This publication takes the form of a report commissioned and funded by The Technology Strategy Board and the HealthTech and Medicines Knowledge Transfer Network. The authors describe their work as desk-based research of reports and peer-reviewed publications on the topic of housing provision for older people, most of which include initiatives that have been evaluated. The stated aim of the report is to outline the case for a ‘revolution’ in long-term care for older people into the future and encompasses the years 2012–2050. The report is based on evidence from the United Kingdom (UK) primarily, as well as evidence from other countries mostly in the European Union. Certainly the content of the report provides a very comprehensive overview of the range of housing initiatives on offer for older people, although some are more developed than others.

There is an underlying assumption within the report that any future models of housing or social care must promote independence for older people and place the older person in the centre as their own designer of care. Therefore, management of services should be done by people who acknowledge that older people can choose a solution that suits them. This is a challenging proposition for both service providers and for older people and their families. It also assumes that older people want to be given these responsibilities, and that any services arising from this approach would be of better quality. One example is the use of personal budgets where older people are allocated resources to cover their own service needs and can direct these as they see fit, rather than being dependent on services that government agencies offer them. The report suggests that older people feel that personal budgets were a burden or the amount was too small to make it worth the effort. Most prefer a local authority package if they could choose the timing and tasks of care workers allocated to them. The use of personal budgets could also add extra work for informal carers of older people, who already have inadequate practical or financial support.

The report summarises the current service context for older people – such as the ageing population where there are greater numbers of older people and very old people, many of whom also have longer-term, chronic conditions. Into the future, we can expect higher levels of employment of older people, higher expectations for the quality of services by older people, an increase in the importance of informal carers, increases in the amount of institutional care required, ongoing financial constraints and further complexity in the funding of any schemes to address the needs of older people. Older people may choose to move into smaller homes or apartments for a variety of reasons in the future – for instance, increased divorce rates, more highly educated older people, more foreign-born older people or older people needing to generate income from the sale of a larger house. This all pre-supposes that housing choices will be available to older people.

Therefore, the link between housing and health for older people becomes more significant as people age, and may be related to higher risks of falls and other issues. Several models are considered in the report:

• • Matching older people with adult placement schemes where they live with people who are unrelated to them for long- or short-term periods.

• • Home-sharing schemes where older people share their homes with other adults. There are examples of these in the UK, European Union and Australia, although no independent research or evaluation about their effectiveness.

• • Co-housing or self-initiated intentional communities where older people chose to live together or in close proximity to each other.

• • Extra-care housing, where older people have their own front door, but help is available.

• • Re-enablement programmes to allow older people to return home as an alternative to ongoing institutional care. Older people often enter institutions during a health crisis with no proper planning, whereas they could be supported elsewhere once their health needs have resolved.

• • Alternatives to nursing home placement because of a lack of longer-term hospital beds – such as non-institutional settings with more proactive services.

• • Sheltered housing consisting of smaller clusters of housing with varying degrees of support available which may be a better fit for older people with low or mild care needs.

• • Retirement villages are often larger communities, which can be vulnerable to schemes going bankrupt and older people may be forced to leave when they become frail.

The report provides a succinct critique of the current systems of housing and care provision for older people. As systems tend to drive the arrangement of public services, they can become impersonal, fragmented and unnecessarily complex for older people to negotiate. Policy in the UK is shifting power from the state to service users, so local authorities and the National Health Service have to work together to build single, streamlined health and social care assessment and eligibility for these services. Other countries have a strong state support system, or systems that include private-sector or mixed models.

Most public services have to provide some form of home-based care for older people. Such care has several challenges around sustainability into the future. At the same time, the rights of older people to live to their fullest potential are paramount. Many home care services are criticised by this report as they restrict choice, have limited funding, and home visits are often rushed and occur at inconvenient times, which do not respond well to the individual needs of older people. Furthermore, many home care services exclude the provision of anything that is not prescribed by the service, such as assistance with participation in leisure activities. Many local authorities have very strict eligibility criteria which often only include older people with severe health needs, and people with moderate needs are not assisted. Therefore, only limited numbers of older people receive services. If the standard is to provide older people with services while respecting their privacy and personal space, and to maintain former lifestyles and a sense of self and autonomy, it appears that public services have not succeeded.

The report includes some vignettes to illustrate some of the dilemmas in providing services for older people and what is needed. The report also indicates some aspects of service provision that are effective, such as changes to homes recommended by an occupational therapist, which are regarded as good value and can prevent a move to an institution. The report also suggests that general practitioners should have a more substantial contribution to make to maintaining older people at home.

The report suggests some key factors that could advance the ‘revolution’ in long-term care. These include:

• • Better design of housing to be more user-friendly for older people and more easily adaptable.

• • More access to informal and formal care. Personal budgets may assist but only if quality of care can be sustained.

• • Better use of technology – defined as any device to assist people to do things they might not otherwise be able to do. Whilst there are ethical issues associated with some new technologies such as surveillance applications, other forms can contribute to older people's quality of life.

• • Use of telemedicine, or health at a distance. However, there is evidence yet to be gathered about its capacity to improve quality of life. Older people also have to be more confident in using technology for this to be developed further.

• • Increased uptake and use of telecare and personal alarms.

This publication provides a useful addition to the reading of any health professional, researcher or student involved with the care of older people, and it outlines the potential future needs of this group with reference to a comprehensive range of the current literature.