A Scoping Review of the Costs, Consequences, and Wider Impacts of Residential Care Home Closures in a UK Context

Background . Between 2015 and 2020, 1,578 care homes in the UK closed, displacing nearly 50,000 older and disabled people with very signifcant care and support needs. It is widely thought that relocation can have a signifcant impact on the health and well-being of older people. Yet, evidence is limited due to sensitivity and logistical difculties with data collection. Tis study aimed to review the published literature in order to (i) identify evidence on the costs, consequences, and wider impacts of care home closures, for older people, family members, care home staf, and local authorities and (ii) understand the causes of and processes surrounding the closure of residential care homes in the UK. Methods . Eight electronic databases (Medline, Embase, Web of Science, Scopus, ASSIA, HMIC, AgeInfo, and SPP) were searched from 1st January 2000 to 9th February 2023; Google and Google Scholar were searched for guidance/policy documents from the grey literature. Data on the objectives, methods, and main results were extracted, and the fndings were narratively reported. Results . Eighteen records, comprising guidance documents and academic publications (quantitative, qualitative, and mixed-method approaches), met the inclusion criteria. We found a lack of good quality evidence on costs of closure and no consideration of outcomes for staf. Studies reporting on outcomes for residents suggest there may not be any long-term adverse efects on their health, in contrast to often-expressed views that care home closures result in harm. Conclusion . Future research should consider the stress and anxiety experienced by staf and families as relevant outcomes and show caution with respect to the use of proxy reporting of resident health outcomes. Given that a sizable portion of the costs associated with care home closure falls on local authorities, an evidence-based approach to closures that includes an assessment of cost-efectiveness will help to improve future outcomes and guide the most efcient use of limited public resources.


Background
Care homes in the UK are estimated to house 421,000 residents and employ almost 700,000 workers [1,2].By 2031, it is anticipated that the age group with the greatest care needs-those who are 80 and older-will account for just under 8% of the population in the UK [3].Despite this predicted increase, 1578 care homes closed in the UK between 2015 and 2020, forcing nearly 50,000 older people to relocate [4][5][6].Some studies attribute the decline in the number of care homes to poor quality.Others believe that pressure on local authorities (LAs) to keep prices low, as well as national policies which raised costs, such as the National Minimum Wage and the National Care Standards, were factors [7,8].Tere are typically three types of closures for care homes: planned, unplanned, and emergency.Te defnitions and timelines are widely debated and usually depend on the reason behind the closure [9].
Over the past 30 years, there have been multiple changes to the provision and fnancing of health and social care in the UK.Te frst reform of social care, explicitly to promote market competition, was implemented in 1993 [10].Te reforms transferred the national government's funding of independent sector residential and nursing home care to local authority social services departments.Te legislative changes aimed to promote care in people's homes or homely environments, while also addressing the challenge of bringing a rapidly escalating central budget under control by devolving it to local Councils with limited budgets.
Te 2001 National Minimum Standards for English care homes mandated the implementation of minimum physical standards relating to the percentage of beds in single rooms, door and corridor sizes, and staf qualifcation requirements, as well as standards for home choice, health and personal care, daily life and social activities, complaints and protection, and management and administration [11].Homes built before April 2002 were only required to maintain environmental standards instead of meeting the requirements of newly registered homes, which could have helped to ease the fnancial burden and prevent widespread closures.However, although the standards were designed to ensure the protection of service users and to promote their health, welfare, and quality of life, they present obvious contributions to the costs of running a new home thereafter and a number of older care homes struggled to bring themselves up to these standards.
Te latest reform which was to come into efect from October 2023, would have allowed private payers (selffunders) to request councils to arrange care on their behalf at lower local authority rates [12].It intends to introduce a new "Fair Cost of Care," which aims to raise care fees paid by councils to providers to make the care market sustainable [12].According to LangBuisson, the government's budget underestimates the need for additional funding and could put the sustainability of care homes across the nation at risk and result in their closure [13].Tis reform was later delayed potentially indefnite, and such issues remain unresolved.
Recent events have put further pressure on the fnancial stability of care homes.During the pandemic, care homes were unable to accept new residents, and families were reluctant for their relatives to move into a care home.As a result, the number of empty beds has increased, leading to permanent care home closures [14].In addition to the pandemic, there are the potential efects of Brexit in a sector which has relied heavily on the labour of migrant care workers [15].Over time, the government's austerity agenda, coupled with rising need and demand, has led to signifcant shortfalls in local government funding, contributing to signifcant fnancial, service, and workforce pressures across the whole of the sector [16].With money so tight, there is very little room for manoeuvre, given that staf costs represent a substantial proportion of total costs [17].Most recently, there have also been concerns regarding increasing infation and energy costs.
Given the inevitability of continued closures within the climate of increasing economic pressure, there is a need to minimise both the tangible and intangible costs of care home closures to all parties involved.Te tangible costs include the equipment, resources, and staf that are required to close a care home [18].Intangible costs are defned as costs that can be identifed but cannot be quantifed or easily estimated and relate to changes in health status brought about by public service interventions (in this case, a care home closing) [19].Tis is part of a broader study into how best to manage care home closures, seeking to estimate costs, improve outcomes, and minimise risks for all those involved.As part of the overall project, a separate review explored evidence on outcomes from a non-economics perspective and with particular attention to whose voices are heard/ unheard during the closure process [19].Te aim of this scoping review was therefore to identify and synthesise evidence both from the academic and grey literature (guidance documents) relating to the costs, consequences, causes, and processes of care home closures for future use in economic analysis (modelling).By gaining a better understanding of the costs, consequences, causes, and processes experienced by diferent parties involved in care home closures, this review will provide a crucial foundation for informing economic modelling, which would involve the mapping out of possible closure pathways and their associated costs and outcomes.In addition to providing a strong foundation for future economic modelling, this review is critical for establishing a comprehensive understanding of the topic and identifying gaps in existing literature.Te overall programme of work will enable decision makers to access the relevant evidence necessary to make efective policy decisions and develop strategies for managing care home closures.

Methods
We conducted a scoping review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [20].Alongside the scoping review, we also conducted a pragmatic search to identify the key cost drivers associated with operating a care home (see Appendix A); the motivation for this pragmatic search was to contextualise fndings from the scoping review.

Search Strategy.
Te search strategy was designed with the help of an information specialist to be as broad as possible, including a search of grey literature.Te following electronic bibliographic databases were searched from 1st January 2000 to 9th February 2023: Medline, Embase, Web of Science, Scopus, Applied Social Sciences Index and Abstracts (ASSIA), Health Management Information Consortium (HMIC), AgeInfo, and Social Policy and Practice (SPP).Google and Google Scholar were searched for guidance/policy documents and items from the press.
We used the following key words: A two-stage process was used to organise relevant papers according to some predetermined themes, adapted from the approach of Roberts and colleagues [21].Quality assessment criteria were not applied to prevent studies from being excluded because there was not a suitable checklist for critiquing the expected diversity of foci from the studies and the expected results.Furthermore, preliminary scoping searches indicated that there would be few relevant papers found, so every efort was made to prevent losing the only existing information.For each paper included, the reviewer extracted data about the source of the paper, the aim of the study, the methods used, the perspective adopted, the primary focus, and the timing of the closure.Te data were tabulated, and the fndings of individual papers were compared narratively.Papers published prior to 2000 were excluded due to the implementation of national minimum care standards the following year.Te exclusion of nursing homes and homes with working-age individuals was motivated by the higher level of complexity and cost implications of their closure.Given their large volume and distinct diference from nursing homes, we focused solely on residential care homes to ensure feasibility and minimise heterogeneity.Only studies from the UK were included in this review because the structure and fnancing of social care are specifc to the UK.We did not impose any restriction with respect to perspective; perspective defnes the scope of the included costs and outcomes, in terms of who bears the cost or is impacted by the outcome.

Stage I: Initial Screening and Categorisation of Results.
Screening was conducted based on an inspection of the titles and abstracts and following the inclusion/exclusion criteria detailed in Section 2.2.All studies/documents meeting the inclusion criteria were further categorised under one of the themes below (A-F); studies/documents meeting the exclusion criteria were categorised under heading G or H. Te reason for categorising papers at this stage was to understand the topics covered in the literature and prepare for data extraction according to the stated objectives of the scoping review.Papers that fell into category 5 were excluded and all others were included.

Results
A total of 16,118 papers were identifed through the initial searches.Prior to screening, 1053 duplicate records were removed and an additional four papers were added from the grey literature.A further 15,036 (categories G and H) were excluded based on the title and abstract (Stage I screening and categorisation).Te remaining 33 papers were taken forward to Stage II screening, at which point they were read in full (see Figure 1).At Stage II screening, further 16 were excluded (either because they were not relevant, the full paper was not available, or papers were related to the same academic study), leaving 17 that were deemed relevant to the objective of the review.One additional paper was identifed through a parallel search, bringing the total number of papers included in this study to 18.

Summary of Selected Papers.
Te eighteen studies that met the inclusion criteria were a combination of journal articles (n � 10), discussion papers (n � 3), reports (n � 2), and guidelines (n � 3).Fifteen of the papers were based on primary research, of which ten were based on primary data.Te papers represented a range of perspectives including, residents, relatives, care staf, local government, and care home providers, with some studies exploring more than one of these perspectives.Appendix B shows a year-by-year distribution of papers with no obvious peak of interest at any point.
Four themes were identifed from the eighteen studies: (i) the causes of care home closures (n � 3), (ii) the costs of care home closures (n � 1), (iii) the outcomes and experiences of care home closures (n � 6), and (iv) care home closure processes, guidance, protocols, and recommendations for closure (n � 8).
Tables 1-4 present details of the papers including aims and context, the source of the paper, the perspective, the health outcomes used in the paper, and whether any fnancial costs were mentioned.

Te Causes of Care Home
Closures.Factors associated with care home closures were discussed by three studies in this review (see Table 1).
Two studies were part of a wider investigation into the supply and causes of care home closures and were funded by the UK Department of Health in the early 2000s (as new care standards were being introduced) [22,23].
Te frst of the three studies was conducted by Netten et al. [23] who investigated home closures in England from the perspective of providers.Tree-quarters of the providers interviewed in this study cited the cost implications caused by the adoption of national standards as a signifcant factor in closures.Other factors included low occupancy levels due to reduced demand for publicly funded places and the local authority price regimen, which providers felt did not cover the true costs of running the homes.Furthermore, eight (40%) of the twenty providers interviewed identifed low demand for care home places as a factor, with four from the Southeast and the remaining four from the Southwest, West Midlands, North Yorkshire, and Trent region.
In a subsequent study, Netten et al. [22] examined care home closure causes from the perspective of regulators, discovering that while a smaller proportion (6%) blamed low demand for closures, a larger proportion (30%) blamed oversupply in regions similar to those mentioned above.Tere appears to be no obvious regional variation in the demand and supply of care homes, but it is unclear from the evidence whether low demand is the predominant issue for closure because it represents a smaller proportion of homes from the regulator's perspective compared with the provider's perspective.Other reasons for closures conveyed by (n = 33) Included in the study:       Sources: Laing [17]; Skills for Care [2]; Health Careers [39].
Health & Social Care in the Community regulators included an immediate fnancial crisis, current and expected care standards, and the personal circumstances of owners.It was notable that several respondents claimed that rather than just one of these factors, home closures typically occur because of a combination of them.Te third study that looked particularly at closures [7] used statistical analysis to examine the determinants of care home closures and discovered that low quality and high competition signifcantly increased the likelihood of closure.Additionally, the authors' model controlled for the region where the care home was located, but this was found to be insignifcant.

Te Costs of Care Home Closures.
Only one study specifcally focused on the costs of care home closures (see Table 2).
Te UK study comprised a model-based analysis which explored the future of residential care home services [6].Tis study was conducted in conjunction with some of the UK's largest independent healthcare providers.Te diference between the funding available and the cost associated with the demand was projected to create a £1.1 billion funding gap by 2020/21.A third of this estimated gap was due to the implementation of the National Living Wage (NLW).It was estimated that the amount of care funded in 2020/21 would result in the loss of 37,000 care homes, a loss which, if diverted instead through the hospital sector, would cost the UK National Health Service (NHS) up to £3 billion per year.Te reported fndings are based on the expectation of reduced funding, increased demand from an ageing population, and an increase in the prevalence of long-term conditions.Te authors did not provide details of the methods used to obtain these fgures but suggested that the assumptions needed to be received with caution and that the funding forecast is optimistic.Tis study suggests that a signifcant portion of the expenses related to closing care homes will go towards alternative services/ accommodation.

Te Outcomes and Experiences of Care Home Closures.
Six papers using similar approaches discussed the outcomes and experiences of residents forced to relocate (Table 3) [9,[24][25][26][27].All the studies identifed in this section are in response to planned care home closures.
A study that used statistical analysis to examine the longterm impact of a closure programme on the residents' selfreported health quality of life found some improvements for some people [25].According to the authors, participants felt their health and well-being either remained the same or improved up to a year after moving to new services.Te health status of the individuals reported at the initial assessment may have been lower than "normal" because residents were informed of the move before initial outcome data were collected, and this could have infated the size of the positive efect that the study discovered about the move.Acknowledging the limitations, this was the only study to use a validated instrument (EQ5D) to document health outcomes after a closure.
Similarly, in the case of temporary closure, Duf et al. [24] supported the fndings of those by Glasby et al. [25].Te authors described a period of disorientation after moving to their temporary residence; however, most residents recovered well with some showing improvements in both physical and mental health.Tus, both studies [24,25] suggest residents are unafected by closures in the long term, with some residents even showing signs of improvements.
Te only study that measured the mortality rate one year after care home closures found no statistical signifcance between the mortality rates of those who were involuntarily relocated and those who had just moved home [9].Te authors did not control for physical and mental diagnoses of residents, nor did they address whether the efect was causal.
Studies looking at the diferent perspectives of the impact of closure and relocation of residents highlighted a disparity between the views of residents, relatives, and staf [26,27].Leyland et al. [26] asked relatives and staf opinions on the impact of the closure on residents' health and received 12 Health & Social Care in the Community mixed responses.Although relatives believed that residents' health had improved or remained the same since moving, staf reported deterioration in mobility, speech, and general health.Williams et al. [27] interviewed residents and family members about their experiences with care home closures from various sites.While more than half of the residents (a total of 43) involved in the closures were described as "ok" or "fne," the authors found that the health of eight residents was said to have deteriorated.However, the authors did not say whether this was because of the closure or because of preexisting medical conditions.Te study did not distinguish between the opinions of residents and relatives, but it did report that a greater percentage (70%) of those interviewed were relatives.Tere may be an issue here in relation to proxy reporting of changes in health.
A more recent study that looked at residents and care staf moving homes after a closure conducted interviews after the move and found that residents had mixed reactions to the relocation [28].Residents who had lived at the home for a longer time were unhappy, whereas those who had only lived there for a few months were more positive and welcoming of the move.Although there was no focus on residents' health outcomes specifcally, the authors discovered that all respondents-residents, staf, and family members-felt that time was crucial for adjusting to and settling into the new care home.
To summarise, most of the studies in this section found that residents' views of their health remained largely unafected by the closure of a care home.Only those studies in which relatives and staf were interviewed on behalf of residents reported a perceived negative impact on residents' health.Tis may be an indication that various viewpoints do not capture the true feelings of the residents, or that the worries and anxiety that staf and family members are feeling afect how they perceive residents are reacting to the closures.Furthermore, it appears that the timings of interviews and data collection may infuence the overall outcome of residents relocating.Williams et al. [27] followed up on participants 1 to 5 months after closures and reported deterioration in the health of a small number of residents.Te study by Glasby et al. [25] appears to confrm this, as they found long-term outcomes difered from those collected in the middle of the closure.Te implication here is that 1 to 5 months may not be long enough for a resident to adjust to their new home and for the real impact to be measured, and the true efects may be overshadowed by the distress experienced during the closure.
An NHS guide published in 2016 developed a checklist/ process for local authorities, clinical commissioning groups, NHS England, Care Quality Commission (CQC), providers, and partners to refer to in the case of an unplanned emergency closure [32].Te checklist included (i) informing the appropriate parties, such as family members and residents about the closure, and (ii) conducting a rapid needs assessment and (iii) safe transfers to an alternative care setting and reviewing the process and its efectiveness.Tere were no formal references cited, and the guides' development process was not explained in any detail.Separate guidance based on evidence from studies on involuntary relocations by Woolham [36] suggests that residents who are vulnerable to stress about the closure should be (i) identifed from the beginning, (ii) properly prepared, (iii) ofered visits to potential new homes, (iv) having written information about them for care staf at the new home, and (v) encouraged to move with staf members.
In describing the process of closing a care home, two additional reports by local authorities were found to broadly concur and reiterate the NHS guidance [29,31].Te process advised in both papers includes (i) a needs assessment, (ii) a decision on a new home, (iii) care planning, and (iv) move coordination.Kennedy and Colley-Bontfont [31] emphasise the importance of having additional transportation services available on the day of the move and the importance of not moving on Friday because some resources and staf are typically unavailable.No apparent updates exist for either of these reports since their publication, nor any information on the outcomes of following such processes.Neither paper discusses the development of any one of these protocols.
Williams and Netten [34] reported that the protocols for closures that exist across local authorities in England difered on several issues, including (i) the length of notice required and (ii) the allocation of roles and responsibilities.One protocol stated that when a closure is enforced, the regulator is responsible, and when it is voluntary, the local authority is responsible."Most" protocols recommended that care staf should be encouraged to be involved in the home closures.Many of the protocols reviewed by Williams and colleagues suggested that follow-up reviews should take place within four to six weeks of relocation.
For the studies reviewed in this section, there was typically no explanation of how the guidelines or protocols were developed, or whether they were based on previous closures or existing evidence.Tere was no information about when the guidelines were created, nor was there any information about when they were last updated or how frequently they are updated.Notably, three of the guidance papers were based on research from the early 2000s, which might be viewed as a diferent period for policy and such guidance might not be considered relevant today.

Process and Pathway
It was not possible to identify a single, clear, or optimal process and pathway to care home closure, from any perspective, from the papers identifed in the review.From the guidance and protocol literature in the preceding section, we extrapolate an example of a potential closure pathway, from the viewpoint of the local authority.
Williams and Netten [34] and Leyland et al. [26] provided some insight into the process of closure from the perspective of the local authority.Te local authority protocols discussed in Netten et al.'s [23] study referred to in the Health & Social Care in the Community previous section suggest that at the beginning, a notice of closure must be issued.Te protocols suggest giving at least one month's notice, if not more.Following that, roles and responsibilities must be assigned, with the allocation of roles varying across protocol documents.Care staf should be involved in the process and should accompany residents on the day they move to the new home if possible [34].Care managers/social services staf should then fnd a list of alternative accommodation from which residents and relatives can choose.Some of the protocols identifed by Williams and Netten [34] recommend temporary accommodation in case of an emergency closure or if places in the resident's preferred home are unavailable.A needs assessment is usually performed next, with protocols varying depending on how much care and support self-funders are entitled to.Te residents will then be moved to their new homes.Te last step is to follow up with residents and review the closure process, with most protocols agreeing that reviews should take place within 4-6 weeks of relocation.From the outcomes and experiences section of this review, it was apparent that changes to health could take place over the course of a year; therefore, a follow-up review should be conducted at 12 months.Te four stages covered in the study by Leyland et al. [26] include re-assessment, choosing a new home, moving to a new home, and reviewing the move.
In summary, despite some studies using similar closure processes, no single recommended processor pathway to which all closures adhere exists.Instead, some steps in the closure process have been articulated and seem essential, though no ordering of these steps is currently advised.Tere is no evidence to suggest that these steps are the most appropriate or efcient; they are described but not analysed in the papers.

Findings from Pragmatic Search "Costs of Operating Care Homes"
A separate pragmatic search was carried out to better understand the operating costs of care homes and whether these expenditures are related to the articles found in this study (Appendix A).Te search yielded three articles that investigated the costs of running a care home.A report by Laing [17] found that staf costs are the largest costs to homes, accounting for nearly half of care home expenditure.
Laing [17] appears to have made the fundamental assumption that these costs are fxed, while Romeo et al. [37] have shown that other factors such as personal characteristics, cognitive ability, and dependency can infuence them.

Discussion
6.1.Summary of Main Findings.Tis scoping review identifed eighteen papers relating to the closure of care homes.Studies included in the review covered diverse topics, including costs, consequences, causes, and processes, with most of the literature focusing on protocols, guidelines, and experiences of care home closures.Te papers difered signifcantly in their methods, perspectives, and sources.Tis review found no studies reporting economic evidence or cost-efective pathways or process for care home closure.
A key motivation for the review was to ascertain the component costs and/or resource use associated with a care home closure from the perspective of a range of stakeholders, but evidence of this sort was not identifed.Te automatic and wholesale diversion of unmet needs due to care home closures into the health care system (used as the basis of the cost calculation reported by Reed and Crawford [6]) is not credible, although there may be some associated resource use (and hence cost) falling upon the health care system, which has not yet been accurately recorded.Although it is likely that many residents remain in the residential care sector, there were no papers that specifcally examined how care home closures afected the demand for community-based support and services.Given their statutory responsibilities and the signifcant role specifed for local authorities to play in cases of care home closure, as specifed in the protocol/guidance documents that we identifed, it can reasonably be estimated that a signifcant proportion of the cost burden associated with care home closures will fall upon local authorities.
Te outcomes of care home closures on residents varied depending on who was asked and when they were asked.Participants in the study by Glasby et al. [25] self-reported QoL and it was discovered that outcomes stayed the same or improved up to a year after switching to an alternative residence.Te improved outcomes may be the result of residents in their new homes receiving better care or living in more modern, purpose-built buildings.Based on the limited evidence, this seems like the obvious assumption to make, but there is not enough information to know if that assumption is supported.However, when care staf were asked, they believed residents' health might decline because of the closure.Te degree to which care staf projected some of their feelings during these interviews may have contributed to the diference in views between residents and staf.Studies on outcomes and experiences were all based on planned closures; therefore, it is unclear whether the same efects would occur if it were an unplanned or emergency closure.While it is reasonable to assume that residents who were able to self-report their QoL may have better health at baseline data collection, Glasby et al. [23] reported that a large proportion of residents in their study had high levels of mental health needs.
While staf and family members were asked to report proxy responses for residents in the studies identifed, no study explicitly looked at the outcomes and costs experienced by staf and family members, which would presumably include anxiety, staf searching for new employment opportunities, and family members' involvement in the relocation of residents.Geography and the extent of competition/supply would presumably impact both employment prospects for staf and relocation and future travel costs for families, but these factors were not explored in the studies we identifed.
Te fndings on the causes of closures revealed a variety of reasons for a care home's closure; however, the reasons varied depending on who was asked.Allan and Forder [7] were the only researchers to use quantitative methods to analyse the causes of care home closures and found that high 14 Health & Social Care in the Community competition and low quality increased the likelihood of a home closing, supporting the regulators' views on closures.Te diference in views may relate to the diferent priorities and motivations of those involved in the closures.Closures of poor-quality homes in areas of excess supply are entirely in keeping with market forces and are likely to increase the quality across the sector as a whole.Tis may explain improved outcomes for displaced residents in the long term.Due to the lack of statutory guidance on care home closures, local authorities have developed their own guidelines and protocols.Te contents of guidelines varied across authorities, suggesting that LAs difer in their approaches when closing a care home.Tere is insufcient evidence to determine which policies both minimise costs and improve outcomes for those involved in the closures.Most guidelines and protocols in this review do not state the methods informing their development, whether they were infuenced by earlier closures, how regularly they are updated, and how many closures have followed the protocol successfully.

Strengths and Limitations of the Study.
Tis is the frst study to focus on the economic evidence associated with care home closures and has revealed that there is a dearth of evidence on the economics of care home closures.A strength of our approach is our systematic search strategy and inclusivity.Te limitations associated with this review relate to the heterogeneity of the few studies that do exist on this subject and their multiple objectives which made identifying relevant studies (with defned and consistent search terms) more challenging, potentially increasing the risk that some relevant papers may have been missed.Te inclusion criteria were deliberately inclusive, to mitigate this risk, and input from an information specialist informed our search strategy.It was also difcult to compare studies and draw conclusions about the diferences between them because of their heterogeneity.

Comparison with Other Studies.
No previous scoping reviews have sought to collate knowledge on the economics of care home closures.Our (separate) pragmatic search (see Appendix A) uncovered studies reporting the costs associated with running care homes, and these suggest that staf costs and capital costs represent the biggest proportion of costs.Te "few" studies identifed in the current review do not refer to either staf, capital, or even running costs as a key component contributing to closure.Furthermore, the efect of Brexit on staf supply [37], the minimum wage [15], and the current energy crises in Europe [38] may well be anticipated to have a detrimental impact and potentially compound difculties in the care home sector, but these recent events will take time to follow through into the literature and reveal any evidence of their impact.

Implications for Current Practice and Future Research.
Tis review highlighted the paucity of consideration given to the economics of care home closures and the challenges of researching this.Tere was a lack of information about and consideration of the costs of care homes in the papers identifed through this scoping review.As a result, the signifcance of these factors has not been explored, nor have they been considered as potentially signifcant contributing factors in the case of future care home closures.Care homes were severely afected by COVID-19, and the aftermath of the pandemic is continuing to prevail.It is urgent to understand the efects of closures and how to make them as minimally disruptive as possible given the efects of Brexit on staf availability and the disruption and trauma caused by COVID-19 in the sector as well as the impending fnancial crisis brought on by rising energy and electricity prices.

Conclusion
Tis is the frst study to systematically identify and narratively summarise papers/documents reporting the costs, consequences, causes, and processes of care home closure in the UK, adopting an economics perspective.It appears that key factors driving care home closures historically (i.e., as discussed in the literature post 2000), relate to poor quality provision (provision not meeting changing national standards) and excess supply in the market.It has been documented that staf costs represent a signifcant proportion of operating costs for care providers, but studies exploring care home closure to date have made little reference to staf costs or workforce constraints as factors infuencing the decision to close.Future care home closures are likely to be driven by constrained income streams (where funding is from the public sector), rising operating costs (as high price infation is experienced), and/or workforce constraints.
If poor quality is a factor explaining care home closures (as suggested in the literature), this may explain why selfreported health-related outcomes for displaced residents in one study were reported not to have deteriorated in the long run (there is transition from poor to better quality care/ residential environments), although the same fnding was not reported in cases where there were proxy-reported changes in health (reporting on behalf of the resident by staf or family members).Future research should account for staf and family anxieties and stress as relevant outcomes in their own right, and caution should be exercised in terms of proxy reporting of resident outcomes by families/staf who are themselves experiencing stress/anxiety.
No credible evidence was identifed regarding the key cost drivers (itemised resource use) associated with the process of closing care homes and associated monetary values; this is an important knowledge gap.Given that a high proportion of the cost burden is likely to fall upon local authorities, an evidence-based approach to care home closures, accounting for cost-efectiveness, could help improve future experiences and inform the best use of scarce public funds.Currently, there is no evidence of protocols and guidance documents for care home closure being evidencebased, or even updated.Information obtained from this review and planned future research could contribute towards modelling costs and outcomes associated with a plausible set of care home closure pathways, hence forming an evidence base to inform future practice.

Appendix
A. Costs of Operating a Care Home A1.Introduction.Tis section discusses the literature discovered through a pragmatic search.Google Scholar and AgeInfo were searched using the following terms: costs, running, and care homes.Te search yielded two relevant articles.Te costs of running a care home were examined in [17].Both papers difer in terms of the costs they determine; Laing [17] examines the major cost components incurred by care homes, whereas Romeo et al. [37] investigate the cost of care for people with dementia in institutional care settings.One additional report was identifed from the references of the articles above.A2.Literature.Te operating costs of efective care homes are calculated in Laing's [17] report using a set of transparent and robust underlying assumptions.Te sources used to calculate the costs included mailed surveys of care homes, data from large care home groups, and telephone surveys of major business transfer agents.Tey based their analysis on the costs per resident per week (prpw) being calculated under the premise of an efective operational scale, which they identifed as 50 beds.Four main costs associated with care homes were identifed: stafng, maintenance and repairs, other current costs not related to staf, and capital expenses.Table 5 illustrates the infated costs for 2021/22 that were estimated in the Laing [17] report, and Figure 2 shows the proportion of these expenses.
Staf costs are the largest cost, accounting for nearly half (43%) of care home expenditure.1.5% of the staf costs were allocated for an agency usage allowance, which was calculated to cost £3 per resident per week.Tis comes out to £150 per week (£3 multiplied by 50 residents), which is signifcantly more than the £52 per week agency cost Curtis et al. (2007) estimated, demonstrating that there is some variability in estimating staf costs.Laing [17] did not factor in the costs of external services (GP visits), but Curtis et al. (2007) calculated that they would cost £16 per week.
Capital costs account for 36% of care home expenditure.Capital expenses vary in line with build and equipment costs and land prices.Tey are the most difcult to measure.Laing [17] assumed that good quality care homes sell in the open market at a multiple of about 8-8.5 times operating proft, which implies that purchasers of care homes are seeking an annual return on their gross investment of 12%, refecting their assessment of care home operation as a moderately risky business.Other current costs not related to staf such as food and utilities account for 15% of total care home expenditure.Te costs represent a stand-alone care home without the beneft of group negotiated discounts.Repairs and maintenance represent 6% of total expenditure.
Laing [17] presented the diferent pay rates between the private sector and the NHS; this information has been updated to refect current rates as shown in Table 6.Te gap in pay between care homes and other sectors may contribute to the high turnover of staf in the care sector, which causes homes to incur additional costs for hiring and training replacements.
Te cost of care for people with dementia in institutional care settings was examined by Romeo et al. [37] to understand the major cost drivers.Te authors built three models, one for the total costs of both types of homes (residential and nursing) and two using each type of care home.Next of kin was the only signifcant variable in residential care homes and was associated with higher costs.Tis was opposite to the results of the model that included both types of homes.Tis implies that the cost of residents' care is increased by the presence of family members or friends.Sensitivity analysis was conducted by replacing the total cost variable with non-residential costs (all costs not inc residential fees) as the dependent variable.Costs were signifcantly higher for residents who did not speak English as their frst language, had been in the care home for a shorter period, had sensory issues, and had more needs identifed.Te authors did not make explicit the number of residents who were either self-funded or receiving public funding, or which model sensitivity analysis was applied to.Hospital expenses were discovered to be 1.76 times higher for residential care home residents than those in nursing homes.It should be noted that all study participants had dementia.However, this expense could be decreased by giving residential home staf members additional training to cut down on unnecessary hospital admissions.A3.Summary.Tis search produced three articles which examined the costs of care homes.A detailed report by Laing [17] provided a breakdown of the four main cost categories.Tey appear to have made the fundamental assumption that these costs are fxed, but Romeo et al. [37] have demonstrated how the cost of care can vary and how personal characteristics, cognitive ability, dependency, and other factors can impact it.Laing [17] did not address external expenses, despite Romeo et al. [37] fnding them signifcant.Tis may be because the cost of external services like GP visits and hospital admissions typically does not fall on the care homes themselves.

Additional Points
What Is Known about Tis Topic and What Tis Paper Adds?. (i) Much of the care home provision in the UK is by the forproft sector.(ii) Nearly 50,000 older and disabled people with care needs were displaced from UK care homes due to closure in the fve years preceding 2020.(iii) Local authorities commission care in some cases and have a statutory responsibility to safeguard vulnerable groups.(iv) Although 16 Health & Social Care in the Community relatively little evidence on the consequences of care home closures was identifed, evidence suggests resident outcomes are not necessarily/always adverse in the long term.(v) Te few studies reporting costs failed to adequately describe a robust methodology.(vi) Where sufcient evidence can be identifed to inform parameters, economic modelling could inform the comparison of diferent closure pathways and hence future policy.

Figure 1 :
Figure 1: Flowchart of various stages in review showing the number of papers at each stage.

Figure 3
Figure 3 depicts the year-wise distribution of 18 papers in the period of 2000-2023.Te number of papers published varied from 0 to 3. Te highest number of papers, i.e., 3, was published in 2002 and 2016.Tere is no obvious peak of interest at any point.
care homes OR residential homes OR homes for the aged OR older people AND closures OR closing OR closed OR relocation OR resettle OR transfer OR transition AND economic OR costs OR impact OR outcomes OR consequences OR cost-efective OR cost analysis OR cost utility OR healthcare expenditure OR healthcare fnancing OR quality of life OR ICECAP OR wellbeing OR ASCOT.ICECAP and ASCOT are commonly used measures of quality of life and social care-related quality of life, respectively, which have been endorsed for use in social care by the Social Care Institute for Excellence 2 Health & Social Care in the Community (SCIE) and the National Institute for Health and Care Excellence (NICE).
Criteria.Studies/documents were included if they met the following inclusion criteria:

Table 1 :
Summary of causes of care home closure papers.

Table 2 :
Summary of costs of care home closure papers.

Table 3 :
Summary of outcomes and experiences of care home closure papers.

Table 4 :
Summary of guideline, process, and recommendation papers.