Robin Darton

Relying on informal care in the new century? Informal care for elderly people in England to 2031

The research reported here is concerned with the future of informal care over the next thirty years and the effect of changes in informal care on demand for formal services. The research draws on a PSSRU computer simulation model which has produced projections to 2031 for long-term care for England. The latest Government Actuarys Department (GAD) 1996-based marital status projections are used here. These projections yield unexpected results in that they indicate that more elderly people are likely to receive informal care than previously projected. The underlying reason is that the GAD figures project a fall in the number of widows and rise in the number of elderly women with partners. What this implies is that ‘spouse carers’ are likely to become increasingly important. This raises issues about the need for support by carers since spouse carers tend to be themselves elderly and are often in poor health. The article explores a number of ‘scenarios’ around informal care, including scenarios in which the supply of informal care is severely restricted and a scenario in which more support is given to carers by developing ‘carer-blind’ services. This last scenario has had particular relevance for the Royal Commission on Long Term Care.

Care management arrangements for older people in England: key areas of variation in a national study

Care management has become a key component in the development of community-based care in many countries, and this paper examines the different care management arrangements for older peoples services that are now emerging. It has been United Kingdom government policy since 1989 that the providers of social services develop care management systems, as confirmed in the White Paper, Modernising Social Services. The paper opens with the background to the policy changes and a discussion of the role of care management in the British social care system. Secondly, evidence from the early phases of care management development is examined; and thirdly, the evidence from a major national study of care management arrangements for older people on the patterns of variation on key dimensions is considered.

Residential or nursing home care? The appropriateness of placement decisions

Routinely-collected statistics show considerable variation between local authorities in Great Britain, in the proportions of supported residents placed in nursing and residential care. This raises the question of whether this is due to variations in demand (the type of resident approaching authorities), supply (the level and type of provision available for local authorities to purchase), or policy (in terms of eligibility criteria or interpretations of need at field level). Data were used from a national longitudinal survey of individuals admitted to publicly-funded residential and nursing home care. Information was collected from 18 local authorities on a cohort of 2,544 local authority supported residents who had been admitted to residential and nursing home care. The paper examines the pattern of admissions, the characteristics of people admitted and the relationship between these characteristics and admissions to residential or nursing home care. Characteristics of the individual explained the placement of over 80 per cent of admissions. Supply factors were statistically significant but did not improve the explanatory power of the model. Survival among those admitted to a type of care that was not predicted by the model, suggested that some unmeasured aspects of prognosis may account for some of the residual variation in placements. Overall, the results indicate a reasonably high level of consistency between authorities in nursing home placement decisions. This suggests that either there is considerable variation in the types of individual approaching local authorities or, more likely, that some authorities are more successful in maintaining people for longer at home than others. In addition to maintaining people at home to a higher level of dependency, prevention of admission to residential care is likely to be associated with: interventions that address carer support, safety issues among people who are deaf, and motivation.

Emerging Patterns of Care Management: Arrangements for Older People in England

One of the key objectives of the community care legislation, implemented in the UK in 1993, was the development of care management systems. Subsequent studies based on limited samples of local authorities have indicated that there is much variation in the forms and types of arrangements being developed. This paper explores whether typologies of care management arrangements for older people can be discerned through the analysis of a series of key indicators. Data were drawn from a survey of all English local authorities, undertaken as part of the PSSRU study: Mapping and Evaluation of Care Management Arrangements for Older People and Those with Mental Health Problems. Care management arrangements were categorized using a limited number of key indicators chosen on an empirical and an a priori basis. This resulted in the formulation of six categories of care management arrangements for older people, within which approximately 80 per cent of local authorities could be included.

Residential and nursing home care of elderly people with cognitive impairment: Prevalence, mortality and costs

Cognitive impairment among residents has considerable resource implications for both individuals and those responsible for publicly funded care. Two linked surveys were carried out in England: (1) a longitudinal study followed 2500 admissions to publicly funded care up to 42 months after admission; and (2) a cross-sectional survey of 618 homes collected information about 11,900 residents. Information was collected about cognitive impairment using the Minimum Data Set Cognitive Performance Scale. Cognitive impairment was associated with source of funding and type of home. Although level of cognitive impairment has some effect, fees and costs were most influenced by type of home. At the same level of impairment, self-funded residents were more likely to be located in relatively low-cost settings than publicly funded residents. In independent homes fees were lower for publicly funded than for self-funded residents. Overall median length of stay of publicly funded admissions was 18 months. For the most part length of stay was not associated with level of cognitive impairment on admission. It is concluded that more information is needed about the effect of quality of care on people with cognitive impairment in different settings. If the same quality of care can be achieved in residential and nursing homes, the evidence would suggest that changes in placement policies could result in potential savings to the public purse.

The characteristics of residents in extra care housing and care homes in England

Extra care housing aims to meet the housing, care and support needs of older people, while helping them to maintain their independence in their own private accommodation. It has been viewed as a possible alternative, or even a replacement for residential care. In 2003, the Department of Health announced capital funding to support the development of extra care housing and made the receipt of funding conditional on participating in an evaluative study. This paper presents findings on the characteristics of the residents at the time of moving in, drawing on information collected from the 19 schemes in the evaluation, and a recent comparable study of residents who moved into care homes providing personal care. Overall, the people who moved into extra care were younger and much less physically and cognitively impaired than those who moved into care homes. However, the prevalence of the medical conditions examined was more similar for the two groups, and several of the schemes had a significant minority of residents with high levels of dependence on the Barthel Index of Activities of Daily Living. In contrast, levels of severe cognitive impairment were much lower in all schemes than the overall figure for residents of care homes, even among schemes designed specifically to provide for residents with dementia. The results suggest that, although extra care housing may be operating as an alternative to care homes for some individuals, it is providing for a wider population, who may be making a planned move rather than reacting to a crisis. While extra care supports residents with problems of cognitive functioning, most schemes appear to prefer residents to move in when they can become familiar with their new accommodation before the development of more severe cognitive impairment.

Does the design of extra-care housing meet the needs of the residents? A focus group study

ABSTRACT The study objective was to explore the views of residents and relatives concerning the physical design of extra-care housing. Five focus groups were conducted with residents in four extra-care schemes in England. One focus group was carried out with relatives of residents from a fifth scheme. Schemes were purposively sampled to represent size, type, and resident tenure. Data were analysed thematically using NVivo 8. Two over-arching themes emerged from the data: how the building supports the lifestyle and how the building design affects usability. Provision of activities and access to amenities were more restrictive for residents with disabilities. Independent living was compromised by building elements that did not take account of reduced physical ability. Other barriers to independence included poor kitchen design and problems doing laundry. Movement around the schemes was difficult and standards of space and storage provision were inadequate. The buildings were too hot, too brightly lit and poorly ventilated. Accessible external areas enabled residents to connect with the outside world. The study concluded that, while the design of extra-care housing meets the needs of residents who are relatively fit and healthy, those with physical frailties and/or cognitive impairment can find the building restrictive resulting in marginalisation. Design across the dependency spectrum is key in meeting the needs of residents. Inclusive, flexible design is required to benefit residents who are ageing in situ and have varying care needs.

Improving housing with care choices for older people: the PSSRU evaluation of extra care housing

Purpose – This paper describes an evaluation of 19 extra care schemes allocated funding from the Extra Care Housing Fund.Design/methodology/approach – Interviewers collected information about the expectations and experiences of 1,182 new residents, and demographic and care needs information for those who received a care assessment (817 individuals) to correspond to previous surveys of care homes. Follow‐up information was collected at six, 18 and 30 months. Comprehensive costs were estimated for individuals based on capital costs, care and support costs and living expenses.Findings – Entrants to extra care were much less physically and cognitively impaired, on average, than entrants to care homes, although residents in several schemes had high levels of physical disability. Overall, residents appeared to have made a positive choice to live in a more supportive and social environment (“pull” factors) rather than responding to a crisis (“push” factors). Outcomes, in terms of physical and cognitive functioni...

Care Home Closures in England: causes and implications

In the United Kingdom, as in many other developed countries, there is an established market in the provision of long-term care-homes for older people. Implicit in the market mechanism is the assumption that homes will close, but it was not until 1999–2000 that closures of care-homes received widespread public attention. This paper draws on a multi-method study that investigated home closures in England from several perspectives. The rate of home closures rose substantially between 1998 and 2000 and, although sources give different estimates, it subsequently appears to have remained at about five per cent each year. The net result has been a reduction in capacity, particularly in smaller homes. While their emphases differed, both regulators and providers broadly pointed to the same factors behind the closures: the local authorities, the majority purchasers of care-home places, were under pressure to keep fees down, and national policies that raised costs were coming into force or were anticipated, notably the National Minimum Wage and the National Care Standards . Other factors, such as problems in recruiting suitable staff, particularly those with nursing qualifications, also played a role. The governments response, driven primarily by concerns about the effect on delayed discharges from acute hospital beds, was to retreat on the Standards and to increase funding to local authorities. While this has been a helpful step, more needs to be done to prevent good homes closing and to provide incentives that will retain and promote diverse provision.

Deciding to move into extra care housing: residents’ views

ABSTRACT Extra care housing aims to meet the housing, care and support needs of older people, while helping them to maintain their independence in their own private accommodation. In 2003, the Department of Health announced capital funding to support the development of extra care housing, and made the receipt of funding conditional on participating in an evaluative study. Drawing on information collected directly from residents in 19 schemes, this paper presents findings on the factors motivating older people to move to extra care housing, their expectations of living in this new environment, and whether these differ for residents moving to the smaller schemes or larger retirement villages. In total, 949 people responded, 456 who had moved into the smaller schemes and 493 into the villages. Of the residents who moved into the villages most (75%) had not received a care assessment prior to moving in, and had no identified care need. There was evidence that residents with care needs were influenced as much by some of the attractions of their new living environment as those without care needs who moved to the retirement villages. The most important attractions of extra care housing for the vast majority of residents were: tenancy rights, flexible onsite care and support, security offered by the scheme and accessible living arrangements. The results suggest that, overall, residents with care needs seem to move proactively when independent living was proving difficult rather than when staying put is no longer an option. A residents level of dependency did not necessarily influence the importance attached to various push and/or pull factors. This is a more positive portrayal of residents’ reasons for moving to smaller schemes than in previous UK literature, although moves did also relate to residents’ increasing health and mobility problems. In comparison, type of tenure and availability of social/leisure facilities were more often identified as important by those without care needs in the villages. Therefore, as in other literature, the moves of village residents without care needs seemed to be planned ones mostly towards facilities and in anticipation of the need for care services in the future.