Current and predicted market position

The purpose of the Joint Strategic Needs Assessment (JSNA) is to provide an objective view across the life course from cradle to grave, of the health and wellbeing needs and inequalities of a local population. Therefore a local JSNA can illustrate the challenges affecting different populations at different stages of their lives, and provide an evidence base for the services commissioners need to commission, to meet the needs of the population.

• South Devon and Torbay Joint Strategic Needs Assessment
• Devon Joint Strategic Needs Assessment

Key points from the current (2020/21) JSNA are:

• There is significant variation in health and wellbeing across the Bay. In our most affluent areas residents can expect to live on average over six years longer than those living in our more deprived communities.
• Torbay is also ranked as the most deprived local authority area in the South West region, with 27% of the population living in the top 20% most deprived areas in England, (shown by the two darker blue shades on the map, where pale areas are amongst the least deprived in England).
• Torbay’s economy is ranked amongst the weakest in England, and has declined in recent years. With the disruption to the economy caused by COVID-19 the economy is expected to weaken further.
• Torbay’s economy is highly dependent on tourism and unemployment is beginning to rise.
• Torbay has an ageing population, with people aged over 85 expected to increase by 50% within the next 10 years, and more people expected to become frail and require support from health and social care services.

Figure 2: Index of Multiple Deprivation, Torbay

Source: Ministry of Housing, Communities and Local Government, www.gov.uk

Population overview

People in more deprived communities generally tend to experience multiple long-term conditions, have poorer health outcomes, and a shorter life expectancy. Disability free life expectancy measures the average number of years a person would expect to live without a long lasting physical or mental health condition or disability that would limit their daily activities, and in Torbay, disability free life expectancy is 3-4 years lower for both men and women than in England as a whole.

Long-term conditions are those that cannot be cured, but can be managed through treatment and behaviour. The Torbay GP registers show higher percentages of patients than in England as a whole, who have long-term conditions such as depression, diabetes, coronary heart disease, hypertension, asthma, chronic obstructive pulmonary disease (COPD), epilepsy and rheumatoid arthritis.

There are 136,264 people in Torbay (ONS Mid-Year Estimate 2019), and 1 in 4 are aged 65 or over (36,612 people, or 27%) which is higher compared to across England (where the 65s and over make up 18%).  The population structure for Torbay is shown in Figure 3, and it clearly shows Torbay has higher proportions (red and blue bars) than the England average (black line) of residents in all age groups above the age of 50 and lower proportions for the younger age groups.

Figure 3: Population pyramid, Torbay (2019)

Source: Office of National Statistics (ONS) Mid-year estimate 2019

Figure 4: Projected future population 2018-2041, Torbay

Source: ONS Population projections, 2018 based

By 2040, it is estimated that over one in three (34%) of Torbay’s population will be aged 65 years and over (52,033), compared to 24% across England. Population projections, by age group, are shown in Figure 4. 

In England in 2015, 54% of people aged 65 or over had two or more long-term conditions. Multiple long-term conditions involves more healthcare professionals and transitions across specialties and healthcare boundaries, and there is correspondence with higher healthcare costs, unplanned or unnecessary hospital admissions, increased use of ambulatory care, delayed transfers of care and long-term institutionalisation. [1] It is likely with Torbay’s ageing population and higher rates of long-term health conditions that numbers with multiple long-term conditions are increasing in the Bay.

Also as our population ages, we expect the number of frail people, people with physical mobility, weakness, weight loss, slowness and or low physical activity to increase, specifically in our older age groups. The number of people with dementia is also expected to increase over the coming years. Estimates for the counts of frail people and also those with dementia are presented in Figures 5 and 6.

Figure 5: Torbay Frailty estimates - Collard et al (2012),

Source: ONS 2018 based population projections

Figure 6: Torbay Dementia estimates

Source: Cognitive Function and Ageing Study (2013), ONS 2018 based population projections

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and determines how we handle stress, relate to others, and make choices. One-in-four adults and one-in-ten children will experience mental illness during their lifetime. In Torbay, the prevalence of depression in primary care, the number of emergency hospital admissions for self-harm and recorded suicides, suggest levels of mental health needs are higher in comparison to the wider England average. Additionally, people with mental health problems are more likely to experience poor physical health, and conversely, people with poor physical health are at higher risk of experiencing common mental health problems. 

Other issues affecting levels of need are the prevalence of learning disability. A learning disability affects the way a person understands information and how they communicate. A learning disability can be mild, moderate or severe. Some people with a mild learning disability can talk easily and look after themselves, but take a bit longer than usual to learn new skills. Others may not be able to communicate at all and have more than one disability. The percentage of GP patients known to have a learning disability is higher across Torbay compared to England. This could suggest higher levels of recognition within primary care. However, there is still estimated to be a noticeable number of persons with a learning disability not known to primary care.

Increasing demand

We know from the predicted changes in demography that the demand for health and social care services will also increase, however, we also know that local factors can influence (increase or decrease) the demand for adult social care (Professor John Bolton ‘Predicting and managing demand in social care, discussion paper’ April 2016, - Institute for Public Care). The local factors are:

• The relative wealth or areas of high deprivation in the population;
• Behaviours of key players in the NHS, i.e. intermediate care and the availability of sufficient therapists and nurses in the community;
• How effective the council ‘front door’ is at finding solutions for people and their problems;
• The degree to which the assets of the person, their family and their local community are recognised and utilised in a person’s solutions;
• The effectiveness of short-term support and a preventive help approach, including the use of assistive technology and aids;
• The practice and supervision of assessment and care management staff;
• The degree to which people with long-term conditions are supported to maintain their independence and self-manage their conditions, including dementia care;
• The availability and vibrancy of the voluntary sector;
• The availability, capacity and nature of supported housing services including Extra-Care Housing;
• The partnership with carers and carer organisations; and
• Performance measures to assess the way providers are delivering outcomes for and positive impacts on the care system.

As well as demographic pressures, demand for adult social care services are impacted on by changes in other service areas within the health and social care system.  

For example, the efficient flow of patients out of hospital and back into their homes, is measured through what we call ‘delayed transfers of care’ and in Torbay rates have risen in 2019/20. However, the large ‘error bars’ for the Torbay figures show that numbers are small so there is no statistically significant difference to the comparator group or England figures.

Figure 7: Delayed transfer of care from hospital per 100,000 population - Average daily rate aged 18+

Source: NHS Digital, Adult Social Care Outcomes Framework (ASCOF) 2c(1)

Figure 8: Delayed transfer of care from hospital per 100,000 population (attributable to Adult Social Care) - Average daily rate age 18+

Source: NHS Digital, ASCOF 2c(2)

With needs and demand for services rising, Torbay Council is working together closely with NHS partners to develop the health and well-being system, investing in intermediate care, specialist domiciliary care and alternative housing options with care. This should reduce stays and unnecessary placements of people in expensive forms of care, and help them to recover and return home sooner.

The current data shows that the number of social care clients in residential and nursing care has fallen in the last eight years, (from approximately 840 down to 710 - a drop of 15%) presumably following the commissioning shift from bed-based care to alternative services in the community (see Figure 10).  

Figure 9: Long-term residential and nursing clients including full cost

Source: TSDFT Jan ‘21

In December 2020 Torbay had about 600 social care clients in residential care, and a capacity of about 1,500 beds, which suggests a significant surplus and that self-funders or placements by other local authorities are a significant group in Torbay care homes.  

It is likely that this downwards shift in demand for residential care will continue and that the surplus of residential beds in the bay will grow to about 250.  However, whilst numbers are dropping, compared to other South West local authorities, and the England average, Torbay still has significantly more under 65s accessing residential care (Figure 10).

Also whilst there are fewer under 65s accessing nursing care than other local authority areas (Figure 10), given increased dependency levels of service users and a shift from acute hospital beds to other community bed-based or community care and support options, this demand is predicted to rise.  

Figure 10: Adult 65+

Source: NHS Digital, Adult Social care, Short and Long Term Support data

In fact, the demand for good quality nursing home care will soon outstrip capacity and so Torbay Council with the CCG is planning to encourage the development of at least 200 more good quality nursing home care beds, whilst encouraging the closure of residential care beds.

Torbay has significantly fewer over 65 clients accessing Council managed Personal Budgets than its comparator group or the England average but more than the South West local authority average.

A key issue is that use of direct payments and personal budgets, need to grow so that care homes placements are not used unnecessarily.

Figure 11: Adults 18-64 Adult Social Care Short and Long Term Support data

For working age adults, Torbay has significantly many more clients accessing Council personal budgets and direct payments than comparator group or other South West local authorities (Figure 11).

However, Torbay has significantly more under 65s accessing residential care than in its comparator group, the South West local authorities or the England average.

Figure 12: Rate of requests for support received from new clients aged 18-64, per 100,000

Source: NHS Digital, Adult Social Care Short and Long Term Support data, ONS midyear population estimates

Torbay has significantly higher request rates for support from under 65s than other South West local authorities or England average but the request rate is lower than its comparator group (Figure 12).

Conversely, Torbay had higher rates of requests for support from over 65s than the South West but lower than its comparator group and the England average (Figure 13).

Figure 13: Rate of requests for support received from new clients aged 65+, per 100,000

Source: NHS Digital, Adult Social Care Short and Long Term Support data, ONS midyear population estimates

Compared to other local authorities, Torbay often provides some kind of service and less rarely provides no services (Figure 14).

Figure 14: Support request rate for new clients 18-64yrs, by what support type received, 2019/20

Source: Table NHS Digital, Adult Social Care Short and Long Term Support data, ONS midyear population estimates

For people aged 18 to 64 years who requested support in 2019/20, Torbay had:

• A significantly higher rate accessing long-term care in the community, than its comparator group, the South West LAs or the England average;
• A significantly lower rate of people went on to receive ‘no services’, compared to elsewhere;
• No one entering nursing care;
• A higher rate for people entering residential care than its comparator group, the South West LAs or the England average;
• Provided more end of life care than other areas; and
• Significantly higher rates of low level support and signposting to other services.

The increase in working-age adults entering residential care is better illustrated in Figure 15 and the table below, which shows a four-fold increase in the last five years.

Figure 15: Number/rate of 18 to 64 Adults moving into long-term residential care from other settings

Source: NHS Digital, Adult Social Care Outcomes Framework 2A (1)

For adults 65 and over who requested support in the 2019/20, Torbay had:

• A significantly higher number accessing short-term care than in other South West local authorities or the England average, but about the same as its comparator group;
• A lower number accessing nursing care (significantly less than the South West) and more accessing residential care than the South West local authorities and England average;
• Significantly fewer people receiving ‘no services’ than other South West local authorities, the England average, or its comparator group; and
• Lower levels of ongoing low level support and long term care in the community, than its comparator group

Figure 16: Support request rate for new clients 65+yrs, by what support type received, 2019/20

Source: NHS Digital, Adult Social Care Short and Long Term Support data, ONS midyear population estimate

For people 65 and over, the number entering residential care has fluctuated, but shown a general reduction over the last 5 years.

Torbay has significantly lower rates of admission than its comparator group and also the England average since 2014/15, see Figure 17.

Figure 17: Number/rate of 65+ Adults moving into long-term residential care from other settings

Source: NHS Digital, Adult Social Care Outcomes Framework 2A(2)

Trends in key alternatives to bed-based care

Domiciliary care

There are 28 providers of domiciliary care and they each provide one domiciliary care service, although some may be registered to deliver services elsewhere as well. Currently we know that:

• 45% of Domiciliary care clients receive between less than 7 hours a week;
• 43% of Domiciliary care clients receive between 7 and 28 hours a week; and
• 10% of Domiciliary care clients receive over 28 hours a week and some of those receive over 56+ hours a week.

Use of domiciliary care has increased over the last three years, with a corresponding increase in the monthly cost of packages, from £496k in January 2018 to £815k in December 2020. 

Demand for services from self-funders

A self-funder is (typically) an individual who uses their own finances to pay for care (in both residential or community settings), as opposed to receiving support from the local authority or another third party. 

Currently there is no requirement for local authorities or care providers to collect data on individuals who self-fund the care they receive, and so there is a significant gap in understanding the demand for services from self-funders.  However there is some evidence that (Social-care-estimating the self-funding population Feb 2021):

• People who self-fund their care make up a significant proportion of revenue for care home providers and care at home providers – estimates are around 40% of people entering residential care each year are self-funders
• 25% of self-funders will become eligible for local authority support during their lifetime due to depleted funds.
• Self-funders pay, on average, 41% more for a place in a care home than those places funded by local authorities in the same homes
• A SW ADASS report in June 2020 found that over half of local authorities have seen a decline in occupancy in homes mainly for self-funders, putting financial strain on providers.

Supply

The key points are:

• We need more services in the community that people can buy directly with a personal budget or direct payment;
• We do not have enough nursing home beds of sufficient quality if we compare ourselves with other authorities;
• We have an oversupply of residential care places in Torbay compared to similar local authorities, and the lower rates of placements into residential care suggests that self-funders and placements by other local authorities are significant in Torbay care homes;
• We would like more providers offering short breaks either in the community or in care homes – so that carers can take a break; and
• We would like more providers offering shorter services that aim to get people back home after a stay in hospital whether in the community or in accommodation.

Care Quality Commission (CQC) registered care providers

Every month the CQC publish details of care providers in local authority areas which are a good source of data. Although the majority of Torbay care homes are CQC rated ‘good’, in comparison to our CIPFA neighbours we have less rated as ‘good’, more (12 homes) rated as ‘requiring improvement’ and fewer rated as ‘outstanding.’

In Torbay there are 71 care homes providing care without nursing and 1,572 beds, and 13 care homes providing nursing and 556 beds (March 2020).

Care homes without nursing

The number of care homes and care home beds registered to each service user type, are shown in Figures 18 and 19. N.B. Homes, providers and beds can be registered to more than one service user band so there are duplicates in these graphs.

Figure 18: Number of care homes without nursing registered to each service user band, Torbay, March 2020

Figure 19: Number of care homes beds without nursing registered to each service user band, Torbay, March 2020
Source: CQC and TSDFT

Figure 20: Care homes without nursing registered to each service user band per 100,000, March 2020
Source: CQC, TSDFT, and ONS 2018 Mid-Year Estimates
Analysis: Torbay Council

Figure 21: Care homes beds without nursing registered to each service user band per 100,000, March 2020
Source: CQC, TSDFT, and ONS 2018 Mid-Year Estimates
Analysis: Torbay Council

In comparison with our CIPFA neighbours Torbay has:

• Almost double the amount of residential beds for older people;
• More than double the amount of residential beds for people with mental health issues;
• Three times as many beds for physically disabled people; and
• Almost double the amount of residential for people with dementia.

As well as reducing the surplus of residential beds for older people, commissioners also want to reduce the usage of residential care for working-age adults, and in particular the number of adults with mental health issues placed in residential care.

Care homes with nursing

In Torbay there are 13 care homes providing 556 nursing beds, and they are registered by service user type as shown in Figures 22 and 23.

N.B. Homes, Providers and beds can be registered to more than one service user band so there may be duplicates between columns.

Figure 22: Number of care homes with nursing registered to each service user band, Torbay, March 2020
Source: CQC and TSDFT

Figure 23: Number of beds of care homes with nursing registered to each service user band, Torbay, March 2020
Source: CQC and TSDFT

Figure 24: Care homes with nursing registered to each service user band per 100,000, March 2020
Source: CQC, TSDFT and ONS 2018 Mid-Year Estimates
Analysis: Torbay Council

Figure 25: Care homes with nursing registered to each service user band per 100,000, March 2020
Source: CQC, TSDFT and ONS 2018 Mid-Year Estimates
Analysis: Torbay Council

Our data shows that in comparison with our CIPFA neighbours Torbay has:

• Fewer nursing beds for older people;
• About the same amount of nursing beds for people with mental health issues;
• Significantly more nursing beds for physically disabled people; and
• Significantly fewer nursing beds for people with dementia.

Commissioners want to increase the number of nursing beds of greater quality by over 200, to meet the growing demand for complex care and nursing needs. They also want to reduce the number of surplus residential beds in the Torbay by between 200 and 300.

Services in the community

Domiciliary care services

Figure 26 shows how many of the 28 Domiciliary Care providers/services in Torbay are registered to each service user band, and as a provider may be registered to more than one service user band, there may be duplicates between columns.  

Figure 27: Rate of domiciliary care providers/services registered to each service user band, March 2020
Source: CQC, ONS 2018 Mid-Year Estimates
Analysis: Torbay Council

Figure 26: Number of domiciliary care providers/services registered to each service user band, Torbay, March 2020.
Source: CQC

Commissioners recognise that we can do more to keep people living as independently as possible for as long as possible, to help them ‘age in place’ and remain part of their community and within their natural ‘circles of support.’  To do this we need: more domiciliary and personal assistant services in the community, which also specialise in complex support, that people can buy directly, including with a personal budget or direct payment. 

Supported living services

Supported living is housing that is purpose designed or designated to provide support for a particular client group. The accommodation is often shared, but can be a single household.

The one-to-one support is provided under separate contractual arrangement to those for the person’s housing.

There are 17 supported living providers in Torbay, registered as social care organisations and providing accommodation with support to over 250 people.  About 70% of supported Living tenants are people with a learning disability.

Most providers are on the Torbay Supported Living Framework which facilitates referrals from practitioners through a vacancy register, and provides a focus on promoting people’s independence, quality of life, health and well-being. There remain four providers not on the Framework but working towards the same quality measures.

There are eight CQC registered supported living service providers which also provide personal care to people as part of the support that they need to live in their own homes. The personal care is also provided under separate contractual arrangements to those for the person’s housing. Supported living providers that do not provide the regulated activity ‘personal care’ are not required by law to register with the CQC.

Figure 28: Number of supported living providers/services registered to each service user band, Torbay, March 2020
Source: CQC

We need to significantly increase supported living provision for people with learning disabilities, autism and mental health issues, both to enable people to leave residential care, and to divert people from entering it. During 2021/22 we will be re-opening the Framework to new providers, and also going out to our current providers, to develop this capacity.  We also want supported living providers to become more skilled at providing enabling support to people with complex issues and behaviours that challenge, increasing the person’s ability to self-regulate and always using the least restrictive practice.

Supported living and extra care increase self-determination, independence and citizenship, and enable people to be part of their community and develop natural circles of support.

Extra care housing services

Extra care housing provides quality, safe and affordable housing with care and support which enables people to enjoy living independently, to build relationships and to live life to the full.  People live in their own home, and there is on-site care and support staffing available 24/7 which flexes to individual needs, and may be provided on a continuous basis or only periodically.

In Torbay, extra care housing is not age-restricted and is available to anyone over the age of 18, who might have or develop ongoing care and support requirements and who would otherwise experience difficulties in other forms of accommodation. 

There are currently (2020) 108 units of Extra Care Housing in Torbay, located over two sites and provided by one  service provider who is registered as a social care organisation. The current residents include people with the following long-term conditions:

• Dementia;
• Learning disabilities;
• Autistic Spectrum Condition;
• Mental health issues;
• Physical disability; and
• Sensory impairment.

There are 175 units of Extra Care Housing already planned for development over two sites from 2021, and there are plans for a potential additional 100 units of Extra Care, to meet the projected demographic demand by 2030. 

Extra care should enable people who need personal care and/or support to live as independently as possible in accommodation that is genuinely ‘their own’, and this is facilitated by separate legal agreements for the care/support provided and the accommodation.

Alternative care and support options

We want to build the market of alternative, more flexible options for people to buy care themselves with a personal budget or direct payment if they want to. This could be support with accommodation or support they receive in their own home.  At the moment we have a small market of providers of support with accommodation, and providers delivering a variety of outreach and support options; largely providing services for people with learning disability, cognitive difficulties or mental health issues.

We would like to extend these options to more people, and to also develop greater consistency of quality, and a focus on measurable outcomes such as improving independence and wellbeing. It is hoped that these improvements, and consistency of costs, will be achieved through the development of an Alternative Care/Outreach Support Provider Framework in 2021.

Personal assistants

Support Networks is a non-profit Torbay community project which specialises in matching enthusiastic, motivated personal assistants (PAs), to clients needing care in Torbay.  The Support Networks Personal Assistant “matching" Service is free to those being funded in Torbay for their care and support and also free to all PAs.

The PAs on the Support Networks’ register all have the right qualifications, experience, and the following:

• An Enhanced DBS check (disclosure and barring system criminal records check);
• A RTW (Right To Work check in the UK);
• Proof of their employment status; and
• Public Liability Insurance.

However, PAs must also be able to work in a person-centred way, putting the client first, listening to their needs, hopes and goals. More details are at Supportnetworks.

A voluntary sector organisation (Disability Focus) helps local people with either employing and managing the payroll for a personal assistant/care worker who provides support to live independently or help with paying of invoices. They were providing this service for 335 Torbay adults in March 2021, which is an increase on previous years.

Shared Lives services

Shared Lives South West supports adults with learning disabilities, autism, mental health issues and dementia by matching them with a carer.  The aim is for the person being supported, to live the fullest life they can, be part of the community and maintain and promote new skills and independence. Carers are assessed and trained first, and then open their own family home to the person needing support.

It’s like adult fostering and an alternative to supported living and residential care.

In February 2021 it was supporting 28 adults funded through Adult Social Care which was a 30% reduction compared to 2017 (when it was 41 adults). The Shared Lives South West organisation, is in its 15th year, and was rated ‘Outstanding’ by the CQC.

Community equipment services

The supply of specialist equipment can also help support people either in their own home or other accommodation.

Complex aids to daily living are provided through a Torbay Council contract. This equipment is provided on loan following an assessment from a Torbay and South Devon NHS Foundation Trust practitioner, and provides for people with short and long-term needs as well as end of life care. 

Source: NRS

We need to give people the advice and information they need, as early as possible, to enable them to live as independently as they can, staying healthy and well for as long as possible.

Activities in the day time

A spring 2020 snapshot (pre- COVID-19) of Torbay day care services and activities, including care homes, shows that 208 people used these services (a drop of 20% compared to 2016).  The proportion of spend on people with learning disabilities is 74%, 18% on physical support & older people and 5% on people with a mental illness.

It is recognised that currently the quality of services provided, and outcomes delivered may vary significantly.  From 2021 there will be a refreshment of day opportunities, including the development of a Day Activity/Day Service Framework for providers with clear outcomes, quality measures, cost settings and performance indicators. 

1. Adults with multiple long term conditions in Brighton and Hove, 2018, pages 5-6