An LGC roundtable examined the potential of extra care housing
- Hana Alipour-Mehraban, senior commissioning manager, Wandsworth and Richmond LBCs
- Andy Begley Executive director, Shropshire Council
- David Buck, senior fellow, public health and inequalities, The King’s Fund
- Ian Copeman principal consultant, Housing LIN
- Sara Crofts, senior project manager, Gloucestershire CC & Gloucestershire CCG
- Sian Davenport, business development manager, Mears Group
- Peter Fahy, director of adult services, Coventry City Council
- Bill Flood, managing director, Wokingham Housing
- Bernie Lally, commissioning manager, Northamptonshire CC
- Alan Long, executive director, Mears Group
- Jeremy Porteus, chief executive, Housing Lin
- Derek Rust, group director growth and development, Barnet Group
- Jane Taylor, deputy director for urgent care, Nene and Corby CCGs
- Dawn Wakeling, strategic director of adults, communities and health, Barnet LBC
- David Williams, director of business development, Northamptonshire Healthcare NHS Foundation Trust
- Kim Wright, group director, neighbourhoods and housing, Hackney LBC
Extra care housing – that is, homes designed specifically for the needs of older people – can provide significant cost benefits to both the NHS and local authority adult social care. So concluded a report by the Housing Learning & Improvement Network (Lin) last month.
This, coupled with the launch of the NHS’s Long Term Plan in January, provided the backdrop for an LGC roundtable event, held in association with Mears Group, in London in April.
Exactly how councils should go about approaching, delivering and benefiting from housing with extra care was top of the agenda for those present.
The discussion started with the stark differences between councils from region to region, in relation to the housing need and delivery of these homes.
Dawn Wakeling, strategic director of adults, communities and health at Barnet LBC, said: “Land is hard to find in London so we’re looking to redevelop where possible. We have a very significant older population that is predicted to grow at a much faster rate than the rest of London and dementia rates that are predicted to grow faster than the rest of London and UK.”
Availability of land was also flagged by Kim Wright, group director of neighbourhoods and housing at Hackney LBC, who said her borough was in the process of shaping its older people homes strategy by pulling in lessons learnt from its ongoing housing programme.
A mixed tenure approach has to be something that is looked at very seriously
“Hackney’s focus is tackling lack of supply in housing. We’ve got 3,000 households in temporary accommodation and 13,000 on waiting lists,” she said.
“We have three supply chains of housing: Woodberry Down, which is about 5,000 units; estate regeneration, which about 2,000 units; and our housing supply programme, which is about 450 units. All of these have a mixed tenure, cross-subsidy model, so our focus is on doing that.”
Outside the capital the picture looks -different. Shropshire Council executive director Andy Begley said: “We’ve got the opposite issue [to the London boroughs]: we’ve got lots of land, which creates its own issues. We’re also a net importer of older adults and exporter of economically active young people, which creates a fantastic mix, but how we deliver services in that environment is particularly challenging.”
Further differences could be seen within top-tier council areas themselves, as Sara Crofts, senior project manager at Gloucestershire CC and Gloucestershire CCG, explained.
“We’re working with our district colleagues around what our actual need is for extra care,” she said. “Looking at the analysis across Gloucestershire, each district is completely different and within each district there are further differences as well around what is needed.”
For this reason there were a number of varying delivery and funding approaches to extra care depending on the needs within that region.
Jane Taylor, deputy director for urgent care at Nene and Corby CCGs in Northamptonshire, explained how they had worked with three extra care providers over the past 18 months as a way to improve intermediary step-down care for patients between hospital and home.
“[Those providers] go into flats and put in a wraparound service to support patients who can’t go home because of fractures, or for another number of reasons,” she said.
“This provided improved independence for the patient and freed up bed space at the hospital. The recovery time to go home was so much quicker.”
David Williams, director of business development at Northamptonshire Healthcare NHS Foundation Trust, said extra care was “part of the solution” for wider elderly care and his team were currently working through the Home First principal, which provides short-term care and reablement in people’s homes or through step-down beds.
Delivery and funding
In terms of the specifics around delivery, Bill Flood, managing director of council-owned Wokingham Housing and for-profit registered provider Loddon Homes, was able to share some lessons learned – particularly around timing.
Mr Flood said Wokingham Housing had recently completed two schemes at the same time, which had caused a delay before rents started to flow in.
As a result, he said: “The expectation of filling extra care needs to be understood because often you make commissioning decisions and when it gets to delivering them, you need to not be surprised [if the] the rent isn’t coming in.”
He also stressed that when done well, extra care housing was “not a cheap thing to do”, and said it was critical to understand the costs and pressure points associated with the build early on.
This was echoed by Derek Rust, group director of growth and development at the Barnet Group, a trading company handling housing owned by Barnet LBC. Mr Rust urged those delivering extra care housing “not to compromise on capital cost because if you do, you will regret it at the back end”.
He added: “Don’t think these are buildings like any other. The architects and contractors you use should understand extra care, it’s not just a building project, it’s very different.”
Elsewhere, Shropshire’s Mr Begley highlighted a number of flexible funding models his council was either trying or considering, particularly around maximising the benefits of those who are able to pay for their own care.
“When we start to understand the basic economics of self-funders alongside people who are eligible for services then we could be really quite imaginative. So, do we wait for those self-funders to come into crisis and then suddenly need to move into a particular property or do we offer a different deal at different time in their lives?
“Could we perhaps say to somebody, ‘if you put a 10% deposit into a property, then the worst case scenario would be you become frail and you may need to move into that property, and the best case -scenario is that [property] would become part of your portfolio’ and that would increase my capacity in the -market … these are the sorts of things we’re toying with.”
Mr Begley said the council is also introducing a deal on up to 30 homes for the elderly. The customer pays £150,000 for the property, which they are able to live in for as long as they wish. They then get their money back once they move out.
Jeremy Porteus, chief executive of the Housing Lin, applauded this and said the sector needed to think more creatively about models and approaches to enable people to make informed decisions around their housing choices.
Hackney LBC’s group director of neighbourhoods and housing Kim Wright added: “We need to rip up the way we’ve done things in the past.
“A mixed tenure approach has to be something that is looked at very seriously alongside creative ways in which units can be funded and people can be attracted to [these homes].”
The attraction of extra care housing was a running theme throughout the discussion, with Pete Fahy, director of adult services at Coventry City Council, saying there was a real need to change the language used to describe extra care – a point which was met with several nodding heads around the table.
“There’s a big public perception issue with anything that has care associated with it,” he said. “As long as extra care housing is a property of adult social care, people will not be drawn to it. I meet very few people who want to be a user of social care.
“So maybe we should stop seeing extra care housing as a property of care and more a property of housing, where there’s a really big an investable private market.”
As for getting support and wider buy-in for schemes on both a local and central government level, the participants’ attention turned on how best to build a business case.
Barnet’s Ms Wakeling said the business case her council made recently for new extra care schemes contained several elements.
It started with the economic benefits extra care housing had, compared with more expensive ways of meeting care needs – which, in Barnet, includes an “incredibly high” cost for people wanting to remain in their own home.
“Another element of the case was it would free up alternative housing stock and the third element was around wellbeing and quality of life,” she said, explaining how the extra care flats were either double one-bed or two-bed properties, so partners did not have to separate from their loved ones.
This issue of quality of life and improved wellbeing, not only for the patient and their carers but the care workforce too, struck a chord with all attendees.
David Buck, senior fellow of public health and inequalities at The King’s Fund, asked the table for its thoughts around the main issues and opportunities for the workforce in extra care as well as domiciliary care, where care workers visit patients within their existing homes.
There was an agreement among participants that extra care workers were on the whole happier, while domiciliary care workers were more stretched for time. On this Northamptonshire’s David Williams said: “A society change needs to come out about of value of domiciliary care as [currently] we don’t value it.”
Alan Long, executive director of Mears Group, described extra care and domiciliary care as “completely different worlds”, with domiciliary staff turnover rates in the sector at around 40%, compared with 20% for extra care.
He said the group didn’t have a problem recruiting into extra care, since they didn’t have to “spend 20% of their time rushing round”.
Responding to this Bernie Lally, commissioning manager at Northamptonshire CC, said: “The negative here is that we are sort of robbing the domiciliary care workforce”, adding that the sector needs to think what it can offer both workers.
Future of extra care
Ms Lally also said the sector needs to think of ways to deliver extra care housing so it is integrated within the wider community, a point which garnered much support around the table.
Gloucestershire’s Sara Croft noted the pitfalls of having gated schemes within her districts: “We’ve got a lot of high-end extra care in Cheltenham that has everything onsite, which isn’t very good for the local economy. [The schemes] have to service the local needs.”
A wider point was made among the panel on the marketability of individual flats within “institutional villages” or gated communities, with families finding it difficult to sell the flats on once their loved ones had passed away.
Mears Group business development manager Sian Davenport said: “For the schemes we’ve worked in, those that work really well are the ones that are an integral part of the community.”
Hackney’s Ms Wright added that in addition to the scheme itself, it was important to think about how the wider neighbourhood supported and promoted independence.
Giving a Northamptonshire perspective, Ms Taylor said projects which had facilities such as restaurants that were available to the wider community could be a good way to integrate, although she warned of the restrictive nature of business rates and council tax banding when it comes to enabling businesses to deliver affordability across the board.
Meanwhile, Mears’ Mr Long said catering was a good way to make extra care marketable, particularly to private high-end or mid-market customers, the latter of which the panel agreed was currently limited in terms of the types of properties available on the market.
On this, Housing Lin principal consultant Ian Copeman said housing associations could be a way to bridge this gap.
He said there was board-level interest among housing assoications to translate the commercial success they had found within the likes of the first-time buyer market for homes for older citizens.
The discussion ended with an exploration of the possibilities around technology across the sector, with Wandsworth and Richmond LBCs senior commissioning manager Hana Alipour-Mehraban saying her latter council was currently looking at how it could use a pot of funding for assisted technology.
Mr Williams said Northamptonshire CC was using IT-based platforms to provide evidence of people moving around their houses, which was helping people to remain in their homes.
Other participants also highlighted how smart technology could help not only with social care but with improving building management and environmental performance such as through improved energy efficiency.
Summing up the importance of building for the future in relation to technology, Gloucestershire’s Sara Croft said: “We need to think about who we are building for.
“They will be much more tech savvy, so need to incorporate that into the building and need to make it adaptable because what we’re building now, in 20 years will be completely obsolete.”
Extra care boosts life quality – for both residents and workers
round table mears kings fund dsf9205
We ask that government and local authorities work together to set a target to build 400,000 extra care properties over the next 10 years.
Extra care housing can be viewed as a preventative alternative to residential care for many people. Lifetime savings to the taxpayer per person from delaying or preventing this move could be as much as £5,000.
We call on NHS trusts and clinical commissioning groups to take an active role in local housing plans to ensure provision for extra care is included.
There is strong evidence that extra care housing residents visit a GP less frequently, require fewer community nurse visits and that the duration of unplanned hospital stays is shorter on average for those living in extra care housing. This is most likely due to the support from on-site care staff and the resident community.
Government plans do not take into account forms of housing which are in severe shortage
We ask that the Ministry for Housing, Communities & Local Government alongside the Department for Health & Social Care specify that the 300,000 annual house building target includes a specific focus on extra care units.
Government plans to meet housing needs do not take into account forms of accommodation which are in severe shortage: lifetime homes, temporary accommodation and extra care housing. We could be releasing current stock if the right communities were available to those who need it.
We welcome the work of forward-thinking CCGs and local authorities which have thought beyond the current social care funding crisis to create homes for people who are able to live independent lives without the fear of social isolation.
A Joseph Rowntree Foundation study found that nearly two-thirds of residents reported they had a good social life after moving to an extra care housing scheme, whereas half of the residents said they felt lonely and socially isolated in their previous homes. Residents also reported increased feelings of control and safety.
Extra care improves the quality of life for our workforce. This includes training, job satisfaction, motivation and health. We ask that the government recognise this in its assessments of the workforce recruitment challenge. Extra care equates to a happier workforce.
The social care workforce faces a huge gap in recruitment with people leaving the sector due to low wages, lack of training and support. The government is already campaigning to address the need for 650,000 more workers needed by 2035 while acknowledging the high turnover of carers leaving the sector. Staff turnover at Mears for domiciliary care is 40% and 20% for extra care.