This section covers residential and nursing provision for people aged 65 years and over.

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1 Residential and Nursing Care Home Provision Introduction Residential Care Homes provide 24 hour care to meet personal, emotional and other care needs whilst enabling the person to continue to be independent as possible in a safe environment Nursing Care Homes provide 24 hour care for people who require the skills of qualified nursing staff and substantial assistance with personal and emotional care. Nursing homes are required by law to have a qualified nurse on duty 24 hours a day. This section covers residential and nursing provision for people aged 65 years and over. What do we know? Facts, Figures, Trends There are 666 care home places available within Central Bedfordshire that are registered to cater for older people. Of these, 523 are also registered to support people with physical disabilities. Most homes are registered for people with dementia however the actual numbers of places available for dementia clients is known only for the BUPA homes, who provide 51 beds currently. BUPA provide 310 places commissioned on a block basis with Central Bedfordshire Council, through 8 facilities. 275 places are provided by six other private companies and the remaining 81 places are provided by private individuals. By October 2011 there were 132 recorded care home placements out of the unitary area 1 with a significant proportion of these in neighbouring counties. These placements account for 24% of the total Local Authority funded placements. The average weekly cost for each care home bed as of March 2011 was 456. This included both the purchase of a number of beds in a care home on a block basis and individually purchased beds. 1 Data extract from SWIFT Database produced October 2011 residential Clients as at xls 1

2 The current negotiated price for the BUPA homes varies for each home but the average price across the seven CBC homes is This compares to an average bed price of for the remainder of the care home provision. Spend for 2010/11 on care home provision for older people was in the region of 13m 2. This excludes expenditure on respite provision or day care services. The provision of residential and nursing provision has been broken down according to the four Clinical Commissioning Group geographic areas. Microsoft Word Document Estimated figures for 2011/12 of Local Authority Funded Older People in Care Home Settings Total Population CBC 259,043 Population over 65 year olds CBC 41,014 Average estimated number of LA Funded people in a residential care home setting 587 Average estimated number of LA Funded people in a nursing care home setting 154 Total LA Funded clients in residential or nursing care settings 741 Estimated figures for 2011/12 of admissions by Local Authority Funded Older People in Care Home Settings Estimated Annual Admissions of LA funded clients to Care homes 262 Estimated Annual Admissions of LA funded clients to Nursing homes 86 Total Admissions for LA Clients 348 Admissions per 1000 of total population 1.3 Admissions per 1000 of over 65 population 8.5 The ONS reports that the total population of Central Bedfordshire in 2009 was 252,900 and is forecast to rise to 335,000 by 2031, an increase of 32.5% over the period. The population of people over 65 years is forecast to grow from 37,900 to 74,400 over the same period (96.3%) and those aged over 85 years from 4,400 to 14,500 (229.5%). With the development of reablement and increased extra care housing strategies then almost 300 people could be expected to avoid taking up a care home place as a result of 2. Data Provided by D.Burton from SWIFT database extracts 2

3 reablement and over 260 people could be living in alternative accommodation by This would reduce the estimated number of care home places required by 2020 from 469 to 163 and these would be required to cater for dementia/complex needs clients. This assumes that alternative accommodation settings will be in place and that those reabled can return to their own home. The figure below shows the profiled estimates for care home places and the associated growth in Extra Care homes required. Local Views From the development of the Central Bedfordshire Older Persons Commissioning Strategysome common themes which have been raised by Older People regarding future delivery of residential provision have included: Social care and health services need to be more coherent and joined-up so as to provide a seamless service to older people in Central Bedfordshire. The future care home provision needs to focus around meeting more complex needs which might feasibly result in less distinction between care homes and care homes with nursing. 3

4 Instead, future residential facilities are likely to centre either around longer term care for those with nursing needs, personal safety or vulnerability issues or around shorter term respite and rehabilitation services, again requiring a level of nursing provision. This, more focused care home provision suggests a need to increase the variety of owned and rented accommodation suitable for older people. As well as promoting the development of extra care accommodation, emphasis needs to be placed on ensuring some homes in the larger developments meet the lifetime homes criteria, enabling older people to stay independent for longer and be integrated into new and existing communities. Estimating Future Demand There are a number of strategic policy intentions that are expected to have a significant impact on the future demand for care home provision. Whilst there is limited evidence to inform the impact of some of these policies on future demand a number of planning assumptions have been made to facilitate these estimates. Population Population is a key driver for future care home needs. It has been assumed that, as the population of older people increases, the underlying demand for care home places or alternative models of care and support will also increase. The planning assumptions have been based on the currently published CBC population forecasts which are available at a ward level and in 5 year age ranges. Account has been taken of known factors that are area specific, for example, known major housing developments. Economic Pressures It has been recognised that the current economic climate might increase the numbers of people turning to the State for support. There are also expected to be increasing pressures on occupational pensions. These pressures, however, might be balanced by a more financially aware and forward planning population of adults. It might be assumed that the net effect of these competing pressures would be a level of equilibrium; however this is not evidenced by recently collected local data. An analysis of the number of people whose savings have dropped below the 23,250 means test threshold between the six months ending June 2010 and June 2011 doubled from 9 to 18. It is not expected that this will increase the total number of care home beds required across Central Bedfordshire over the longer term however could be expected to have an impact on the cost of care provided by the Local Authority. 4

5 The Quality Innovation Productivity and Prevention (QIPP) Programme The Bedfordshire QIPP Work stream 1 Urgent Care, Long Term Conditions and Elderly, includes action to find alternative provision for some elderly people currently occupying acute facilities. In a number of cases this involves the provision of care home resources suitably re-purposed to cater for these clients. An example is the provision of Step Up / Down facilities which forms part of wider re-ablement support. Planning assumptions for this area have been drawn from the Bedfordshire QIPP programme s own research on this issue 3. Increasing prevalence of Dementia The number of people with dementia is set to increase significantly over the next 20 years. Advice from subject matter experts suggests that this increase is directly proportional to the rate of increase of the older population, particularly those over 85. In estimating future demand for care home provision, it has been assumed that the number of people with dementia requiring care home level services will remain proportional to that currently provided. The significant increases in the older population, particularly over 85 years, will serve to proportionally increase the demand estimates for this group. Preventative Strategies There are a number of measures being deployed that are aimed at improving the independence of older people allowing them to remain active and in their own homes for longer. These include tele-care, tele-health, equipment provision, aids and adaptations and information and advice. Initial research has not identified any specific evidence demonstrating the combined impact of these strategies on the future demand for care home provision. A planning assumption has therefore been estimated and predicts that, as a combined result of these strategies the demand for future care home places will be 15% less than current provision. Lifetime Homes If policies influencing the development of lifetime homes were to be formally adopted across Central Bedfordshire then in some areas, particularly in the South where the plans are still in development, older people might be afforded access to accommodation settings that can cater for a wider range of support and mobility needs. This would allow more people to remain in their own homes for longer. Such policies would encourage developers to build a number of these homes within planned significant developments. Such 3 Developing sub acute care in South Bedfordshire, Garraway, L., (2011). 5

6 opportunities might exist in Leighton Buzzard, North Luton and Houghton Regis. In these areas a total of 13,500 homes are planned over the next ten years. If 1% were to be designated as lifetime homes then this might be expected to reduce the demand across these areas by 135 and have most significant impact in the Chiltern Vale and Leighton Buzzard Practice Based Commissioning (PBC) areas. It is recognised that such a policy would need cross Council support and the impact on other requirements placed on developers would need to be assessed. Extra Care The provision of Extra Care or supported living accommodation (referred to as Assisted Living by developers) in Central Bedfordshire is currently quite low however the developer community are beginning to recognise that the increasing population of older people could provide a profitable market for this type of development. With appropriate market shaping the availability of such facilities could be increased over the next 5-10 years and provide alternatives to residential care for a number of current care home clients. It is felt that these homes would be particularly relevant for frail and vulnerable clients where security and wandering issues are not a prime concern but where the availability of 24/7 care support is needed. For the purposes of demand estimation is has been assumed that 50% of frail and physically disabled clients and 20% of vulnerable clients currently in a care home setting could be catered for in an extra care facility. It is also assumed that this type of setting would not be appropriate for people currently in a care home setting and falling in the temporary illness category. More ambitious rates of diversion in this area have also been considered, assuming a rate of 85% for frail elderly, physically and sensory disabled people and 50% rate for vulnerable people. These rates have been used in a business case by Staffordshire Local Authority in relation to the percentage of people that would prefer to remain in their own home rather than a care home 4. Reablement Central Bedfordshire is currently developing reablement facilities to support Preventative policies. Some evidence suggests that reablement services can reduce the long term costs of social care by 15% 5. No specific evidence has been found specifying the impact on care home demand. For the purposes of demand estimation it has been assumed that reablement support will reduce the demand for care home places by 10% on the current levels. The impact of a more challenging target for reablement has been considered and 4 Langbourne Development Project Outline Business Case, June The Reablement Agenda: Challenges and Opportunities, Brief overview and analysis (2011). Whole Systems Partnership. 6

7 evidence from another Local Authority s business case has been used to support a diversion rate of 40% 3. Personal Budget The increase in personalised budget (CBC has a target to provide for 100% personalised budget by March 2013) 6 will provide clients with greater choice about how their care is delivered. This might result in care homes that are run directly or contracted through block provision or guaranteed minimum volumes being in direct competition with the private market provision. It is not anticipated that personalised budgets will have a direct effect on predicted future demand but it is likely to be a consideration for how future supply is sourced and how Council funded provision compares in terms of cost and quality to private sector facilities In the years ahead. This may not be immediate but as the expectation is for all those seeking support through Local Authorities to be offered a Personal Budget by April 2013, this area needs due consideration in all planning Dilnot Recommendations The report published on 4 th July made a number of recommendations that might affect the cost of care home provisions in the future. One particular suggestion was to raise the means test threshold from 23,250 to 100,000 for those people in a care home. Such a change could be expected to increase the number of care home clients that are funded by the State quite dramatically in the first instance and thereafter increase the proportion of State funded clients. Since these proposals are yet to be considered by Government no adjustment or predictions have been made in this case however it is suggested that any move to adopt these recommendations should stimulate a reassessment of need. 6 Directorate Roadshow, 4 th March Social Care: How could it be paid for in the future; Dilnot;

8 What is this telling us? What are the unmet needs/ service gaps? This section sets out a summary of the demand and supply at a Central Bedfordshire level. It first makes some assessment of the overall relationship between demand and supply for care home places and then highlights key issues within the four PBC areas. It also considers the availability of both nursing care home places and extra care provision. A total of 666 care home places are available for people over 65 across Central Bedfordshire and at March 2011 there were 552 care home placements funded by the Local Authority. If all these customers were provided with a placement within the council area it would consume 83% of the available supply. With an over 65 population of 37,900 there are 17.6 care home places per 1000 people over 65 and 34.1 care / nursing home places per 1000 people over 65. This is less than the average of 41.9 care home places per 1000 population for Eastern Region 8. The number of care home places available to meet predicted demand needs to increase if efforts to reduce the volume of out of county placements are to be realised. In Chiltern Vale and Leighton Buzzard it might be possible for future provision to be met by private sector market expansion however in West Mid Beds and Ivel Valley the local private sector provision is such that significant market stimulation would be required to develop the private market. Whilst current provision in Leighton Buzzard and Chiltern Vale could be expected to continue to meet future demand based on the successful delivery of strategic intentions, the provision in Ivel Valley and West Mid Beds needs to be increased. In both these areas the demand presently exceeds supply and, even accounting for successful delivery of alternative strategies, will continue to do so unless additional provision is made. In all areas the availability of dementia provision will need to be increased. This could be achieved through repurposing existing general care home places or, if new facilities or services are procured, stipulating sufficient additional dementia capabilities. The supply of care homes with nursing places is sufficient to meet current and predicted future needs. This case has not, however, considered the range of different types of nursing home provision or the predicted demand arising from Health and so cannot comment on the anticipated mix required to meet future needs. A significant number of nurses in care Homes are registered to provide care home services for a proportion of their places 8 Care Quality Commission; The Adult Social Care Market and the Quality of Services Technical Report;

9 however, since nursing care placements attract a higher fee rate; significant changes to the proportion of care home customers will have an impact on the commercial viability for the home. Further work would be required to determine the extent to which nursing homes could be used to accommodate excess care home demand. If the reductions in care home provision estimated in this case are to be realised there will need to be a significant increase in the provision of alternative accommodation settings for Council funded customers, eg Extra Care, in all four areas. In total there are 149 places in Central Bedfordshire and by 2015 there needs to be an additional 35. By 2020 there needs to be a total of approximately 475 alternative supported care settings and this figure grows to almost 800 by These estimated figures are based on an assumption that 56% of the places taken in an extra care facility will be publicly funded and the remainder will be privately owned, rented or leased. This suggests that there needs to be a comprehensive market shaping exercise to generate private interest in this form of older person s accommodation. With the strategic aims, if 85% of frail elderly, physically disabled and 50% vulnerable people were to be accommodated in alternative accommodation this would suggest a need to develop almost 850 extra care places by 2020 and over 1400 by The requirement for care home provision, however, would fall with an expected 445 care home places needed in 2020, falling to 260 by 2030, all of which would be to cater for clients with dementia. REFER TO SEPARATE DEMAND FORECAST GRAPHS which show predicted demand for residential care/nursing and Extra Care-along with a current Market position graph of current provision. C:\Documents and Settings\dzifa.agbenu\Desktop\graphs Resc- JSNA 2011.ppt 9

10 Recommendations for consideration The strategic information gives a clear indication that the future care home provision is likely to focus around meeting more complex needs which might feasibly result in less distinction between care homes and care homes with nursing. Instead future residential facilities are likely to centre either around longer term care for those with dementia and complex needs leading to end of life care or around shorter term respite and rehabilitation services requiring a level of nursing provision. More Extra care housing options in all areas of central Bedfordshire need to be developed and a range of floating support services for older people More flexible care home provision, particularly in the North of Central Bedfordshire, catering for dementia and short term reablement services need to be developed 10