CELG(4) HA 25

Communities, Equality and Local Government Committee

Inquiry into Home Adaptations


Response from : Nigel Appleton



The duty of public authorities in relation to the needs of people with disabilities has been set out in legislation from the National Assistance Act of 1948, through the Chronically Sick and Disabled Persons Act of 1970 to subsequent legislation and guidance from both Westminster and Welsh governments.  This has identified three main areas of responsibility:


·         To develop an understanding of the nature and volume of need that people with disabilities might have within each geographical area (normally the boundaries of the “Welfare Authority”).


·         To provide professional assessment to those who appeared to have needs to which the Authority could respond through the provision of services.


·         To ensure that the needs that are assessed are appropriately met.


Although within Wales there has generally been a more progressive approach to the delivery of services to meet the needs of disabled people when compared with some other countries of the United Kingdom even here the expectations generated by legislation and guidance have been only incompletely delivered.


·         Attempts to quantify need have been, at best, sporadic for fear of creating expectations and demands beyond likely resources.


·         Various techniques have been used to restrictively gate-keep access to assessment and criteria used, such as the grotesquely mis-named “Fair Access to Care” criteria.


·         Resources to support the delivery of assistance have generally been regulated to meet budget management requirements, rather than to respond to the presentation of need.


The Benefits of timely and appropriate adaptations


There is an extensive literature documenting the benefits that arise for a range of stakeholders from the provision of adaptations in the homes of disabled people. Reporting in 2001[1] Heywood identifies a range of benefits for the disabled person, their carers and family members.  These are principally in the area of mental and physical well-being and, for the disabled person, improved dignity, privacy, independence, health (both physical and mental), social inclusion, and opportunities for education and employment.  The impact on well-being is further documented in the wide-ranging literature review undertaken by Heywood and Turner in 2007 for their report “Better outcomes, lower costs”.[2]  Their report also reviews studies that had sought to establish cost savings to the health and social care economy through the provision of adaptations.


The question of cost benefit from the provision of adaptations relies on an equation which is simpler to state than to specify: how many events requiring high cost health or social care services have been avoided, multiplied by the estimated cost of providing those services.  The second part of that equation is less problematic than the first; there are many sources that will provide the cost data.[3]


Work by the Lean Enterprise Research Centre at Cardiff University reports a study of people moving to residential care over a five year period[4].  Of the total of 750 people moving to residential care 244 had been identified by OT services for a Disabled Facilities Grant (DFG), 85 had received a DFG and 159 had not.  Those who received a DFG entered residential care at an average age of 84 years, whilst those who did not entered at an average age of 80 years.  The report suggests that there is a high correlation between receiving a DFG and an average delay in admission of four years.


Whilst there are a number of imponderables in making the calculation (whether the person receiving the adaptation also receives home care before transfer to residential care and whether, once there, they were meeting part of the cost of their care themselves) the gross cost of four years of residential care is in the region of £80k per person to set against the average cost of a DFG of around £7k.


The second area in which financial benefit is widely asserted is in the prevention of falls and resulting fractures.  The cost to public funds of a hip fracture was estimated at £28,665 in 2007.[5]The difficulty here is that the circumstances that lead to a fall are multi-factoral and a single intervention will only have a partial rather than determining impact.  Whilst an adaptation may identify and remove tripping hazards, improve accessibility and generally modify the risk inherent in the home environment it will represent only one element in determining a safer outcome.  Other factors may include underlying health conditions, medication, nutrition and hydration, chronic joint conditions, balance, and lifestyle.


The Care and Repair England report ‘Time to Adapt’[6]cites a notable example of how really close links between home adaptations providers and the health service can improve services for disabled people considerably.  Blackpool Care and Repair has organised their service from the perspective of the user, not the provider and the PCT, home improvement agency and local authority have worked together to bring the time it takes to complete a home adaptation down from a year to an average of 8 weeks - or even less if a case is urgent. John Turner, the Integrated Systems Manager at Blackpool PCT states that


‘The links between housing suitability and health are incontrovertible.  If we want to improve older people’s health, enable their independence at home, prevent falls and reduce other common problems it is absolutely critical that we work effectively with housing colleagues to make older people’s homes safe, decent and adapted places to live’.


The delivery of adaptations


The arrangements for the provision of assessment and delivery of adaptations to dwellings to meet the needs of disabled people seem uniquely structured to encourage delay, bureaucracy and fragmentation in the delivery of service.  Through the initiative and imagination of individuals the system is, in many cases, made to work for the benefit of disabled people. Where goodwill, adequate financial resources, inter-disciplinary trust and corporate leadership are absent disabled people suffer delay and compounded risk for themselves and their carers.


The principal means of delivering statutory funding and public assistance to provide adaptations relies upon the Local Government and Housing Act of 1989 which introduced a specific grant: the Disabled Facilities Grant, to fund eligible adaptations for eligible applicants. The Housing Act 1996 and the Regulatory reform Order (Wales) 2002 further refined that provision.


Where the National Assistance Act and the Chronically Sick and Disabled Persons Act had laid responsibility squarely on the Welfare Authority the introduction of the Disabled Facilities Grant gave the lead in delivery of adaptations to the Housing Authority.  Application for the grant was made to the Housing Authority who would administer a Test of Resources to determine financial eligibility for assistance. The legislation suggested that in administering the grant the advice of Community Occupational Therapists, generally working within Social Service Departments, should be taken into account. In practice the Occupational Therapy service generally came to be the gatekeepers to this provision, determining what works are “necessary and appropriate” to meet the disabled persons needs, whilst housing colleagues determine whether what is proposed is “reasonable and practical” and generally supervise their delivery.


Whilst the primary responsibility for identifying, assessing and responding to the needs of disabled people remained with the Welfare Authority this was often obscured or poorly understood at an operational level. Thus the exhaustion of available budget within Private Sector Housing, where the administration of the grant was generally located, would be taken as an absolute bar to delivering any adaptations until further resources became available.


Because the delivery of Disabled Facilities Grant now occupied centre stage in the response of local authorities to the provision of adaptations those who did not qualify for financial assistance were often offered no assistance at all. Their right of access to assessment, specification of works and support through the execution of adaptations for which they themselves were going to pay too often met with no service response.


The whole system is characterised by delay: applicants waiting to be assessed to find that they will not qualify for financial assistance; requirements to prove title for home owners or to secure landlord’s consent that will often be problematic in anything other than very straight-forward circumstances, delays in process between departments; all contribute to delay. The review of housing adaptations including Disabled Facilities Grants in Wales, undertaken by Chris Jones and reported on in March 2005, drew attention to delay in delivering adaptations as the greatest limitation in the then existing system. The average time from referral to completion reported by Jones was eighty-five weeks.


To a person confined to the house or remaining in hospital because their home is not accessible, to the carer carrying their disabled loved one to the shower or to the toilet because the only one available is inaccessible, eighty-five weeks is an intolerable period to wait.


As a result of the work by Chris Jones and a parallel consultation in England to improve DFG delivery, revisions to the DFG in Wales were introduced in Annex D of the National Assembly for Wales Circular 20/02 in 2007[7]. This had the aim of putting the needs of the disabled person at the heart of the service, improving co-ordination between different service providers and reducing delays.  The DFG Review Report also recommended that lower cost adaptations should be streamlined and made less bureaucratic by channelling adaptations up to the value of £3,000 through a fast-track system rather than through the traditional DFG route. Whilst these improvements are welcome timeliness, or the lack of it, remains the most pressing issue in devising a fit for purpose system for the delivery of adaptations.


In the work undertaken in 2011/2012 to evaluate the Independent Living Grant[8] initiative six local authorities within Wales were identified as case studies.  In those six areas the time taken from referral to completion of an adaptation under the DFG process, even after the improvements of 2007, ranged from 315 days to 632 days, with a typical average period of 340 days.  The time from referral to completion of an Independent Living Grant ranged from 32 to 78 days with an average of around 58 days.


The challenge


The need for adaptations will not go away. The ageing of society will, as a consequence of the chronic conditions and functional inhibitions that characterise extended old age, drive an increasing level of demand.  The continuing advances made by surgeons and physicians in improving survival rates for people born with serious disabilities and those who suffer serious illness or injury adds a smaller number, but often with more complex needs for adaptations to their homes.  


The provision of assistance, including financial assistance, to achieve adaptations in the homes of disabled people should rightly be regarded as an issue of citizenship. The right to inclusion, to the dignity and maximisation of independence that an adaptation can bring is just that: a right, not a privilege.


However the administration of assistance to those requiring adaptations is firmly locked into a “welfare” model: one in which applicants must demonstrate incapacity and impoverishment to achieve eligibility.  Where concern to constrain and account for public expenditure can over-ride all other considerations.  One in which flexibility to achieve timeliness in delivery adaptations is thwarted by vested interest.  In which only need defined by professionals is valid and aspiration by disabled people and their carers is felt to be inappropriate. In all the professions and organisations involved in the delivery of adaptations to people in Wales there are those who are committed to working collaboratively and flexibly, with imagination and empathy to achieve the best outcomes for disabled people and their carers. They need to be empowered by the support of policy makers and legislators.


To meet the continuing requirement for adaptations, to do that in a way that recognises that this is a rights based activity, and to deliver adaptations in a timely way, requires flexibility, imagination and commitment to the person rather than to the bureaucratic process.  Wales has shown how this might be achieved: in the Rapid Response service, in the Independent Living Grant experiment and the innovative patterns of working that some were able to adopt through that initiative.  It is time to “mainstream” those approaches, so that the delivery of adaptations in Wales sets a new standard in responding to the needs and aspirations of those of its citizens who live with disability.


Nigel J W Appleton

February 2013

[1] Money well spent: the effectiveness and values of housing adaptations, Heywood F, Joseph Rowntree Foundation , 2001

[2] Better outcomes, lower costs- Implications for health and social care budgets of investment in housing adaptations, improvements and equipment: a review of the evidence”, Heywood R & Turner L, Office for Disability Issues and University of Bristol, 2007.

[3] See for example: Unit costs of health and social care services 2011, Curtiss L, 2011, PSSRU

[4]Lean Enterprise Research Centre, Cardiff Business School (2010) Lean and Systems Thinking in the Public Sector in Wales

[5] Better outcomes, lower costs- Implications for health and social care budgets of investment in housing adaptations, improvements and equipment: a review of the evidence”, Heywood R & Turner L, Office for Disability Issues and University of Bristol, 2007.

[6] Adams, S. and Ellison, M. (2009) Time to Adapt - Home adaptations for older people: The increase in need and future of state provision, Nottingham: Care and Repair England.

[7] National Assembly for Wales (2007) Circular 20/02 Annex D – Revision of Disabled Facilities Grant

[8] Evaluation of the Independent Living Grant (ILG), Appleton N, Leather P & Mackintosh S, Welsh Government Social Research, 2012 ISBN: 978 0 7504 7505 1