Curtains for care homes?

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care, criticising the “tired outdated forms of accommodation”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