CELG(4) HA 24
Communities, Equality and Local Government Committee
Inquiry into Home Adaptations
Response from : Older People’s Commissioner
30th January 2013
Re: Inquiry into Home Adaptations
Dear Ann,
Thank you for the opportunity to submit evidence to the Committee’s Inquiry into Home Adaptations. I very much welcome the Committee’s decision to revisit its 2009 report into this issue in order to scrutinize the progress that is being made in a service area that is of significant interest and relevance to older people.
Older people consistently tell me how it important it is to them to maintain their independence and to be able to stay living within their own homes as long as they wish. Home adaptations provide essential support in helping achieve this outcome for many older people in Wales and can make a major contribution to their wellbeing, helping them experience a life that has value, meaning and purpose.
Home adaptations therefore have the potential to be a very high impact but low cost service area. They play a crucial role in the early intervention and preventative agenda and as such, can deliver major cost savings across other health and social care budgets.
My evidence to the inquiry (attached) outlines in detail my concerns at the significant variations in delivery times that currently exist for adaptations services, in particular Disabled Facilities Grants, across Wales. Despite successive reviews, reports and good practice guidance, public services are still not getting it right for many older people in Wales and there is much that still needs to be done to ensure that all older people have access to that little bit of help on a timely basis. I have also set out what I, as Commissioner, am doing support and encourage ongoing improvement in this area over the next twelve months.
I have outlined my views in respect of the urgent need to move towards a more simplified system of adaptations in Wales which is centred on the needs of the individual. I very much welcomed the Commitment to a whole-scale review of adaptations which was presented in the recent Housing White Paper and I have written to the Housing Minister Huw Lewis asking him to expedite this review as a matter of urgency. Within this, there is a pressing need to move towards fairer and simplified funding arrangements for adaptations, and a system which monitors the impact of home adaptations on wider wellbeing outcomes for older people.
I look forward to expanding on these points
when I give verbal evidence to the Committee in February.
I hope that we can work
together to ensure that older people live in their own homes for as
long as possible and receive assistance in a timely manner, because
this is fundamental to their continued independence and
wellbeing.
Yours sincerely
Older People’s Commissioner for Wales
Communities, Equality and Local Government Committee:
Inquiry into Home Adaptations
January 2013
1 Why there are still significant variations in the time it takes to deliver aids and adaptations funded by Disabled Facilities Grants across Wales
1.1 As the Older People’s Commissioner, I am deeply concerned and have spoken very publicly at the significant variations in delivery times that currently exist for Disabled Facilities Grants across Wales. The majority of people who benefit from DFG-funded adaptations are older people[1] who need this assistance so they can return to their home from hospital, stay within their own home, maintain their safety and independence, and exercise choice in the way they live their lives. Yet, older people across Wales are facing unacceptable waiting times for sometimes very basic adaptations and significant variations may exist because of the different ways that different LAs in Wales deliver their DFG and adaptation services.
1.2 The most recent Local Government Data Unit Local Government Report revealed that local authorities took an average of 326 days to deliver a Disabled Facilities Grant and seven local authorities in Wales recorded average waiting times exceeding the 12 month statutory timescale. One local authority had an average delivery time in excess of 600 days.
1.3 Whilst I acknowledge that these figures represent a marked overall improvement over recent years, with delivery times having reduced substantially since 2005 when DFGs were taking 544 days on average, the fact remains that some older people are being denied the help they need on a timely basis. This situation is, in my view, wholly unacceptable.
1.4 In September 2012 I wrote to Local Authorities[2] in Wales outlining my deep concern that some older people are waiting too long for an adaptation that would make a significant difference to their quality of life, and which in some instances is essential to keeping them safe and in their own homes. I asked those local authorities who are not currently complying with the statutory timescales to provide me with information on how they were planning to improve delivery times in their area. I also wrote to local authorities who are performing well and asked them to share with me examples of good practice and innovation so I could pass this on to poorer performing organisations.
1.5 The responses that I received to this correspondence suggested that supporting older people to remain safe and independent in their own home is an issue which local authorities do take seriously. There was overwhelming consensus around a commitment to make improvements in the way that DFGs are delivered across Wales, and this was supported by many examples of creativity and good practice.
1.6 However, whilst there is positive work being undertaken by many local authorities in Wales, I am very concerned that for some people, long waiting times, ineffective processes and under-resourcing of aids and adaptations mean that we are letting down older people at a point in their lives when are particularly vulnerable and in need of low level but timely support. Evidence that the Commission has received directly from older people has revealed that during this time of waiting, some are forced to move to residential care before the help they need is provided.
1.7 I am aware that there are current discussions about the need to balance speed of delivery of adaptations with meeting needs of and choices of the customer and the quality of outcome for the individual. I would support the need for a service that is person centred and focused on the needs and preferences of the individual receiving that service, but I do not see this as a barrier to delivering adaptations on timely basis. Whilst I accept that there are often good reasons why individual cases can take longer to complete, for example when an applicant’s circumstances change, or when they have to go into hospital, and that these can skew average figures somewhat, I am not convinced that these cases can be used to justify average waiting times that exceed 365 days.
1.8 As Commissioner, I will be taking an on-going interest in the performance of all local authorities in relation to this service area and will be looking for evidence of sustained improvement over the next 12 months. I have informed local authorities[3] that I will be writing to them in September 2013 seeking assurance of improvement in the following areas:
· That progress has been made in reducing end to end waiting times for DFGs, without the use of ‘front-end’ waiting lists. I have suggested that a 20% annual reduction in waiting times is a reasonable target.
· That there is a fast and effective route for the completion of minor adaptations, particularly those linked to hospital discharge, so that no older person is left waiting for the little bit of help they need on a timely basis.
· As part of the performance management of aids and adaptations, that local authorities are monitoring and reporting evidence of the customer experience of the service, and the overall outcomes for the wellbeing of individual older people.
1.9 I believe that these revised expectations are appropriate and deliverable in the current environment and I will be undertaking further scrutiny in 2013 to ensure that a focus remains on a service area which is so important in allowing older people to stay within their own home, maintain their safety and independence, and exercise choice in the way they live their lives.
1.10 I am keen to work with closely with the Committee to support your own scrutiny of performance in relation to home adaptations and to continue push for on-going and sustained improvements in provision of these services across Wales.
2. Whether sufficient progress has been made on implementing recommendations from the Equality of Opportunity Committee’s 2009 report on home adaptations
2.1 The inquiry by the Committee in 2009 found that older people were waiting unacceptably long times for adaptations, that these waiting times could be longer for people living in different parts of Wales and in different types of housing, and that there had been little progress for improving the situation for older people in Wales since the Welsh Government’s extensive review of DFG’s in 2005.
2.2 Despite the fact that waiting times for DFGs have improved significantly since 2005, as I have outlined above there remain some significant challenges to the effectiveness and timeliness of services provided by some local authorities in Wales and there are unacceptable variations in quality of services that have still not been addressed.
2.3 In relation to progress made on some of the specific recommendations of the 2009 report, a number of recommendations have not yet been implemented. For example, Recommendation 3 called for evaluation and research to inform revised guidance to local authorities. I am not aware of any specific guidance that was produced following the Committee’s report. Furthermore, from the work that I have undertaken in this area over recent months it is clear that good practice is still not standard practice and there remains substantial scope for improvement in the way that knowledge and learning is shared effectively between organisations.
2.4 Recommendations 5 and 6 relate to the performance monitoring of adaptations services and this is another area where little progress has been made. More detailed comments on the impact of the current lack of strategic approach to performance monitoring are included below.
3. What impact reduced resources for housing are likely to have on the provision of home adaptations?
3.1 The significant financial challenges faced by public services at present mean that the operating environment is uncertain, difficult and rapidly changing. Older people are already directly feeling the impact of the current economic climate and the impact of financial constraints upon social and community support and amenities.
3.2 Aids and adaptations are an excellent example of a low cost, high impact service area that play a crucial role in the early intervention and preventative agenda. There is much evidence to show that timely adaptations can deliver major cost savings across other health and social care budgets. Care & Repair Cymru for example, have estimated from information gathered over the last 10 years that each pound spent on Rapid Response Adaptations saves Health/Social Services around £7.50.
3.3 The following table, taken from Welsh Government’s own research provides further evidence of the cost savings that can be derived from affective home adaptations.
|
|
Cost of DFG £ |
Cost / saving to other service £ |
Comment |
|
Hip fracture |
300-1,000 |
30,000 |
DFG cost form basic stair lift to Estimated cost to NHS (Parrott, 200, adjusted to 2009 costs) |
|
Delayed transfer to residential or nursing care |
18,000 |
108,000 |
DFG costs to cover installation of level-access shower and extension to bedroom to accommodate. Saving based on delaying transfer to residential or nursing care by 4 years |
|
Discharge into independent living from residential care |
6,500 |
270,000 |
DFG cost based on finding appropriate level access property and further adaptations. Saving based on 10 years not needing residential care |
|
Discharge seriously disabled child from hospital to home care |
36,000 |
251,850 |
Maximum DFG/ Saving based on cost of hospital care for a seriously disabled child, ODPM figures 2005, adjusted to 2009 costs |
|
Reduced need for social care |
10,000 |
20,000 |
DFG cost based on installation of ground floor bathroom. Saving to care budget as only needs 1 person to attend daily, based on 5 years |
Source: CEL Transform (2010) Reviewof progress in inmplementing recommendations on the provision of Adaptations Services in Wales: Report for Welsh Assembly Government
3.4 This is a period of opportunity, to be smarter in the design and delivery of public services, to work with the energy and creativity of older people to meet their own challenges and to shift patterns of service so that they prevent dependency far more effectively.
4. Is the Welsh Government effectively monitoring the provision of adaptation services?
4.1 At present, the DFG is the only type of adaptation process for which there is a performance indicator; there is no common approach to monitoring the quality or impact of other adaptation grant routes. The need for a more strategic approach to monitoring housing adaptations was a key recommendation of the 2009 Committee Inquiry that is yet to be progressed.
4.2 In relation to the current framework for monitoring DFGs, successive reports have raised issues aboutappropriateness of the current performance indicator. In particular, these relate to:
· Consistency of interpretation of the current indicator by local authorities
· The extent to which this indicator is currently measuring ‘like for like’ across different local authority areas
· The potential for particularly complex applications to skew overall average delivery times
· The extent to which local authorities are reporting on stages of the process that they feel they do not have responsibility for, e.g. contractor delivery times.
· The effectiveness of the current monitoring framework in capturing the customer experience and the outcomes and impact of the adaptations service.
4.3 Whilst I acknowledge that the current performance indicator does not currently paint a full picture in respect of adaptations services in Wales, it does provide a small but important part of that picture, focusing on the statutory duties of local authorities. I have already set out my position that concerns with the quality of the PI should not be used to justify unacceptably long delivery times. I do however, agree with the concerns relating to the customer experience and that is why I have asked local authorities to work towards capturing this information in future. A number of local authorities are already doing this effectively and there is an opportunity to learn from this good practice.
4.4 Overall, as Commissioner I see a strong need for consistent, accurate and comparable data on performance in relation to the provision of adaptations across Wales, regardless of the particular funding route. A DFG is only one of several means to achieve an outcome: it is not an outcome in itself. Any useful monitoring needs to be in relation to the outcome and impact for the individual. There is potential for some strong alignment to the new National Outcomes Framework and I would recommend that Welsh Government gives further consideration to the links that can be made with this programme of work in order to ensure that effective person focussed outcome measurement is used to monitor the impact and outcome for all service users.
5. What more needs to be done to improve home adaptation services in Wales?
5.1 The overall context within which aids and adaptations services are funded and delivered is complex. Adaptation services have developed from a range of different pieces of legislation, supplementary orders and guidance and new policies which have been introduced to improve parts of the system over time. This has created a disjointed and complex system which needs fundamental review and reform to meet modern needs. Local authorities in Wales are subject to statutory duties to provide effective Disabled Facilities Grants and also have discretionary powers to deliver a wide range of adaptations services as they see appropriate. Public, private and voluntary agencies fulfil different, sometimes overlapping roles. These multiple routes can create unnecessary complexity and unfairness, and create bureaucratic processes which often inhibit a common sense response to a problem.
5.2 There are also inconsistencies and inequalities in the current funding arrangements, with access to resources dictated by housing tenure, age, and complexity of the adaptation. There are at least six different funding streams including:
· Disabled Facilities Grants (DFG)
· Physical Adaptations Grants (PAG) delivered by housing associations (excluding LSVTs)
· Individual solutions developed by LSVT’s
· Minor Adaptations directly funded by local authorities or housing associations
· Fast Track Adaptations
· Independent Living Grants (ILG)
5.3 Differences in the way that these funding streams are administered and implemented, depending on local policies and decisions, create a serious risk that people with complex needs will fall through one of these funding gaps. For the older person trying to access the help they need, navigating this complex web of eligibility criteria can act as a significant barrier. I am concerned that current funding arrangements are not conducive to developing a common sense solution to the needs of an individual but instead are directed by the accessibility of the strands above.
5.4 There is consequently much to do to improve the wider framework and funding arrangements within which aids and adaptations are delivered in Wales. Home adaptations should be delivered as part of an integrated prevention service, with all sections working to enable people to live independently irrespective of tenure, age, or ability. A modern adaptation service needs to put the individual at the centre and create an experience which delivers outcomes centred around the wellbeing of that individual.
5.5 In light of this, I strongly have welcomed the commitment to the whole-scale review of the current framework for aids and adaptations in Wales that was set out in Homes for Wales, the Housing White Paper and I have written to the Housing Minister Huw Lewis asking him to expedite this review as a matter of urgency. I would recommend that this review needs to consider how we might move towards:
· A simplified system focused on meeting the needs of the individual on a timely basis
· Fairer and simplified funding arrangements
· A monitoring framework for adaptations, centred around the outcomes for an individual’s wellbeing, and which takes account of the customer experience
5.6 I look forward to contributing to the Welsh Government’s review in due course. I also committed to working with the Committee to support your continued work relation to Home Adaptations and to play my own part in pushing for on-going and sustained improvements in provision of these services across Wales. There is a need to eliminate unacceptable variations in the delivery of what should be a simple, low cost service and to prevent the risk that older people lose their independence unnecessarily. This would be a failure in public service and should not be tolerated. I am confident that we can work together to ensure that older people live in their own homes for as long as possible and receive assistance in a timely manner, because this is so fundamental to their continued independence and wellbeing.
Appendix 1
24 September 2012
Dear
Following the publication of the Local Government Data Unit’s most recent Local Government Report, I am writing to you in relation to Disabled Facilities Grants (DFGs). The majority of people who benefit from DFG-funded adaptations are older people who need this assistance so they can return to their home from hospital, stay within their own home, maintain their safety and independence, and exercise choice in the way they live their lives.
I am disappointed to learn that your local authority was not successful in meeting its statutory duty to deliver DFGs within 12 months from the date of application (where the application is approved). It is not acceptable that some older people in your area are waiting too long for an adaptation that would make a significant difference to their quality of life, and is in some instances essential to keeping them safe and in their own homes. During this time of waiting, some are forced to move to residential care and, sadly, some may even die before the help they need is provided.
As Commissioner, it is my expectation that your local authority will, as a minimum, be compliant with the statutory requirement for delivering DFGs by this time next year. In light of this, I invite you to write to me providing me with an action plan that sets out how you plan to achieve this.
I would be grateful if you would provide me with this information no later than Monday 5 November 2012.
The variance in timescales for delivering DFGs is a clear example of the postcode lottery that many older people experience. I am also writing to all local authorities that meet the statutory requirement asking them to share with me good practice, which I am happy to forward to the WLGA so it can be shared with you.
There is a wider issue regarding the way in which basic aids and adaptations are provided to older people in Wales. Failure to provide aids and adaptations to older people on a timely basis not only undermines their safety and independence, it also places an additional burden upon local authorities. There are a number of strong reasons for requiring that this issue is a priority across Wales, hence my writing to you as the Commissioner for Older People.
I look forward to receiving your response.
Yours sincerely,
Sarah Rochira
Older People’s Commissioner for Wales
Appendix 2
19th November 2012
Dear
Re: Disabled Facilities Grants
I recently wrote to you regarding aids and adaptations,
specifically the delivery of Disabled Facilities Grants. As a Local
Authority that is not currently complying with the statutory
timescales for delivering this service, I set out my expectation
that your local authority will, as a minimum, be compliant with the
statutory requirement for delivering DFGs in a years time and
invited you to provide me with an action plan setting out how you
plan to achieve this.
Thank you for your response to this letter which made it clear that, supporting older people to remain safe and independent in their own home is an issue which you take seriously and which reassured me that you are committed to making improvements in the way that DFGs are delivered in your locality.
Despite some of the positive work being undertaken by many local authorities in Wales, I am very concerned at that long waiting times, ineffective processes and under-resourcing of aids and adaptations are resulting in some older people aren’t getting the help they need, when they need it.
As Commissioner, I will therefore be taking a on-going interest in the performance of all local authorities in relation to this service area and, as I suggested in my previous letter, will be looking for evidence of sustained improvement over the next 12 months. I will be writing to all local authorities in September 2013 seeking assurance of improvement in the following areas:
· That progress has been made in reducing your end to end waiting times for DFGs, without the use of ‘front-end’ waiting lists. I suggest that a 20% annual reduction in waiting times is a reasonable target.
· That there is a fast and effective route for the completion of minor adaptations, particularly those linked to hospital discharge, so that no older person is left waiting for the little bit of help they need on a timely basis.
· As part of your performance management of aids and adaptations, you are monitoring and reporting evidence of the customer experience of the service, and its overall impact on older people.
I believe that these revised expectations are appropriate and deliverable in the current environment and I hope this will provide the necessary independent scrutiny and focus on a service area which is so important in allowing older people to stay within their own home, maintain their safety and independence, and exercise choice in the way they live their lives.
As Commissioner, part of my role is to ensure that good practice becomes standard practice and to support improvement through sharing knowledge and learning. I recently wrote to those local authorities who are currently performing well in their delivery of DFGs and asked them to provide examples of good practice so that these could be shared with other organisations to support them in improving their performance in this area.
I am currently compiling those examples of good
practice and innovation that were provided to me by all the
organisations who responded to me in a separate briefing which I
intend to share with you shortly. I hope you find that you can make
use of this information in your efforts to continually improve the
service you offer to older people in your local area.
As well as examples of good practice there were a number of other common issues that were raised by local authorities in their responses to me. These included:
· The legislative framework relating to DFGs
· The effectiveness of the current performance indicator
I have therefore taken the opportunity to set out my views and expectations in respect of these issues in the attached appendix, which I hope provides the necessary clarification.
I am also aware that there is much to do to improve the wider framework and funding arrangements within which aids and adaptations are delivered in Wales. In light of this, I have already written to the Housing Minister Huw Lewis asking him to expedite the review of aids and adaptations that he committed to in this year’s housing White Paper. I have also welcomed the announcement of a follow-up inquiry into aids and adaptations by the Assembly’s Communities, Equality and Local Government Committee and look forward to sharing my views with that Committee as part of their evidence gathering.
Getting aids and adaptations into the homes of older people on a timely basis is fundamental to their safety and independence I look forward to working with you and other partners to further improve the way we deliver aids and adaptations services across Wales.
Yours sincerely
Older People’s Commissioner for Wales