Jane Ashcroft CBE, head of the UK’s largest not for profit care home provider, Anchor, says a radical rethink on funding and health and care integration is required to provide a care sector fit for the 21st century
Care Home Professional: Can we start by putting Anchor into historical context?
Jane Ashcroft: We will be 50 years old in two years time. Anchor started life as a housing association specifically for older people. For the first 30 years we were building sheltered housing with an onsite warden. We grew quite quickly across England then in the mid to late 80s we started building care homes and built a large portfolio. In the last couple of years we have been building some new care homes as well as retirement villages, including apartments, swimming pools, gyms and dementia care homes. Last year we bought two care home groups – Cavendish in Suffolk, which has five care homes, and 24 care homes from Ideal in the Midlands and the north.
Now we have about 24,000 tenants in our rented sheltered housing, 8,000 people in our leasehold sheltered housing and about 7,000 residents in our care homes. Before the acquisitions we had about 100 care homes, a small proportion of those were nursing but because it wasn’t really a core part of what we did about three years ago we decided we would concentrate on residential, particularly dementia care in a residential setting. We have either remodelled some of the nursing homes and re-registered them as residential or we’ve sold some of them as going concerns.
CP: Could you tell me about your career with Anchor?
JA: In January I will have been here for 17 years. Before that I worked for Bupa where I was personnel director in their care services division. Before that I worked for a housing association in the Midlands. I then saw the HR director role advertised with Anchor and thought it was interesting as I had worked in housing and care and I wanted to see how Anchor put them together. About two years later, I took my first general management job with our homecare domiciliary care business. I’ve done different jobs over the years. Six years ago I was managing director of our care business and then I applied for the chief exec job and somehow got it.
CP: How is Anchor split in terms of the type of care you offer?
JA: We no longer operate domiciliary care in the community business. We have extra care in some of our sheltered schemes which are registered with CQC as domiciliary. People can come and live with us at the age of 55, rent a flat off us and have absolutely no care needs at all. They might buy or rent a flat off us, use facilities in some of our bigger developments such as our retirement villages and access care as they need it and ultimately they might enter our care homes and go all the way through to dementia and end of life care.
Turnover wise we look at the business in terms of how much is housing and how much is care. Last year, for the first time, more than half our £300m turnover was care (£160m). Most of the staff work in care as it’s much more labour intensive than the housing side. I think that’s a strength of the business that although care and housing are quite different it means they help us manage our risks and funding and we are not just exposed to one market. When housing is in a difficult space, hopefully care is not in a crisis. Actually at the moment the housing that we’re in is very affected by government policy, rent cuts, those kind of things, and of course the care sector has quite a lot of challenges.
CP: Is care a growing proportion of your business?
JA: We have been building a couple of care homes a year and have set out a five year plan. We’re just into year two of that. We said over those five years we would also acquire some care homes. We wanted purpose built, residential because we got out of nursing. We wanted to acquire some good quality stock as well as new buildings and good staff. We were just fortunate that two opportunities came so we delivered on our plan of growth by acquisition, which we were planning to do over five years, in year one. Now we are working hard to consolidate those two acquisitions, which is going really well.
CP: Are you seeking to grow through acquisition rather than building your own homes?
JA: For the time being we have acquired enough. Our predominant growth for the next couple of years is likely to be in independent living. That’s typically a block of flats of 68-70 two-bed apartments built so that they are really easy for old people to live in with some community facilities such as a coffee bar and a little bit of well-being for people to buy care as and when. We are planning to have 20 of these over the five-year plan. We have already opened four. We are catering for people in the late 60s, early 70s, looking to downsize into something which is nice to live in with care if they need it. Independent living is ideal for couples where one person is starting to need support.
CP: How do retirement villages and care homes compare in terms of profitability?
JA: it’s a different model. One is selling a property with a development return up front and then there’s the ongoing revenue stream from the services, whereas care homes, of course, provide a weekly fee. I think it’s interesting because the government has not been able to find different ways of funding care homes.
I do think we should be looking at what other countries do. I cannot see the government introducing the Dilnot reforms before the next election. I don’t think the Dilnot individual care contributions cap will come in the way it was originally planned. We need to look at how we can change our business models so that people who are selling their properties to fund their care will know that they have something left at the end of that.
The benefit of being a housing association is that we do have an asset base that enables us to take a long term view. The board sets me and the team targets to make a profit but we don’t have to distribute these. It doesn’t mean we don’t have to make a profit but we can put the profits back into the business. We built our first retirement village about 12 years ago. We are able to do some things a bit ahead of the pack because we can take a longer term view because we haven’t got shareholders who need a dividend and a share price to maintain. To me it’s equally important that we are efficient in how we operate because if we are efficient the money that we are using could be used for so many other things.
CP: Are there any other type of funding models abroad that you think we could adopt in the UK?
JA: The Australian model where people pay a bond up front and the provider can use that money to borrow against and there’s a guarantee that a proportion of that money will be left at the end of your time in the care home is the way that I would like to consider because it is about giving that certainty that people are not going to run out of money.
My experience is people don’t necessarily mind selling their home. There’s a issue about fairness where people say why should I sell my home when if I lived in another part of the country the rules would be different. There’s a lack of financial products to help people. The only game in town is the immediate needs annuity. The point that someone moves into a care home there’s the insurance product and they can gamble how long they are going to live for and they can say if I pay a significant premium to the insurance company they can carry on paying my fines regardless of how long I live. That’s a very blunt instrument for a very sophisticated purchase. The challenge for the financial service providers is the only way to get leverage is if you are pooling everybody’s risk. When the Dilnot report was looking at options there was quite a lot of talk about a compulsory model but there was resistance to this. But if it’s not compulsory you are only likely to get contributions from people who think they will need insurance so you are only going to get the higher risk people and this is not going to stack up from a financial services perspective.
The immediate issue for our government is that it is starving social care without giving any thought to what happens to the NHS. I don’t think that message has got through. All these problems about bed blocking and discharge, the answer is to think more sensibly about social care. We have been doing a project in Birmingham with the CCG to use rooms in some of our care homes for the rapid discharge from hospital of some older people who don’t need clinical care but who are still not able to go home. We have started off with about a dozen rooms and now we use about 20 rooms. We have tried to offer that in other parts of the country as well but fundamentally that has still to be viable so it does mean that the CCG or whoever is funding it pay about £600 a week but of course that’s saving the public purse compared with someone being in hospital. A day in hospital seems to cost about a week in a care home.
Providers and commissioners are trying at a local level to make things work but there isn’t a national framework to enable that. How you get anything to happen at scale is the real challenge. There’s too many people holding budgets and they are failing to do what is right for the public budget overall. It’s a bust system. We have to play the hand we are dealt and come up with ways of working at a local level but there comes a time when we can’t continue to spend money on coming up with new models of working with the NHS . It’s better to just concentrate on delivering a great service.
The care model we are working with at the moment was created after the Second World War. Only some of the Care Act changes have been implemented. There’s a fundamental issue around dementia not being treated in the same way as other long term conditions. Dementia is still considered as something which people have to fund rather than a health need. With an ageing population we are likely to have more people living with dementia but where are we going to find the money to look after them? The longer that problem isn’t addressed – the worse it will get. It’s difficult to see when it is going to top the government’s agenda.
CP: There’s been a lot of talk from ministers about increasing tax to fund care.
JA: Fundamentally it’s either tax or we have got to pay some more from our personal resources. Any debate about increasing tax is always very difficult for politicians. A reshaping of how we fund health and social care has got to be where we get to but who is going to be brave enough to do that?
CP: Do you think being not for profit puts you at an advantage to private operators?
JA: I think it’s a double edged sword. There’s a benefit in terms of being able to take a long term view. I have worked in for profit organisations. If you are a listed company it gives you a momentum and focus so you have to be on your numbers but it does mean you have to be quite short term and have to change your mind very quickly. The downside of being not for profit can be that people have high expectations and they don’t necessarily expect to have to pay the going rate. There can be an assumption that because you are a charity you should be better and cheaper, which is illogical.
CP: Is that a problem for you in terms of getting residents to pay the same amount as private operators?
JA: The sector’s becoming more savvy and more mature. There’s so many models around what a fair price for care is. It’s a really difficult time for the local authorities because the lack of funding available to them means they are having to make really tough decisions. I wouldn’t be critical of local authorities by any means but I do think we have to be realistic that to provide good care costs money, particularly it’s about staff costs. I only want great people working in our company and want to make sure we award them appropriately.
CP: Avery told us they are reducing the proportion of local authority beds and can see the point where some care operators will not offer any local authority provision.
JA: I think it’s really worrying where people will go in the future but the logic of it is if every person in a care home is underfunded then ultimately the care home goes bust. There’s a debate about what’s an acceptable level of profit and sometimes there’s a naivety about the fact that we do have to buy the land and build the buildings. People look at the cost of running a care home without seeing it in its entirety. The whole sector has worked on a cross subsidy basis for quite some time. It’s something that we don’t really talk about. The thing that’s changed with the Health and Care Act last year is the ability to charge a top up. There are still some local authorities that are still uncomfortable about that. If the local authority is way below the acceptable price then we will look for a top up.
CP: What is your split between local authority and private care?
JA: In Anchor homes it’s broadly a third, a third, a third: a third of people living with us are funded by the local authority; a third are self funded; and the other third have some local authority funds but we also charge a top up. Like Avery and others I would see the proportion of local authority reducing. The last survey I saw there were still some local authorities paying under £400. If you make any kind of comparison with the Travel Lodge or the average children’s nursery, it’s clear that’s untenable.
CP: What is the minimum figure required to provide good care?
JA: It depends on where you are in the country and the level of needs that somebody has. Although our portfolio is quite similar there are many different levels of care required. Anything less than £550-600 is marginal. When you look at regulatory requirements the CQC and others who are trying to raise quality additional costs are incurred, I think good regulation is necessary in this sector but it must be proportionate.
CP: What are Anchor’s priorities?
JA: In our business plan we talk about having four priorities. The first is providing the best customer service. We have tenants, we have residents, service users – customers is our all encompassing word for people who use our services. In care homes, we were a founder members of the Your Care Rating, which asks residents for their feedback. We have seen improvements year on year in our rating. We see CQC ratings and other forms of customer feedback as one of our objectives.
Our second objective is to be the best place to work. Recognising that we have good quality people who are really engaged with what they are doing. We have done some good stuff around colleague engagement. Our staff turnover is typically 11-12%, which is pretty low for the sector. Our absence rates are usually quite low. Our agency use is quite low. Some of it is about rewards; we were paying the Living Wage well before it was a requirement. Some of it is about good management practice. It’s about making sure colleagues are listened to and the things that matter to people are the things we focus on. We offer staff benefits – we have shop discount cards or shopping vouchers at Christmas time. We also offer career development. One of our district managers who won some awards last year started with us as a volunteer about 10 years ago and she has been able to progress to a carer, team leader, deputy manager, home manager and to a district manager. The benefit of being a big organisation is that we should be able to give people the ability to do that.
Related to that is being the best run company, which is all about efficiency in procurement of good quality food as well as electricity and gas at the best price and making sure our processes aren’t cumbersome and using technology effectively to cut down on travel costs. We want to make sure our money is being spent on customers and not running the big Anchor machine. The fourth objective is growth.
CP: What is your currency occupancy rate?
JA: Our average occupancy rate is 93-95%. Within that most homes are full. Where are people going to go if all our care homes are full? In the current market if a home is good it’s probably going to be full.
CP: What is the average size of your care home?
JA: It’s very variable. We have some homes that are 28-30 rooms. Our newer homes are larger and that is because of the issues around efficiency and demand. The new homes have been built in a way that people live in a household. They live in a group of six or 12 so it doesn’t feel like one large care home. We have one or two homes that are around the 100 room mark. We have a lot homes that have 45 or 50 rooms. The ideal is still about 70. It depends on the site you can buy and what the demand is locally. You have to have sufficient capacity to make it viable and sustainable. It’s a challenge for us all to understand what it is about the smaller homes that are getting the best CQC ratings so that we can replicate that in the larger home environment. Some of our larger homes do get good ratings. It’s not impossible for a large home to be good or outstanding. I suspect consistency of staffing is one of the reasons for the smaller homes success.
CP: Are you optimistic about the future?
JA: I have to be. There are many things that have improved in the sector over the past 25 years. Rising demand will drive us forward in the coming years.