Authors' objectives: Extra care housing is a model of housing for older people where residents live in self-contained accommodation with flexible care and support available at all times. Ageing populations, seen globally and in the United Kingdom, mean increasing demand for this type of housing. While extra care housing may help people live longer independently, its provision poses challenges (e.g. resourcing flexible care). By identifying existing evidence, this scoping review will inform future research into extra care housing, to support the development of schemes that meet the needs of older people. To identify the volume, focus/questions, study design, quality and main findings of empirical research and evaluations relating to extra care housing in the United Kingdom. Extra care housing (ECH) is a model of housing for older people, generally considered as combining independent housing with the provision of flexible care and support. Its key features include: Self-contained accommodation (e.g. a flat or bungalow in a larger complex). Communal activities (e.g. social events) and facilities (e.g. café/restaurant, hairdresser, lounge). Flexible and individualised 24-hour care provided onsite (including emergency assistance). Accommodation and care contracted and paid for separately. Some research shows that it could help people live independently for longer, provide social support, improve quality of life, and reduce healthcare costs. However, research has also identified challenges, particularly relating to resourcing flexible care, caring for residents with high support needs (e.g. dementia), and enabling ECH to be a ‘home for life’. Understanding ECH is important given longstanding policy objectives in the UK and internationally, around enabling ‘ageing in place’ – allowing people to live independently for as long as possible without having to move home or to a different area. ECH has the potential to enable healthy ageing; this has been recognised by the UK Government, which has supported its development through initiatives such as the Department of Health Extra Care Housing Fund. However, the provision of ECH is far lower in the UK than similar countries, with market research from 2015 finding that at least 5% of over-65 second live in housing with care (HWC) settings in Australia and the USA, compared to 0.6% of over-65 second in the UK. Demand for ECH is also increasing given the ageing population. The number of people aged 80 and over is predicted to more than double in the next 40 years, from 3 to 6 million in the UK, with similar patterns seen globally, and corresponding increases in the need for health and social care. To support the development of ECH schemes, ensuring that they meet the needs of older people, it is important to know what existing research in and about ECH already shows. To identify the volume, focus/questions, study design, quality and main findings of empirical research and evaluations relating to ECH in the UK.

Authors' results and conclusions: Ninety-eight publications were included. Thirty-seven were qualitative, 28 were quantitative, 19 took a mixed-method approach and 2 were modelling studies using secondary data. Older people were participants in 57 studies. Many studies provided limited information on the characteristics of participants and the included extra care housing schemes. Included studies had three overlapping areas of focus: (1) the supply of extra care housing and older people’s decision-making regarding relocation; (2) living in extra care housing (e.g. impact on quality of life, residents’ experiences of community, physical infrastructure); and (3) leaving extra care housing (there was little research in this area). While much of the available research supports the provision of extra care housing as a model of housing with care for older people, studies were variable in their methodological quality and reporting. Consultation with extra care housing residents raised topics that corresponded with the findings of included studies (e.g. the importance of care provision in supporting independence). There is a growing body of evidence regarding the provision of extra care housing as a model of housing for older people. However, given the changing health and social care landscape and increasing care needs of the population, further research is needed to support the future development of extra care housing. Searches of databases resulted in 7976 hits; after duplicates were removed, 5132 records were screened at title and abstract level. Of those, 224 were selected for full-text screening and 86 were included in the review. A further 3 publications were found via websites with search functionality, and 9 publications from citation chasing, meaning a total of 98 publications were included in the review. Over one-third were qualitative studies (37), 28 were quantitative, 19 took a mixed-method approach and 2 were modelling studies using secondary data. Of the quantitative and qualitative studies, 45 were cross-sectional (i.e. collected data a single time point; 21 quantitative and 24 qualitative), and 19 longitudinal (i.e. collected data at multiple time points; 6 quantitative and 13 qualitative); 1 randomised controlled trial (where participants are randomly assigned to either an experimental or control group) was also included. In terms of quality, qualitative studies scored well on the MMAT checklist, but critical appraisal of other study designs indicated their quality was variable, particularly for the mixed-method studies, many of which scored poorly. Older people – most of whom were residents of ECH, although some studies focused on older people living in the community who might consider living in ECH – were participants in the majority of studies (n = 57), with 32 studies only including older people. The number of older people included as participants in the studies varied, ranging from 7 to 7071, with a median of 65 [interquartile range 26–152]. Other participants included professionals, either staff working in a scheme (n = 24 studies) or external stakeholders (n = 21 studies) such as housing providers, local authorities or architects. Family members or informal carers were also participants in some studies (n = 10). What was considered to be ECH was not clearly defined in many studies, with 22 studies providing no explicit definition. Of those that did, most indicated that, in ECH, residents should have self-contained accommodation (n = 46 studies). Thirty-six studies specified that ECH should have communal facilities and services, 35 studies mentioned the provision of individualised and flexible care, and 30 that care and support staff should be present on the premises at all times. Fifteen studies indicated that accommodation should be rented or owned by the resident; only five studies specified that housing and care should be contracted separately. None specified all of the criteria included in our definition of ECH when describing ECH. Thirty studies did not report details on the location of participating scheme(s). Of those that did, 20 included both urban and rural ECH schemes, 9 only urban schemes, 6 included either urban and suburban schemes or only suburban schemes, and there were 2 studies focusing solely on rural schemes. In studies that reported details of the ECH provider (n = 40), the majority (n = 26) focused on schemes run by non-profit organisations (e.g. housing associations, charities), 1 study included only a private provider, and 13 studies included both non-profit and private providers. Other characteristics of the included ECH schemes, such as the number of residential units and their communal facilities, were not reported consistently. Characteristics of participants were also reported inconsistently. Age and gender were most often reported, with 39 studies reporting age and 42 studies reporting gender, and a significant proportion of studies also reporting marital or cohabiting status (n = 28). LGBTQ+ status was least often reported (n = 7). While ethnicity was reported by 23 studies, in most studies of these studies the majority of participants were White (n = 15), and there were 5 studies that did not include any participants from ethnic minority backgrounds. In terms of focus, most publications (n = 45) focused on the experiences of older people living in ECH; 18 investigated the effectiveness of ECH, and 12 costs, while the focus of 43 publications was classified as ‘other’. Twenty-seven studies had more than 1 focus (e.g. 7 of the 18 effectiveness studies also evaluated the costs of ECH). We further explored the focus of the included studies by considering them within three categories, representing a resident’s journey through ECH: Moving into ECH – this category included two types of study, those that looked at the supply of, and demand for, ECH, and those that investigated older people’s decision-making regarding relocation. Living in ECH – the majority of studies were in this category. Some investigated the effectiveness of ECH (n = 18) for a range of outcomes, such as quality of life or ability to perform daily activities; others considered cost (n = 11). However, most studies explored experiences of living in ECH; some of these were directly focused on residents, exploring independence and community within ECH, changing care needs and relationships with staff, and inclusivity and diversity. There was also a group of studies focusing specifically on the experiences of residents living with dementia. Other studies looked at the ‘implementation’ of ECH, through investigations of the building design, the use of technology, and management and workforce. Moving on from ECH – there were few studies in this category, with only one focusing specifically on whether and how older people came to leave ECH. While much of the available research supports the provision of ECH as a model of HWC for older people, studies were variable in their methodological quality and reporting. More high-quality evidence on effectiveness and cost-effectiveness is needed, as well as research to address specific gaps, such as whether ECH can offer a home for life. Knowledge on whether and how residents may need to move on from ECH is important both to ensure the provision of support for any transition and in the context of increasing numbers of residents with high care needs entering ECH. This topic was discussed by ECH residents at Edwards Court during patient and public involvement and engagement (PPIE) consultation, with the high turnover of residents within their scheme having an impact on their social and psychological well-being and support needs. Conversations with ECH residents and staff further placed the findings of the review in context, with residents’ motivations for moving in and the importance of the provision of care and support to their feelings of independence corresponding with findings of included studies. Future research should consider methodological quality, following best practice guidance for conducting and reporting specific study designs. Special attention should be paid to full and consistent reporting of participant characteristics, especially those relating to inequality in opportunity or outcomes (e.g. ethnicity, LGBT+ status), and any variations in findings between groups (e.g. differences in preferences among social minority groups). Providing a detailed description of participating ECH schemes (e.g. housing and care providers, size, facilities) will allow comparison between different types of scheme, and improve the usability of research by allowing decision makers to decide on the applicability of findings to their specific case. We also identified implications for policy and practice based on our findings: the need for a nation-wide approach to create a standard definition for ECH; ensuring the physical infrastructure of schemes meets the needs of residents; and that training is available to enable a skilled workforce (a need raised by ECH staff at Edwards Court). ECH is known by different names (e.g. assisted living). This created challenges in finding studies and understanding whether the housing model being studied met our definition of ECH. As we took an inclusive approach, some included studies may have focused on other types of HWC. There is a body of evidence that supports the provision of ECH as a model of housing for older people. However, given the changing health and social care landscape and the increasing care needs to the population, more and higher quality research may be needed to support the future development of ECH, both adding to the evidence base on its effectiveness and cost-effectiveness, and addressing specific knowledge gaps, such as whether it can offer a home for life. There is also a need in policy and practice to more clearly define ECH.

Authors' methods: We conducted a scoping review of evidence syntheses and primary research. Applied Social Sciences Index and Abstracts, Cumulated Index in Nursing and Allied Health Literature, MEDLINE, Health Management Information Consortium, ProQuest Dissertations and Theses Global, Social Policy and Practice (SPP) and Web of Science, along with relevant websites, were searched for studies (June 2024). We also completed citation-chasing on included studies. We included systematic reviews and empirical evaluations published since 2010, conducted in the United Kingdom, focused on extra care housing for older people, and investigating any outcome. Data were tabulated and summarised narratively. Critical appraisal was conducted using the Mixed Methods Appraisal Tool checklist (primary studies) or A MeaSurement Tool to Assess systematic Reviews 2 (systematic reviews). Consultation with stakeholders and extra care housing residents informed the review. Extra care housing is known by different names (e.g. assisted living). This created challenges in finding studies and understanding whether the housing model being studied met our definition of extra care housing. As we took an inclusive approach, some included studies may have focused on other types of housing with care. We conducted a scoping review of evidence from the UK. In June 2024, we searched Applied Social Sciences Index and Abstracts and ProQuest Dissertations and Theses Global (via ProQuest), Cumulated Index in Nursing and Allied Health Literature (via EBSCOhost), Health Management Information Consortium, MEDLINE and Social Policy and Practice (via Ovid) and Web of Science (WoS): Core collection for studies. We also searched relevant websites for publications and completed backwards and forwards citation chasing on included studies. Two reviewers independently screened all identified records at title/abstract level and the full texts of the records selected in the first round. Systematic reviews and empirical studies were included in the review. We included studies looking at any outcome (e.g. effectiveness, cost-effectiveness, experiences) of ECH for older people, as defined above. Study participants could include older people, their families, and professionals associated with ECH (e.g. scheme managers, housing associations, local authorities). Only evidence published since 2010 was included, based on changes to the funding, demographic, housing design and policy landscape for ECH over time. We extracted data on categories including: Study characteristics (study design, aims, focus, number and type of participants). Characteristics of participating ECH schemes (number of schemes, rurality, type of housing provider, tenure, capacity). Characteristics of participants or residents of participating ECH (age, sex, LGBTQ+ status, ethnicity, health and disability, marital status). Data were extracted from each included publication by one reviewer and checked by a second reviewer. These data were tabulated, with categories for ‘focus’ determined by grouping studies thematically according to their aims, and summarised narratively. We then mapped the main findings so that they followed the journey of an older person from (1) considering moving into ECH, to (2) living in ECH, and potentially (3) moving on from ECH. We also analysed whether and how the included studies defined ECH by assessing how many criteria they met from our definition of ECH (as given in the Introduction). Critical appraisal of individual studies was conducted using the Mixed Methods Appraisal Tool (MMAT) checklist (primary studies) and AMSTAR 2 (systematic reviews). Stakeholders were consulted throughout the production of the review. We also visited an ECH scheme in Exeter to discuss our preliminary findings with residents, informal carers and staff.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR174287

Year Published: 2026

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/GJRA2822

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/GJRA2822

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk