The effectiveness of housing adaptations

Frances Heywood

Money well spent is the first large-scale study of the outcomes of public expenditure of £250 million a year on housing adaptations in England and Wales.

The research is the result of a unique partnership between housing and occupational therapy professionals and researchers. It presents, for the first time, evidence about the effectiveness of housing adaptations for older people and disabled people of all ages (including children). Based on interviews in seven local authorities, the report includes:

  • evidence about how housing adaptations improve the health, quality of life and opportunities for disabled people and their families;
  • proposals for ways to make housing adaptations even more effective; and
  • information to help health, housing and social services determine Best Value and allocate budgets.
Summary

Summary

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-


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.

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