Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: The crisis in care home supply

BMJ 2018; 363 doi: (Published 02 October 2018) Cite this as: BMJ 2018;363:k4076
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

Care homes are a neglected area of public policy that we have to get right. Pressure on care home places is increasing, alongside huge recruitment and funding problems.

Last year Oxford Brookes University’s Institute of Public Care (IPC) studied data from the Care Quality Commission and found that, from April 2012 to April 2017, the number of care homes in England fell by 8%, from 17 801 to 16 392.1

In the UK the term “care home” commonly refers both to residential care homes and nursing homes. While nursing homes employ registered nurses, care homes now increasingly care for older people with highly complex needs and significant physical dependence, disability, or cognitive impairment.23 The IPC found that the average size of newly opened care homes (37 places) was greater than in those that closed (29), so the overall number of places for older residents increased by 4%, from 387 485 to 404 163. Yet potential demand has outstripped this expansion, as the number of citizens aged over 85 increased by 16%.

Staffing these homes is also a challenge. Skills for Care4 has estimated 1.6 million jobs in adult social care, with annual turnover of 30%. Nearly half of these staff work in adult residential and nursing care, with vacancy rates of 11%.5 The workforce is ageing, low paid, and heavily reliant on immigration.4 The NHS, and less emotionally demanding and responsible industries, compete with the sector for staff, and recruitment and retention may be further harmed by visa restrictions and the impact of Brexit. Repeated cuts in local government funding (hence adult social care) have made the care home market ever more challenging for operators.67 The introduction of the national living wage has created further pressures.8

The adult social care workforce is ageing, low paid, and heavily reliant on immigration

I see no meaningful prospect of care homes no longer being required in my lifetime, no matter how much we invest in age friendly housing, prevention, and support at home. Modelling has shown that people living longer will lead to more years spent in high dependence.910 Even health systems lauded for their excellence, person centred processes, and community approaches such as those in the Netherlands and Sweden still have significant per capita places in long term care homes, exceeding those in the UK.11

England has serially slashed investment in public health.12 We’re building too few age friendly homes,13 including schemes such as sheltered accommodation or extra care housing for frail or dependent residents. Unpaid, informal family caregivers are already working flat out, at detriment to their own health. The national State of Caring 2018 survey by Carers UK portrayed a grim picture of poor support, inadequate information, and low morale.14

With an ageing population and around three times as many people in care homes as in hospitals,15 and with many hospital patients unable to access community assessment or rehabilitation after acute illness or injury,16 the issue of care homes shouldn’t be treated by policy makers as invisible or relegated to the “too difficult” file. It deserves far more prominence and attention.