Councils are being encouraged to direct
spending into care in people's own homes as opposed to residential
care, partly on the premise that it would be cheaper
With councils facing increased demand for adult
social care and deep cuts in funding expected from 2011 onwards,
efficiency savings are sought after.
A Department of Health report last month on the use
of resources in adult care set out its latest thinking in this
area.
Top of the list was reducing expenditure on
residential care by investing in services to support people at
home.
Councils were told they should be aiming to spend
no more than 40% of their overall adult care budgets on care or
nursing home placements. In 2008-9 the England-wide figure was
47%.
The report sparked controversy, despite the
government’s longstanding focus on care at home. Provider umbrella
body the English Community Care Association and adult protection
charity Action on Elder Abuse emphasised that residential care
could be a positive choice for people.
The DH report set out the wide variations in
council spending on residential care.
It showed that the proportion of council older
people’s social care budgets that was devoted to residential care
ranged from 30% to 70%.
The report’s author, John Bolton, strategic finance
director for social care at the DH, says these variations cannot be
explained away by demographic differences.
He says that while Hull Council spent an estimated
70.8% of its older people’s budget on residential care in 2008-9,
the demographically similar Liverpool spent 40.4%.
“There’s no evidence that the correlation is
related to demographics,” Bolton says, adding “overwhelmingly, this
has to be an issue for commissioners”.
Bolton refers to his time as director of community
services at Coventry Council until 2007, when he joined the DH. He
says: “We had a clear policy over five years to reduce admissions
and halved them by building community-based solutions.
Coventry spent an estimated 41.6% of its older
people’s care budget on residential services in 2008-9.
“Overall it’s to do with whether commissioners have
a clear commissioning plan which has a focus to keep people at
home,” Bolton adds.
He says that residential care is not “wrong” but
that there has to be a mix of services for “tomorrow’s
generation”.
Some services designed to support people at home,
such as telecare or home care reablement to help people regain
independence after a crisis, can be introduced relatively easily,
he says. Options such as investing in extra care housing are more
long-term.
Richard Humphries, senior fellow in social care at
the King’s Fund, says in some areas an historic oversupply of care
homes has crowded out other services, meaning usage can be cut.
However, he also points out there is also a political dimension to
last month’s DH report. He says the variation in spending on
residential care makes it more difficult for the DH to argue for
more resources from the Treasury for adult care.
Professor Andrew Kerslake of the Institute of
Public Care, which carried out some of the research for the DH
document, says there are several reasons for the wide variations in
residential spend. These include the price of labour and property
locally, and the competitiveness of the local care home market.
He says most people do not want to go into care
homes. Many who do haven’t made a “positive choice” to end up
there.
Unsurprisingly, many local authority
representatives are, unlike Bolton, keen to emphasise the
importance of demographics.
Edward Smith, cabinet member for adult social
services at Enfield Council, says the council wants to keep people
at home as far as possible, but “has a lot of elderly people
compared with a lot of other boroughs”.
In 2008-9, the north London borough spent an
estimated 46.4% of its older people’s social care budget on
residential care, compared with a London average of 44.1%.
Appropriate care
English Community Care Association chief executive
Martin Green says the DH document “seems to be predicated on people
with low-level needs”, not people with more complex conditions for
whom residential care may be more appropriate.
Green says that if domiciliary care is the
government’s preferred option it must provide the necessary
investment to support people at home, something he says is not
currently the case: “It’s about giving the minimal amount of
support to allow them to struggle along in their own homes,” he
says.
This view is supported by Colin Angel, head of
policy and communication at the United Kingdom Homecare
Association, which has long criticised councils and government for
under-funding home care.
It is also not altogether clear whether supporting
someone of a given level of need is cheaper at home or in
residential care.
Humphries, a former social services director, says
the latter is sometimes cheaper for people with high needs.
The NHS Information Centre has calculated that
councils spent £455 per person per week on residential and nursing
care for older people in 2007-8, compared with £151 per person per
week on home care, but this does not compare spending on people
with similar needs.
Curbing residential care use may also run into the
problem of demographics. Market analyst Laing and Buisson’s latest
survey of the UK market for the care of older people found demand
for care home places across all client groups was unchanged from
2008-9, at 419,000 places, marking the end of a 15-year decline. It
predicted that the number of occupied places would increase to
424,000 by 2014 and 459,000 by 2019, due to the ageing
population.
While Laing and Buisson predicts that the number of
places funded privately will rise faster than those funded by
councils, chief executive William Laing says he expects the latter
to grow: “In future I would expect to see local authority-funded
residential and nursing care continuing to climb slightly, but at
the same time privately-funded tending to increase and we would see
over a long period of time that there will be more of everything Ð
more home care going on and more residential care.”
Case study
Ray Foord, 84, says he would never consider letting his wife,
Elsie Thompson, go into residential care.
Thompson, 78, cannot walk without the aid of a walking frame,
has an arthritic condition and has been fitted with a
pacemaker.
Foord looks after Thompson, 78, at their home in Woodford Green
in the east London borough of Waltham Forest, and she also receives
half an hour a day of domiciliary care from an agency commissioned
by the council. The local Age Concern also helps the couple with
support services such as shopping, funded by the local primary care
trust.
Foord says: "Residential care is the end of the road. Her mother
went in one and died soon after. I wouldn't do that to a dog."
However, the couple have not been happy with the level of
domiciliary care provided.
They used to get two half-hour slots of care in the mornings and
evenings, but the couple cancelled the evening slot because the
carer was arriving at "ridiculous times" and often had little to
do.
Waltham Forest Council admits that there were teething troubles
at the start of the contract with the agency that provides
domiciliary care for Thompson and standards fell below what was
expected. The provider will not be retendering for the work.
More broadly, Waltham Forest makes greater use of residential
care than comparable councils.
Provisional data shows it spent an estimated 52.2% of its older
people's social care budget on residential care in 2008-9, compared
to an average of 44.1% across London.
In 2008, an estimated 982 people aged 65 were admitted to
residential or nursing care in the borough for every 100,000 in the
population. The average for comparator councils was 591.
Also, 74% of people aged over 65 discharged from hospital in
2008-9 who intended to return home were still at home three months
after discharge in 2008-9, compared with 88% for comparable
councils.
Liz Phillips, cabinet member for health, adult and older people,
says: "We recognise that Waltham Forest has previously placed
higher numbers of people in residential care than neighbouring
boroughs, and we are aiming to reduce this."
This year, she said, the aim is to reduce the number of people
admitted to residential care by 28% and this target is being
met.
She added: "In the future, residential care will mainly be
provided to people with higher physical and mental health care
needs, with particular focus on specialised care for people with
dementia.
"There will also be increased support to people in their own
homes and in extra care tenancies."
Residential care? No way!
Waltham Forest Council bids to cut care home admissions
as carer vows his wife will remain at home
Ray Foord, 84, says he would never consider letting his wife,
Elsie Thompson, go into residential care.
Thompson, 78, cannot walk without the aid of a walking frame,
has an arthritic condition and has been fitted with a
pacemaker.
Foord looks after her at their home in Woodford Green in the
east London borough of Waltham Forest. She receives half an hour a
day of domiciliary care from an agency commissioned by the council.
The local Age Concern also helps the couple with support services
such as shopping, funded by the local primary care trust.
Foord says: "Residential care is the end of the road. Her mother
went in one and died soon after. I wouldn’t do that to a dog."
However, the couple have not been happy
with the level of domiciliary care provided.
They used to receive two half-hour slots of care in the mornings
and evenings, but the couple cancelled the evening slot because the
carer was arriving at "ridiculous times" and often had little to
do.
Waltham Forest Council admits that there were teething troubles
at the start of the contract with the agency that provides
domiciliary care for Thompson and standards fell below what was
expected. The provider will not be retendering for the work.
Higher use of residential care
Waltham Forest makes greater use of residential care than
comparable councils.
Provisional data shows it spent an estimated 52% of its older
people’s social care budget on residential care in 2008-9, compared
to a London average of 44%.
In 2008, 982 people aged 65 or over were admitted to residential
or nursing care in the borough for every 100,000 in the population.
Similar councils averaged 591.
Also, 74% of people aged 65 or over discharged from hospital in
2008-9 who intended to return home were still at home three months
after discharge compared with 88% for comparable councils.
Liz Phillips, cabinet member for health, adult and older people,
says: "We recognise that Waltham Forest has previously placed
higher numbers of people in residential care than neighbouring
boroughs, and we are aiming to reduce this."
This year, she says, the aim is to reduce the number of people
admitted to residential care by 28% and this target is being
met.
She adds: "In the future, residential care will mainly be
provided to people with higher physical and mental health care
needs, with particular focus on specialised care for people with
dementia.
"There will also be increased support to people in their own
homes and in extra care tenancies."
This article is published in the 26 November 2009 edition
of Community Care magazine under the headline Your home or
a home?