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Care homes have been out of favour with the government for some time. Disputes over care standards and fees have not helped relations, but the crux of the matter is the government's long-term intention for all vulnerable people to be helped to live independently. Yet for frail older people who have traditionally ended up in residential homes, is there really an alternative to institutionalised care?

On occasions it has seemed that community care minister Stephen Ladyman has been on a personal crusade to rid the country of care homes. Last November he made a speech on the future of adult social care, criticising the "tired outdated forms of accommodation" currently on offer to older people. The situation would be different, he reckoned, if only individuals had access to personalised budgets and were free to choose the services they wanted: "I am not convinced that individuals would consider the option of residential care as often as it is chosen now."

So it came as little surprise to find Ladyman's anti-residential care stance very much apparent in the recent green paper
Independence, Well-being and Choice. Section 4.17 of the document proposes a "right to request" not to live in a residential or nursing care setting. Under this right to request, service providers would have to explain why they believe residential care is the best option for some people.

Ladyman has made little secret of his preferred alternative to residential care - extra care housing. He told a conference in February that care homes were "certainly not the inevitable solution" for older people requiring care and support. "I think extra care housing will be the dominant model for accommodation for older people over the next generation," he added.

As yet there is no universal definition of what constitutes extra care housing. Indeed, the very term "extra care" is not used consistently - extra care housing is just another name for assisted living, very sheltered housing, and category 2.5 housing.

However, the term extra care housing is often applied to accommodation with certain characteristics. Generally it is used to describe flats and bungalows for older people that are self-contained - have a separate front door - but with some communal facilities and at least one meal provided every day. Support is usually available 24 hours a day, with personal, and sometimes even nursing care, on hand during working hours.(1)

Extra care housing is considered to offer several benefits. Older people can live independently while still remaining part of a community, and the intensity of the care provided can be adjusted according to a resident's needs. Couples can remain together rather than being separated through one partner going into a care home, and increased levels of care and support can be accessed as and when needed.

It is a concept that the government has been keen to support financially. Via the Extra Care Housing Fund it has made £87m available during 2004-6 to enable local authorities to develop provision. Local authorities have to compete for the funding, and in February the Department of Health announced that 20 local authorities had this year been successful in their bids, following on from the 16 that received a share last year. A further £60m will be available for extra care housing in 2006-8.

So, does this government drive towards extra care housing spell the end for care homes? Not according to Martin Green, chief executive of the English Community Care Association.

"I think there will always be a place for good quality residential care," he says. "For some people residential care is a need and a choice. The government is in total denial that there are some people who need residential care because of their complex and severe needs and vulnerabilities."

There are always staff on duty in care homes, so more intensive support is available. If an older person with severe care needs drops their glasses on the floor, someone will be able to pick them up immediately.

"That is where a residential setting wins. People who have severe needs and vulnerabilities can have lots of little care interventions because there are people on site all the time," says Green.

One of the attractions to extra care housing is that it allows people to live independently behind their own front door, if that is what they choose. Care homes, on the other hand, are seen to discourage independent living. However, Green thinks that for some people, the ease of living in a care home can have the opposite effect and actually enhance their independence.


"The government thinks independence is a geographical location, but it isn't. It's a state of being," he says.

He insists that some people actively choose to live in care homes, a view that Gillian Crosby, director of the Centre for Policy on Ageing, agrees with.

"People choose to go into residential care for various reasons. It may be the right time in their life or they may want extra support. Residential care still has a major part to play in the continuum of care," she says.

While she welcomes the development of extra care housing, she believes that good residential care should continue to be available for people who need it, particularly those with dementia or other mental health problems. "There shouldn't be one of these housing options to the exclusion of the other. One size does not fit all. It's about choice, choice and more choice, and making sure that choice is real and not just a good idea," she says.

But do people really want residential care as an option? A report published by the Commission for Social Care Inspection last year suggests not. It found that few people aged under 60 would choose to live in a residential care home when they got older. But then again, sheltered accommodation was not that popular either.(2) Instead, most people wanted to stay in their own homes for as long as possible, receiving care from family, friends and professional carers if necessary. To this end, extra care may be more suitable for some people. While moving into extra care premises may require them to give up their home, at least they can buy another property to live in, unlike residential care where residents effectively rent rooms. Buying an extra care property not only gives security of tenure, but also means an older person retains an investment that they can pass on to relatives.

Local authorities could also benefit financially. While it is more expensive to provide a self-contained flat than a room in a care home, it is thought that residents' continued independence, combined with support from others around them, results in lower care needs and therefore lower costs.

If extra care is to become the dominant housing model for older people, as desired by government, then it needs to expand quickly. Currently just 20,000 older people live in extra care schemes, compared with almost half a million living in care homes. And this is notwithstanding the projected increase in the number of older people, which some estimates suggest could rise almost fourfold by 2056.

Extra care housing may be the thing of the moment, but there is still some way to go before it becomes a realistic option for all older people. Even when it is, it is important that it remains exactly that - just one option out of many. CC

(1) Laing and Buisson, Extra-Care Housing Markets 2005, 2005
(2) Commission for Social Care Inspection, When I Get Older, CSCI, 2004