|Author(s):||Michela Tinellia; Phillip Whitehead;|
|Institution(s):||a CPEC, London School of Economics and Political Science;|
|Production date:||February 2023|
|Acknowledgements:||We are grateful to the ESSENCE project advisory group for their helpful comments on earlier versions of this case summary and Mike Horn for support in formatting, editing and proofreading the final document.|
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Adaptations to make homes more accessible are becoming increasingly important as the population ages. The majority of the mainstream housing stock in England often has small room sizes, steep internal stairs, baths rather than showers and steps outside. These might become difficult to manage as people lose mobility with age or have to deal with sight loss or other conditions. To remain independent at home, some older people, their families and carers need effective ways to adapt and modify their homes. This could potentially reduce the risk of falls and other accidents in the home, relieve pressure on accident and emergency services, speed up hospital discharge and reduce the need for residential care.
The majority of older people (over 90%)1 in England live in older housing stock, that often has small room sizes, steep internal stairs, baths rather than showers and steps outside. As people get older these might become increasingly difficult to manage, with increasing long-term conditions and disabilities impacting on day-to-day activities within the home. Very little attractive, affordable housing has been built in locations which enable people to move to properties that are more accessible. Moreover, most older people prefer and choose to remain living in their current home. The EHS Home adaptations report2 reveals that of the 1.9 million households in England which included one or more people with a health condition/disability that required adaptations to their home, 1 million (53%) did not have all the adaptations that they needed [up from 45%/ 864,000 in 2014-15].
Adapting the home can increase the usability of the home environment and support people to remain at home and maintain their independence for as long as possible. This could potentially reduce the risk of falls and other accidents, relieve pressure on accident and emergency services, speed up hospital discharge and reduce the need for residential care. The cost benefit to the NHS arising from preventative housing interventions3 identified the need for preventative building work in around 3 million households which include occupants with a long-term sickness and disability. Such remedial work would reduce the likelihood of NHS treatment and the need for more costly interventions.
Home adaptations are permanent alterations which aim to make buildings more suitable for older people and have been identified as one of the 10 most promising prevention interventions for older adults.4 There are many adaptations that can help make different parts of the home safer or more accessible. A survey of local authorities and home improvement agencies identified that the most requested major adaptations (costing more than £1,000) were stairlifts and level access shower installations as well as more costly home conversions.5 Fitted handrails were the most frequently requested minor adaptations (costing less than £1,000), but other adaptations included widening doorways and installing lighting to outside steps. Adaptations to bathing facilities, usually involving the removal of a bath and replacement with an accessible shower, are the most commonly requested.6
The primary purpose of home adaptations is to reduce the barriers within the physical environment of the home or immediate vicinity in order to maximise the person’s ability to function with increased independence and/or safety.7
In England, housing adaptations are funded in a variety of ways. People living in a privately owned property might pay for the adaptation themselves or apply for a means tested grant called the Disabled Facilities Grant8 which is administered through the local authority council. Social housing tenants might have the adaptations arranged through the local authority council or through their social landlord. For all tenure types, an application to the council may involve an assessment from a social care occupational therapist or trained assessor.
Research into the effects of home adaptations has largely focussed on ‘minor’ adaptations (costing less than £1000)9 such as grab rails, steps or threshold alterations, and most studies have included a myriad of adaptations. A large RCT focusing on minor adaptations conducted in New Zealand reported a 26% reduction in the rate of injuries caused by falls in the intervention group.10
Empirical reviews have found a moderate amount of evidence that interventions within the home environment have an effect on the disabling process and/or functional outcomes for older adults.9,11-13 Primary outcomes in studies are divided among usability, functional ability, and safety/falls. For example, a before and after study involving 131 participants in Sweden with a median age of 75 years, found that accessibility and usability improved significantly after home adaptations were completed, particularly in relation to bathing.7
In a further longitudinal study in Sweden involving 103 adults with an average age of 75 years, participants reported experiencing less difficulty in everyday life and increased feelings of safety after home modifications at 2 months14 and 6 months.15 A systematic review also found that environmental assessment is effective at reducing falls16; subsequent analysis indicates that this may only be for high-risk participants.17 Adaptations to bathing facilities, may have a strong preventative effect, delay functional decline and bring an improved sense of physical functioning which gave a sense of ‘freedom’.18
The Centre for Ageing Better9 reviewed international academic evidence about the impacts of home adaptations carried out for older people. They concluded that speedy provision of home adaptations and meeting the priorities of the individual were critical success factors.
Evidence from a national home adaptation service, Care&Repair Cymru (C&RC), identified individuals at risk of falls occurring at home and reduced the likelihood of falls. C&RC also identified people who were more likely to have an emergency fall admission occurring at home. The service reduced the odds of falling post intervention.19
A feasibility Randomised Controlled Trial (RCT) – the BATH-OUT study – randomised 60 older adults to an expedited bathing adaptations process, compared to an approximate 4‐month routine waiting list control.20 The results showed indicative improvements in both groups following the adaptations, with outcomes including increases in perceived physical and mental health status, quality of life and decreases in fear of falling.
Home adaptations are widely appreciated by those who receive them and their carers, and they believe that they lead to improvements in their health and well‐being. For example, semi‐structured interviews were completed with 104 recipients of major adaptations drawn from seven areas in England and Wales. The findings showed that participants believed the adaptations led to improvements in their physical and mental health and that of their family members.6 Furthermore, findings from postal surveys revealed extremely high levels of satisfaction with home adaptations and self‐reports that the adaptations led to improvements in their quality of life.6
The BATH‐OUT study20 focused specifically on bathing adaptations for older adults aged 65 and over. Qualitative interviews with 21 older adults and five of their carer who received bath adaptations showed that the removal of the physical barriers causing the bathing difficulties led to increased ease of use and feelings of independence and restored the ability to function within the bathroom. The main positive impacts reported by older adults and their carers were: (a) feeling safe, (b) feeling clean and (c) managing independently (choice and control).21
Overall, such improvements led to people generally ‘feeling better’, with increased confidence and improvements in their quality of life. The positive lived experiences reported immediately after the installation of the accessible shower were still evident up to 28 months later in this cohort of older adults.22
Findings from Powell et al.9 confirmed that mitigating worse than average hazards associated with falls on stairs has the best return on investment (ROI). Preventive work to mitigate worse than average hazards associated with falls on stairs among households with an adult aged 65 or over would coast around £290 million and confer a benefit to society of around £470 million, which corresponds to a positive ROI of 62p for every £1 and a payback period of less than eight months. They also found that minor housing adaptations were cost effective for preventing falls and injuries, but most of the evidence comes from outside the UK.
Powell, et al.9 concluded that there was insufficient evidence to quantify the overall return on investment of housing adaptations and further research was needed, particularly using randomised or experimental designs. A further systematic review of bathing interventions for older adults (not limited to adaptations) Golding-Day et al.18 identified only one study.23 Although the findings were promising, particularly in relation to reduced need for assistance from carers, the sample was small and the study was not randomised.
There is a growing body of evidence that home adaptations can transform the lives of older and disabled people by extending safe, independent living at home, while reducing health and care costs.24 For example, Public Health England published a report in 201825 on falls prevention which found that home adaptations resulted in a yearly 23% reduction in hospital admissions and a financial return of investment of £3.17 for every pound spent. They estimated a social return on investment – which includes the impact of the adaptation on wellbeing – of £7.23 for every £1 spent. The Wales Rapid Response Adaptations programme estimates that £7.50 of health and care costs are saved for every £1 spent on adaptation.26
West of England Care and Repair delivers minor repairs and adaptations for people returning from hospital and an independent review estimated that £13,500 in hospital bed days were saved for a spend of £1,000.27 A review of evidence for the Department of Work and Pension found that home adaptations improved quality of life for 90% of recipients as well as resulting in reduced costs to health and care.28
Falls are the most common cause of injury related to deaths in people over the age of 75 in the UK, with up to 35% of people aged 65 and over falling one or more times every year.29 The estimated annual cost of falls to the NHS is over £2 billion.30 A significant protective factor for falls in older adults is environmental modification and delays in the provision of home adaptations may increase the risk of hospitalisation and associated costs.28 More research is underway to measure the effectiveness and cost-effectiveness of bathing adaptations.31
The Centre for Ageing Better and Care and Repair England report32 demonstrated that in many areas councils have been able to take advantage of the opportunities opened up by the Better Care Fund to provide high quality, cost effective and streamlined adaptation services. This helps raise awareness of what is possible, helps older people navigate the system, and delivers home adaptations quickly. A range of local innovations and good practice examples about helping older people with home adaptations were identified and the report describes 24 local exemplars and provides links to councils’ housing assistance policies (where available).
The NHS Quick Guide to Housing and Health33 provides practical resources and information about how housing and health can work together to prevent and reduce hospital admissions, length of stay, delayed discharge, readmission rates and ultimately improve outcomes. The Centre of Ageing Better and Care and Repair England31 have produced a collection of publications since 2017 on the importance of home adaptations, including links to existing good practice.
The Royal College of Occupational Therapists34 explored the circumstances when Trusted Assessors are able to advise on and manage adaptations, and the circumstances when the specialist skills of occupational therapists are required. This report outlines a framework which aims to make implementation more effective by considering the complexity of the situation rather than by cost and type of adaptation.
The LGA / ADASS High Impact Change Model35 for the Better Care Fund has been refreshed to include a section on housing which highlights the important role of home adaptations.
Meeting the Home Adaptation Needs of Older People LGA & ADASS Guidance23 highlights important aspects of home adaptations and provides links to examples of local innovation and good practice. Alternatively, the Royal College of Occupational Therapists34 Guide to planning and delivering home adaptations demonstrates how home adaptations can be delivered in all four UK nations, with the individual at the centre of the process.
With their recent work, the Foundations36 provides councils with a deeper dive into the workings of adaptations for social housing tenants. This new guidance examines the current situation and makes key recommendations for improving delivery.
The Home Adaptations Consortium provides a forum to share and promote good policy and practice. This includes a detailed ‘Home Adaptations Challenge checklist’37 of questions and indicative responses for anyone who would like to improve local services.
Further research funded by NIHR SSCR, led by Whitehead,31 is underway to explore whether having a walk-in shower improves or maintains older people’s health, safety, quality of life, and ability to manage their personal care. It will also explore whether delayed installation has a negative effect on older people’s physical and mental health and independence, and also leads to more costs.
Dr Philip Whitehead (email@example.com) is the researcher who led the BATH-OUT feasibility trial20 and qualitative work,21 and is currently leading new work (BATH-OUT-2 trial).31
NIHR School for
Social Care Research