Introduction
The current policy context places much weight on the value of maintaining independence in old age and offering people sustainable alternatives to residential care in later life (Department of Health 2005a). The personalisation and social care transformation agendas emphasise placing individuals at the centre of the process of bringing housing, health and social care together, with the aim of giving people greater choice and control over the services they receive (Department for Communities and Local Government 2008; Department of Health 2010). As part of these agendas, the growth of extra care housing has been encouraged and indeed funded by the government through the Department of Health's Extra Care Housing Initiative Fund. This paper reports findings from an evaluation of extra care housing by the Personal Social Services Research Unit (PSSRU), which is the first evaluation of specialised housing for older people supported by the Department of Health. In particular, this paper focuses on older people's motivations for moving to the new schemes and explores whether these differ for people moving to smaller extra care facilities or to larger retirement communities. These issues are important to understand if we are to truly put older people, their experiences and aspirations at the centre of housing, health and social care, with the aim that choice, not just circumstances, drives residential relocation in later life.
The aim of this paper is two-fold. First, to describe the factors motivating older people to move to extra care housing and their expectations of living in such a new environment, and to interpret these results with regards to the theories/frameworks of residential relocation. Second, to establish whether these factors differ for residents moving to smaller extra care schemes or to larger retirement communities. The paper starts by describing extra care housing in the current housing and social care policy context in the United Kingdom (UK), before outlining current literature on residential relocation among older people, drawing on both UK and international studies. Results are reported based on a large-scale sample of older people who moved into 19 new-build extra care schemes in England, funded in the first two rounds of the Department of Health's capital grant programme (2004–06), three of which were retirement village communities. The decision to move is discussed in terms of ‘push’ factors pertaining to residents’ previous accommodation versus ‘pull’ factors such as attractions of the new extra care housing environment. The paper concludes by considering how the findings contribute to the current UK evidence base, and to what extent the choice of extra care housing can be said to be a real one.
Extra care housing in context
Specialised housing for older people in Britain dates back at least to the Middle Ages (Tinker Reference Tinker1997), and a number of trade-based continuing care communities were established in the 19th and early 20th centuries (Hearnden Reference Hearnden1983). In North America, specialist developments for older people form part of a substantial retirement community industry, dating back to the 1920s, and catering for older people who are predominantly healthy and active (Hunt et al. Reference Hunt, Feldt, Marans, Pastalan and Vakalo1984). The extent and range of retirement communities in the United States of America (USA) has been attributed to the availability of land and areas with attractive climates (Streib Reference Streib2002). There have been similar developments elsewhere, for example in Australia and New Zealand (Kupke Reference Kupke2000; Manicaros and Stimson Reference Manicaros and Stimson1999; Wolcott and Glezer Reference Wolcott and Glezer2002) and West Germany (Hearnden Reference Hearnden1983), although in many European countries there has been more emphasis on smaller housing-based solutions for providing accommodation with care (Winters Reference Winters2001). In Britain, in recent years, there has been some development of retirement villages. However, the main form of specialised housing during the period of reconstruction following the Second World War was sheltered housing, one aim being to provide accommodation for older people and ensure that family housing was available to families (Ministry of Local Government and Planning 1951). Although sheltered housing was seen as part of a continuum, for people who did not need the degree of care provided in residential care, it differed from residential care in tenure status, regulatory requirements and financial arrangements and increasingly accommodated people with similar levels of disability (Oldman Reference Oldman2000).
However, by the 1980s, sheltered housing was being criticised as over-provision for people with low needs and under-provision for those with high needs (Butler, Oldman and Greve Reference Butler, Oldman and Greve1983; Middleton Reference Middleton1987). Furthermore, some sheltered housing schemes became difficult to let, partly due to earlier standards no longer being considered acceptable, for example bedsits and shared facilities (Tinker, Wright and Zeilig Reference Tinker, Wright and Zeilig1995). Instead, there was a trend towards greater support to people in their own homes and towards the development of very sheltered housing, which provided some meals, additional services and improved physical design (Oldman Reference Oldman2000) and aimed to support residents as they became more frail and reduce admissions to care homes. More recently, ‘housing with care’ has become generally accepted as the overarching term for purpose-built accommodation, such as ‘extra care housing’ which promotes independent living in one's own home by providing care and support services (Department of Health 2004; Laing and Buisson 2010; Murphy and Miller Reference Murphy and Miller2008).
Although there is no agreed definition, Laing and Buisson (2010) suggest that extra care housing can be recognised by several characteristics: it is primarily for older people; the accommodation is (almost always) self-contained; care can be delivered flexibly, usually by a team of staff based on the premises; support staff are available on the premises for 24 hours a day; domestic care is available; communal facilities and services are available; meals are usually available, and charged for when taken; it aims to be a home for life; and it offers security of tenure. A distinction needs to be made between smaller extra care schemes, typically with 40 or more units of accommodation, and larger retirement villages, with 100 or more units (Croucher, Hicks and Jackson Reference Croucher, Hicks and Jackson2006; Evans Reference Evans2009). Retirement villages provide a wider range of social and leisure activities and more accommodation for purchase. Individuals are encouraged to move into retirement villages at a younger age to stimulate the development of a mixed community of interests and abilities. However, the maintenance of a balance between fit and frail residents can be difficult for providers (Croucher, Hicks and Jackson Reference Croucher, Hicks and Jackson2006), and the attitudes of the less frail residents towards the more frail can be a source of tension (Callaghan, Netten and Darton Reference Callaghan, Netten and Darton2009; Croucher et al. Reference Croucher, Hicks, Bevan and Sanderson2007).
Local authorities are interested in extra care housing because it can be seen to widen choice for service users, offering a potentially sustainable housing alternative to residential care (Department of Health 2005a) and complementing the government's personalisation and social care transformation agendas (Department for Communities and Local Government 2008; Department of Health 2010; Laing and Buisson 2009). These agendas emphasise placing individuals at the centre of the process of bringing housing, health and social care together, with the aim of giving people greater choice and control over the services they receive (Department for Communities and Local Government 2008). Extra care housing should, ideally, give choice to older people whose care needs might until recently have been met by residential care (Department of Health 2005b). Indeed, some have advocated the complete re-provision of residential care by developing extra care housing (Appleton and Shreeve Reference Appleton and Shreeve2003; Housing Learning and Improvement Network 2003), a view encouraged by the previous government (Department of Health 2004). Yet, Darton et al. (Reference Darton, Bäumker, Callaghan, Holder, Netten and Towers2011a) found that, overall, the people who moved into extra care were younger and less physically and cognitively impaired than those who moved into care homes. The 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. However, prevalence of the medical conditions examined was more similar for the two groups, and several of the extra care schemes had a significant minority of residents with high levels of dependence. Thus, extra care housing may be operating as an alternative to care homes for some individuals, but it is also providing for a wider population.
However, the volume of extra care is still much lower than that of care homes. Taking a very broad definition, there were about 43,300 extra care dwellings in England in 2009 (Elderly Accommodation Counsel 2009), compared with about 276,000 personal care places and about 179,000 nursing care places in care homes in the UK (Laing and Buisson 2009). In contrast, there were nearly 480,000 sheltered housing dwellings in England in 2009 (Elderly Accommodation Counsel 2009), somewhat exceeding the number of care home places. That said, extra care provision more than doubled during the previous six years, from around 21,000 dwellings in 2003 (Department of Health 2003). Between 2004 and 2010, the Labour Government had stimulated growth of the extra care housing market through the Department of Health's Extra Care Housing Initiative Fund, in partnership with the Homes and Communities Agency (formerly the Housing Corporation). Furthermore, sheltered housing and extra care dwellings may be occupied by more than one person, typically a married couple, and so these comparisons underestimate the relative level of provision of sheltered and extra care housing to some extent.
The intention for extra care housing is that the older person moves home as they might have done throughout life – to a new self-contained dwelling that will become their new home. An important question, therefore, is whether choice rather than circumstances guide the decision to move to extra care housing, which is rarely the case for a move to a care home (Johnson, Rolph and Smith Reference Johnson, Rolph and Smith2010; Peace, Kellaher and Holland Reference Peace, Kellaher and Holland2006; Williams Reference Williams2005). Whilst it is widely accepted that people prefer to ‘age in place’ when they are older (McCafferty Reference McCafferty1994; Sykes and Leather Reference Sykes and Leather1997; Tinker Reference Tinker1984) and the policy context (The Royal Commission on Long Term Care 1999) supports this through initiatives such as the Disabled Facilities Grant Programme and the requirement that new housing is built to lifetime homes standards (Department for Communities and Local Government 2008), it is questionable how many of our older population will be in a position to do so given that approximately 1.8 million households occupied by older people fail the decent homes standards (Evans Reference Evans2009). The Commission for Architecture and the Built Environment (CABE), a statutory body advising the government on architecture, urban design and public space, reported in 2009 that much of the current UK housing stock remains inaccessible for many older people (CABE 2009). Therefore, when older people do choose to or need to move, there is little housing choice available to them. Without better housing in the community, the choice is often between coping in unsuitable accommodation or up-rooting to some form of institutionalised home, often removed from familiar surroundings (Homes and Communities Agency 2009). This reinforces the notion that moving is a last resort.
Theories of and literature on residential relocation
Several conceptual frameworks have been proposed to explain residential mobility in later life. Lawton and Nahemow (Reference Lawton, Nahemow, Eisdorfer and Lawton1973) proposed a person–environment framework known as Lawton's ecological model of ageing. Research using this framework often focuses on how declining competence leads to a poor fit between the individual and his or her housing (environmental press), which can result in additional health consequences and poor quality of life. The developmental framework of Litwak and Longino (Reference Litwak and Longino1987) describes the transitions that older people move through as they attempt to optimise their living environment. In this framework, three kinds of moves are associated with significant life events. The first time an older person relocates is generally after retirement and is motivated by amenities and comfort. The second move is often to move closer to relatives who can provide assistance when one becomes less able to manage independently due to health problems. This second stage move has also been interpreted by some researchers as an ‘anticipatory’ move, taken in anticipation of worsening abilities (Speare and Meyer Reference Speare and Meyer1988). Finally, older people might relocate to an institutional setting, such as a care or nursing home, when care needs increase and informal carers are no longer able to provide adequate support (Longino et al. Reference Longino, Bradley, Stoller and Haas2008).
Both the person–environment and development framework are often used to focus on problems with the older person's current housing (Erickson et al. Reference Erickson, Krout, Ewen and Robison2006), but this is not the whole story because decisions concerning where to move to are also influenced by factors associated with the new environment, although arguably this is less applicable to those moving into residential care following a crisis, such as a fall. The push and pull framework (Lee Reference Lee1966) emphasises that the attractions of the new living environment, so-called pull factors, work together with the negative aspects of the current environment, the push factors, to explain why people move or how they choose between different accommodation types. Although the push–pull dichotomy is a useful one, it can be improved by also examining the content or type of motive (e.g. personal versus environmental reasons); the very same reason (e.g. housing amenities) can, in one case, be a push motive, and in another case, a pull motive (Oswald et al. Reference Oswald, Schilling, Wahl and Gaeng2002). Lawton's later work acknowledged issues of proactivity and environmental richness (Lawton Reference Lawton, Binstock and Shanas1985, Reference Lawton, Scheidt and Windley1998) in order to address the criticism that their initial model promoted a one-sided image of older people as ‘pawns’ of their environmental circumstances. Older people can proactively change housing conditions according to their own personal wishes and needs in order to maintain independence, allowing them to cope with environmental press and to profit from environmental richness. Older people frequently report a number of reasons for moving (Oswald et al. Reference Oswald, Schilling, Wahl and Gaeng2002) and viewed without a framework these can seem idiosyncratic and largely driven by physical and/or mental decline. However, viewed within the context of the frameworks outlined above, we can begin to make sense of how the environment, person and opportunities available at the time interact to influence whether, when, where and how often older people move.
Research which uses these frameworks to explain residential relocation in later life is predominantly from the USA, even when comparative data or secondary analysis of large data sets include other countries (e.g. Golant Reference Golant2002; Hazelrigg and Hardy Reference Hazelrigg and Hardy1995; Parr, Green and Behncke Reference Parr, Green and Behncke1988). Although purpose-built or age-restricted accommodation has existed for some time in North America, the past decade has seen an expansion of the types of such accommodation, including different kinds of assisted-living, continuing-care retirement communities (CCRCs), and, on a larger scale, independent retirement communities (Citro and Hermanson Reference Citro and Hermanson1999; Frank Reference Frank2001; Sherwood et al. Reference Sherwood, Ruchling, Sherwood and Morris1997). Several studies of older people's patterns of decision-making behaviour have specifically examined reasons for moving to retirement communities (see e.g. Krout et al. Reference Krout, Moen, Holmes, Oggins and Bowen2002; Laws Reference Laws1995).
In comparison to the US literature, there is a rather limited body of empirical evidence about older people's moves to housing and care in the UK and Europe, despite growing interest and investment. The studies which have been undertaken to date have often concentrated on individual developments (e.g. Bernard et al. Reference Bernard, Bartlam, Sim and Biggs2007; Croucher, Pleace and Bevan Reference Croucher, Pleace and Bevan2003; Evans and Means Reference Evans and Means2007; Kingston et al. Reference Kingston, Bernard, Biggs and Nettleton2001), were conducted or commissioned by the provider agencies to evaluate their own schemes, and the information collected has tended to be specific to the particular study, thus it is difficult to make comparisons across schemes. Recently, however, Evans and Vallelly have undertaken studies of several schemes managed by one housing provider, including an investigation of the care of people with dementia (Evans and Vallelly Reference Evans and Vallelly2007; Vallelly et al. Reference Vallelly, Evans, Fear and Means2006), and Croucher and colleagues have published a comparative study of seven schemes (Croucher et al. Reference Croucher, Hicks, Bevan and Sanderson2007).
To aid clarity, the results of the studies outlined above have been described in terms of Lee's conceptual framework, focusing on push and pull factors. This framework is helpful because it complements the broader environmental-fit framework (in that a poor person–environment fit can be considered a push factor and good person–environment fit a pull factor) and can apply to the developmental framework at both a macro (to help explain the need for transition between stages) and micro (within each developmental stage) level.
Push factors
Research from the UK suggests that the motivation amongst older people to move to housing with care is influenced by several generally agreed factors. Most often the reasons for moving relate to increasing health and mobility problems (e.g. Baker Reference Baker2002; Biggs et al. Reference Biggs, Bernard, Kingston and Nettleton2000; Evans and Means Reference Evans and Means2007; Kingston et al. Reference Kingston, Bernard, Biggs and Nettleton2001) which had been exacerbated by people's living arrangements, such as inappropriate accommodation (Baker Reference Baker2002; Croucher et al. Reference Croucher, Hicks, Bevan and Sanderson2007; Evans and Means Reference Evans and Means2007; Fletcher et al. Reference Fletcher, Riseborough, Humphries, Jenkins and Whittingham1999). Such ‘push factors’ sit well within both the developmental and environmental-fit frameworks. Baker (Reference Baker2002) and Fletcher et al. (Reference Fletcher, Riseborough, Humphries, Jenkins and Whittingham1999) also found that moves tended to be precipitated by either a crisis or a chronic problem worsening, and that staying put had not been an option for many (Vallelly Reference Vallelly2002). For others the feeling that they were becoming less able to cope led them to explore the options open to them (Fletcher et al. Reference Fletcher, Riseborough, Humphries, Jenkins and Whittingham1999). Considerations of no longer wanting to be a burden to one's family and concerns around security were also found to be at the heart of people's decisions to move (Baker Reference Baker2002; Fletcher et al. Reference Fletcher, Riseborough, Humphries, Jenkins and Whittingham1999; Kingston et al. Reference Kingston, Bernard, Biggs and Nettleton2001).
In a study of Berryhill Village, a retirement community in the West Midlands with more than 150 tenants operated by The ExtraCare Charitable Trust, it was people's own health or their partner's health that was identified as a very important factor, together with their previous home and or garden being too much for them to manage (Bernard et al. Reference Bernard, Bartlam, Biggs and Sim2004). However, another study of a retirement community found that, although many people had moved to the community citing poor health, they rated their own health as significantly better than a matched sample of older people drawn from the locality where many of the retirement community's residents had formerly lived (Kingston et al. Reference Kingston, Bernard, Biggs and Nettleton2001). This may indicate that people moving into retirement communities are ‘planners’, acting as soon as they feel their own health decline in anticipation of further loss of mobility or general health, or it may be that the move into retirement housing compensated for their loss of functioning and so led to better ratings of health than in the community.
In the USA, Krout et al. (Reference Krout, Moen, Holmes, Oggins and Bowen2002) found that a decline in the residents’ own health or the health of residents’ spouses represented push factors for those who moved to a CCRC, as did concern regarding property maintenance, albeit apparently to a lesser degree than other factors (Sheehan and Karasik Reference Sheehan and Karasik1995; Tell et al. Reference Tell, Cohen, Larson and Batten1987). Interestingly, a study of Hartrigg Oaks, a UK retirement community operated by the Joseph Rowntree Housing Trust with more than 200 residents (Croucher, Pleace and Bevan Reference Croucher, Pleace and Bevan2003), found that health worries were not a particularly prominent reason for people leaving their last home. However, perhaps this is not unexpected, given that the majority of residents had to pass a medical assessment before they could move to the village. In this study, the principal push factors were that their previous home and/or garden had become too much for them to manage.
Pull factors
A review of the studies involving smaller extra care schemes in the UK suggests that residents mostly move to these schemes because of factors associated with their previous circumstances (push factors), rather than the decision to move being based on the attractions of their new living environment (Tribal, Walker and Jarvis Reference Tribal, Walker and Jarvis2006). Conversely, most of the studies involving retirement communities conclude that older people move to these larger settings because of the attractions of the new living environment; the ‘pull factors’ according to Lee's push–pull framework (Lee Reference Lee1966). As Erickson et al. (Reference Erickson, Krout, Ewen and Robison2006) observe, even the ‘push factors’ associated with the upkeep and maintenance of a previous home, cited as reasons for moving in the study of a UK retirement community, can be viewed as a criterion by which to evaluate new housing options and thus be viewed as ‘pull factors’.
Certainly, in the two longitudinal studies of the Hartrigg Oaks and Berryhill Village retirement communities in the UK, the attractions seem to have played a more active role in the decision process, which is similar to the findings in the more extensive US literature. The major attractions of Hartrigg Oaks were the quality and size of the accommodation and the extensive care services that were available on site (Croucher, Pleace and Bevan Reference Croucher, Pleace and Bevan2003). Residents also reported their determination not to be a ‘burden’ on their families as they got older and expressed a wish to stay independent, desires that are echoed in the literature from the USA (Krout et al. Reference Krout, Moen, Holmes, Oggins and Bowen2002; Sherwood et al. Reference Sherwood, Ruchling, Sherwood and Morris1997). Bernard et al. (Reference Bernard, Bartlam, Biggs and Sim2004) report that people gave three main reasons for choosing to live in Berryhill Village: autonomy, security and sociability. Social opportunities were often cited as one of the reasons for moving, although independence and security were generally stronger motivations (Croucher, Hicks and Jackson Reference Croucher, Hicks and Jackson2006). Evans and Means (Reference Evans and Means2007), in the study of Westbury Fields retirement community in Bristol with more than 200 residents, reported that location was an important consideration, both in terms of access to everyday amenities and retaining family and/or social networks.
In general, studies involving retirement communities in the USA and to a lesser extent Australia (Kupke Reference Kupke2000; Manicaros and Stimson Reference Manicaros and Stimson1999; Wolcott and Glezer Reference Wolcott and Glezer2002), paint a similar picture. Access to on-site health care and medical services in order to maintain independence and avoid the potential problems of ‘ageing in place’ seem to be one of the most important influences (see Krout et al. Reference Krout, Moen, Holmes, Oggins and Bowen2002; Longino, Perzynski and Stoller Reference Longino, Perzynski and Stoller2002), as well as the guarantee in the contract between provider and residents that personal care will be delivered (Manicaros and Stimson Reference Manicaros and Stimson1999; Sheehan and Karasik Reference Sheehan and Karasik1995; Sherwood et al. Reference Sherwood, Ruchling, Sherwood and Morris1997). Anticipation of future declines in health and wellbeing is therefore significant in ‘pulling’ older people into housing which enables independence. Pinquart and Sorensen (Reference Pinquart and Sorensen2002) explicitly linked the reasons for planning for future care needs to security and coping independently. Two studies from the USA reported that those most likely to cite independence from family as a reason to join a CCRC include women and those individuals who are younger or who have grown-up children (Cohen et al. Reference Cohen, Tell, Batten and Larson1988; Sheehan and Karasik Reference Sheehan and Karasik1995). Other pull factors often reported include better living environments, location near family/cultural activities, amenities and activities provided (Erickson et al. Reference Erickson, Krout, Ewen and Robison2006; Krout et al. Reference Krout, Moen, Holmes, Oggins and Bowen2002; Manicaros and Stimson Reference Manicaros and Stimson1999), and when deciding between different villages, factors found to be most important to residents included the size, design and price range of the accommodation units (Kupke Reference Kupke2000).
Thus, one of the key themes that emerges from this literature is that residents moving to retirement communities (compared with smaller housing and care schemes) may be ‘pulled’ rather than ‘pushed’; that is, they were proactive in their housing choice and focused on the desirable features of the new housing situation rather than planning their move under pressing circumstances.
Method
Approximately £60 million of the £87 million capital allocation from the 2004–06 Department of Health funding rounds was allocated to 22 local authorities with social services responsibility to work with housing association partners to develop a range of new-build extra care housing schemes. A condition of receiving financial support from these first two rounds was that the schemes would participate in a national evaluation by the PSSRU. Three schemes were dropped from the evaluation because of delays to planned opening dates. The 19 schemes covered by the evaluation opened between April 2006 and November 2008.
The evaluation aimed to examine the development of schemes from their implementation, and to follow the residents’ experiences and health and social care needs over time. The schemes included three care villages, each with approximately 250 units of accommodation (all apartments or bungalows), and 16 smaller developments, with between 35 and 75 units of self-contained accommodation. The schemes were developed to support residents with a range of levels of disability and long-term conditions, as well as to provide facilities for members of the community living outside the scheme. A number of the schemes provided intermediate care, designed to help people make the transition from hospital care back to their own homes. These individuals were not included in the evaluation, because of the focus on long-term residents. The schemes offered a mixture of housing tenures, including social rented accommodation, leasehold and shared ownership arrangements. Three of the six smaller schemes that opened in 2006, three of the seven smaller schemes that opened in 2007, and one scheme that opened in 2008 only provided accommodation for social rent. However, the villages provided relatively more accommodation for sale. Each type of local authority with social services responsibility was represented in our sample, with the exception of Inner London. Three schemes were in metropolitan districts, three in Outer London boroughs, five in shire counties, and eight in unitary authorities. The 19 schemes were located in eight regions: five in the Yorkshire and The Humber, four in the South East, three in London, two in both the North East and the East Midlands, and one in each of the North West, West Midlands and East of England.
Prior to the opening of each scheme, a local interviewer was recruited to co-ordinate data collection and undertake interviews with residents. An assistant was also recruited for the villages. Two main sets of information were collected about the individual entrants. First, information was collected about their demographic characteristics and care needs, using a questionnaire to record information collected in the assessment process undertaken prior to moving in. The questionnaire was designed to correspond to those used in several previous studies of admissions to care homes, most recently in 2005 (Darton et al. Reference Darton, Forder, Bebbington, Netten, Towers and Williams2006, Reference Darton, Forder, Netten, Bebbington, Holder and Towers2010), and was developed in consultation with representatives of the schemes. The information collected included demographic information, previous accommodation and living arrangements, the receipt of informal care and formal care services, medical history, activities of daily living, instrumental activities of daily living, cognitive impairment, financial circumstances, and planned accommodation and services in extra care. Subject to the consent of the resident or their representative, the interviewer completed the questionnaire using the assessment information. Separate questionnaires were completed for each member of a couple.
Second, new residents were asked to complete a questionnaire about their reasons for moving and their expectations of living in the new schemes, assisted, where necessary, by the local interviewer. For residents that did not require care services and did not receive a care assessment prior to moving in, i.e. those classified in this paper as residents without care needs, information was only collected about their reasons for moving, expectations and experiences. A full description of the evaluation is contained in a technical report (Darton et al. Reference Darton, Bäumker, Callaghan and Netten2011b). The resident questionnaire contained both push and pull factors, which in previous studies were identified as particularly relevant to the relocation of older people. Also, a single question using a five-point scale was included as an indicator of self-perceived health (Robine, Jagger and Romieu Reference Robine, Jagger and Romieu2002).
The questionnaires were completed soon after residents moved in. Inevitably, some residents moved from the schemes during the evaluation period, and new residents moved in. The evaluation was designed to include new residents, but this paper is based on individuals who moved into each scheme within six months of opening. The process received ethical approval from the appropriate Research Ethics Committee at the University of Kent and, because some residents may have lacked the mental capacity to consent, from a local research ethics committee within the NHS National Research Ethics Service (Leeds (West) Research Ethics Committee, reference number 08/H1307/98).
The data were analysed separately for three groups: those residents with and without care needs who moved into the retirement villages, and those residents who moved into the smaller schemes all of whom had some level of care need. For comparison between the groups in terms of demographic characteristics, chi-squared (χ2) tests with one degree of freedom (df) were computed with a correction for continuity. For comparison between the groups, where categories associated with the variables could be rank-ordered (e.g. in terms of a criterion from highest to lowest), the Mann–Whitney U-test for two unrelated samples was computed. The statistical analysis was undertaken using the SPSS for Windows, Release 15.0.1 (SPSS Inc., 2006) computer program.
Results
The three villages accounted for 770 units of accommodation and the 16 smaller schemes for 716 units, a total of 1,486 units. Excluding the accommodation designated for intermediate care reduced the total to 1,439 units. Of the 770 units in the villages, 530 units were designated for people who exercised a housing choice and did not require personal care services. The information presented relates to 949 individuals who moved into the schemes within six months of opening, 456 to the smaller schemes and 493 into the villages. Of the residents who moved into the villages, 368 did not receive a care assessment. The ratio of individuals to units represents an approximate response rate of 66 per cent. Since extra care accommodation may be occupied by more than one person, this ratio is likely to be an overestimate. Conversely, the calculation is based on the assumption that all the units were occupied. At the scheme level, the 'response rates’ ranged from over 85 per cent for five schemes to under 40 per cent for three schemes. The lower figures were related to problems of obtaining consent (two schemes), delays in setting up the fieldwork in one of the villages at the request of the scheme management and interviewer recruitment (two schemes) as this position involved flexible, irregular working hours because the data collection for the research occurred in waves.
The villages were intended to provide a balanced community with between 60 and 90 units set aside for people who required care services. As a consequence, the majority of residents did not receive a care assessment at take up of their tenancy or lease. For these people, only basic demographic information was available, which is presented in Table 1 alongside information on those residents with care needs in the villages and residents in the smaller schemes. The people without care needs who moved into the villages were slightly younger, on average, and more likely to be married/cohabiting, especially compared with residents in smaller schemes (p<0.001). More than 55 per cent of village residents without care needs were married/cohabiting and were not living alone, compared with about 30 per cent of residents with care needs in both the villages and smaller schemes. The proportion of men to women in all groups was the same, with female residents accounting for 65 per cent of residents. Also for all groups, the mean length of time residents had been living in their previous accommodation was approximately 20 years, with the majority reporting that they had relocated from a different community or different area entirely.
Table 1. Demographic information
Table 2 presents the distribution of scores on the Barthel Index of Activities of Daily Living (Mahoney and Barthel Reference Mahoney and Barthel1965) and the Minimum Data Set Cognitive Performance Scale (MDS CPS) (Morris et al. Reference Morris, Fries, Mehr, Hawes, Phillips, Mor and Lipsitz1994) for residents in the smaller schemes and for residents with care needs in the villages. The scores on the MDS CPS indicate that only 6 per cent of those who moved into the villages with care needs suffered from cognitive impairment, compared with 21 per cent of those moving into the smaller schemes (p<0.001). The mean scores on the Barthel Index illustrate the difference between the two groups in terms of performing activities of daily living (ADLs) and it was the case that this was significant at the 10 per cent level (z=1.824, p=0.068). People with care needs in the villages had slightly more need for assistance with ADLs than those in the smaller schemes. However, a note of caution is needed as for some smaller schemes the sample of residents who participated in the study might not have been fully representative of the scheme's dependency profiles. For the five schemes that were making specific provision for people with dementia, two had ‘response rates’ of below 50 per cent.
Table 2. Functional and cognitive impairment
Notes: The above information is not available for residents without an assessment in villages. ADL: activity of daily living. MDS CPS: Minimum Data Set Cognitive Performance Scale.
On the indicator for self-perceived health, about 25 per cent of people with care needs in the villages considered themselves in good or very good health, compared with over a third of residents in the smaller schemes. There was evidence of an association between physical functioning (scores on the Barthel Index) and self-perceived health. The self-perceived health measure tends to be used as an indicator of objective health and is closely associated with wellbeing (e.g. Palmore and Luikart Reference Palmore and Luikart1972). For residents without care needs in the villages, only scores on the indicator of self-perceived health were available; more than half considered themselves in good to very good health, and a further 40 per cent considered their health as fair.
Information on tenure was available for residents who received a care assessment, as presented in Table 1. Although individual data were not available, from other information supplied by the schemes, residents without care needs in the villages were most likely to have been previous owner-occupiers and to have purchased their extra care accommodation. Of the residents with care needs in the villages, approximately two-thirds rented and a third either purchased their accommodation fully or on a shared ownership basis. Units purchased or part-purchased were much more likely to be two-bedroom units, although units rented in the villages were also more likely to be two-bedroom units than those rented in the smaller schemes. Ninety per cent of residents in the smaller schemes rented their accommodation at affordable rent levels, and of these more than 70 per cent were one-bedroom units.
Push factors
Residents were asked to score several factors in terms of whether they were very, quite or not at all important in their decision to move to extra care housing. Table 3 presents the percentage of residents who scored the push factors listed as very important. For residents in the smaller schemes, the most important reasons for moving out of their previous homes were related to health and managing their long-term condition. This was even more the case for residents with care needs in the villages. The majority identified their own physical health as a very important reason, whilst a further 20 per cent stated that it was quite important. Just over 20 per cent of residents without care needs in the villages also identified physical health as a very important reason, and a further 40 per cent stated that it was quite important. However, approximately 70 per cent of these residents without care needs in the villages reported that all other health-related factors (as in Table 3) were of no importance in their decision to move. By comparison, approximately 60 per cent of residents with care needs reported that problems with coping with daily tasks and lack of services and/or support were very or quite important factors in their decision to move. Residents who were unmarried and female residents were slightly more likely to cite lack of services and their ability to cope with daily tasks as factors influencing their decision to move. For all health-related push factors, the differences between the groups of residents with care needs and those without were significant (p<0.001).
Table 3. Push and pull factors (% of residents who rated factors as very important)
Note: Values are shadowed from lowest (white) to highest (darkest shade of grey).
Difficulty with mobility in their previous homes, and the need for adaptations, were important incentives to move for the majority of residents with care needs, compared with less than a third of residents without care needs. Managing the home was a reason to move for about half of the overall sample. Garden maintenance was a relatively more important reason for residents without care needs in the villages than for residents with care needs; two-thirds reported it as quite or very important, compared with less than half of residents with care needs. Overall, all other housing-related factors (e.g. home too large, home in disrepair, home too far from shops, cost of living) were not at all important for two-thirds to nearly all of the residents.
A quarter to a third of residents stated that various social issues were quite or very important in their decision to move; the proportions were quite similar for the smaller schemes and the villages. However, residents in the smaller schemes attached slightly more importance to isolation from the community, whereas residents without care needs in the villages attached more importance to fear of crime.
Pull factors
Table 3 presents the percentage of residents who scored the pull factors listed as very important. The most important attractions for the majority of residents, with little difference between those in the smaller schemes or the villages, were: tenancy rights or ‘having your own front door’, flexible on-site care and support (24 hours a day), security offered by the scheme, accessible living arrangements and bathrooms, and size of the units. Approximately 90 per cent or more of the residents indicated that these factors were influential in their decision to move, with the vast majority stating that they were very important factors, as shown in Table 3. However, the reassurance of care and support on-site was more important for residents with care needs than those without (p<0.001).
The type of tenure available was identified as a very important incentive to move for 70 per cent of residents without care needs in the villages, compared with 50 per cent of all residents with care needs (p<0.001). About a further quarter in each group identified this factor as quite important in their decision to move. Similarly, a higher proportion of residents without care needs in the villages identified the availability of social/leisure facilities as an important attraction, compared with those with care needs in either the villages or the smaller schemes (p<0.001); approximately 60 per cent compared with 40 per cent, respectively, with a further 30–40 per cent identifying this factor as quite important. Married respondents were more likely to cite the availability of communal or social facilities as an important factor in moving. The proximity of the scheme or village to family and/or friends was a very or quite important consideration for approximately 70 per cent of the sample. Female residents were more likely to say that proximity to family and/or friends was an important reason for moving. The reputation of the Registered Social Landlord (housing association) was a more important attraction for residents in the villages, whether with or without care needs, than for residents in the smaller schemes (p<0.001); only a third of residents in the smaller schemes regarded reputation as very or quite important compared with more than half of residents with care needs in the villages and more than 80 per cent of residents without care needs. For approximately 70 per cent of residents of all groups, the least frequently identified attraction of extra care was the fact that a care home was the only alternative.
Expectations
Table 4 presents residents’ expectations of living in their new extra care housing environment. More than two-thirds of residents expected their social life to improve and, as a result, that they would be less isolated and would socialise more. There were associations between these expectations and reporting that social facilities (r=0.320, p<0.001) and security (r=0.231, p<0.001) were very important attractions of extra care housing. There was also an association between this expectation and citing isolation from the community as a reason for moving out of their previous accommodation (r=0.289, p<0.001). Notably, approximately a third of respondents, irrespective of whether they had care needs or not, did not expect their social life to change after their move to extra care. A quarter of residents in all groups expected to see their family and/or friends more often, whereas between 60 and 70 per cent did not expect to see a change in the frequency with which they saw family and/or friends. The only significant difference between the groups in terms of expectations was that more residents in the smaller schemes indicated that they had no intention of moving on from extra care into a care home in the future, whereas more residents in the villages expected it to be a less likely future possibility but did not rule it out.
Table 4. Expectations
Data were not collected on the sources of information residents accessed to find out about extra care housing before their move, and which might have influenced their expectations. Nearly 90 per cent of residents and 80 per cent of their families visited the scheme or village before moving in. This was similar for all groups. However, only 10 per cent of residents in the smaller schemes visited an alternative beforehand, whereas nearly 30 per cent of those in the care villages evaluated alternative schemes (p<0.001). Approximately 10 per cent of residents in all groups visited a care home prior to their move.
Discussion
The evaluation reported on in this paper, the first large-scale evaluation of extra care housing of its kind funded by the Department of Health, focused on schemes that were developed in response to a specific government capital funding programme. While this focus means the schemes may not be representative of the wider extra care housing market, with providers across the not-for-profit, voluntary and private sectors, this large-scale quantitative study adds significantly to the evidence base on extra care schemes and their residents. In comparison to the smaller qualitative studies undertaken in the UK, this present study involved the collection of equivalent information across 19 extra care housing settings, three of which were retirement villages.
An important factor that will influence which types of individuals move into extra care schemes will be the basis on which older people are able to access the schemes. Applicants for the villages who did not require care services were only prioritised according to criteria such as age, links to the local community, and housing needs. Moreover, as they were most likely previous owner-occupiers, they had the benefit of purchasing power, for example through releasing equity. Applications for those apartments set aside for care needs, however, would have had to meet more specific entry assessments against local eligibility criteria (Murphy and Miller Reference Murphy and Miller2008). The smaller schemes, specifically, were developed to support a balance of residents with high, medium and low care needs. Results from the evaluation on resident characteristics reported elsewhere (Darton et al. Reference Darton, Bäumker, Callaghan, Holder, Netten and Towers2011a) suggest that generally this intended balance of dependency was being achieved. Applications for the schemes could be received from a variety of sources, such as the local social services department or housing department, self-referrals, relatives, carers, general practitioners or other health professionals. However, typically, the local authority had a nomination agreement in place with the Registered Social Landlord detailing the number of properties to be allocated to applicants they decided to put forward for consideration after an assessment to establish their housing, care and support needs. Therefore, local authorities’ extra care strategies might target extra care schemes to certain client groups, and those schemes would not be able to accommodate people who were seeking primarily to make plans for the future, or merely looking for somewhere else to live, to the extent which villages could. For example, extra care housing is viewed by some local authorities as an alternative to moving into a care home (Department of Health 2005a), and some of the schemes included in the evaluation were designed specifically to replace existing residential care homes, or to provide for residents with dementia. However, the idea that older people with care needs who move to the smaller extra care schemes are a passive audience who fail to make decisions about their future accommodation needs is not supported by this or other studies (Dalley Reference Dalley2001; Stillwell and Kerslake Reference Stillwell and Kerslake2004).
This present study confirmed that health concerns were the most important motivation for people to move out of their previous homes. This mirrors results from the other UK studies (e.g. Baker Reference Baker2002; Biggs et al. Reference Biggs, Bernard, Kingston and Nettleton2000; Evans and Means Reference Evans and Means2007; Kingston et al. Reference Kingston, Bernard, Biggs and Nettleton2001). As would be expected, a much higher proportion of residents with care needs in both the smaller schemes and villages, compared with residents without care needs in the villages, felt pushed by health-related factors to relocate. However, it was not only those residents who had higher levels of dependency in terms of ADLs, or who considered themselves in poorer health on the self-perceived health indicator, who reported that their own physical health was an important reason to move. Thus, future health needs were an important consideration even for residents with only low or even no immediate care needs. Furthermore, although physical health was identified as the most important push factor, a higher proportion of residents in all groups indicated that the availability of flexible care and support on-site was a major pull factor of extra care housing. Not unexpectedly, the difference was significantly greater for residents without care needs in the villages, for whom the move to extra care was clearly motivated by the desire to obtain guaranteed access to care services for future, and not for current needs. For the majority of residents in all groups, one of the least frequently identified reasons for choosing extra care housing was the fact that a residential care home was the only alternative. This links in with results reported elsewhere (Darton et al. Reference Darton, Bäumker, Callaghan, Holder, Netten and Towers2011a) which found that residents with care needs in extra care housing were substantially less physically and cognitively impaired than those who moved into care homes in a 2005 study of admissions.
By aiming for a balanced community model, the retirement villages have developed into quite complex social structures with cohorts of residents with varying care needs. The residents with care needs in the villages were not dissimilar to people who moved into the smaller schemes, although there was some indication that they were in fact physically slightly frailer, whilst cognitively more intact. In comparison, residents without care needs in the villages considered themselves in much better health. Therefore, it is not unexpected that their moves seemed to be planned, rather than in response to an immediate need and that their decisions were overwhelmingly directed by pull factors, as is the case in the US literature on retirement communities. In addition, these residents were most likely to have been previous owner-occupiers who purchased their extra care accommodation. Accordingly, a higher proportion indicated that the type of tenure, the reputation of the scheme and the cost of living were important considerations in their decision to move, and the difference with residents with care needs, both in the smaller schemes and in the villages, was significant.
Interestingly, the only very significant difference between residents with care needs in the villages and those in the smaller schemes was that the former were influenced to a greater extent by the reputation of the Registered Social Landlord. A different perception seemed to exist about what service was being offered by the smaller schemes and the retirement villages. The large providers who develop retirement villages produce some of the most customer-friendly marketing material, which is often dominated by the spatial, lifestyle and specification aspects rather than a focus on the integration of care or end-of-life care strategies (McCarthy Reference McCarthy2009). This emphasis seems to have shaped resident's expectations to an extent; residents in the villages, both those with and without care needs, were more likely to consider a move to a care home a less likely future possibility but did not rule it out. In comparison, residents in the smaller schemes more often reported that they had no intention to move again once living in the scheme. Some of the smaller extra care schemes were viewed by the local authorities as alternatives to, or as likely to prevent a move to, residential care (Department of Health 2005a). A term which has been used in some local authorities’ extra care housing strategies is ‘home for life’ – the idea that residents should, due to the flexible care, be able to remain in extra care housing well beyond the point where they would have had to leave dispersed home care and have been admitted to a care home or hospital. It remains to be seen to what extent residents’ expectations will be met over time.
In addition to the flexible care and support on-site, other pull factors which had an important influence on residents’ decisions to move in all three groups were: tenancy rights, the security offered by the schemes, accessible living arrangements including bathrooms, the self-contained nature of the accommodation (‘having your own front door’) and the size of the accommodation. Tenancy rights indicate that the extra care accommodation is not inexplicitly bound up with the care received, and gives the security needed for a resident to consider their accommodation to be their own home (Laing and Buisson 2010). As stated previously, a sense of security might be derived from the knowledge that 24-hour flexible care is available on-site, and also from an accessible environment which makes people less fearful of falling or injuring themselves (Croucher, Hicks and Jackson Reference Croucher, Hicks and Jackson2006). These features are promoted as distinguishing extra care housing from other forms of housing provision for older people. Overall, it would seem that the people who moved to extra care housing seemed to have an accurate perception of the model on offer. However, because the study was conducted after residents were given time to settle in, it could be that residents rationalised retrospectively in an attempt to justify their choice.
Relative to these pull factors, the availability of on-site social facilities was equally important to residents without care needs in the villages, but was less important to residents with care needs both in the smaller schemes and the villages. Residents with care needs were less likely to visit alternative settings before their move than those without care needs, and may therefore have been less aware that the extra care facilities extended beyond those available in sheltered housing or care homes. Yet, the extent of the social facilities in the retirement villages is quite apparent. Health and mobility impairments may have created an inability or an initial reluctance to engage in an active social life, which is in line with findings of other research (Croucher et al. Reference Croucher, Hicks, Bevan and Sanderson2007; Evans and Means Reference Evans and Means2007; Evans and Vallelly Reference Evans and Vallelly2007). However, as reported elsewhere (Callaghan, Netten and Darton Reference Callaghan, Netten and Darton2009), a lag can exist in establishing social activities in newly opened schemes, and therefore it would be interesting to explore whether people moving into existing schemes had similar views.
Conclusion
Most older people move for a complex combination of reasons which are not necessarily discernible with quantitative methods. Nonetheless, 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 resident's 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 extra care schemes than has been identified in the previous UK literature, although moves also related to residents’ increasing health and mobility problems. Reasons for moving are by definition multi-dimensional, and push and pull factors of Lee's model (1966) are necessarily interrelated. Nonetheless, when considering Litwak and Longino's framework (1987), residents with care needs in both the smaller schemes and the villages could be considered as falling into the second category more often than the third category; i.e. moving proactively when independent living is proving difficult rather than when staying put is no longer an option. As in other literature, village residents without care needs could be categorised in terms of the first and second types of moves; planned moves mostly towards facilities and in anticipation of worsening abilities and the need for care services in the future. The results therefore suggest that moving to extra care housing in old age is not by definition a stressful event and that older movers do not always react passively to environmental restrictions or ‘environmental press’ (Lawton Reference Lawton, Binstock and Shanas1985, Reference Lawton, Bengtson and Schaie1989; Lawton and Nahemow Reference Lawton, Nahemow, Eisdorfer and Lawton1973). Peace et al. (Reference Peace, Wahl, Oswald, Mollenkopf, Bond, Dittmann-Kohli, Peace and Westerhof2007) comment that ‘environmental press’ will push people towards option recognition and many older people will be able to take action. Our findings suggest that most people in our sample wanted to optimise their mastery over their environment and, when it appeared right to do so, considered the next step to proactively optimise their environment and enhance their ‘environmental richness’ (Lawton Reference Lawton, Scheidt and Windley1998, Reference Lawton, Friedman and Wachs1999; Parmelee and Lawton Reference Parmelee, Lawton, Birren and Schaie1990). It would seem that older people might consider extra care housing an accommodation option that can fulfil their preferences and wishes, as well as meeting their basic needs to stay independent.
Acknowledgements
This research study was funded by the Department of Health and was conducted as part of the PSSRU Housing and Care Programme. We would like to thank Jeremy Porteus at the Department of Health and the members of the Steering Group for their guidance; the Housing Learning and Improvement Network (funded by the Department of Health); our social services liaison contacts; the Registered Social Landlords (housing associations); the staff of the schemes; and, particularly, the residents who gave up their time to be interviewed for the project and shared their personal views and experiences with us so openly and honestly. Lesley Cox and Jane Dennett undertook the data preparation work at the PSSRU. The views expressed in this paper are those of the authors and are not necessarily those of the Department of Health.
