CELG(4) HA 09
Response from
: College of Occupational Therapists
1. Introduction
There are 1.32 million homes in Wales (Welsh Government 2011), yet in 2011 Wales spent £35million on Disabled Facilities Grants; £8.5million on Physical Adaptation Grants and £1.5million in Independent Living Grant. Adaptation services have developed from a range of different pieces of legislation, supplementary orders, guidance and new policies which have been introduced to improve parts of the system over time. This has created a disjointed and complex system. The provision and funding of adaptations needs to be simplified, services need to focus on meeting people’s needs rather than the funding process. The College welcomes the proposal in “A White Paper for Better Lives and Communities” (Welsh Government 2012) to review these funding methods and their interface.
2. Occupational therapists enable individuals to live their life to the full. Adaptation of unsuitable environments is an important part of this intervention and should not be seen in isolation from other interventions such as reablement, long term care or support for carers. Currently the focus tends to be on the process (which funding route will be used) when it should be on the outcome of the assessment (the identified solution). There needs to be a thorough examination of the benefits of a single, tenure-blind, age-blind and preferably non means-tested adaptation system throughout Wales. In the interim there are a range of changes which could improve provision and these are listed in the section on improving services at the end of the document.
3. Adaptations systems in Wales
A modern adaptation service should put the individual at the centre and deliver the outcomes the person needs. It is vital to get the assessment right and, if an adaptation is required, the provision must be effective and timely. The delivery should form part of an integrated service working to enable people to live independently irrespective of tenure, age, or ability to pay.
4. There are great inconsistencies and inequities in the systems for funding adaptations, which are dependant on tenure, age, and complexity of the adaptation. The current funding streams are: -
Disabled Facilities Grants (DFG)
Physical Adaptations Grants (PAG)
Direct Provision by Social Services or Housing Associations (usually minor adaptations of less than £1000)
Fast Track Adaptations
Stock Transfer Organisations Solutions
Independent Living Grants (ILG)
Housing Revenue Account Major Repairs budget (used by some of the authorities who have
retained their stock)
The administration of each one of these processes may be affected by a range of local policies and decisions.
5. Some local authorities use DFGs for every adaptation, others fast track some adaptations, such as stair lifts, using discretionary grant; yet use the DFG (and thus a means test) for a different solution such as a shower.
6. Some Registered Social Landlords (RSL) simply and quickly install minor adaptations with their own technical staff; others require an occupational therapy assessment; For larger adaptations the RSL has access to PAGs however some still refer for DFG funding. In some cases the adaptation is refused.
7. Stock transfer organisations cannot access PAGs and tenants have to rely on the RSL’s budget or local authority social services department and the DFG process. Again, permission for the adaptation may be refused.
8. ILG’s are administered by Care and Repair and as such are restricted to applicants over 60 years of age in the private or privately rented sector. The criteria for eligibility are determined by each Care and Repair agency and their health and local authority partners.
9. Funding streams with criteria based on tenure, age, diagnosis or personal contributions all generate boundaries and gaps for people with complex needs. Too often decisions are not based on what would best solve the problem but on which of the systems we are driven to use.
10. Variation, Performance and Timescale
Variation in performance and delivery time is inevitable in such a complex system. The term adaptation can cover an enormous range from providing a simple handrail to an extension of a property to provide a ground floor bedroom, bathroom, and other complex components. The range of housing types and complex funding systems has an impact on the timescales involved.
11. At present, the DFG is the only type of adaptation process for which there is a performance indicator (PI). It measures average waiting time and does not differentiate between simple and complex adaptations. The separation of the measurement of children and adult adaptations is a recent improvement and allows some improved comparisons of like for like adaptations. A comparison of provision across tenure cannot be made because there is no PI for other adaptation grant routes. There is also no consistent measurement of the whole service of the person’s journey through services to show which elements are creating delay.
12. Delays arising from other parts of the service which generate a wait may be attributed to the DFG process. For example, a request for an assessment for bathing difficulties may be placed as a low priority causing people to wait for an assessment. Once that person is assessed it is possible that an adaptation may be required via a DFG. The wait for the assessment is (rightly) included as it is part of the wait for the person. However, this is not a part of the DFG process but is a result of lack of capacity to manage demand across the service. Some authorities may attempt to overcome this by fast tracking DFG referrals, but these cannot always be identified from information provided at referral. There is a risk that the PI encourages DFG work to be fast tracked to the detriment of other priorities or tenures. If this continues it may mean that even with national eligibility criteria, different priority will be given to processes rather than people and their needs.
13. Following meetings with Welsh Government during 2012 the College was pleased to be involved in a stakeholder meeting to consider areas of consensus in improving adaptation services in Wales. The meeting, ‘Homes for Wales: transforming Housing Adaptations’ held on the 18th July 2012, included representatives from all the main stakeholder groups and the final report outlined the agreed four main priority areas: issues around complexity and equity of means testing; the quality of performance indicators; the value of the Rapid Response Adaptations Programme being available across tenure and age; and effective use of the occupational therapy resource. The report was submitted as part of the consultation response to “A White Paper for Better Homes and Communities”. The meeting also identified the principles of a good service. These were agreed as: putting the service user at the centre of the process; getting housing right the first time via lifetime standards; create a single age and tenure blind adaptation process across Wales; equity and access to services.
14. Progress on implementing recommendations from the Equality of Opportunity Committee’s 2009 report on home adaptations
The College welcomed the recommendations of the Equality of Opportunity Committee’s report in 2009. Many occupational therapy services have redesigned their part of the DFG and adaptation system in order to make them more lean and efficient. Local authorities have worked hard to continue to improve and deliver excellent services to their clients despite complex and difficult processes.
15. Recommendation 9: the College worked with the Older People’s Commissioner, Age Cymru and Care and Repair Cymru to produce a short Information Leaflet (Care and Repair Cymru et al 2010) to help people navigate their way around the system. The leaflet directs older people, their families, health or social care professionals to the relevant page on the Care and Repair website which gives detailed information and links to the adaptation pages of each local authority’s website.
16. Recommendation 10: most occupational therapy services are developing improved partnerships across health housing and social care services in their area and between neighbouring local authorities. The All Wales Occupational Therapy Advisory Forum (OTAF), whose members include senior occupational therapists from every health board and local authority across Wales have produced a progress report in respect of integrated occupational therapy services outlining some of the innovative developments (WTAC 2012).
17. Recommendation 12: Information at the stats-wales website shows the whole time equivalent of occupational therapists has risen from 216 in 2009-10 to 242 in 2011-12. It is not clear whether these posts are in the community occupational therapy teams which service adaptations or whether this increase is in the rapidly developing reablement services. Services remain very small and fragile; easily susceptible to impact from long term leave such as maternity leave, long term sickness or from staff turnover. Eight of the local authorities have establishments in single figures; the range is 2-21. Such small numbers mean that even a short period of sickness can have an impact on capacity to maintain a service. It places huge pressures on sustaining specialist expertise, such as a children’s specialist or a housing specialist therapists. There must be sufficient staff employed to provide the service.
18. Recommendation 13: the Care Council for Wales now collects workforce information on occupational therapists as part of the planning for the whole social care workforce. This ensures that decisions about the numbers of occupational therapy students trained include the demand from social services as well as the NHS. This helps maintain the levels of therapists available and has been vital as local authorities have sought more therapists to meet the demand to provide reablement and other services.
19. Although recommendation 14 was rejected, the Housing Minister created an opportunity for improved communication between occupational therapists and government officials; and enabled the College to join the South East Wales Housing Renewals and Adaptations Group with Private Sector Housing Officers.
20. The impact of the reduction in resources for housing on the provision of home adaptations
Making the system simpler and more efficient would ensure that best use is made of the remaining available resource. Since the last committee review, many social landlords are making better use of existing adaptations and are trying to avoid removing adaptations by first checking waiting lists for tenants who may require that type of adaptation.
21. The impact of increased access to reablement and rehabilitation services needs to be recognised. These services enable people to become more independent and thus can reduce or remove the need for adaptation. Improved integration of all services makes a coherent whole for the individual and their family.
22. Monitoring the provision of adaptation services
A DFG is only one of several means to achieve an outcome: it is not an outcome in itself. Monitoring needs to be in relation to the identified need, agreed outcome and the impact for the individual. The College recommends that the new National Outcomes Framework should ensure that effective person-focussed outcome measurement is used to monitor the impact and outcome for all service users. All parts of the service should be monitored, including all routes for adaptation provision.
23. The Regulatory Reform Order has enabled local authorities to be more creative in providing adaptations or alternative solutions to achieve improved timescales. Examples of this are fast track schemes and relocation grants. Some authorities provide certain types of adaptation through a discretionary grant which removes the need for a means test. Others may use a DFG for a whole range of adaptations, including small works. None of this is made overt in the performance indicator.
24. What more could be done to improve adaptation services
The College and the College of Occupational Therapists’ Specialist Section- Housing response to the Welsh Government consultation “Meeting the Housing Challenge” called for
24.1 Improved design of all new housing, including private developments, to meet lifetime homes standards: the need for adaptation should be a sign that housing policy has failed.
24.2 A single, tenure blind, non means tested public funding system of providing adaptations to reduce inconsistency and potential discrimination in supporting people with varying needs and resources.
24.3 Commitment to making best use of housing stock across the social housing sector. This includes registers of adapted or accessible properties and links between adaptation and allocation processes to ensure existing available properties are an alternative to adaptation where they exist.
25 An excellent adaptation system would:
Meet the needs of the individual and deliver the right outcomes
Be integrated with other services and agencies, delivering the right outcomes together
Measure performance in terms of outcomes not funding processes
Consist of a simplified funding stream: applied equitably across Wales
Be delivered by an agency with a lean, well integrated journey across departments
Be tenure and age blind
Apply any bureaucratic elements (such as means tests if retained in a proportionate and sympathetic way.
Enable effective fast-tracking and the provision of ‘minor adaptations without delay’
Articulate clearly how to access professional advice and make best use of staff expertise in complex situations
26 Changes can be made now to improve performance even within this existing complexity. A good example of this are the systemic changes made to deliver a more focussed person centred and cost effective service in Bristol City Council (Mackintosh 2012). Many of these proposals are being implemented by many Welsh local authorities.
26.1 Develop proportionate responses including fast track and direct access for simple adaptations. These should be removed from the DFG system which should only be used for works over £5,000 as recommended by both Jones (2005) and Mackintosh (2012).
26.2 Occupational therapists working in housing and social services are highly expert in assessing for and designing effective adaptations to meet complex need. Using that expertise can reduce costly mistakes and increase effective solutions.
26.3 Implement ‘Minor Adaptations without Delay’ (COT 2006) even more widely around Wales. This offers a practical guide to help provide straightforward adaptations without the need for an occupational therapy assessment.
26.4 Enable people to access assessment and advice even if they then wish to self fund the provision.
26.5 Redesign services to improve integration within agency departments
26.6 Learn the lessons from the local authorities who have employed specialist occupational therapists in housing departments
26.7 Improve the collaboration and partnership working across housing health and social care.
26.8 Some RSLs pass maintenance, warranty and replacement costs on to the tenant following the adaptation. This means that tenants may refuse an adaptation because they can’t afford the increased rent or they may be faced with an unexpected cost at the end of the process. The Minister’s review of adaptations offers an opportunity to develop some regulation or guidance about what is charged to tenants in these situations.
26.9 Using progress chasers or support workers to help people navigate the complex system can be very effective in order to keep the process active.
26.10 Accurately examine the whole adaptation journey as part of a holistic service for citizens to identify where delays or bottlenecks occur. It is important to consider impact on the whole journey before investing extra resource or making changes which simply move a problem to another part of the process.
27 Conclusion
The College of Occupational Therapists recommends that a thorough review is undertaken into the whole range of adaptation grants and funding processes with a view to establishing a more modern, cost effective and efficient, age and tenure blind system which puts the person at the centre. Sufficient resource, such as occupational therapy establishment to meet demand is vital. Adaptations must be viewed as a response to an assessed need rather than focussing on the DFG alone as a service.
28 References
Care and Repair Cymru, College of Occupational Therapists, Age Cymru, Older People’s Commissioner (2010) Adaptations: the Key to Independent Living. (http://www.careandrepair.org.uk/housing-adaptations-information/ accessed 23.1.13)
College of Occupational Therapists, (2006) Minor Adaptations without Delay. London
COT (http://www.cot.co.uk/publication/books-z-listing/minor-adaptations-without-delay accessed 23.1.13)
Jones C, (2005) Review of Housing Adaptations Including Disabled Facilities Grants – Wales. Cardiff, Welsh Government
Mackintosh S, (2012) From Housing Adaptations to Accessible Homes: putting people at the heart of redesigning the adaptation service in Bristol. Housing Learning and Improvement Network Case Study 62.
(http://www.housinglin.org.uk/_library/Resources/Housing/Practice_examples/Housing_LIN_case_studies/HLIN_CaseStudy_62_Adaptations.pdf accessed 23.1.13)
Welsh Government (2011) Meeting the Housing Challenge: building a consensus for action. Cardiff Welsh Government
Welsh Government (2012) A White Paper for better lives and communities. Cardiff Welsh Government
Welsh Therapies Advisory Committee (2012) Occupational Therapy progress report in respect of the development of integrated services. (http://wales.gov.uk/topics/health/ocmo/committees/therapies/reports/6260875/?lang=en accessed 23.1.13)