Time for different thinking: housing need, policy and practice for people living with dementia and older people in Scotland

Abstract

Purpose

This paper aims to examine housing need for older people and people with dementia, with reference to Scotland. This paper also examines policy responses and tensions arising from such need and looks critically at the evidence of care needs and what older people want in relation to later life conditions, including dementia.

Design/methodology/approach

Taking the Being Home: Housing and Dementia in Scotland report (2017) as a baseline descriptor, the authors have collated evidence from a range of sources to help them examine what has changed in terms of policy, practice and population ageing. Set against this backdrop, using desk-based analytical methods, the authors interrogate existing planning processes and systems in Scotland.

Findings

Scottish Spatial Planning has a policy blindness on the overwhelming evidence of the housing needs derived from an ageing population. Policy focus is geared towards the amount of housing supplied, rather than appropriate types of housing, leaving older people with little choice of suitable accommodation. A key area to improve is in establishing greater co-operation and policy synthesis between health, social, housing and planning functions. Broad policy ambition must be transferred into detailed reality for older people and people with dementia to benefit.

Originality/value

The integrated approach and in-depth analysis, linked to planning policy and housing need, is highly original and much needed.

Citation

Tolson, D., Ritchie, L., Smith, M., Brown, M.M. and Tolson, S. (2023), "Time for different thinking: housing need, policy and practice for people living with dementia and older people in Scotland", Housing, Care and Support, Vol. 26 No. 2, pp. 41-52. https://doi.org/10.1108/HCS-10-2021-0028

Introduction

Housing matters throughout life but becomes inextricably linked with care needs in old age. Global predictions suggest that the proportion of people aged 60 years or more will almost double from 2015 to 2050, rising from 12% to 22% (World Health Organisation, 2021). There are over 55 million people living with dementia worldwide (World Health Organisation, 2020).

Scotland’s population is ageing. The number of people aged 65 and over is projected to grow by 29.7% by mid-2045, from 1.06 million to 1.37 million – an estimated increase of 310,000 people. Over the same period, it is estimated that Scotland’s population will decline by 1.8%, with 90,000 fewer people. Scotland is the only one of the four UK nations with a projected declining population. Importantly, the working population is projected to decrease at a time when the older population is increasing creating potential additional stress on the provision of care (National Records of Scotland, 2022).

Currently, there is an estimated 90,000 people in Scotland living with dementia. Dementia is one of the most feared and prevalent later life conditions, associated with inequalities, and is a global health priority (Alzheimer Scotland, 2019; Barbarino et al., 2021). Dementia is a condition that has greatest impact as people age, as the risk rises with each decade.

Housing is a social determinant of health and well-being (Rolfe et al., 2020; Public Health Scotland, 2021). The Scottish Government’s ambition is that “[…] everyone will have a safe, high-quality and affordable home that meets their needs in the place they want to be” (Scottish Government, 2021a, p. 15). For people living with dementia, this includes support to live within their family home for as long as possible (Alzheimer Europe, 2018). In 2020, The World Alzheimer Report stated that enabling people living with dementia to age in place and avoid or defer entry into long-term care “[…] requires appropriate housing options in the community, in combination with home and social care […]” (Fleming et al., 2020a, p. 15). The challenge is how to translate this ambition into action.

With the exception of the Being Home report (Brown et al., 2017), there have been few rigorous analyses of housing or housing with care provisions for people with dementia living in Scotland. Amidst international calls for rights-based approaches and interventions that are wanted and timely (Tolson et al., 2016), we examine what has happened since Being Home – wrestling with policy contradictions, need and provision within Scotland.

Dementia as an illness experience

The World Health Organisation (2020) defines dementia as “[…] a syndrome in which there is deterioration in memory, thinking, behaviour and the ability to perform everyday activities”. Dementia is an umbrella term for a clinical syndrome associated with illnesses such as Alzheimer’s disease. Impairment of memory is common, alongside other cognitive deficits in language, comprehension and functional ability.

Dementia prognosis is imprecise, but it is recognised to be a terminal condition requiring dementia specific palliation (Hanson et al., 2019). For those diagnosed early, it is possible, with the right support, to live “well” and with relative independence. As the disease progresses, both brain and bodily health decline and dependency increases. Persons living with advanced dementia may live for several years with high levels of functional dependency, frailty and complex nursing care needs (Abreu et al., 2018).

Dementia-related design considerations

Since Marshall’s (1998) early work on design for dementia, much has been written about age and dementia-friendly design. Positive design principles and guidance promoting an enabling living environment is readily available, although the underpinning evidence for some guidance is variable (Brown et al., 2017). In terms of positive design principles in practice, Alzheimer Disease International’s 2020 World Alzheimer Report focusses on dementia-related design and outlines 84 case studies that demonstrate principles of dementia-friendly design (Fleming et al., 2020b). In a UK context, a 2021 report by the All-Party Parliamentary Group on housing and care for older people provides a series of case studies that demonstrate positive design for people living with dementia (Twyford and Porteus, 2021). The King’s Fund (2020) in collaboration with the University of Worcester, and the Dementia Services Development Centre (DSDC) at the University of Stirling (DSDC, 2021), offer guidelines for dementia-friendly design in different contexts, including care homes, housing and hospitals.

In addition, Barrett et al. (2019) propose three needs-driven design principles for both personal and shared spaces:

1. manageable cognitive load;

2. clear sequencing; and

3. appropriate levels of stimulation.

Acknowledging that, as helpful as such design principles are, they cannot be divorced from the provision of appropriate dementia care and support. The UK Royal Town Planning Institute (RTPI) good practice advice for planning professionals also recognises the importance of good quality, well-designed housing for people with dementia, highlighting the importance of a well-planned local environment (RTPI, 2020). RTPI explicitly states that appropriate housing and well-planned places can have a substantial impact on people with dementia, increasing quality of life and enabling them to live within their own community for longer. RTPI acknowledge the potential high cost and complexity of adapting a person’s existing home, explaining that this challenge can trigger early admission to a residential care facility.

In addition to enabling design, there are a broader set of considerations and later life needs that require attention in relation to housing. Although the prevalence of dementia rises sharply with increasing age, dementia diagnosis is not always timely. This can delay advance planning, including decisions to move to a more appropriate home.

Later life considerations

As people live longer, increasing numbers will experience later life conditions, including dementia and co-morbidities. Well known age-related changes include deteriorating eyesight, age-related hearing loss, reduction in mobility and physical strength, changes to dentition and gum health, urinary and bowel functions (Brown et al., 2020). These age-related changes and co-morbidities need to be considered alongside dementia related need (Browne et al., 2017) within integrated approaches to care, care services and the wider set of policy provisions including housing. The recent Independent Review of Adult Social Care in Scotland (IRASS; Scottish Government, 2021b) concluded that three changes are needed, namely, shift the paradigm, strengthen the foundations and redesign the system. Calling for different thinking, our propositions set out housing for older people and for those living with dementia, against the IRASS’ transformative criteria (Table 1).

Being Home findings

In Being Home (Brown et al., 2017), available Scottish data was explored relating to housing provision for older people. The report challenged the lack of practical detail about what should be done and, in particular, the failure to pay attention to dementia.

The lack of support and advice for older people in owner-occupied housing, and a high level of disrepair and poor energy efficiency in this stock was particularly worrying given three quarters of people aged 65 years and above live in homes they owned. Drawing on the 2012–2014 Scottish House Condition Survey, Being Home highlighted poor housing conditions of older people, particularly in rural locations. Thirteen percent of people over the age of 65 years were deemed to live in housing that was “unhealthy, unsafe and unsecure” (Scottish Government, 2020a). Such living conditions intensify the level of risk for people living with dementia.

The Scottish Housing Condition Survey 2019 (Scottish Government, 2019a) reported that the Scottish Housing Stock comprises 36% flats, 23% detached, 20% semi-detached and 21% terraced housing, with 71% of houses occupied by older people compared to 29% living in flats. The survey highlighted that rural housing is 31% larger than urban housing with an average floor area of 121 sqm for rural compared to 93 sqm for urban property.

The majority of older households live in dwellings built between 1919 and 1982. Interestingly, the survey indicates that 27% of older households (218,000) were in fuel poverty in 2019, it is possible to speculate that both house size (larger than required) and building age (lower energy efficiency) may be contributing factors.

Despite protective legislative framework in Scotland, based on human rights (Brown et al., 2017, p. 20), there were and still are few housing options or housing policies specifically focused on accommodation for people with dementia.

After the publication of Being Home, Scotland’s third National Dementia Strategy (Scottish Government, 2017) included a commitment (Commitment 12) to work with local stakeholders to implement actions in the anticipated refreshed housing strategy for Scotland’s older people, Age, Home and Community (Scottish Government, 2018). When Age, Home and Community was updated and published in 2018, it acknowledged but did not elaborate in relation to Commitment 12. Connectivity between policies is a step in the right direction, but the absence of an integrated implementation plan invites criticism and undermines progress. Disappointingly, Scotland’s latest housing policy document, Housing to 2040 (Scottish Government, 2021a), does not explicitly refer to dementia, nor does it mention the National Dementia Strategy, or Age, Home and Community.

What is wanted?

In the 1950s, the first sociological study of the family life of older people dispelled myths about what older people wanted. At that time, it was generally believed that older people wanted to live with their married children. Townsend (1957, p. 227), contrary to popular belief, reported that although people feared social isolation or institutionalisation, moving in with their sons or daughters was often a forced economic necessity, and what people really wanted in their old age was “supported independence” within their own communities. More recently, an Age Scotland survey indicated that 36% of older people would prefer to move from their current home, with 38% indicating that their home was “not very suitable” or “not at all suitable” (Age Scotland, 2020). Unsurprisingly, the survey found that people aged 75 years and over were not minded to move, whereas those younger than 75 years preferred to live in a home more suitable for their later life. In other words, anticipation of later life health risks creates a predisposition to live in accommodation that individuals believe will allow them to live well for longer. People with higher health literacy are more inclined to take preventative action in relation to anticipated needs as they age (Chesser et al., 2016).

Following a diagnosis of dementia, an individual’s ability to understand future health, care and housing needs might be compromised, necessitating shared decision-making with family or others. Research in The Netherlands found that people living with dementia become less involved in decisions about housing and care as dementia progresses, often leading to avoidable early care home admission (Garvelink et al., 2019).

Fifty-four percent of the Age Scotland (2020) survey respondents highlighted that the main reason for their preference to move was that they wanted to live on one level, 24% wanting lower running costs and recognised their health was deteriorating. Around half of the survey respondents wanted to live in a bungalow. This finding is reflected in Mulliner et al.’s (2020) survey of older people’s housing preferences in the UK. In addition, they found that older people (75+) wanted housing that was easy to maintain, with bathroom adaptations (e.g. accessible showers and non-slip floors). In addition, the oldest age group (75 years and above) placed importance on the use of assistive technology and space for wheelchairs or mobility scooters. The surveys highlight that when thinking about housing, older people tend to focus on declining mobility and concern over increased falls risk in older age, with less focus on cognitive and mental health.

Availability

Many factors influence a person’s or family housing choices and preferences not least the availability of housing and housing options. The “ageing in place” agenda, suggests that older people should be supported to reside in the same place until the end of life (Chippendale and Bear-Lehman, 2010; Kaplan et al., 2015). There are also perceived advantages for people with dementia to remain in familiar environments, where this is safe and practicable. Across the UK provision exists to provide support for home “care and repair services” and home adaptations, in Scotland as detailed in Being Home (2017, pp. 60–63), responsibility for this rests with Integrated Joint Boards and involves both need and financial assessment. Proponents contend that provision of aids and adaptations, and help with home maintenance and repair, are enabling. Critiques highlight inherent risks with this “care and repair” approach. A recent UK Collaborative Centre for Housing Evidence report concluded that much remains to be understood in terms of health benefit and personal outcomes for recipient of aids and adaptations (Wang et al., 2022). They also highlight the importance of understanding the impact of such adaptations on cohabitants. For older people who become frail, property under maintenance is a risk. Home maintenance worries, and reticence about home adaptations, might explain why over a third of respondents to the Age Scotland (2020) survey wanted to move. It is important to understand the factors that influence a desire to move, alongside the desirability of available options.

A major issue is that, while some three quarters of older people live in private housing, the market is not building bungalows, and many apartments are not specified or provided with passenger lifts (Scottish Government, 2018). Despite recognising demand for bungalows, developers regard this housing type as expensive in terms of construction and land costs, as bungalows are unlikely to carry additional value that covers the extra build expenditure. Hence, the development economics are a deterrent to provision, particularly in areas of high market demand.

We contacted the National House Building Council (NHBC; 2021) who estimated that in 2018 only 2% of new build housing were bungalows, compared with 15% terraced, 27% semi-detached and 31% detached housing. Despite population ageing, in the UK over the past 40 years, trends seen in NHBC data reveal the development of bungalows has significantly declined from 14% of production in 1989 to between 1% and 2% of today’s production. Hence, market suppliers, as well as customer demand, favour larger family housing. This leaves the needs and requirements of non-family households, particularly older people, with limited choice.

While some older people will be motivated to purchase a new build house, as this is likely to be more energy efficient and easier to maintain, they may still compromise their housing choice by living in family designed houses that are larger than they require. Under occupied parts of these dwellings still need to be heated and maintained. Such under use of new build property conflicts with policies seeking to address the climate emergency.

Therefore, with an unmoved market seeking to continue to meet demand, change will only happen through transformative policy and regulation. Using Age Scotland’s (2020) survey data, we estimate that there may be around 360,000 older people preferring to move home.

It is important to consider housing choices and options that include housing with care. In Scotland, the term supported housing refers to settings offering a low level of support to help with independent living (e.g. retirement or sheltered housing), through to settings offering a higher level of support and, often, care (e.g. very-sheltered or extra care housing) (Care Information Scotland, 2020). Accounting for population ageing and housing demand, projections suggest that to meet demand for supported housing in Scotland by 2030, the country will need 48,000 supported housing dwellings for older people (Wittenberg and Hu, 2017). This does not mean that increasing the amount of supported housing available is enough to meet the needs of those living with complex health conditions, like dementia. A recent systematic review of international literature, focusing on the experience of living with dementia in supported housing, noted that although the ethos of supported housing is to support the maintenance of independence and autonomy, this was not necessarily experienced by those living with dementia (Smith et al., 2022). There is a suggestion that settings like extra care housing can offer alternatives to moving to a nursing or care home. However, the review showed that low staff numbers, limited staff training, a lack of funding, risk-averse care practices and poorly designed environments often contributed to a loss of independence and autonomy for people with dementia (Smith et al., 2022). This frequently led to residents with dementia being referred or moved out of these settings as their condition progressed (Smith et al., 2022).

Assessing local needs and demand

In England, the National Planning Policy Guidance (updated in 2019) on housing for older and disabled people, calls on planners to plan for people with dementia within an ageing population (UK Government, 2019). This means assessing need, provision of specialist housing, inclusivity and accessibility. The guidance emphasises a requirement for a range of housing options and tenures available to people with dementia, including mainstream and specialist housing. Correspondingly, in Scotland, the Planning (Scotland) Act 2019 sets out a requirement to meet the housing needs of older people and people with disabilities (Scottish Government, 2019b).

The Housing (Scotland) Act 2001 (Scottish Government, 2001) requires Local Authorities to prepare a Local Housing Strategy, which is informed by evidence gathered by a Housing Needs and Demand Assessment (HNDA). The HNDA informs planners’ decisions about land use and the amount of land required for housing within the local authority. The assessment of housing need and demand examines both the future need of new households and existing needs of current households in terms of adaptations.

Curiously, the guidance suggests that need will be met mainly through adaptations, with a small proportion of need met through additional housing units. The implicit message being that an under supply is a marginal matter. However, as already explained, under supply is far from marginal given the substantial growth in the older people in Scotland and numbers living with dementia. Building some 2% of new build housing for an age group that represents one-fifth of the total population highlights that planning is disregarding the needs of older people. As people aged 65 years and above will soon represent a quarter of the population, their housing needs urgently warrant recognition within planning policies. Deciphering why this issue is not receiving the urgent attention it requires is complicated. Interrogation of extant policies reveals inconsistences between public health, housing and planning, multiple implementation barriers and variance in the interpretation of source data at a local level.

Complicating matters through a healthcare perspective it is difficult to explain why care home beds are counted as housing provision in the classifications of “Specialist Provision” (Scottish Government, 2020b, p. 30). Although the labelling of these facilities euphemistically includes the word “home”, internal décor and the culture of care described as “homely”, these are care facilities and residents occupy a “care home bed”. Internationally, it is recognised that care/nursing homes are designed to provide a level of care, not possible to provide on an individual basis to people living within their own home, for reasons of cost, intensity or complexity of care needs, or inaccessibility of services locally (Tolson et al., 2013). Nonetheless, some Scottish local planning authorities regard bed places within care homes as part of their assessment on their wider housing supply within their area, when clearly a bedroom is not a dwelling house. Interestingly, The Social Institute for Excellence also classify care homes as a type of housing (King et al., 2020). However, there is fundamental difference in that people living within housing, including supported housing, are either home owners or tenants by law, whereas care home residents are not. The counting of care home beds in this way seems erroneous as it falsely inflates data on provision of housing for older people and serves only to maintain the status quo.

The challenges experienced by those attempting to innovate and provide age-appropriate housing reveal the complexity of current systems, as illustrated through the scrutiny of recent Planning Appeals (Planning Appeal, 2021). In the cited case the Reporter sees a clear need but nonetheless concludes that the planning proposal be rejected. Unless we examine how to achieve new provision, progress will not happen.

The Scottish Government’s HNDA Guidance for Practitioners (2018, p. 31) indicates that “the HNDA should focus on the scale and type of specialist provision required rather than on an individual’s illness, condition or equality group”. How it will be possible to determine the scale and type of accommodation required without reference to age related changes and conditions such as dementia is unclear.

The reliance by the HNDA guidance on other broad public policies that do not specifically focus on the specific needs of an age group is inconsistent with its own statements that say specialist housing will “[…] support independent living for as long as possible and help to enable people to live well and with dignity” (Scottish Government, 2018b, p. 30).

Despite suggesting that focus should not be given to “[…] an individual’s illness, condition or equality group” (Scottish Government, 2020b, p. 31), the guidance goes on to say:

When undertaking this section of the HNDA, planners and housing practitioners should engage with health and social care planners to share evidence, identify needs and plan for solutions across health, social care and housing. Housing Contribution Statements in Joint Strategic Commissioning Plans will be useful to focus discussion. (Scottish Government, 2020b, p. 31)

Therefore, it is difficult to understand that, on the one hand, focus should not be given to people’s health condition, but then on the other hand, the guidance is suggesting that we do need to understand and identify health and social care needs and how housing solutions can assist in “[…] enabling people to live well, with dignity and independently as long as possible” (Scottish Government, 2020b, p. 31).

Despite the Scottish Government guidance on HNDA reports, there is no guarantee that the HNDA evidence of housing need flows into local development plan policy commitments or land allocations within any local authority area. If there are no such policies within the statutory plan, then it is much more difficult to deliver housing for the betterment of older people.

Discussion

In the earlier part of this paper, we set out five points of different thinking (see Table 1), required to ensure that the delivery of housing choices and housing with care for older people and people living with dementia are viewed as investments. We then overviewed the current housing situation for older people in Scotland, and in particular, for those living with dementia. If we simply ignore the needs of older people and fail to recognise dementia as a terminal illness that gives rise to significant and progressive disability, this is at best an injustice and at worse a manifestation of ageism.

Housing is a basic human right. The United Nations Convention for Rights of Persons with Disabilities, Article 19, states that people have the right to “Living independently and be included in the community” (United Nations, 2006) – and indeed, this is reflected in the Scottish Government’s most recent major housing policy document, Housing to 2040 (Scottish Government, 2021a). Parties to this Convention recognise the equal right of all persons with disabilities to live in the community, with choices equal to others, and shall take effective and appropriate measures to facilitate full enjoyment by persons with disabilities of this right and their full inclusion and participation in the community. However, the evidence we have presented suggests that in Scotland, housing is not adequately considered within integrated health and social care systems for people living with dementia and older people. Given the growth in Scotland’s oldest old along with current estimates suggesting some 90,000 people are living with dementia (Alzheimer Scotland, 2019), there is an urgent need to address this issue.

The UK planner’s professional body, The Royal Town Planning Institute, highlights the importance of recognising the needs of people living with dementia at the earliest stage of the planning policy process, stating that failure to do so risks “a piecemeal approach that ultimately creates further barriers to independence and increased costs” (RTPI, 2020, p. 26). However, throughout this paper, we have identified issues with housing stock, provision of new builds, housing conditions and availability of adaptions for older people and people living with dementia. This is a failure to create the conditions to support this growing number of people to meet their basic human rights. Ageism and stigma around age-related conditions such as dementia are not new in society (Yun and Maxfield, 2020), and there has been many areas of research and good practice which have specifically focused on understanding and addressing stigma (e.g. dementia-friendly communities work; Shannon et al., 2019), however there is a lack of research which focuses on the impact on the housing sector.

To make informed decisions about housing and future housing needs, clearer information about the link between health, housing and functional independence is required. While this is true for all older people, we argue that meeting the diverse housing needs of an individual with dementia living at home is challenging, and research shows a high level of unmet needs. This can range from personal safety and lack of meaningful activity to direct personal and practical support (Morrisby et al., 2018). Given the progressive nature of dementia, it is important to have conversations about the future, including housing needs, soon after diagnosis, so that the individual, family and professionals all have a clear understanding of housing needs. If these conversations are delayed, it could mean that the person with dementia no longer has capacity to make important decisions. In these situations, legal frameworks protect individuals with supported decision making (Hirschman et al., 2008). As advocated in the Being Home report, there is a need to ensure that all housing staff (including practitioners, tradespeople and support and maintenance staff) receive training on dementia and are confident in addressing conversations about housing need. Importantly, for the individual with dementia, a person-centred and flexible needs-led approach is key to decisions about the home, changes and adaptations.

In their 2020 World Alzheimer Report, Alzheimer’s Disease International state that enabling people living with dementia to age in place and avoid or defer entry into long-term care “[…] requires appropriate housing options in the community, in combination with home and social care […]” (Fleming et al., 2020, p. 15). As we have argued, we are failing to meet the housing needs of older people and people with dementia, resulting in many older people living in inappropriate, unsafe and inefficient housing. There is an urgent and international need for politicians, policymakers, spatial planning and housing providers to better understand later life changes and challenges, including conditions such as dementia. Such understanding is required to underpin the development of robust policies and actions which integrate housing, health and social care needs.

The need for an integrated approach to housing, health and social care for people living with dementia is clear. However, there are challenges in achieving this aspiration. Earlier in this paper, we have argued that consistent and fair approaches are required to support age positive and dementia friendly housing, irrespective of tenure. However, in the six years since this was first discussed in the Being Home report, there has been little progress.

Conclusion

Our scrutiny of housing provision and needs in relation to later life and dementia has exposed gaps between policy intentions and planning practice within Scotland. This apparent policy blindness and failure to acknowledge overwhelming evidence perpetuates the status quo. Without positive choices, some older people are living in housing that is not suitable, and 13% are in houses that are in poor condition. If we value older people and believe in person-centred approaches, we need to deliver housing choices that allow people to live well in homes that meet their changing needs, rather than merely exist. There is no doubt that housing and where a person lives is a major determinant of health and well-being, but we need to move beyond the mantra of homes for life as a single dwelling and recognise that global mobility pressures make this ideal unrealistic and unsustainable.

What is required is informed debate that looks at positive housing choices for all within the context of a significant growth in the older population, including rising numbers of people living with dementia. We call for different informed thinking and age positive approaches that embrace the preventative agenda. Prevention is about taking steps early enough to avoid something happening or reduce the impact of something on our lives. Illness is not an inevitable part of ageing, but the prevalence of conditions such as dementia escalates as people age. The cumulative impact of multiple, small, age-related changes, later life conditions and co-morbidities combine adding to the challenge of everyday living, increasing usage of our health and social care services. If people live in the right housing, that is enabling, this will reduce dependency and new housing with care options have the potential to delay admissions to 24-hour care accommodation. Housing should be part of the solution, but unless we embrace new thinking, it will remain part of the problem.

Table 1

Different thinking

Different thinking recommended in the IRASS	Mapped to housing for older people/people with dementia
Social care support is an investment (not burden)	Seeing the delivery of housing choices and housing with care for older people and people living with dementia as a combined investment in independent, person-centred, living
Enabling rights and capabilities (as opposed to managing need)	Older people and people with dementia have a right to appropriate housing/housing with care that is enabling to optimise functional autonomy
Preventative and anticipatory (as opposed to available in a crisis)	Positive housing solutions and choices are preventive/anticipatory in relation to age related changes and common conditions including dementia
Collaboration (not market and competition)	All stakeholders (state, market and communities) should co-operate while being shaped and regulated through statutory duties and functions
Relationships (not simply transactions)	Co-operation is delivered through empathetic rather than adversarial behaviour
Consistent and fair (rather than variable and unequal)	Consistent and fair approaches are required to support age positive and dementia friendly housing across the housing spectrum irrespective of tenure

Source: Table by authors