August 2001 - Ref 811
The effectiveness of housing adaptations
Public spending on housing adaptations - permanent or fixed
alterations to make homes more suitable for disabled occupants and
their families - amounts to more than £220 million every year, and
both numerical demand and unit costs are growing. This research
examined the effectiveness of these investments from the point of view
of those who have to live with them. The study found that:
- Minor adaptations (grab rails, handrails, etc.) produced a range of
lasting, positive consequences for virtually all recipients. Of a
range of benefits reported, 62 per cent of respondents suggested they
felt safer from the risk of accident as a result of the work done and
77 per cent perceived a positive effect on their health.
- Major adaptations (bathroom conversions, extensions, lifts, etc.)
in most cases had transformed people's lives. Before alterations,
people used words like 'prisoner', 'degraded' and 'afraid' to
describe their situation; following adaptation work, they spoke of
themselves as 'independent', 'useful' and 'confident'. Asked to
give the adaptation a mark out of 10, the average score awarded was
8.9.
- Where major adaptations failed, it was typically because there were
weaknesses in the original specification. This was most likely where
assessment had been constrained by rigid rules. In some cases,
policies intended to save money resulted in major waste. Examples
included extensions that were too small and/or too cold to use, and
cheap but ineffective substitutes for proper bathing facilities.
- The evidence from recipients suggests that successful adaptations
deliver many of the government's key objectives: they keep people out
of hospital, reduce strain on carers, and promote social inclusion.
Benefits were most pronounced where there had been careful
consultation with users, where the needs of the whole family had been
considered, and where the integrity of the home had been respected.
- The researchers conclude that spending on adaptations appears to be
a highly effective use of public resources. They suggest that an
investment of health resources to increase over-all funding for
adaptations could well be justified.
Introduction
In 1995, £221 million of public money was spent on the capital
costs of adapting properties in all tenures in England and Wales, and
available figures suggest that spending is increasing. The growing
cost of adaptations reflects both increasing numbers of requests
(largely due to demographic changes) and the increasing costs of
individual adaptations (partly due to advances in technology, partly
to rising building costs).
This qualitative study - using a fieldwork team of professionals
involved in the adaptation process - was designed to gather evidence
on the effectiveness or otherwise of housing adaptations, large and
small, based on the views of those who had received them. The main
measure of 'effectiveness' was the degree to which the problems
experienced by the respondent before adaptation were overcome by the
adaptation, without causing new, equally or more serious problems, and
without perceived waste.
Minor adaptations
The study's definition of minor adaptations included rails, ramps,
over-bath showers and door entry systems, but not portable items of
equipment. The results of the postal survey revealed that these small
alterations - all costing no more than £500 and most costing
considerably less - were a highly effective use of money (see Table
1).
Table
1:
Outcomes
of minor adaptations
| Objective
achieved as consequence |
Number
ticking this item |
%
(n = 162) |
| |
|
|
| Feeling
safer from risk of accidents |
101 |
62 |
| Taking a
bath or shower |
79 |
49 |
| Using
the toilet |
63 |
39 |
| Needing
less help from others |
59 |
36 |
| Running
your home generally |
51 |
31 |
| Being
able to go out |
39 |
24 |
| Continuing
with your interests |
20 |
12 |
| Preparing
meals |
13 |
8 |
| Having a
social life |
13 |
8 |
| Caring
for someone else |
5 |
3 |
| Getting
to work |
2 |
1 |
| Total
number of positive effects |
445 |
|
|
|
In addition to this positive assessment, 77 per
cent of respondents
said that the adaptation had helped their health and 86 per cent said
they would have spent the money in the same way. For the other 14 per
cent, discontent was either about the quality of work or about needing
a proper walk-in shower but being given only a cheaper substitute. In
general, the minor adaptations questionnaire showed that many people
were thoroughly content with simple adaptations, with the benefits
felt over years, and often by more than one person.
Major adaptations
Being unable to bathe was the most common reason for requesting a
major adaptation. This was followed by: being unable to reach the
toilet; problems with stairs; cold; fear of falling or actual falls;
problems of lifting and children's needs being unmet. Figure 1 gives
a flavour of the problems people were facing before adaptation work
was carried out, and the type of changes that were achieved.
Figure
1: Interviewees’ views before and after
adaptations
| |
|
| Before
adaptations |
After
adaptations |
| |
|
| "A
major issue is that she cannot get into the bath
and has been waiting four years for a shower. She
was assessed in 1996 and told she was entitled but
not a high priority because she is not
incontinent." |
"She
thought the shower was fantastic… She could sit
down in the chair, turn it on and use the shower
by herself. She enjoyed no longer needing help to
wash." |
| |
|
| "It
was about two and a half years between the time of
the accident and the date adaptations were
completed. In that time it was really terrible.
People would come to visit and he was embarrassed.
The commode was in the kitchen and sometimes the
smell was terrible - had to spray deodorant
everywhere." |
"The
first time I was able to flush the toilet, I
cried." |
| |
|
| "Getting
upstairs was an agonising process. She would do it
one foot at a time, her husband supporting her
bottom while she pulled herself up step by step.
It took 15 minutes to climb the stairs, and
reduced her to tears every night." |
"The
ability to gain access to the whole house is
wonderful. No longer a prisoner." |
| |
|
| "Before
the adaptation, sitting, walking, any movement
caused pain. The cold temperature increased the
pain; he needed to wrap up in a sleeping bag to
keep warm." |
"He
can now go into a warm bedroom rather than wait
for it to heat up and he doesn't have to lie out
on the sofa any more." |
| |
|
| "Their
daughter was getting heavier to carry and the
stairs were very awkward with two turns in them.
The parents have slipped themselves on the stairs
so carrying her up to the toilet and bed was
getting increasingly dangerous." |
"The
child is much more confident and in control.
Having the space for her friends to come has made
a big difference especially as some are also
disabled." |
|
|
As well as the simple, practical benefits to individuals of being
able to go in and out, take a bath, keep warm, and use the toilet and
bedroom, the adaptations restored confidence, dignity and
self-respect. They promoted independence, reduced stress and allowed
people to interact with their families. Carers felt more supported;
the health of disabled people and other family members was seen to
have improved, social isolation was overcome and children began to
flourish and develop.
At the end the interviews, most respondents were asked to sum up
their views by giving a score out of ten for the effectiveness of the
adaptation. The teams of interviewers were also asked to agree a
score, based on their professional judgement (see Table 2).
Table
2:
Scores out of ten for effectiveness?
| Age
at time of adaptation |
Average
scores effectiveness scores of adaptation |
Average
officer scores for same adaptations |
| |
|
|
| Adults
65 and over (n=26) |
9.4
(range 5-10) |
9.1
(range 8-10) |
| Adults
18-64 (n=21) |
9.0
(range 2-10) |
8.9
(range 6.5-10) |
| Children
0-17 (n=22) |
8.3
(range 5-10) |
7.8
(range 2-10) |
|
|
Officers were often less satisfied with the adaptation than were
recipients, perhaps reflecting the low expectations of those whose
homes had been altered. Adaptations for children received the lowest
average scores from officers and families alike. Failure to allow for
the child's growth was particularly noted.
Problems with adaptations
Although most of the evidence pointed to positive outcomes, the
research also exposed some serious problems.
Some of the more commonly described problems had their origins in
poor consultation and communication, poor quality work and failure of
supervision. The lack of attention to detail, especially in bathing
adaptations, was cited on a number of occasions by both officers and
disabled people. Examples of the difficulties caused included shower
areas that were too small to use comfortably or too awkward to clean
properly, controls that had been fitted in the wrong place, and
failure to provide necessary accessories (from soap trays to grab
rails).
Some adaptations were unused, unusable, or caused increased stress.
Examples of all these things came to light during the research, in
cases where costs ranged from £12,000 to £35,000. Some extensions
for children were so small there was no room for a parent to sleep
when the child was seriously ill, and some were too cold to be usable.
In other cases, through-floor lifts and hoists were barely, if ever,
used.
When reasons for dissatisfaction were analysed it became clear that
inadequate or compromised specification was the most common cause of
wasteful adaptations. Some shortcomings revolved around failures in
implementation, such as insufficient attention to detail, failure to
consult adequately, failure to understand and assess psychological
needs or recognise cultural requirements.
Above all, however, poor specification was the result of
professionals having to work within policies and criteria imposed by
local committees and departments. Examples of such criteria included
the stipulation that older people must have a medical need to bathe,
that heating is an 'extra', or that occupational therapists might
normally make only one visit. The failure to take account of the need
for space and warmth left some very major investments unusable. The
provision of through-floor lifts as an imposed alternative to
extension was a particular cause of concern, since lifts could
exacerbate shortages of space and have a detrimental rather than
positive effect.
Other causes of waste included delay, often down to inadequate
staffing levels and deficient capital budgets. Delay led to out-dated
assessments, accidents and hospitalisation during waiting time, and
habits of dependency becoming established which were hard to unlearn.
Conclusion
Adaptations improved health, produced a range of lasting positive
effects, and the overwhelming majority of users would have used
resources in the same way. Table 3 shows the range of beneficiaries
who gained from the capital investment that adaptations represent:
Table
3: Who benefits from adaptations?
| |
|
| Individuals |
Improved
dignity, privacy, independence, health (physical
and mental), social inclusion, opportunities for
education and employment. |
| Family
carers |
Reduced
physical and mental strain
More freedom and
peace of mind. |
| Other
family |
Improved
social inclusion, members improved educational
chances. |
|
|
This study considered adaptations costing more than £600,000 in
total. 97 per cent of these capital costs came from the public purse
and, of this, 96 per cent came from housing monies (disabled
facilities grant or housing revenue accounts). The evidence of this
study suggests that there may be a case for the input of extra capital
resources - perhaps from non-housing sources, since many of the
benefits of this investment are likely to be felt in other spheres.
About the study
The research was carried out in 1999-2000 by teams of professionals
(housing, environmental health and occupational therapy staff) working
in partnership with a research co-ordinator and with two disabled
researchers. It looked at adaptations completed between 1992 and 1998,
the aim being to assess long-term effectiveness not just satisfaction
shortly after completion. The study focused on seven local authorities
in England and Wales. The findings are primarily based on direct
interviews with 104 recipients of major adaptations and 162 postal
questionnaires returned by recipients of minor adaptations. In
addition, evidence from administrative records was considered, and the
views of the visiting professionals were recorded.
How to get further
information
The full report, Money well spent: The
effectiveness and value of housing adaptations by Frances Heywood,
is published for the Foundation by The Policy Press (ISBN 1 86134 240
3, price £12.95).
Click on the 'order report' icon in
the left margin to order online.
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