Care homes v care at home? Council spending patterns reveal the cost equation is not clear cut

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?