Better housing for older people means better lives for all

“Sheltered Housing – MVRDV” by KJBO is licensed under CC BY-ND 2.0

Housing is at the heart of a good quality of life. This is especially true as we get older, when health and wellbeing, independence and end-of-life care can all be greatly enhanced by decent housing.

Four recent reports have underlined the importance of good housing for older people, and the wider benefits for society.

Housing with care: progress and problems

The Commission on the Role of Housing in the Future of Care and Support  (CRHFCS) was established last October by the Social Care Institute for Excellence (SCIE). The new commission aims to produce a blueprint to enable greater choice and availability of housing and support for people aged 65 and older who may find it difficult to live independently at home, or who choose to live somewhere which provides more support options. The Commission will focus on five key areas: care homes; retirement communities; retirement housing; supported living; and the Shared Lives schemes.

The first report of the CRHFCS highlights progress made since the Commission on Residential Care 2014 (CORC) reported its findings in 2014. There have been some positive developments concerning the take-up of more new technologies in care settings, such as telehealth, telecare and smart home devices to help people maintain their independence.

Progress has also been made on age- and dementia-friendly housing design. And the report commends the Housing our Ageing Population Panel for Innovation (HAPPI) reports for raising awareness of housing specifically designed for older people.

However, little progress has been made on CORC’s recommended expansion of the market to give greater choice of housing with access to care. Options remain limited, especially for those struggling to pay for accommodation.

The CRHFCS sets out some initial policy proposals. These include planning reforms to make it easier to build retirement community housing, and improved information and advice to support informed decision-making for older people seeking housing with care and support facilities.

The Commission’s final report will appear in the summer, when it will make recommendations about the future shape of housing that facilitates care and support.

Needed: a clear vision about housing for older people

The findings from the CRHFCS report are echoed in another report, published in April by the Cambridge Centre for Housing and Planning Research. The Cambridge report identifies numerous constraints to supply, investment and demand in the market for specialised housing for older people. 

One of the study’s key findings  is that retirement community development is unviable in many areas outside of London and the South East of England.

“Coupled with the fact that the majority of house moves made by older people are relatively local, this constraint to supply reduces housing options for those living elsewhere in the country, particularly home owners who do not qualify for assistance with housing costs. Unless the viability of retirement community development can be improved and the supply of mid-range retirement properties be raised, these households will have very little choice around moving in later life.”

Among the recommendations in the Cambridge report are calls for national government to provide a clear vision about housing for people as they age:

“For example, greater clarity is required around the joint priorities of ‘downsizing’ and ‘ageing in place’, and how these priorities can be best implemented at the local level.”

The report also recommends that local authorities should give priority to housing for older people, through the creation of clear strategic and local plans and guidelines for developers:

“Collaboration between local authority planning, social care, health and housing teams could allow for better planning around retirement housing. For example, retirement housing may make savings possible within health and social care budgets.”

The Cambridge report encourages housing providers to diversify the retirement housing offer, and to gain a better understanding of preferences of different older people:

“Rather than drawing on stereotypes of old age, providers face the challenge of recognising older people as a complex and heterogeneous group of consumers with diverse aspirations.”

Closing the generational divide

According to a report by the Intergenerational Foundation (IF), England now has two housing nations: the first is older, well-housed, often well-off, with space to work and self-isolate; the second nation is younger living in cramped flats or shared homes with little or no access to outside space.

The IF says that the pandemic has exacerbated housing inequalities between the young and the old, and observes that “…while younger generations have lost their jobs, their homes and even their mental health during COVID-19, older generations have stockpiled space.”

The report also highlights a rise in the number of second homes as a consequence of the pandemic.  There are now 5.5 million second homes in England – a 50% increase between 2011 and 2020 – most of them owned by older people.

Space inequality has also increased. Owner-occupied homes have a third more space on average than privately rented homes, and almost double the space as social housing.

Like the previously mentioned reports, the IF calls for market failures on retirement housing to be addressed. It recommends reform of stamp duty to encourage downsizing, and reforms to the planning system both to give a greater voice to the homeless and badly housed and to encourage developers to build more retirement homes.

Making a house a home: impacts of poor-quality housing

While some older people enjoy the benefits of good housing,  there are substantial numbers of people aged 50 and older living in poor-quality accommodation.

A report by the Centre for Ageing Better (CfAB) has found that living in cold, damp housing, or homes in a state of disrepair can increase the risk of illness and accidents. Poor housing also has wider impacts: first-year NHS treatment costs for over-55s living in the poorest quality housing are estimated at £513m.

But there are barriers preventing older people from making the improvements that would help them live healthier, more independent lives. These include a lack of finance and uncertainty about where to find trustworthy information about home improvements.

The CfAB report calls for a  wider range of financing options, including government grants and loans, to help older people adapt their homes. It also recommends clear signposting and advice to support informed decisions about home improvements, as well as initiatives to raise awareness about the impact of poor quality homes on health and wellbeing.

Final thoughts

The number of people aged 65 and over is set to rise from 12 million to more than 20 million by 2030. While poor quality housing presents risks for older people, age-appropriate housing can keep them healthy, help them to live independently and reduce the need for social care.

These reports highlight important issues that must be addressed not only to support older people, but to advance the radical changes needed to fix Britain’s broken housing market. Better housing for older people is better for us all.


The reports highlighted in this blog post have recently been added to The Knowledge Exchange (TKE) database. Subscribers to TKE information service have direct access to all of the abstracts on our database, with most also providing the full text of journal articles and reports. To find out more about our services, please visit our website: https://www.theknowledgeexchange.co.uk/

Further reading: more on housing for older people on The Knowledge Exchange blog

A nudge in the right direction? Using behavioural insights in health

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Behavioural insight is a term which has been increasingly heard across a range of policy areas worldwide in the past decade. Essentially it involves using a combination of psychology, economics and studies of behaviour and decision making to better understand how people react to specific interventions, and evaluating and learning lessons from the way people react to help decision makers to develop better, more effective policies.

Its application has been widespread in the USA and Europe. In the UK, first under the Conservative-Liberal Democrat coalition and then more recently under the Conservative administrations in the UK, the approach has gained increasing traction, with the establishment of a UK government “behavioural insights team”.

The Behavioural Insights Team, also known as The Nudge Unit, is now a social purpose company. It is partly owned by the Cabinet Office, employees and Nesta

The coronavirus crisis has posed a big challenge for those who need to be seen to be creating policies that protect and support the public. It has also been challenging for those trying to predict how people will respond, whether they will comply and how we can “nudge” the public to make what the government sees as “better” choices.

As well as informing steps to ease lockdown and the recovery from coronavirus, behavioural insights is being more widely applied to understand how people make choices in relation to their health, and how these can be applied to preventative health measures and health based inequalities.

Nudging as part of policymaking

Nudging as a technique has been used widely across a number of different policy areas, including criminal justice and education. Its application in relation to public health has been wide ranging and has had significant implications for health policy of previous governments.

Key policy areas in public health for the UK behavioural insight team include:

  • antimicrobial resistance
  • vaccination
  • obesity
  • mental health

Using behavioural insights across all of these areas, the idea is to develop an understanding of how people think about these topic areas as issues and how their behaviour is influenced by their own thoughts, patterns of behaviour and environmental factors like ease of access to services.

Techniques like direct incentives (such as vouchers in return for healthy behaviour), measures that restrict choice (like restricting takeaways from schools), and outright bans (such as the restriction on smoking in public places) are all interventions designed in one way or another to “nudge” us towards certain behaviours.

Steps like text message reminders for appointments, offering salads or fruit instead of fries as a side, or opt out organ donation are further examples of how behavioural science techniques are being applied to encourage people to make healthier choices and reduce the strain on health services.

Many of the steps being taken are designed not only to save time and money for the public and organisations delivering services, but also to help encourage early intervention and preventative action, a key focus of public health strategies in the UK.

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A crucial role to play in understanding vaccine rollout

Vaccination decisions can be a complicated and emotive process, but with the rollout of the coronavirus vaccine understanding the routes to uptake and how people make decisions on vaccination are more important than ever.

Behavioural scientists have been at the forefront of the vaccinations programme, looking to create a better and more thorough understanding of how to manage the rollout and develop an understanding of how people see the benefits and challenges of vaccination, both collective and individual.

The ‘Increasing Vaccination Model’ they say is a helpful framework for categorising the barriers to vaccination and possible behavioural interventions. The evidence indicates that closing the ‘intention–behaviour gap’ in vaccination behaviour by improving ease of access (and thus removing practical barriers to vaccination) is the most effective type of intervention. In contrast, focusing on motivation or educational interventions appears to be less helpful.

However, behavioural scientists have noted that in relation to the coronavirus vaccine even more barriers exist, with one survey reporting that 16 per cent of UK adults would ‘probably’ or ‘definitely’ avoid a COVID-19 vaccine. There is a suggestion that compressed development timelines, misinformation and media reporting could all undermine confidence and therefore uptake. Behavioural scientists are working hard to understand what steps could be taken to understand vaccine hesitancy and improve uptake across all communities in the UK and internationally.

Final thoughts

Behavioural insights, data analytics and “nudge” techniques have been part of policy making for the best part of ten years. They aim to help policymakers understand people’s reactions to policies and use this insight to help more effective policy in the future.

The coronavirus pandemic has presented a new and challenging opportunity for behavioural insights and has required them to apply their knowledge and understanding of how policy is applied and received like never before, with vaccine rollout being just one key area, along with other lockdown measures which require mass compliance in order to be effective.

How behavioural insights will continue to inform the recovery and public health strategies more widely remains to be seen, but it does appear that for the meantime at least, the “nudging” will continue.


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Multi-agency partnerships and the transformation of domestic abuse support

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Domestic abuse has been rising up the political agenda in the past few years. 2019 saw the appointment of the UK’s first Domestic Abuse Commissioner, and last month, the updated Domestic Abuse Bill was introduced to the UK Parliament (expecting to see Royal Assent in April 2021). But domestic abuse is still a widespread and endemic problem across the UK, with figures suggesting incidents across all areas of the country and across multiple demographic groups.

Often people who experience domestic abuse are difficult to identify and can struggle to engage directly with domestic violence support services. However, there is a growing recognition that knowledge sharing, and partnership working between statutory services, like housing or health teams, is vital to identifying and supporting victims and survivors in a timely and effective way.

Increasingly, the criminal justice system, health sector, social housing providers, charities, and local government have been attempting to work together to ensure that they are all able to respond effectively and provide the necessary support to domestic abuse victims and survivors.

The impact of lockdown

The most recent Crime Survey for England and Wales released by the Office for National Statistics (ONS) showed that an estimated 2.3 million adults aged 16 to 74 years experienced domestic abuse in the last year (1.6 million women and 757,000 men). Research published by the London School of Economics (LSE) after the first lockdown found that in London domestic abuse calls to the police increased by 11.4% on average, compared with the same weeks in 2019. The increase was, in a large part, due to an increase in calls from third parties not directly witnessing the incident, including neighbours or family members.

Similarly a report from Women’s Aid found that those delivering services needed to grapple not only with increased demand for support, but also with the challenge of delivering effective support in a different way as many services were only able to be accessed virtually.

Coordinated community responses transforming support for survivors

Organisations are becoming increasingly aware of the roles they can play in supporting people who experience domestic abuse and in the early identification of people at risk. Research also suggests that if someone is experiencing abuse, there is a high likelihood that they will also be experiencing other “needs”, which may cause them to come into contact with multiple services at once. Co-ordinating the response between services encourages organisations to share information to ensure consistency of care and experience; it can also help identify any gaps in support and allow for appropriate signposting and places the onus on the organisations, rather than on the person experiencing abuse.

Coordinated community response (CCR) approaches encompass the broadest possible response to domestic abuse; CCR addresses prevention, early intervention, dealing with crisis, risk fluctuation, and long-term recovery and safety, working with a wide range of services, pathways, agencies, and systems.

The fundamental premise of the CCR is that no single agency or individual can see the complete picture of the life of a family or individual within that family, but all may have insights and can provide interventions that are crucial to their safety and wellbeing. The CCR enables a whole system response to the whole person. It shifts responsibility for safety away from individual survivors to the community and services existing to support them.

The CCR is made up of 12 components: survivor voice; intersectionality; shared objective; structure and governance; strategy and leadership; specialist services; representation; resources; co-ordination; training; data; policies and processes. Taking a CCR approach provides communities with method for coordinating a response to domestic abuse. It places survivors at the heart of decision making and is an approach many frontline services can and do take when designing and implementing support services for people who have experienced domestic abuse.

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A pilot roll out for wrap around housing support

The Whole Housing Approach (WHA) to domestic abuse was first conceptualised in 2018 by the Domestic Abuse Housing Alliance (DAHA) in collaboration with the National Housing and Domestic Abuse Policy and Practice Group This approach aims: “to improve the housing options and outcomes for people experiencing domestic abuse so that they can achieve stable housing, live safely and overcome their experiences of abuse.”

The approach enhances how people who have experienced domestic abuse have control over their own lives, considers what they want to achieve and change, and offers interventions based on this. The key principles of the WHA are outlined as: safety; inclusivity; empowerment; accountability; and prevention, with 12 additional key components which make up the practical application of WHA programmes.

The initial WHA pilot project was delivered in three areas from October 2018 to the end of March 2020. Six specialist domestic abuse organisations, as well as a civil society organisation, have been working with 10 local authority areas, including in London, Stockton and Cambridgeshire to establish comprehensive and consistent housing practices and deliver a WHA.

A whole housing approach toolkit has been published which contains more information on the pilots, evaluations and analysis of the programme. The toolkit includes a dedicated section for each of the twelve components of the WHA. Each section can be read as a standalone toolkit that outlines key initiatives to help survivors achieve safety and stable housing. It offers practical guidance and resources to local areas to deliver a consistent WHA to domestic abuse.

Image Via DAHA

Final thoughts

While the landscape of domestic violence support is varied and is delivered in different ways by different agencies, there is a growing understanding of the practical steps which should be taken to ensure that partnership working and effective coordinated responses between services are offered to survivors of domestic abuse. It is clear that there is an appetite among those who work within frontline services to improve the availability of support. The ultimate aim of a coordinated response and a wraparound service to survivors of domestic abuse is achievable if current best practice and effective pilot schemes can be built upon, with additional funding and wider roll outs.


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Devolving health and social care in England: an opportunity to transform how we approach health and care?

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In recent years, the Department of Health and Social Care (DHSC) has increasingly encouraged the transfer of powers over health and social care in England away from central government and towards city regions. These bodies, DHSC argues, are uniquely placed to understand the challenges faced by their local populations, the capacities and expertise of their local NHS and to develop plans for the future. This should enable them to approach health at a local level, promoting increased delivery of care in the community, and a greater integration between health and care services.

Putting local places at the centre of “Build back better”

In August 2020 the Health Devolution Commission launched its final report, Building back health and prosperity. Among other themes, like taking a “health in all policies approach”, the report found that devolving accountability and power to a more local level creates the potential to understand communities and places better, and to meet their needs.

The NHS Long Term Plan has also outlined a new direction for the NHS based on the principle of collaboration rather than competition, and the introduction of new structures such as Integrated Care Systems, Integrated Care Providers and Primary Care Networks. These partnerships bring health and social care commissioners together to plan and deliver integrated and person-centred care.

In the context of “building back better”, awareness of how our external experiences and contexts impact our health and wellbeing (for example the impact of poverty, deprivation, housing, and unemployment) is increasingly important.

Beyond the immediate recovery from the pandemic, health devolution could be one way of opening up the possibility of integrating not just disparate services within the NHS – or even NHS and social care services in a locality – but bringing together in a combined strategy and structure all of the services, systems and partners in a community that have an impact upon the health of a local population, and the care services to better meet their health needs.

“It doesn’t have to be a battle”- partnerships and balance are the key to effective devolution

The move away from centralised processes and organisations towards more local ones can sometimes be portrayed as a rejection or an attempt to “break free” from central government. However, practitioners have been increasingly stressing that devolution does not mean complete independence, and that while improved local decision making will improve outcomes for local people, that does not mean that the need for some centralised decision making is completely removed.

On the contrary, some decisions should and will be taken at a national level, but the ability to distribute power, decision making and accountability to a local level will have significant positive impacts for improving “citizen voice”, transparency and co-production in decision making.

This is where the Health Devolution Commission argues that balance, communication, and partnership between the local and national infrastructure needs to be aligned so that devolution can be successful and sustainable. Integrated planning and management of long-term health care strategies is important, as is the ability to bring citizens and local decision makers into discussions about national health policy.

The Voluntary, Community and Social Enterprise (VCSE) sector, including patient voice and carers organisations, also plays an important role in linking together services and communities. As well as partnering to deliver services, these organisations also often offer vital bridges between statutory systems and those communities which can often be excluded from engagement with services or who can find it harder to access them. The commission also emphasised the importance of bringing these bodies into the conversation on devolution going forwards as they will be invaluable partners in the process.

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DevoManc providing the blueprint?

In 2016, as part of a pilot, control of the health and social care budget for Greater Manchester was transferred to a partnership team in the area comprising local authorities, clinical commissioning groups, NHS foundation trusts and NHS England.

The combined authority identified that the health of its population was one of the key obstacles to its economic growth. By relating the concept of regional economic prosperity with health, they began to see health in a completely different way – as part of a wider plan and an investment for growth, not a burden.

“It’s better to have decisions made locally, because local people understand what local problems are and what Greater Manchester needs. We need to work together.”

Lord Peter Smith, Chair of Greater Manchester Health and Care Board

The Greater Manchester Health and Social Care Partnership are working in partnership with other sectors including education and housing to support everything from good eating habits and exercise to education and everyone’s ability to earn a decent living. The partnership is taking action to give children the start they need, support independence in old age, tackle illness earlier on and even prevent it altogether by improving the lifestyles of local people.

Other areas of England are also currently undertaking their own health devolution journeys, including London, West Yorkshire and Harrogate, as well as some other combined authority areas. However, one of the big challenges is that currently, while we can learn from the experiences of those already on their devolution journey, there is no common, consistent or comprehensive understanding of what good heath devolution looks like, full evaluations of the benefits it brings or overarching strategies on how it should be developed.

This is something that will need to be addressed if health devolution is to be successfully rolled out across England.

Final thoughts

Devolution of health to a more local level provides an opportunity to tackle the big public health challenges of our time at source, and to create a better, more joined up community health ecosystem. It also provides the chance to share and collaborate, learning from best practice and delivering improved health and social care services at a regional and national level.

It has been suggested that the coronavirus pandemic, while traumatic in more ways than one for the NHS and its staff, may provide the re-setting point needed to implement some of the changes proposed in relation to greater health devolution. Proponents of this view argue that improved funding to support effective and high quality care, improved integration between health and social care, and greater positioning of health and assessment of the impact of decisions on health across all policy areas, should be among the top priorities as the country looks to recover from the pandemic.

As the Health Devolution Commission underlines:

The pandemic has shown we cannot go back to the way things were. We need a ‘new normal’ and we believe that comprehensive health devolution is the only viable solution to the challenges the country now faces.”


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“The infrastructure of everyday life” – has the time come for the foundational economy?

The last few years has seen growing interest in what has been termed the ‘foundational economy’ and its potential value for achieving economic security and social sustainability. Accounting for around 44% of UK employment, it has been argued that supporting this section of the economy could ultimately improve productivity. And the current pandemic has placed even more emphasis on the importance of the foundational economy – the part of the economy that cannot be shut down.

What is the foundational economy?

The foundational economy provides universal basic services built from the activities which provide the essential goods and services for everyday life, regardless of the social status of consumers. Primarily delivered locally, these goods and services encompass infrastructures, utilities, food, retailing and distribution, education, health and welfare. Because of this, it is thought to have considerable potential to regenerate the areas where the local economy is relatively weak – perhaps the perfect solution for the levelling up agenda?

The initial manifesto for the foundational economy from researchers at the University of Manchester resulted from dissatisfaction with generic industrial and regional policy focused on promoting competition and markets; with success measured in terms of job creation and GDP growth. According to the manifesto, the foundational economy is “the mundane production of everyday necessities” which is taken for granted by all members of the population. As such, it is often also referred to as the ‘sheltered’ or ‘invisible’ economy.

Scale and value

In providing the infrastructure for everyday life, the foundational economy is also very large. It has been noted that in all European countries, it directly employs around 40% of the workforce. In the UK, around 44% of the workforce is employed in foundational activities. In Germany, it is 41% and Italy it is 37%. The value of foundational output and volume and diversity of foundational employment is therefore much larger than in high-tech and tradeable services, with which policymakers are determinedly focused on.

Other measures of value have also been highlighted, such as household expenditure. The initial manifesto notes the importance of weekly spend on the foundational economy with nearly 30% of all household expenditure going on foundational activities.

Despite providing vital services, and employing a significant portion of the UK population, the foundational economy is marked by low-tech, low-wage, part time and often precarious employment and is potentially at risk from automation, despite the significant ‘human’ element to many of the different job roles which make up this part of the economy. Within society a lot of foundational jobs are still considered by many (often who don’t work in the sector) to be “jobs you move on from” where in reality, for many people, particularly women and migrant workers, this isn’t the case.

But where would we be without these roles providing for all citizens’ basic needs? Job creation and GDP growth may suggest a successful economy but this, it is argued, does not show the wellbeing of all society or sustainability. In the face of current, and indeed future, crises, it seems perceptions may be starting to change as more and more people become concerned with health and wellbeing and the environment. Indeed, it has long been argued that necessity is only recognised in times of crises.

Has Covid-19 shone a vital light on the foundational economy?

While many sectors were shut down due to the coronavirus pandemic, the foundational economy remained open as it was considered systemically important for meeting basic needs. The pandemic has highlighted that this part of the economy is needed at all times, including at times of crisis.

Healthcare staff have become frontline heroes and food delivery drivers are recognised as key workers. But this enhanced status has also highlighted the poor pay and conditions of many key workers delivering these essential goods and services and the inherent inequality that exists in society.

Just like other crises, from natural disasters to large scale economic shocks, these bear most heavily on the poor and vulnerable. The pandemic has shown that these inequalities must be addressed so that basic everyday services are more equally available.

The pandemic has also shown that economies are about more than market economies. It has been argued that there needs to be a move towards meeting a population’s basic needs rather than on individual consumption.

Way forward

Advocates of the foundational economy argue that public policy should focus on securing the supply of basic goods and services for all citizens in a socially responsible way.

The 2020 manifesto for the foundational economy from The Foundational Economy Collective argues for the renewal of the foundational economy with a ten-point programme, including proposals related to:

  • better health and care
  • housing and energy
  • food supply
  • social licensing
  • tax reform
  • disintermediation of investment from pension funds and insurance companies
  • shorter supply chains in foundational commodities
  • citizen engagement
  • better technical and administrative capacity at all levels of government
  • international constructive responsibility

It has been widely agreed that a return to business-as-usual approach following the pandemic is not the way forward and that there needs to be a shift in economic policies in order to achieve a more socially and economically just society. Perhaps if such policy change is achieved, a more balanced economy that provides a good quality of life for all can eventually be realised.


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Healthy ageing: how health inequality can be tackled at the local level

Image: Peter Kindersley via Centre for Ageing Better

Older people make up a significant portion of our population, and projections show the proportion of people over the age of 60 within the global population is set to rise even further over the coming years. ONS data shows by 2066 there will be a further 8.6 million projected UK residents aged 65 years and over, taking the total number in this group to 20.4 million and making up 26% of the total population.

Supporting people to age well, and age healthily is something which both local and national policymakers will have to take account of in order to not only ensure good quality of life for their ageing populations but also ensure that services are not overwhelmed.

Studies show the higher levels of deprivation people face in their earlier years, the more likely they are to enter older age in poor health and die younger compared with people who experience lower levels of deprivation. This highlights the need to tackle inequality across the life course, with the preventative action having a positive knock on impact on health inequalities in later life.

Some of the main drivers of inequalities include: social exclusion and isolation; access to and awareness of health and other community services; financial difficulties including fuel poverty and housing issues; insecure or low paid employment, with reduced opportunity to save or enrol in a formal pension to prepare for retirement; a lack of transport and distance from services; low levels of physical activity; and mobility or existing poor health, often characterised by long term chronic health issues.

These inequalities often combine and overlap to create even more challenging situations as people move into older life. More recent research has shown that the Covid-19 pandemic has only exacerbated these inequalities further.

Tackling inequalities at the local level

Alongside the national discussions around ageing, local demographic change has received comparatively less attention, despite place-based policies and concepts like “ageing well in place” being used in public health conversations for a number of years.

Research from the Resolution Foundation explores the intersection between demography and place, and its implications for politics and policy while further research is looking increasingly at local level case studies to highlight pockets of best practice which could help to inform the national approach.

A review from Public Health England looked at the specific experiences of older people in coastal and rural areas and the specific challenges they face in comparison to people living urban areas, exploring local level interventions and interventions which adopt a place- based approach, responding to the specific needs of people living in the area.

Other research in this area stresses that councils have a clear leadership role in supporting an ageing society and that they are uniquely placed to create strategies which reflect the needs of their populations. Through local engagement of older people systematically and regularly, and through co-production and co-design in the production of local policies and services, councils are in a position to underpin a more positive outlook on ageing, ensuring that older people are regarded as full citizens, rather than objects of charity or pity.

Approaches to poverty reduction in Greater Manchester

In Greater Manchester, healthy ageing and age inequalities have been made mayoral priorities and the Greater Manchester Combined Authority set up the Greater Manchester Ageing Hub to respond to what policymakers there see as the opportunities and challenges of an ageing population.

In 2018 the city published an “Age Friendly Strategy” to promote increased social inclusion within the city by trying to tackle the barriers to inclusion created by poverty and inequality, including creating age friendly places which allow older people to participate within their local communities, and promoting healthy ageing through strategies like GM Active Ageing, a partnership with Sport England.

Image: Peter Kindersley via Centre for Ageing Better

Creating a consensus on healthy ageing

The Centre for Ageing Better and Public Health England established 5 principles for healthy ageing which they are urging government and other policy actors to adopt to support future healthy ageing the five principles are:

  1. Prevention
  2. Opportunities
  3. Good homes and neighbourhoods
  4. Narrowing inequalities
  5. Tackling ageism

These principles can be used as building blocks to help organisations create strategies and policies which accurately reflect the core needs of people as they age. One thing which continues to be a challenge, however, is integrating intersectionality into both research and strategies or frameworks on ageing.

Not treating “older people” as one homogenous group, but taking account of the individual experiences of specific groups and how this may impact on their experience of inequalities: this is something researchers are making efforts to resolve in their work, and while there are limited studies which look specifically at BAME or LGBT groups, in the future taking account of intersectionality in ageing and inequalities will become more commonplace.

The future of ageing

We are living longer than ever before. Taking steps to reduce inequalities and support healthy ageing will ensure that those extra years are fulfilling, both for the individual and for society.

Helping people to continue to contribute to society, to really live into old age, embrace and enjoy it and not just exist in old age should be a priority for everyone, Reducing inequalities to support people to age well will be a major contributor to ensuring this happens.


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Cross-border handshakes: what’s next for digital contact tracing?

As we enter a new year, and a new phase of the Covid-19 pandemic, we are reminded of the need to follow public health advice to stop the spread of the virus. The emergence of new variants of Covid-19, which appear to be more transmissible, has resulted in tougher restrictions across the world. Although the emergence of new variants of Covid-19 can seem frightening, we are not powerless in preventing the spread of the virus; face coverings, social distancing, regular handwashing and self-isolating remain effective.

Additionally, the development and subsequent roll-out of numerous vaccines should provide us all with hope that there is light at the end of the tunnel. However, although vaccines appear to protect people from becoming seriously ill with the virus, there is still uncertainty regarding the impact vaccines will have on viral transmission of Covid-19.

Therefore, the need for those with symptoms to self-isolate, get tested and undergo contact tracing when a positive case is detected is likely to remain. This will become even more important in the months ahead, as we see the gradual re-opening of hospitality, leisure and tourism sectors.

Effectiveness of contact tracing

Contact tracing is a tried-and-tested public health intervention intended to identify individuals who may have been in contact with an infected person and advise them to take action that will disrupt chains of transmission. Prior to Covid-19, contact tracing was often used to prevent the spread of sexually transmitted infections, and has been heralded as vital to the eradication of smallpox in the UK.

According to modelling, published by the Lancet Infectious Diseases, a combination of self-isolation, effective contact tracing and social distancing measures, may be the most effective and efficient way to control the spread of Covid-19.

However, for contact tracing to be at its most effective, the modelling estimates that for every 1,000 new symptomatic cases, 15,000 to 41,000 contacts would have to be asked to self-isolate. Clearly, the logistical burden of operating a manual contract tracing system is high. As a result, governments have chosen to augment existing systems through the deployment of digital contract tracing apps, which are predominantly built using software developed by Apple and Google.

Digital contact tracing

As we go about our day-to-day lives, especially as restrictions are eased, it may not be possible to name everyone you have encountered over the previous 14 days if you later contract Covid-19. Digital contact tracing provides a solution to this issue by harnessing the Bluetooth technology within our phones to help identify and remember potential close contacts. Research by the University of Glasgow has found that contact tracing apps can contribute substantially to reducing infection rates when accompanied by a sufficient testing capability.

Most countries have opted to utilise a system developed by Apple and Google, known as Exposure Notifications, as the basis for digital contact tracing. Public health authorities have the option to either provide Apple and Google with the criteria which defines when an alert should be generated or develop their own app, such as the Scottish Government’s Protect Scotland.

Exposure notification system

In order to protect privacy, the exposure notification system can only be activated by a user after they have agreed to the terms; the system cannot be unilaterally activated by public health authorities or Apple and Google. 

Once activated, the system utilises Bluetooth technology to swap anonymised IDs with other users’ devices when they come into close contact. This has been described as an anonymous handshake. Public health authorities set what is considered as a close contact (usually contact at less than a 2-metre distance for over 15 minutes), and the app calculates proximity measurements over a 24-hour period.

Anonymised IDs are not associated with a user’s identity, change every 10-20 minutes and collected anonymised IDs are securely stored locally on user devices for a 14-day period (incubation period of Covid-19) before being deleted.

If a user tests positive for Covid-19, the public health authority will provide them with a code that confirms their positive diagnosis. This will then provide users with an option to upload collected anonymous IDs to a secure public health authority server. At least once a day, the user’s phone will check-in with this server to check if any of the anonymised IDs collected in the previous 14-days match up with a positive case. If there is a match, and the proximity criteria has been met, a user may receive a notification informing them of the need to self-isolate.

Analysis conducted by the National Institute for Health Research highlights that the use of contact tracing apps, in combination with manual contact tracing, could lead to a reduction in the number of secondary Covid-19 infections. Additionally, the analysis revealed that contact tracing apps identified more possible close contacts and reduced the amount of time it took to complete contact tracing. The analysis concluded that the benefits of digital contact tracing include the ability to trace contacts who may not be known to the infected individual and the overall reliability and security of digitally stored data, rather than an individual’s memory or diary.

Therefore, it could be said that digital contract tracing apps will be most effective when restrictions ease and we are more likely to be in settings where we may be in close contact with people we may not know, for example, when we’re on holiday or in a restaurant.

Cross-border handshakes

Covid-19 naturally does not respect any form of border, and as restrictions on domestic and international travel are relaxed, opportunities will arise for Coivd-19 to spread. In order to facilitate the reopening of the tourism sector, there have been calls for countries which have utilised the Exposure Notification system to enable these systems to interact.

Examples of interoperability already exist internally within the UK, as an agreement exists between Scotland, England and Wales, Northern Ireland, (plus Jersey, Guernsey and Gibraltar), that enables users to continue to receive exposure notifications when they visit an area they do not live in, without the need to download the local public health authority app.

EU Exposure Notification system interoperability, European Commission, 2020

Additionally, the European Union has also developed interoperability of the Exposure Notification system between member states, with a commitment to link 18 national contact tracing apps, establishing the world’s largest bloc of digital contact tracing. The EU views the deployment of linked apps as vital to re-establishing safe free movement of people between member states, for work as well as tourism.

Over the next few months, it is likely that links will be created across jurisdictions. For example, the Scottish Government has committed to investigating how interoperability can be achieved between the Scottish and EU systems. The interoperability of Northern Ireland and Ireland’s contact tracing app highlights that on a technical level there appears to be no barrier for this form of cross-jurisdiction interaction.  

Therefore, as restrictions ease, the interoperability of digital contact tracing apps may become a vital way in which to ensure safe travel, as we learn to live with the ongoing threat of Covid-19.

Final thoughts

Covid-19 has proven itself to be a persistent threat to our everyday lives. However, the deployment of effective vaccines provides us with hope that the threat will be minimized soon. Until then, the need to utilise contact tracing is likely to remain.

As the roll-out of mass-vaccination programmes accelerates, and restrictions are relaxed, we are likely to be in more situations where we will be in contact with more people, not all of whom we may necessarily know. This will be especially true as domestic and international tourism begins to re-open. In these scenarios, the Exposure Notification system, and interoperability between public health authority apps, will become increasingly vital to the operation of an effective contact tracing system.

In short, digital contact tracing may prove to be key to the safe re-opening of the tourism sector and enable users to easily and securely be contact traced across borders.


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Further reading: articles on COVID-19 and digital from The Knowledge Exchange blog

Why are we still talking about healthy places?

In recent years, there has been a wide ranging debate across the housing, planning, health and infrastructure sectors about the development of healthy places in both regeneration and newly approved projects.

In 2016, Town and Country Planning Journal published an article on building health and wellbeing into the built environment (Town and Country Planning, Vol 85 No 11 Nov 2016, Knowledge Exchange customers can login to view the article here) In 2017 and 2018 the talk was all about healthy towns initiatives, and a Design Council report in 2018 looked at the relationship between healthy placemaking and the impact on our communities. In 2019 the Town & Country Planning Association (TCPA) called on members to “reunite” health and planning

It is clear that everyone involved in placemaking agrees building places that promote health and wellbeing for all is of vital importance to our communities, The Covid-19 pandemic brought this into sharp focus, and the idea remains at the forefront of design policy, particularly in urban city contexts. But, over four years after the initial conversations and thought pieces, why are we still talking about it, and what actions still need to be taken to integrate the idea of a healthy place into planning to the extent that it just becomes the norm in the planning and design of our places?

Preventing avoidable disease

The phrase ‘healthy placemaking’ has been defined by Design Council as: “Tackling preventable disease by shaping the built environment so that healthy activities and experiences are integral to people’s everyday lives”.

Public Health England defined healthy placemaking as: “Placemaking that takes into consideration neighbourhood design (such as increasing walking and cycling), improved quality of housing, access to healthier food, conservation of, and access to natural and sustainable environments, and improved transport and connectivity”

Research has shown preventable diseases linked to lifestyle and environment are among the most significant threats to public health. Lifestyle-related conditions like heart disease and cancer, as well as being health problems in their own right, can also contribute to the development of other chronic conditions, exacerbate symptoms and create complications with care which are costly to the NHS.

Creating healthy spaces is not just about encouraging people to live more active lifestyles by facilitating active travel and improving the environment around buildings, although this is a significant part of it. “Healthy places” include approaches to improve air quality, reduce loneliness, allow people to age well in place, promote mental as well as physical wellbeing, reduce deprivation and inequality through projects like housing, infrastructure development, and high street regeneration.

Healthy places also have a preventative role to play in public health management, not just a health improvement role; such interventions are essential to help avert the onset of disease, improve people’s quality of life and reduce health inequalities. And evidence shows the return on investment from public health interventions is high and creates value of different kinds – economic, social and personal.

In short people who live in healthy places, tend to live healthier lives, place less strain on services and “contribute” more to society, both economically through work or spending and socially through community engagement.

Victoria Park, Belfast. Image: Fiona Ann Paterson

Enabling planning practitioners to think about creating healthy places

Research published in 2020 by the Royal Town Planning Institute (RTPI) explored local, national and international planning practices that enable the creation and delivery of healthy places. While a lot of research draws attention to the barriers to building healthy places – including a lack of funding, different requirements from developers and conflicting policy priorities – the RTPI report instead sought to identify important challenges faced by planners who try to integrate healthy placemaking principles in their decisions and then offer potential solutions to these in practice. Key themes emerging from the report include a need to improve collaboration, knowledge sharing and the skills of planners.

The report provides case studies looking at: the place standard tool; the livewell development accreditation; connecting communities in Tower Hamlets; health planning in South Worcestershire; and train station district rejuvenation in Grasse, France. It also identifies seven steps to plan for healthier environments

Across the sector there have been calls for planners to be allowed to be innovative, creative and take a “visionary” approach to planning to help make places healthier in order to address the convergence of challenges around public health, the climate emergency, and economic recovery from Covid-19.

How has the coronavirus pandemic changed how we think about healthy spaces?

The lockdowns  imposed as a result of the coronavirus pandemic have thrown the importance of quality space into sharp focus. Places that facilitate health and wellbeing among the people who live there, and places where the indoor living quality is as important as the outdoor space have become incredibly important.

The pandemic has highlighted what it really means to have a healthy space. It has also demonstrated how wider socioeconomic deprivation and inequality – linked to living conditions as well as other factors – is having an impact on infection and hospital admission rates, with those groups who live in more deprived areas being found to be at a higher risk of becoming seriously ill or being admitted to hospital with Covid-19. 

The 2018 Design council report found in its survey of practitioners that focus was given far more to outdoor space than to indoors, as it was easier and more cost effective to make changes that could produce demonstrable impacts (an increase in cycling, for example). But the pandemic and the increased time we have been forced to spend indoors has encouraged designers and urban planners to think even more creatively about quality space in their developments.

Where now?

Public Health England (PHE) which for many years was a strong voice in the conversations around healthy placemaking has been disbanded and will be replaced by a National Institute of Health Protection. It remains to be seen how, or if this new organisation will fit into the conversation going forward. But reflecting on recent reports on the significant public health crisis facing the UK in the long term, it is clear that the work must continue, driven collectively by those in planning, urban design and public health.


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The year of living differently: reviewing The Knowledge Exchange blog in 2020

2020 has been a year like no other. A microscopic virus – 10,000 times smaller than the width of a human hair – has dominated, disrupted and redefined the way we live and work.

Although the pandemic is primarily a public health emergency, its effects have been felt in all areas of public and social policy, from economic development and employment to transport and the environment. Throughout this year, our blog has reflected on the impacts of the coronavirus and the restrictions introduced to prevent its spread.

The COVID-19 knock-on

While the coronavirus pandemic has dominated the news headlines, it has also obscured the knock-on effects on the NHS. In October, we reported on the impacts of delays to preventative healthcare measures, such as screening and routine medical care in the form of pre-planned operations for long-term chronic and non-urgent conditions.

As the blog post noted, the impacts have been wide-ranging, including not only delays in care for case of physical ill health, but also for those seeking treatment for mental health conditions:

“Research suggests that incidence of mental illness during the coronavirus pandemic increased. However, the numbers of people accessing services and being referred for treatment have not increased proportionate to this.”

The ‘hidden epidemic’

Long before the coronavirus pandemic, domestic violence had become known as a ‘hidden epidemic’ in the UK. In September, our blog highlighted the unintended consequences of quarantine for domestic abuse victims.

After the UK entered lockdown in March, calls and online enquiries to the UK’s National Domestic Abuse line increased by 25%. Three-quarters of victims told a BBC investigation that lockdown had made it harder for them to escape their abusers and in many cases had intensified the abuse they received.

Despite additional government funding, the local authorities and charities which support victims of domestic violence have been struggling with the financial fallout from the pandemic. Even so,  important partnerships have been formed between local government, educational institutions and third sector bodies to provide safe spaces for women and their children fleeing violence. Among these was an initiative at the University of Cambridge:

St Catherine’s College formed a partnership with Cambridge Women’s Aid to provide over 1000 nights of secure supported accommodation during the lockdown period.

‘Same storm, different boats’

As the recent Marmot review has stressed, the coronavirus pandemic has exposed and deepened many of the deep-rooted inequalities in our society, including gender, ethnicity and income.  It has also shone a light on more recent inequalities, such as the growth of precarious employment among sections of the population.

In July, we looked at the uneven economic impact of the pandemic, focusing on the heavy price being paid by young people, women, disabled people and Black and Minority Ethnic (BAME) communities.

Women often work in the frontline of care services and have had to juggle childcare during lockdown. BAME communities are over-represented in key-worker jobs, and so were particularly vulnerable to coronavirus.

And although there has been much talk about ‘building back better’, our blog post drew attention to the observations of Dr Sally Witcher, CEO of Inclusion Scotland during a Poverty Alliance webinar:

“She asks whether indeed we should want to build back, when the old normal didn’t work for a large proportion of people, particularly those with disabilities. Dr Witcher also questions ‘who’ is doing the building, and whether the people designing this new future will have the knowledge and lived experience of what really needs to change.”

The impacts of a pandemic

Many other aspects of the impact of COVID-19 have been covered in our blog:

  • How housing providers have embraced the fluidity of an emergency situation, including tackling homelessness, engaging effectively with tenants and addressing mental ill health.
  • Digital healthcare solutions for those with coronavirus and for the continuity of care and day-to-day running of the NHS.
  • Creating and managing a COVID-secure workplace.
  • How COVID-19 is changing public transport, including an acceleration towards contactless payment and mobile ticketing.
  • The additional challenges of the pandemic facing autistic children and young people.
  • The impact of the coronavirus restrictions on the arts.
  • The role of green new deals in tackling climate change and economic inequality as part of the post-Covid recovery.

Beyond the virus

Although the pandemic has been at the forefront of all our minds this year, The Knowledge Exchange blog has also taken the time to focus on other important issues in public and social policy:

We’ve also taken advantage of the ‘new normal’ experience of remote working to join a number of webinars, and to report back on the observations and ideas emerging from them. Most recently, our blogs have focused on a series of webinars organised by Partners in Planning, which included contributions on how the planning system can help address climate change.

Final thoughts

The health, economic and social impacts of the pandemic are likely to be long-lasting – restrictions on travel, work and socialising will continue into the spring, and insolvencies and unemployment numbers are likely to rise. And the continuing uncertainty over the UK’s new trading relationship with the European Union will generate additional challenges.   

But, as a frequently difficult, often challenging and sometimes distressing year draws to a close, there is cause for optimism about 2021. Vaccines to prevent the spread of the virus have been developed with lightning speed. Across the UK people are already being vaccinated, with greater numbers set to receive the jab in the coming months.

Here at The Knowledge Exchange, we’ll continue to highlight the key issues facing public and social policy and practice as we move towards the post-Covid era.

Season’s greetings

It’s with even greater meaning than ever before that we wish all our readers a happy Christmas, and a healthy, prosperous and happy new year.

Best wishes from everyone at The Knowledge Exchange: Morwen, Christine, Heather, Donna, Rebecca, Scott, Hannah and James.


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Virtual reality: a game changer for mental health treatment?

Photo by fauxels on Pexels.com

Demand for mental health treatment in the UK far outstrips supply. And the outbreak of COVID-19 has forced many primary care services to think creatively not only about demand and supply, which has increased further during the pandemic, but also about delivery. GPs and community mental health teams in particular are thinking about more innovative ways to deliver remote support to people with mental health conditions, including the use of Telehealth and virtual reality (VR) platforms.

People are probably most familiar with VR in a digital gaming context, with devices like Oculus headsets offering immersive gaming experiences where players can place themselves “in the game”, but it has been suggested that integrating VR, alongside other telehealth options like apps and videoconferencing into mental health consultation and treatment could make counselling and alternative treatment options more accessible to those living and working remotely. Early research suggests that while discussions about investigating the benefits of this type of delivery of care have been accelerated by the coronavirus pandemic, researchers and practitioners were already beginning to explore how VR and Telehealth could be a tool that could be utilised more regularly in the treatment and engagement of people with mental health conditions, not just during periods where face to face contact is a challenge.

Blended treatments to help improve outcomes

Telehealth encompasses a number of different approaches and techniques, including using platforms like skype for mobile conferencing, or mobile apps to help people manage conditions and to help deliver some treatment options. It has previously been used in other areas of medicine, for example to help those with chronic conditions self-manage, with various levels of success and uptake.

One foundation embracing remote mental health support, even before the arrival of coronavirus, is Greater Manchester mental health foundation trust who use a mobile app called ClinTouch, to support people recovering from psychosis, schizophrenia and bipolar disorder. Although patients will typically see a care co-ordinator monthly, symptoms of a relapse can appear within days; with the app, users are asked how they feel a few times a day, and an alert is generated if a relapse looks likely.  Some NHS organisations have also adopted telepsychiatry – videoconferencing therapy sessions. 

Using VR for remote therapy almost takes telehealth a step further, and involves using a complete virtual environment, with the potential for this to be integrated into treatment plans, so clinicians can, for example, create a setting which looks like the inside of their office, or use virtual environments to model external scenarios that may cause anxiety to help patients practice coping techniques like breathing exercises.

One of the potential extended uses for VR and telehealth in a clinical mental health treatment setting which has emerged is its application for rural populations, or for people who are isolating because of exposure to coronavirus. However, this has raised some additional questions about the potential barriers to uptake exacerbated by digital illiteracy and poor access to digital devices, as well as the problem of poor or slow internet connections, something which will need to be considered by health boards if they decide to offer these treatment options.

Photo by cottonbro on Pexels.com

More research is needed, and is being done

While recent research has shown face-to-face therapy remains the optimal treatment method in mental health care, VR-based therapy has been found to be more effective than Skype-based or phone only counselling. The research also suggests VR-based Telehealth sessions could improve engagement, compared to phone only sessions and greatly reduce dropout rates for clients which in turn can support positive clinical outcomes. It appears the general consensus is that self-service, VR and automated technology, in the form of apps and notifications could support and augment healthcare professionals and help support the delivery of more traditional approaches.

The virtual reality lab at the NIHR-Wellcome Trust-King’s Clinical Research facility aims to improve the understanding of the mechanisms that play a role in the onset and maintenance of mental health problems. They use virtual reality environments to assess and develop treatments to improve the well-being of people with mental health problems.

Research is also being done on the specific reaction to young people of engaging with digitally driven treatment options. There are some suggestions that the delivery of digital interventions to support young people with mental health problems may help them to engage more, in part because they are more familiar with digital platforms and may feel more comfortable using them day-to-day, however there is also a suggestion that young people also prefer the feeling of “distance” and “impersonality” that a digital platform provides which can lead to some feeling more able to express how they are really feeling, compared to a face to face meeting with a clinician which can sometimes be a stressful and intimidating experience.

Where next?

So far in clinical psychology and psychiatry, the primary focus of VR has been its role in treating anxiety and stress-related disordersspecific phobiaspanic disorder, and post-traumatic stress disorder. However the disruption to face to face mental health treatments caused by the coronavirus pandemic has led to clinicians thinking even more creatively about the applications of VR and telehealth options to help support the treatment of people with a wider range of mental health conditions.

While it is clear that virtual treatments should not replace the face to face consultation in mental health treatment entirely, research suggests there is a growing role for VR and Telehealth options in augmenting face to face treatment options and that they could be offered as an option for those who are unable to attend face to face sessions. Telehealth and remote treatments are something which will continue to be explored beyond the coronavirus pandemic and could soon be integrated into practice as part of the standard delivery of mental health care and treatment.


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