(1) Legislation, Agreements and Regulations

The first key area is the financial and legislative arrangements between governments, which determine the conditions and funding available for disability housing support policy planning and implementation. The Disability Services Act provides standards and key performance indicators for organizations receiving government funding for providing disability services. Since the introduction of the CSTDA, now the NDA, the coordination between different levels of government and service provision has improved. The NDA more explicitly outlines consumer participation and choice through its emphasis on person-centered services (AIHW, 2009). Remaining problems include questions about the success and equity of the funding arrangements; coordination, inefficiencies and gaps from the multiple services and funding sources (AHURI, 2002; Bridge et al, 2002; DHS, 2007; SCCA, 2007).

An approach, taken in some Australian states and the United Kingdom, is to develop a planning response to key issues facing housing support (Innes, 2006; NCIL, 2006; SCCA, 2007). Some housing support arrangements are also affected by the Commonwealth State Housing Agreement (CSHA), which provides funding to assist people whose needs for appropriate housing cannot be met in the private market. The CSHA includes steps to reform the housing assistance system (AHURI, 2002a). Remaining problems are the continuing growth in unmet housing need; the impact of targeting in the social housing system; and rundown and inappropriate housing stock (AHURI, 2002a). Governments are developing a national housing policy framework to integrate and coordinate housing policy and other social policy objectives across all levels of government (AHURI, 2002). The lack of outcome information is a barrier to policy planning. Currently, Australia does not have a comprehensive outcomes framework which operates nationally or state wide to measure the effectiveness of housing support. Developing an outcomes framework is an area that requires further evidence-based research to prioritize service funding and respond to demand (DFCS, 2007).

Some state departments have noted that while building regulations protect quality standards, they can also act as a barrier to accessible and affordable housing stock. This is particularly the case for residential facilities, which have complex codes. Statutory regulations can have an adverse impact on housing, including in relation to the development of new housing and maintaining current housing arrangements for ageing residents (Innes, 2006). For example, in Victoria, building regulations about safety conditions can prevent people with disabilities who have paid housing support from organizing their own homes like other members of the public (DHS, 2007).

Facilitative regulations include building standards to improve universal accessibility, which are increasingly supported because of an ageing population. Availability of accessible housing is important. The United Nations in a special report on housing in Australia has commented on the lack of suitable and affordable housing for people with disabilities. The report recommended that all new private and public construction should have accessible design arrangements, which if included during the design phase, could avoid the cost of later modifications, and could also benefit other members of society, such as older people and young families (Kothari, 2006).

(2) Funding and Demand Management

The service system does not meet the demand for either affordable housing or specialist disability services. Resource facilitators and barriers include the implications of the competition for support funding; prioritizing prevention or critical care; the availability of social housing and other housing stock; and the costs of changing needs. One funding problem is the high unmet demand for affordable and accessible housing and housing support (Bleasdale, 2006; Foundation for People with Learning Disabilities, 2001; McNamara, 2001; Sachs & Associates, 1991; Department of Health, UK, 2003). Governments also acknowledge the difficulty in addressing 'under-met' need (AIHW, 2007b). The urgency of meeting critical demand has had the effect of reducing the choices available. The rationing of housing support services mitigates against people making lifestyle choices and decisions, either because the hours of support they receive are insufficient or the required support is too costly (AIHW, 2007b). Most available options are locked into current arrangements, leaving little opportunity for service providers to shift resources to maximize choice and flexibility. Funding of services is often prioritized for people with complex, high and/or critical levels of need, which results in service gaps for people with other support needs.

Due to the high level of unmet demand, housing support is often only provided in response to a crisis. In these circumstances, funding and service provision is often based on available budget rather than individual need (NCIL, 2006; Ozanne, 2001; Simons, 1998). One of the barriers to housing support is the tight housing market, with a shortage of affordable housing and high demand for social housing. According to AHURI (2002), the number of public housing units has decreased, while the population and number of people requiring such housing have increased. At the same time, the lack of affordable private rental units keeps people with disabilities out of the private market (Bleasdale, 2006; National Community Housing Forum, 2004). In addition, inappropriate housing stock that is located away from public transport and employment opportunities is still used. This makes it difficult for providers to integrate services.

(3) Interagency Coordination

The third systemic facilitator and barrier is the effectiveness of interagency coordination between government agencies and the numerous service providers in the sector, either through case management, service system or policy coordination mechanisms. Effective coordination of housing support is necessary for a number of reasons. People with disabilities have needs that are not neatly packaged within the systems and support associated with or offered by only one government agency or service provider. Bigby (2006) found that housing providers and support service providers did not adequately share information about their service provision to people with disabilities, which reduced the suitability of the housing (also Sachs & Associates, 1991). Agencies have difficulties assigning responsibility for people with a multiple diagnosis (e.g. mental health, drug or alcohol and disability) (Disability Services Queensland, 2007). Bridge et al (2002) argue that linkages are still primarily based on informal cooperative efforts that vary in their effectiveness. Bostock and Gleeson (2004) suggest that the lack of coordination between housing support services often results in disability agencies focusing more on the support requirements of clients to the detriment of housing requirements and mainstream housing options (Bleasdale, 2006).

One of the key policy questions is whether to separate or integrate housing and support. Historically, residential care was a single package of housing and housing support. In contrast, community care typically separates them (Oldman, 2000). Reynolds and O'Brien (2002) suggest that if a range of approaches to link housing and support services are available, this can respond to people's needs. Bigby (2006) argues that separation is only successful where organizations coordinate and communicate with each other. The preferences of people with disabilities for integrated or separated housing and housing support services are not clear from the research for this project. Funded coordination is one way to bridge the two approaches.

Other human services sectors also play a key role, as people with disabilities who access other support systems (e.g. mental health, health or criminal justice) often receive types of support not traditionally offered by the disability service system. The federal government (FaHCSIA, 2007) noted the gaps in coordination between departments, for example in relation to juvenile justice, which results in a lack of proper rehabilitation and the risk that a young person ends up with higher, more complex needs. Memoranda of understanding between agencies are a formal response to this need. The intersection between service streams can also have consequences for people living in housing support services. One example is in relation to housing support packages that do not include funding for community participation or transitions, such as from institutional care and age-related services (18 and 65 years). In contrast, good transitions require coordination between the formal and informal support services, at least temporary case management and the associated costs of temporary additional support to manage changes.

(4) Range, Flexibility and Choice of Housing Support

The fourth facilitator and barrier is the responsiveness of housing support policies to people's choices about their housing support arrangements. This includes the type of housing; the location and co-location; who they live with; the condition and quality of the housing; the appropriateness to the person's support needs; and direct payments and individualized service provision. Government officials commonly agreed that availability, flexibility and diversity of affordable and purpose appropriate housing options was important for successful policy implementation. The number of people in any housing arrangement (particularly in group homes) is a contributing factor to quality and satisfaction. Stancliffe and Keane (2000) in a study of semi-independent living arrangements found that participants in smaller (staff-to-user ratio) arrangements experienced better outcomes. Bigby (2000) describes quality housing support as including: a house which is appropriate in its design; affordable and secure tenure; and access to formal or informal support that meets the person's needs and circumstances.

More recently, governments have begun to re-introduce cluster housing to integrate people into the community. However, researchers have criticized clustered community housing as providing an overall poorer quality of life when compared to dispersed housing. The European Intellectual Disability Research Network (EIDRN) (2003) have argued that family and community ties continue to be disrupted even with more progressive cluster community housing arrangements, which are reminiscent of institutional services. Epstein-Frisch et al (2006) suggest that a risk of cluster housing it that it has many of the features of institutional living, including: a whole of life approach to service delivery; a custodial and impersonal nature of care; segregation from the community; inability to provide a home-like environment; and difficulty meeting the physical, emotional, social and skill development needs of people grouped together (also Emerson et al, 2000).

One of the main barriers to goals of choice and control, as noted by people using services is sharing housing with other people not necessarily by choice (either sharing at all, or sharing with particular people). The policy direction in Australia is to offer support services based on personal requirements, including individual support packages so that the person can access their preferred housing support. Internationally, this includes individualized funding (Bostock & Gleeson, 2004; Lord & Hutchinson, 2003). Australian state governments are also experimenting with individualized funding arrangements, such as Western Australia, Victoria and NSW (e.g. Fisher & Campbell-McLean, 2008). Individualized funding arrangements can include: direct payments, indirect payments and funding held by organizations. Services to be purchased include personal support, domestic services and social services. The implementation of such arrangements can be through service brokers, personal agents and voucher schemes that provide assistance with budgeting, service selection, payment management and accountability. Benefits include responding to personal preferences and needs, lowering administrative costs, increased competition, and employment opportunities (SCCA, 2007). Risks arise in the operationalization of the system, including: tax implications; accountability over funds; and the level of funding to meet the person's needs. In the UK, successful implementation involves training policies, mandatory duties, performance indicators and duty of care targets (Priestley et al, 2006).

As discussed earlier in the article, housing support that offers flexibility and choice facilitates quality of life goals for people with disabilities. Several participants in the research emphasized that flexibility of support was important to people on a range of levels: for example, being able to determine on which day of the week they shop (when needing staff support to do so); and organizing hours of support to supplement the caring role a family filled during part of the week. Practices, funding and approaches to service delivery are facilitators or barriers to choice experienced by many people using services and trying to access them. Although disability legislation principles include diversity, choice and flexibility, Australian government departments find it difficult to implement them. As a consequence, some officials and providers consider that parts of the current disability housing support policies are too inflexible and prevent people making real choices (MacArthur, 2003; McNamara, 2001). For example, if a person has current housing, even if not ideal, then their need for other disability housing support is given lower priority (DHS, 2007; DHHS, Tasmania, 2007).

(5) Staffing Quality

The fifth facilitator and barrier is quality staffing in housing support, including availability, training, service approach and managerial support in the employing organization. Staffing is well established as a key determinant to the success of service quality and outcomes for people with disabilities in housing support arrangements. The literature demonstrates that for people with high support needs, three key factors are important: (i) available activity for all — which involves moving from the 'hotel' model to resident participation; (ii) available personal support including well developed method for staff/resident deployment and activity planning; and (iii) effective assistance to help people who lack skills to accomplish activity successfully (Epstein-Frisch et al, 2006). The importance of quality staffing is echoed by people with disabilities and their family members. It is necessary to have experienced well-trained staff who have a positive vision of what is possible for the person. Another key issue with staffing is the managerial or organizational processes of service provision. Bigby (2006) suggests that often the primary focus is on day-to-day care by staff and managers, with little weight given to planning and vision for people's quality of life.

(6) Informal Carers

The sixth facilitator and barrier is support for informal carers. Most people with disability housing support needs are only supported by their family and friends because they are unable to access the very limited government housing support or chose not to do so. For people who do use government funded support, robust informal support (practical and emotional) from both family and friends is considered to be a key facilitator of a good housing support experience. This sort of support is particularly helpful in ensuring the person is viewed as more than a 'client' or 'resident'. While many adults are content to remain in the family home, often this choice is because of a lack of viable alternatives. EIDRN (2003) note that, although family care may appear to be a cheaper and more preferred option, the need to accurately estimate costs of family care remains when determining equity and measuring the effectiveness and efficiency of public services. AHURI (2002) suggest that while some community care services are available to assist informal carers, often financial restraints often limit access to this assistance, which puts long-term informal carers at risk of financial hardship.

A key barrier is the interface between formal and informal support. If a person has a well developed, effective network of support, their priority of access to more formal support is limited, even though the level of funding or support that is required to sustain such arrangements is often relatively low (Disability Services Queensland, 2007). Lack of housing options places an unacceptable demand on many families and informal carers, restricting choice and opportunities for developing an independent life for many people with disabilities. The degree and type of support needed is a major determinant of quality of life for the families and carers of people with disabilities. Where families have control over respite and personal assistance services, they experience an increase in service satisfaction and community participation, as well as reduced turnover in the workers supporting their family member with a disability (AIID, 2006). Similarly, where families have an abundance of social, emotional and material resources, the stress of caregiving can be minimized. However, very few families have access to such levels of support.

While home-based supported living can improve the quality of life of a person with a disability, it can have a negative impact on the quality of life of the caregivers or family members. Primary carers are at considerable risk of high stress, clinical depression and abnormally low subjective quality of life (Cummins, 2001). The needs of people with an intellectual disability and their informal carers can conflict, which is especially problematic for ageing carers who have care needs of their own (Ozanne, 2001). Furthermore, informal care may actually negatively affect the independence and autonomy of people with disabilities, particularly people with an intellectual disability (Burchard et al, 1991; Buys and Tedman-Jones, 2004).

(7) Discrimination

Discrimination on the grounds of gender, culture, language and Indigenity is an additional barrier for some people with disabilities. Some housing support services have practices to address this risk. Socio-economic barriers and stigma about particular disabilities are also a barrier to access to housing support for independent living. A key issue in the provision of housing services to diverse groups of people with disabilities is ensuring support is culturally sensitive. This is sometimes difficult to achieve, particularly because of the relationship between the housing setting and access to culturally specific community support, such as social networks and cultural facilities (FaHCSIA, 2007). In the Northern Territory, a high percentage of Aboriginal people living in remote areas do not have access to housing support, and are instead relocated to the urban areas — often hours away from their family and friends and in a white-dominated urban setting. The cultural mix of staff can also be problematic, with some service providers having little flexibility or knowledge about cultural issues (DHCS, 2007). In a study undertaken by Carlson and Kooten (2001), five main factors were found to affect the level of support received by people from a culturally and linguistically diverse (CALD) background: isolation, cultural beliefs and cultural differences; language difficulties; inter-sectoral links; and access. Strategies to avoid the risk of discrimination include: service staff awareness about cultural needs; where possible, support is tailored to the cultural norms and beliefs of the family; bi-lingual staff; liaison between organizations, including memorandums of understanding; and dissemination of all information about the support in multiple languages and distributed through as many communities as possible. Improved data collection based on ethnic and linguistic factors can also lead to better understanding of the needs of people in diverse communities (Carlson and Hutchinson, 2001). New South Wales has a CALD unit to improve understanding about the issues faced by people with disabilities from diverse backgrounds across the State (DADHC, 2007).

In addition to cultural barriers, a number of socio-economic barriers prevent some people with disabilities from accessing appropriate housing support, such as stigma and high costs of housing. Despite the shift towards community-based housing, some communities are less welcoming and accepting of people with significant disability, which results in pressure to return to congregate environments (DSQ, 2007). Lack of acceptance of the potential capacities of people with an intellectual disability can also act as a barrier. For example, some formal and informal carers can disregard and dismiss requests for support with semi-autonomous activities or in enabling autonomous activities to occur (Buys & Tedman-Jones, 2004)