1. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Making a case for Extra Care: Perspectives from three Extra Care Housing Providers Dylan Kneale & David Sinclair, International Longevity Centre, Housing LIN Extra Care Housing Annual Conference December 8 th 2011

2. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Overview of session 1.Presentation of results from ILC-UK research 2.Presentation of policy recommendations 3.Guided discussion

3. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. We influence Government policy and debate The ILC-UK was established in 2000 to explore and address the new longevity revolution and its impact on the life-course and society.  Think Tank  Global (12 ILCs)  Evidence Based  High visibility around Westminster (e.g. 17events/1000 people in 2010)  Engage at highest levels of Government  Focussed on life-course

4. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Some of our publications

5. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Housing: Lived in same house for 40+ years (17% 1993/4; 24% 2007/8) Rising levels of under occupancy? Rising levels of housing wealth?.....Rising inequality? (Older people still biggest consumers of social housing) Less retirement housing being constructed Health care: Compression of morbidity? (Zaninotto et al 2010) Non communicable diseases (stroke, dementia) Social Care: Rising cost; Unequal provision; Who pays? Rates of receipt of domiciliary care at home declining… Health, social care and housing among the ageing population

6. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. What is it? Little consensus…. Wide spectrum of self-designated extra care housing Some common principles of extra care housing:  Ergonomically designed  Flexible and continually adapting care packages delivered onsite  Communal facilities  Group activities  Independent homes within small-medium sized retirement communities  Usually age specific  Leasehold tenure as well as rental tenure  Community balance of care needs Extra care housing

7. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Extra care housing What do we know about extra care housing? What does extra care housing claim to do?

8. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Research Questions  1.What is the social profile of extra care housing residents and how does this compare with residents in the community setting?  2.Can extra care housing be considered a home for life for older people?  3.Does residence in extra care housing facilitate healthier and more independent life?  4.What impact does residence in extra care housing have on the uptake of overnight hospital beds?  5.What inferences can be made about the costs and benefits of extra care housing?

9. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Data and Methods  Data: Longitudinal data from 3 partners on almost 4,000 residents of extra care housing since 1995;  British Household Panel Survey; English Longitudinal Survey of Ageing; Survey of English Housing (descriptive)  Limitations/Challenges 1. Characteristics of residentsDescriptive analysis 2. Extra care housing as a home for life Event history analysis (Lognormal and Competing Risks); Propensity Score Matching 3. Extra care housing as a healthy home for life Event history analysis (Competing Risks); Propensity Score Matching 4. Extra care housing and hospital beds? Zero inflated negative binomial regression; Propensity Score Matching 5.N Inferences on the costs and benefits of extra care housing? Descriptive analysis

10. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change.  Gender  Age  Living arrangements  Additional care needs  Health shocks that may predict entry to extra care housing:  Stroke  Dementia  Parkinson’s disease Characteristics of residents

11. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Characteristics of residents

12. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Extra care as a home for life I Length of time until exit (all exits) First quartile (25%)Median (50%) All residents3.16.5 Gender Male2.66.0 Female3.46.7

13. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Extra care as a home for life II: Competing Risks Framework Risk 1: moving to an institution Risk 2: death All residents8.2% (6.7-9.9)25.0% (22.4-27.5) Gender Male6.4% (4.3-9.1)30.6% (26.0-35.3) Female9.1% (7.2-11.3)22.0% (19.2-25.1) Health Status/Care Needs on Arrival No additional support package 5.5% (4.0-7.3)16.8% (14.2-19.6) Level 1 (very low package needs) 12.8% (6.8-20.8)29.6% (20.0-39.7) Level 2 (low support package) 17.5% (11.7-24.4)39.8% (31.6-47.6) Level 3 (moderate support package) 11.9% (5.2-21.5)41.0% (28.3-53,1) Level 4 & 5 (high or very high support package) 9.9% (4.9-17.1)56.9% (46.1-66.3) Age Group 50-646.8% (2.8-10.9)10.2% (5.8-16.3) 65-69 6.2% (3.1-11.0)13.0% (8.2-19.1) 70-74 6.0% (3.4-9.8)18.2% (13.3-23.7) 75-79 9.0% (5.8-13.0)24.6% (19.4-30.2) 80-84 8.0% (4.8-12.3)27.2% (21.3-33.5) 85+ 12.7% (8.5-17.7)49.0% (41.8-55.8) N 1,189

14. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Extra care as a home for life III

15. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Extra care as a home for life IV All community match sampleDomiciliary care match sample Age 65+ Model 1 Age 75+ Model 2 Age 80+ Model 3 Age 65+ Model 4 Age 75+ Model 5 Age 80+ Model 6 Models adjusted for Age, Sex, Living Arrangements, Year Sub-hazard ratio of moving to an institution Extra care housing 1.7761.2160.9050.6940.532*0.316** (0.659)(0.471)(0.463)(0.207)(0.167)(0.121) N1714103462416301028634

16. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change.  Diminution in loss of functional ability? Extra care as a healthy home for life

17. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change.  Conceptualising ‘risk’ of health improvement Extra care as a healthy home for life Risk: improvement in health (decrease in care needs) All residents24.0% (20.6-27.5) Gender Male25.7% (19.5-32.3) Female23.8% (19.3-27.5) Health Status/Care Needs on Arrival No additional support package30.8% (24.7-37.1) Level 1 (very low package needs)16.3% (9.4-24.8) Level 2 (low support package)26.0% (19.1-33.5) Level 3 (moderate support package) 15.3% (7.5-25.6) Level 4 & 5 (high or very high support package) 14.9% (7.9-24.0) Village or Court development Court9.2% (5.8-13.7) Village32.1% (27.4-36.8) N 603

18. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change.  Falls (fractures), stroke and heart disease account for the main financial burden of older people’s health care  Within extra care setting, most accidents represent falls (“loss of balance”, “got up too quick”, “turned around”)  Ergonomic adaptations? Group exercise classes?  Compare rates for small sample size with sample from ELSA  Matching indicative of a lower rate in extra care (49% vs 31%)  Sample size – caution – indicative evidence  Men susceptible to falls in extra care setting? Falls in extra care

19. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Extra care and overnight hospitalisation I  Number of available beds for geriatric medicine declined by 61% (1987-2008); Bed blocking an issue  Comparison group  Inverse care law – evidence in BHPS (or other effect?)  Incidence rate is higher than in overall community sample BUT reflects length of stay  Number of episodes of admission consistently lower in extra care sample i.e. less people go to hospital in the extra care sample, but those that do stay longer  Closely matched comparison group overall incidence lower in extra care sample  Mechanism?

20. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Extra care and overnight hospitalisation II

21. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Extra care and inferences on costs  Social care costs (median community care package and extra care)

22. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Extra care and inferences on costs II  Initial social care costs of extra care housing may be higher than if remaining in the community  But, because of higher probability of transition to institutional accommodation, long-term costs lower –Planning for retirement  Cost of lower rate of hospitalisation  Cost of reduction in social care package (comparison?)  Cost of falls

23. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Pressing need for development of older people’s retirement housing Extra care housing: 1.Supports some of the most vulnerable in society 2.Appears to be a home for life for the vast majority Compared to those with similar characteristics appears to be lower rate of transition to institution; plausible mechanism (age, living arrangements, gender, in receipt of care at home) 3. Associated with fewer inpatient stays 4. Associated with fewer falls 5. Is a healthy home for life Extra care not a panacea for all older people’s housing issues, but evidence suggests benefits for a sizable majority of residents Summary of conclusions

24. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Policy Recommendations I 1.Policy-makers need a co-ordinated response to providing housing, health care and social care for our ageing population. 2.Policy-makers should make specific pledges to increase the level of provision of extra care housing. 3.The proposed National Planning Policy Framework should champion far more robustly the housing needs of older people. 4.Policy-makers should recognise and encourage private sector development of extra care housing. 5.The findings in this report suggest that policy-makers drafting the Health White Paper should explicitly consider and make specific pledges to increase the role of housing with care.

25. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Policy Recommendations II 6. Policy-makers should enhance and sustain programmes of education and information for those who are retired and newly retired to plan their housing and financial futures. Furthermore, consumers need reassurance that policy changes will not negatively impact their retirement decisions. 7. Any National or Local Falls Prevention Strategy should include housing as a key component of preventing further falls. 8. Receipt of Attendance Allowance opens a gateway for many older people to access extra care housing, through helping to finance monthly care costs and to help access other benefits. We would urge policy-makers to ensure that all who are eligible to claim Attendance Allowance do so which could enable greater numbers of older people to support a stay in extra care housing. 9. Further research is needed into the extra care housing sector.

26. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Discussion points ILC-UK have been getting the report “out there” (presentations; media work; summary reports; websites) But despite powerful findings, there remains a (relative) lack of mainstream interest We want your views and will write up some of the comments for a Guardian housing blog/ILC-UK think piece

27. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Questions  What do you think are the most significant findings?  What do you think are the barriers to growth in this model of housing  How can we best communicate the messages to decision makers and opinion formers?  What should be the next steps?  Do you want to work with us?

28. The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change. Full report available: www.ilcuk.org.uk Further information: David Sinclair, Assistant Director of Policy and Communications: davidsinclair@ilcuk.org.ukdavidsinclair@ilcuk.org.uk Dr Dylan Kneale, Head of Research: dylankneale@ilcuk.org.uk dylankneale@ilcuk.org.uk Thanks for your attention