This blog is based on an article in Social Policy and Society by Robin Darton. Click here to access the article.
Extra care housing aims to meet the housing, care and support needs of older people, while maintaining their independence in self-contained accommodation. In a paper published in Social Policy & Society last year I examined a number of studies to consider the reported benefits for residents, and the extent to which residents with different care needs, particularly people living with dementia, could be supported in this form of housing. The evidence suggests that it has benefits for residents in terms of costs and outcomes, and can provide a supportive environment for people with dementia, although the benefits for residents with greater care needs are less clear.
A long-standing principle underlying government policy, reiterated in the 2021 Adult Social Care Reform White Paper, People at the Heart of Care, has been to help people maintain their independence in their own homes for as long as possible. Over the last 50 years the physical standard of housing has improved significantly: 25% of homes in 1967 lacked one or more basic amenities, whereas now the number is negligible. However, most mainstream housing has been designed for families with children, not for people with a disability, and only 9 per cent of homes in 2018 had four key accessibility features, such as level access and a WC at the entrance level.
Grants are available for home modifications or adaptations to enable people to remain in their own homes, and older people have also been encouraged to consider moving to a smaller property in order to free-up family housing for younger people (‘downsizing’ or ‘rightsizing’). However, mainstream housebuilders have shown little interest in developing properties that would appeal to older people, and several other factors may deter people from moving.
More specialist forms of integrated housing with care, such as extra care housing, have been developed where adequate care and support cannot be provided in mainstream housing. This can take a variety of forms, but the principal features include self-contained living accommodation, the availability of 24-hour care and access to communal facilities and services. The majority of schemes are free-standing developments, typically with 40 or more units of accommodation. Larger retirement villages, typically with 100 or more units, offer more social and leisure ‘lifestyle’ activities and more accommodation for purchase. Specialist housing with care has also been viewed as a possible alternative to a care home, while potentially reducing costs, although care homes are still needed for residents requiring high levels of care. Furthermore, although the supply of extra care housing has increased steadily over time, there is much less provision than in care homes or in supported housing that offers less care (sheltered housing).
Comparisons between residents living in extra care housing and care homes have indicated that people who moved into extra care were younger and much less physically and cognitively impaired, although a minority of residents had similar levels of dependency to those who moved into care homes. However, compared with people living in mainstream housing in the community, residents in extra care were less able to undertake personal and domestic tasks. In a recent study the care needs of residents moving into extra care housing appeared to be increasing, in line with changes in the local authority eligibility criteria used for the nomination of residents. Funding restrictions and changes in eligibility criteria were reported to be placing pressure on the model of care, requiring care workers to focus more on completing specific care tasks and reducing their ability to respond flexibly to residents’ needs.
Various studies have suggested that extra care housing schemes can accept people in the early stages of dementia and can support people who develop the disease while they are residents. Levels of severe cognitive impairment among residents are much lower in extra care schemes than in care homes, even among schemes designed specifically for residents with dementia. However, with increasing levels of dementia among the population, extra care housing is being seen as offering a model for supporting people with dementia. Recent research has examined the relative roles of specialist and generic extra care housing, but integration can be unpopular with residents living without dementia, and residents living with dementia in generic schemes may be at risk of social exclusion. It may be easier to provide more dementia-friendly design in specialist schemes, but this would appear to be at the cost of promoting independence.
Studies of the costs and outcomes for residents have indicated that living in extra care housing can help to reduce care needs and the need for hospital admissions, thus achieving a range of cost savings, with consequent benefits to quality of life. Significant reductions have also been reported in the costs of providing social care services in extra care housing compared with the wider community. A comparison of matched groups of residents also found that costs were slightly lower in extra care schemes than in care homes. Although a study of one extra care scheme found that the overall cost per person increased after moving in, this was associated with improvements in quality of life.
Despite housing quality being central to health and well-being, housing has not been very well-aligned with health and social care, and references to housing in policy documents have been quite patchy. Investment is needed in housing that facilitates care and support. During the COVID-19 pandemic, the design of extra care housing schemes generally helped to ensure a safe environment for residents, but understanding the impact of the pandemic on people’s choices, for example the demand for communal provision, will be essential for future planning.
Research evidence suggests that extra care housing can provide improved social care outcomes and help to reduce care needs compared with residential care and mainstream housing. However, budgetary pressures and increasing eligibility criteria are altering the balance of care and resulting in more task-focused, less personalised care. Furthermore, shortfalls in provision and incentives for developers to concentrate on ‘lifestyle’ provision raise additional questions about the long-term viability of the model for supporting local authority-funded residents. Further research is needed on supporting people with dementia and on the needs of people in ethnic and other minority groups. Research has tended to concentrate on detailed studies of relatively small numbers of schemes, and the alignment of housing with other forms of provision also needs to be supported by broader cost-benefit analyses.
About the author
Robin Darton is Senior Research Fellow at the University of Kent.