwelling is available for an individual.  However, the housing might be out of the area.  This provides part of the solution but requires the person to potentially move away from the things that are familiar to them, their families, care team and surroundings.  This isn’t necessarily the most suitable solution for obvious reasons, and additionally, it creates complex challenges in relation to funding. The issues around the funding are further complicated by the Worcester judgement, which states that Ordinary residence should be determined by reference to where the person was living immediately before their last stay.  Presumably this is likely to generate some resistance from some areas to commit to the necessary provision for someone outside of the local or authority area.  It is obvious that the problems and barriers are complex and difficult to plan for and manage.

What are the barriers for Registered Providers in developing supported housing?

Abdul Latif, from Golden Lane Housing offered the following comment “Flexibility of grant funding and rethinking who manages the capital funds is needed”.

The management of funding was a key discussion point at our round table.  In principle, there is funding, however, the complex rules around funding make it difficult to navigate and apply within practice.  NHS funding is available for specific types of housing development and this depends on the person and their needs.  And in theory, Homes England affordable housing grants can be used together with NHS funding, however, hierarchy of charge against the property and complexities of tri-party funding arrangements make this a complicated process.  Homes England funding imposes rules with regards to rent standards, which are set at social or affordable level, and this is a big part of the problem.  

As far as specialist supported housing is concerned, rent charges need to be higher to allow for the higher costs to provide a specialist home when compared to general affordable housing.  The rent values associated with Homes England funding are often set too low as true market comparison and for very specialist accommodation it is difficult to pinpoint and fix an appropriate affordable rent. Social rent levels simply would not allow the RP to achieve a viable scheme.

Additionally, Registered Providers are generally too risk adverse and most will opt to continue delivering general needs affordable housing, rather than explore the ways in which they can contribute to relieving the problem of insufficient housing for people with learning difficulties and/or autism.  It is clear to see there are complexities in relation to funding specialist support housing schemes and why partnership with Registered Providers is not instinctively part of the current solution.

Clare Skidmore, National Housing Lead, Learning Disability and Autism Team at NHS England said, “We need a place-based approach, with local health, housing and social care partners working together with local people for a long-term approach to meeting people’s housing needs. It’s really important that NHS and government leaders recognise that, with 56% of delayed discharges of autistic people and people with a learning disability from mental health hospitals being due to lack of suitable housing, the need for more high-quality homes to enable people to live good lives in the community is a priority issue which requires the support of us all.”.

With Steve Metcalf from Sefton Council further adding, “Devolution of grant funding and a new strategy could create a large fund to work alongside Local Authority Capital programmes”.

The above statements demonstrate that part of the problem lies in the area of funding, but they also hint at potential change, that if acted on, could have the potential to bring about positive influence.

Part of the solution might also lie in the re-use of existing buildings, through appropriate conversion and adaptions, but again, historic connections with funding sources associated with the original development (e.g. Homes England funding) create barriers.  Places for People do purchase properties to carry out adaptions and to acquire land, however, the organisation cannot access Homes England grant funding  as public assistance in the form of a capital grant cannot be secured by a legal charge being invested into a scheme then precludes the application of the specialist supported housing exempt rent to achieve viability  and purchasing from the open market has its obvious challenges.

So, we come back round to the issue that there is a need for bespoke and purpose designed homes for people who have complex needs, learning difficulties and autism, but the current funding structures do not provide the opportunity for the higher rent charges to be accommodated.  Subsequently, this means that the Registered Providers do not automatically engage as part of the solution and many potential opportunities in terms of developing the right type of housing whether it be new build or converted properties are not featuring in what we would assume to be a major part of the solution.

Chris Bowen, Torus commented “More combination of funding programmes into single, flexible funds, potentially devolved to local areas would create a better platform to deliver more supported housing and better value for money across housing and health sectors.”

Paula Underwood, Torus added “It’s of paramount importance to raise the profile and size of the issue and more flexibility in the Homes England funding.”

However, many Registered Providers are contributing to finding solutions and are delivering housing for people with complex needs.  Paddock Johnson is currently working alongside Regenda and Care Housing Association to deliver a project of 11 ‘own front door’ homes.  Planning for the longer term, a group of families wanted to ensure the occupiers, their sons and daughters who have learning difficulties, have access to quality specialist supported housing to enable them to live happy and fulfilled lives.

Likewise, Golden Lane Housing is one of the country’s leading supported housing landlords, working with people who have a learning disability or autism.  Golden Lane Housing want all their tenants to live in good quality, safe, environmentally friendly homes.  And they want to provide this for more people with complex needs across our diverse communities.

Torus, alongside their affordable housing development programme, is also committed to providing specialist homes to support people with a learning disability and autistic people.  Two recently completed schemes in St. Helens, which were developed in partnership with the NHS are allowing residents to benefit from integral design features and support with their home, while living close to their families.  Additionally, the housing is providing them with a tenancy integrated within the community with access to 24 hour specialist support and care.

The above examples demonstrate how some organisations are finding ways to make specialist supported development happen.  However, through our discussion it was generally felt that a lack of awareness of the issues facing insufficient suitable housing for this group of people is a large part of the problem.  In reality the impact is huge and affects us all.  While medically fit people are living in the hospital setting, these spaces are not available to other people who might need them.  Therefore, it is clear that several factors need to come into play if we are going to try and find suitable viable solutions.

The issue does not seem to be at the forefront of the minds of people and organisations who are in a position to influence positive change.  Government officials and Homes England need to be fully briefed on the problem and the barriers, which are contributing to the lack of suitable housing development and the delays in the planning and management of this.

How can we overcome the barriers?

From our discussion it seems there are several things that need to change, with some of these potentially requiring a staged approach.  Around the table we discussed how there generally seems to be an initial need to raise awareness of the actual problem.

Several of our guests suggested a need for planning reform and lobbying to create the necessary change.  It was generally agreed that supported housing just isn’t high enough on the agenda, or even featuring on the agenda as it should be.  Shouldn’t housing for people with learning disabilities and autism be part of the country’s housing strategy?  A change in regional and local policy featured significantly in this part of the discussion, suggesting a collective passion to instigate change.

“We need to understand how we can change systems by working through regional agencies and regional forums”  said Katie Fleeman of the LCR Combined Authority.  And this was followed by a statement from Sarah Houghton-Grimshaw, NHS Cheshire and Merseyside “When planning permissions are awarded to large private house builders, local authorities should consider including restrictions that a mandatory slice of the homes and land be allocated for supported housing.  This could be part of a Section 106 agreement.  This would help embed this type of housing into communities.”

There was also collective thought in relation to availability of land and vacant properties, all of which could assist in providing solutions.  However, while these assets continue to target the wider open market, it is obvious that change is needed so these options can become a more viable part of the solution in terms of specialist supported housing.

Martin Davies, Regenda asked “Could local authorities offer their land for development of supported homes”  and also added “Should private developers be encouraged to be more purpose driven by using a small proportion of their development for supported housing”.

Through our work we are all familiar with inflated land values and the cost of conversion and refurbishment, and therefore it comes as no surprise that even with development collaboratives between the NHS and Registered Providers there are still barriers effecting the delivery of supported housing.

However, the general consensus around the table was that it will take a combination of changes, all interlinked, to start to make a difference and allow more specialist supported housing to be delivered, which in turn, will start to reduce the number of people living in hospital. 

Libby Eastley, Magenta made a suggestion in relation to the problem, “The solution must include planning reform and grant incentives”. 

With Victoria Millward, Paddock Johnson adding “There should be more repurposing of existing empty buildings for supported housing.  This could be incentivised through VAT relief”. 

Raising awareness of the issue of a lack of suitable housing for people with complex needs was a collective agreement around the table.  As stated by Paula Underwood, Torus, “It’s of paramount importance to raise the profile and size of the issue and more flexibility in the Homes England funding.”

However, it is understood that this alone will not provide the ultimate solution but provide the opportunity for wider in-depth discussions in relation to funding and local policy.  It was felt that Government Officials and Homes England need briefing on the issues and the current constraints that are contributing to the problems and delays in the provision of this type of housing.  An awareness of the problem, we hope, will open up a wider discussion, which will lead to solutions.

And following an initial ‘awareness raising stage’ surely part of the follow-on solution has to be how the funding process can work more effective to benefit the delivery of housing for people with learning difficulties and autism.

As stated by Jane Bellwood, NHS England Reginal Housing Lead (North West) “A new devolved, capital fund could be the solution”.

And this could certainly contribute to a solution, particularly one that might work in line with the varying needs and numbers across the country.  This also starts to imply that funding for this type of development will not necessarily be managed through existing organisations, but potentially managed through new organisations.

Simon Halliwell, Paddock Johnson posed the following question “Is Homes England the right place for this type of funding to sit?  We need planning incentives and a new agency to manage the funds for supported housing”. 

We have The Supported Housing Act which came into force in August 2023, which aims to ‘stop rogue operators from entering the market and ensure that action is taken against bad faith providers’.  However, the Act incorporates the much wider designation of supported housing, which includes homelessness and rough sleeping, but does not seem to make sufficient reference to housing for people with a learning disability or autism.  The Act is primarily focused on improving the quality of what is available and ensuring the housing is accessible, appropriate, safe and improves value for money within the area of supported housing, which will all agree is of foremost importance. 

The Act recommends that local councils carry out an accommodation needs assessment across all groups of people including those with a support or care need, which will then allow them to plan strategically against current and future needs.  We then see this filtering through to the revised National Planning Policy Framework, which requires local planning authorities to identify their development requirements based on the assessed need.  In recent years we have seen this transpire in the authority areas local to us with new housing developments being required to provide a percentage of accessible housing as defined by M4(2) and M4(3).  This is allowing local areas to provide a larger number of dwellings which are therefore more accessible for older people, having previously established that there is a lack of appropriate housing for the ageing population.

We are also familiar with HAPPI (Housing our Ageing Population: Panel for Innovation) and the report published back in 2009.  This did a fantastic job of raising awareness of a need to design better homes for older people.  And we have found that the recommendations and principles have become embedded within the current mandatory and legislative guidance relevant to our work.

Isn’t it time we gave the appropriate level of consideration to work together to reduce the number of medically fit people living in hospital by raising awareness of the issue and working collaboratively to find solutions to overcome the barriers currently stopping this from happening. 

Maria Killick, Paddock Johnson stated, “Raising awareness of the issues and lobbying to create change is needed” with the outcome aiming to ensure that supported housing becomes embedded within local plans.  Maria added “We need new legislation that supports a policy to enforce a percentage of new homes being available to supported living in all new developments”.

As agreed collectively among our guests, several changes also need to occur to support this and its delivery, primarily, the barriers around funding and how funding is made available, matched and managed.  We all felt this is a problem that can be fixed, which is most likely to happen if we can bring together government officials, local authorities, Homes England, registered providers, NHS teams and private developers.

Contributors to the discussion included:

• Abdul Latif - Golden Lane Housing
• Amanda Wrenn - Places for People
• Chris Bowen - Torus
• Clare Skidmore - National Strategic Housing Lead, Learning Disability and Autism Programme, NHS England
• Jane Bellwood - NHS England Regional Housing Lead (North West)
• Katie Fleeman - LCR Combined Authority 
• Libby Eastley - Magenta
• Maria Killick - Paddock Johnson
• Martin Davies - Sett Housing Consultancy
• Paula Underwood - Torus
• Sarah Houghton Grimshaw - NHS Cheshire and Merseyside
• Simon Halliwell - Paddock Johnson
• Steve Metcalf - Sefton Council
• Victoria Millward - Paddock Johnson