Indicative budget 2015/16- Written evidence for Finance Committee
1. Introduction
1.1 This is the response from Care & Repair Cymru to the call for information on Welsh Government indicative budget proposals for 2015/16, issued in July 2014. It is provided from the specific perspective of the work of Care & Repair in Wales-services for older people to help keep them independent, safe and warm in their own homes, consequently reducing demand in the NHS through reduced A&E admissions, speeding up safe transfers of care, and reducing the need for expensive residential care by helping older people live independently in their own homes in safety and warmth (where most older people tell us they want to be)
1.2 Care & Repair in Wales- who we are and what we do: Care & Repair Cymru (CRC) is the national body for Care & Repair in Wales, and the “Older People’s Housing Champion”. We are a third sector, charitable organisation and actively work to ensure that all older people have homes that are safe, warm and appropriate to their needs. There are 22 Care & Repair Agencies covering the whole of Wales. Each agency provides a wide range of services and support for older and vulnerable people, helping them to remain living independently in their own homes and communities. Care & Repair Cymru is committed to improving the health & wellbeing of older people by providing advice and assistance with home improvements, adaptations and general repairs. We work in partnership with a number of organisations including the Welsh Government, Local Government Housing and Social Care Teams, NHS, Occupational Therapists, other third sector organisations, the Older People’s Commissioner, and Housing Associations to ensure that older people have access to a range of housing and social solutions that enable them to live in housing that meets their individual needs.
1.3 The 22 Care & Repair Agencies in Wales provide housing services to some 40,000
older people every year. Agencies are part funded by the Welsh Government and attract funding from local government, local health boards, housing associations and other sources. The types and scale of services provided annually are:
Core Care & Repair service:
· Approximately 30,000 older people helped every year with core casework service, and tailored solutions to their housing problems.
· Average client age 75 years of age
· 60% self referrals- i.e not currently clients of any of the statutory services
· £2.5 million increased household income and benefits
· £500,000 raised on behalf of 475 clients from charitable funds to pay for repairs or adaptations
· £11million repairs and adaptations facilitated
· 2500 older people helped make their home more affordable to heat
· £1.8m privately funded work ( counters fear of/ use of cowboy builders and substandard work)
· 1800 helped with improvements to home energy efficiency
Rapid Response Adaptations Programme
Care & Repair operates the Rapid Response Adaptations Programme (RRAP) on behalf of the Welsh Government. RRAP was introduced by the Welsh Government in 2002. The scheme, invented in Wales has since been replicated in England. The programme facilitates an immediate response to specific needs by providing minor adaptations such as ramps and handrails, to enable people to return safely from hospital to their own homes, or to prevent the need for admission to hospital or residential long term care. The programme is a fast response initiative and requires jobs to be completed within a maximum of 15 working days. It is widely regarded as best practice in delivering small adaptations, and provides direct benefits to Health in terms of prevention (reducing demand) and Delayed Transfer of Care (helping speed up safe discharges). Annually, the Rapid Response programme achieves:
· Average time enquiry to completion 8 days, average cost £118
· 13,000 older people helped….
· 4200 of whom helped return home from hospital
· 8800 of whom had works that helped prevent hospital admission
For every £1 spent on RRAP, we have estimated reduced demand and savings of £7.50 for Health and Social care.
2. What, in your opinion, has been the impact of the Welsh Government’s
2014/15 budget?
Looking at the indicative budget allocations for 2015-16, do you have
any concerns from a strategic, overarching perspective, or about any specific areas?
What expectations do you have of the 2015-16 draft budget proposals? How financially prepared is your organisation for the 2015-16 financial year, and how robust is your ability to plan for future years?
2.1 The above 3 questions are addressed in the following comments:
2.2 The indicative budget for 2015/16 under the Housing and Regeneration MEG, gives a standstill figure for Care & Repair revenue and capital. Following the 10% budget cut to Care & Repair this financial year (2014/15), we have embarked on a rigorous and proactive journey of change, specifically reconfiguration of Care & Repair through series of mergers which will reduce the number of Agencies from 22 down to 12 or 13, (broadly in line with the Williams recommendations for local government in Wales). The aim of our mergers is to reduce management and overhead costs so that the impact of this year’s 10% cut is minimized to front line services we provide for older people. Our “Framework for Change” also includes wider reform which seeks to improve governance and promote innovation and more diverse income streams for Care & Repair services.
2.3 The process of mergers and organizational change we have embarked upon is extremely time consuming and resource intensive. The challenge over the past 9 months has been difficult, and the major process of change will continue for the next 12 months or more, due to the complexities of changing legal and governance structures, financial due diligence, TUPE and other issues, including physical relocation of some organisations, and cultural change of 2 different staff groups joining together.
2.4 Having engaged positively in the merger agenda, the big concern for the 2015/16 budget is that further budget cuts before change within Care & Repair has been finalised, and before the new organisations have bedded in, will hamper the change process and ultimately reduce front line service delivery. Consequently, while we would ideally like to see increased investment in Care & Repair’s core budget (not least as this would save money in other budgets as outlined in detail below), we believe that we need at least a flat-line budget in 2015/16 to enable us to effectively deliver the mergers and change we have embarked on.
2.5 Our other major concern, for which written and verbal evidence was provided to Finance Committee last year, is that the cuts already seen in Care & Repair’s budget in reality mean cuts in preventative serves for older people that increases demand for highly pressurised NHS and Social Care services (and ultimately costs more to the public purse). This is discussed in detail in 3. below.
2.6 The Intermediate Care Fund £50m in the 2014/15 budget, is an excellent approach to creating greater integration of services for older people and achieving greater preventative spend in the budget. The ICF clear intention to create a more joined up approach between Housing, Health and Social Care, and statutory and third sectors is welcomed. We believe it will be successful in helping individuals live independently, and relieving pressures across public services, (e.g. preventing admissions to A&E), and helping speed up safe transfers of care).
4.5 In terms of actual service delivery and outcomes, it is too early to comment on the impact of ICF to older people. However, from Care & Repair’s perspective, overall the process of being engaged and involved in developing ICF proposals has so far been positive on the whole, and we would welcome its continuation as a cohesive long term approach to prevention, and integration of work across public and third sector services.
3. The Committee are would like to focus on a number of specific areas in the scrutiny of the budget, do you have any specific comments on the areas identified below?
Approach to preventative spending and how is this represented in
resource allocation (Preventative spending = spending which focuses on
preventing problems and eases future demand on services by
intervening early)
3.1 Care & Repair services have a huge preventative impact helping older people
retain their independence at home. It is important to distinguish the ‘type’ of prevention we provide with prevention such as healthy eating campaigns. Our view is that making an older person’s home accessible, safe, and warm produces an instant effect rather than cost saving years down the line. For example, a timely housing adaptation can have the immediate outcome of helping keep an older person out of a residential care home; a new fuel efficient boiler and loft insulation will prevent many incidences of respiratory and circulatory disease, reduce excess winter deaths, and make life comfortable and more affordable; a timely, well placed grab rail and repairs to broken steps will stop a fall and serious injury, followed by longer term residential care placement due to the negative cycle created by falls in older people. The following details the work we do that has a preventative effect in terms of early intervention, and easing future and more expensive demand:
3.2 Looking firstly at falls prevention, every year in Wales it is estimated by Age UK that around 30% of people over 65 and 50% of over 80’s will have a fall in their home, many of which are preventable. The effect of falls to older people in Wales was estimated in Shelter Cymru’s publication “The Real Cost of Poor Housing” to directly cost the NHS in Wales £56 million per year.
3.3 According to Public Health Wales, in 2009 there were 1102 deaths, 41,817 hospital admissions and at least 444,274 Emergency Department attendances due to injury, incurring direct costs of at least £25.9 million. The leading cause of death from injuries was falls (23%). Falls also account for 48% of injury inpatient admissions. Inpatient injury admissions led to 309,844 bed days, an average of 7.4 bed days per admission. The direct medical costs of these injuries in Wales were £25,944,352 (related to inpatient admissions and emergency department visits.) The leading cause of death and in-patient admission in Wales, due to injury, is falls.
Fall death rates are low in all age groups until 70 years when they start to rise, from 9.7 per 100,000 (males) and 7.2 (females), to 138.7 (males) and 120.8 (females) by age 85+. Serious fall injuries mainly affect older people. [1] Amongst older people falls are extremely common; 30 to 60% fall each year and 15 to 30% fall more than once. This high incidence means that fall injury incidence and serious fall injury incidence is high; 2-6% of falls lead to serious injury and 1% lead to hip fracture[2]. The average cost of a fall at home which results in a hip fracture is nearly £29,000, over 100 times the cost of installing hand and grab rails in an average home. Hip fractures are also the trigger for entry into residential care in up to 10% of cases.
3.4 The majority of falls occur at home[3]. The cause of a fall at home is often multi-factorial, involving both environmental hazards and an underlying medical condition. Environmental hazards are largely preventable. Care & Repair agencies complete a home safety check with clients to assess their home for hazards and then help to make the necessary modifications, adaptations and repairs to improve safety in the home.
3.5 The impact of Home improvements and Adaptations. Home repairs and adaptations make performing tasks easier, reduce accidents, and support independent living. Adaptations and repairs range from low-cost to more expensive work. They include repairs such as improved wiring (to eliminate the need for dangerous extension cords), repairing broken and missing steps, repairing uneven paths, fixing loose stair treads and removing hazards (e.g. clutter, throw rugs). Adaptations include adding special features or assistive devices (e.g. grab rails, ramps), moving furnishings, adaptation to enable a change where activities occur (e.g. sleeping on the first instead of second floor) and conventional adaptations such as stair-lifts and walk-in showers.
3.6 Home modifications and adaptations can reduce the demands of the environment while making the home safer and more supportive. A review[4] by the Office of Disability Issues of the outcomes and costs of adaptations stated “For older and disabled people, the choice between adaptations and other options is a choice between independence and dependence.”
3.7 Prevention of falls and injuries has been a major focus of research, stimulated by ageing populations and by growing awareness of the mortality and morbidity resulting from falls. Reviews of falls prevention interventions have concluded that interventions are successful; including assessment of hazards at home and modifications of the environment, such as adaptations.[5] Reviews have concluded that home improvement and adaptations reduced the risk of falls, particularly for those discharged from hospital and for those with a history of falling.
3.8 A recent trial of falls prevention of older people who were determined at high risk of falling found that those who received falls prevention, such as improving home safety, were significantly less likely to fall than a control group.[6] Another trial specifically looking at environmental factors found that home safety assessments reduced the risk of falling by up to 39% in those who were at high risk.[7]
3.9 A report by the Wales Audit Office Lean and systems thinking in the Public Sector in Wales, January 2010 considered NPT Council’s Lean review of Disabled Facilities Grants (DFG), and reported that postponing entry into residential care saves an average of £19,760 per year per person. It also concluded that a timely DFG can postpone entry into residential care by 4 years, giving a cost saving of £72,000 for each person, net of the average £7000 DFG cost. The report commented “Clearly, by providing appropriate DFG at the appropriate time people can be sustained within their own accommodation, not only reducing residential care costs but arguably delivering considerable emotional and community benefits to service users. Nevertheless, the impact of timely DFG service could go beyond delaying admission into residential care, for example to alleviate costs in the home care service or to discharge existing clients from residential care”
3.10 Cost effectiveness. The Office for Disability Issues[8] found in a review of current evidence that provision of housing adaptations and equipment for disabled people increased people’s quality of life and independence. Such provision also produced savings to health and social care budgets in four major ways;
· Reducing or removing an existing outlay – residential care and home care
· The prevention of an outlay that would have been incurred – prevention of hip-fractures and other care costs
· The prevention of waste – delay in supply of adaptations
· Achieving better outcomes for the same expenditure – improving quality of life.
3.11 All evidence indicates that adaptations and basic repairs/home improvements are
cost effective methods in preventing falls for older and disabled people. The review conducted by the Office of Disability Issues[9] stated; ‘The evidence from the review is that, unless the cost of the adaptation is very high compared with the life expectancy of the person concerned, adaptation (and independence) will always be the better value option.’
3.12 Cold Homes and fuel poverty.According to Age Cymru in 2013, fuel poverty
affects 30% of households in Wales – 386,00 households - with three main factors determining if a household is fuel poor; income, energy prices and energy efficiency. The last Living in Wales survey in 2008, estimated the total number of fuel poor households as 332,000 or 26% of all households. The figure for pensioners were that they represent 26% of all households in Wales, and of these 140,000 (42%) were in fuel poverty.
3.13 The Older People’s Wellbeing Monitor for Wales 2009 indicated 1 in 5 households
containing someone aged 60 or over as fuel poor, twice the rate of all households.
3.14 BRE research for Shelter Cymru “The Real Cost of Poor Housing” 2011, reported
the following from the Living in Wales Survey 2008:
· At least 29% of Wales homes had at least 1 category 1 hazard (under the Housing Health and Safety Rating System, HHSRS), failing the current minimum standard for housing in Wales and England.
· The most common category 1 hazards are accidents/falls, excess cold and damp.
· Older people are more likely to live in housing with category 1 hazards, and over 75’s are more likely to live in housing where there is excess cold.
· 25% households over 80 live in damp homes
3.15 In 2010/11, there were 1960 excess winter deaths amongst older people in Wales.
79% of these were to people aged over 65, 68% were people aged 75 and over. These deaths are higher than the average for the UK and linked to respiratory disease, circulatory disease, and hypothermia, all exacerbated by cold, damp housing conditions. Winter illness figures, linked to cold, damp homes are difficult to find, but it is clear given the mortality rates that countless thousands more older people will present to local GP surgeries and A&E Departments with illness brought on or exacerbated by their poor living conditions and inability to keep warm at home.
3.16 Care & Repair’s overall proposition is that a greater focus on prevention within
public services (including social care and health services) will reduce A&E admissions (unscheduled care), residential care places and speed up safe transfers of care. Targeted investment in preventative services that improve housing conditions would improve the wellbeing of the people of Wales, whilst saving public funds.
3.17 The above information aims to demonstrates the cost effectiveness of investing in preventative services, and in particular Care & Repair, and we would like to see greater direct investment in our services so that we can deliver more services that improve the quality of life of older people, and deliver greater preventative spend.
3.18 As mentioned above, we also believe that the Intermediate Care Fund £50m (£15m capital and £35m revenue), is an excellent approach to creating greater integration of services for older people and achieving greater preventative spend in the budget and would welcome it’s continuation.
Chris Jones
CEO, Care & Repair Cymru
September 2014