Foundations Webinar, Tuesday 25 January 2022
The Department of Health and Social Care appointed the University of West of England to carry out an independent review of Disabled Facilities Grants (DFG) in England. The University worked with Foundations, the Building Research Establishment, Ferret Information System and an experienced Occupational Therapist to look at both the operation of the grant and the wider delivery of home adaptations to support the independence of disabled people living in their own homes.
Despite increases to the annual DFG budget, demand for adaptations has always outstripped supply and this is set to continue as the population ages. The review sought to ensure that home adaptation policy remains fit for purpose and that funds are being allocated as effectively as possible.
Topics explored included:
- How the DFG is used currently – who gets what and how it’s delivered;
- How the DFG could change in the future – focusing on the means test, the £30,000 upper limit, the allocation formula and methods of delivery;
- The link between adaptations and health and social care services, including timely discharge from hospital;
- The changing aids and adaptations market – considering new innovations and technology, market development and supporting people who are not eligible for a DFG; and
- The impact of Section 36 of the Equality Act 2010 on adaptations to communal areas.
The review reported back in June 2018 with evidence-based recommendations on how the grant could operate in the future.
A series of consultation workshops were held during March in London, Leeds and Wolverhampton to debate the issues and draw conclusions for the final report.
In 2019 the Disabled Facilities Grant (DFG) will be 30 years old. Originally, it was one of several housing grants available to fund repairs, improvements and adaptations. All the other grants have now gone, and the DFG is part of the Better Care Fund; a pooled budget seeking to integrate health, social care and, through the DFG, housing services.
This Review looks at how the DFG currently operates and makes evidenced based and practical recommendations for how it should change in the future. The aim is to (1) support more people of all ages to live in suitable housing so they can stay independent for longer; and (2) make the case for more joined up action across housing, health and social care.
Home is central to everyone’s lives, but is particularly important for disabled and older people, as it is where they spend most of their time. Increasing numbers are living alone, especially in later life. Ability to get in and out of the home, move around inside, access the bathroom, receive friends, cook and go to bed has a significant effect on people’s dignity, autonomy and wellbeing.
The majority of disabled people are living in ordinary housing but only 7% of homes in England have basic accessibility features such as downstairs toilets and level access. Three quarters of deaths relating to falls happen in the home, and falls represent 10-25% of ambulance call-outs to older adults. Once admitted in an emergency, older people use more bed days than other people (65%) and falls often precipitate a move into residential care.
The DFG is often seen as simply providing level access showers, stair lifts and ramps. This review proposes a fresh approach that is all-encompassing and creates a home environment that enables disabled people to live a full life. Districts and counties, housing and social care, occupational therapists and grants officers will need to work together to establish person-centred services that meet a disabled person’s needs in a more preventative, holistic and timely way.
How the DFG is used Now
Government investment in the DFG has more than doubled over recent years. However, local authorities have reduced the amount of additional funding that they contribute. This has meant the number of homes being adapted has not significantly increased (although numbers for 2017/18 are not yet available).
Nearly two-thirds of DFG applications are for older people, just over a quarter for working age adults and a small but growing minority for disabled children and young people.
Nearly 60% of applications are made by owner-occupiers, not surprisingly as most older people own their own home. A third of applications are made by tenants of housing associations, with only 8% from private tenants, although the numbers of disabled tenants are now similar in each tenure. This highlights a clear disparity between the ability of disabled private and social tenants to adapt their home, a situation which is particularly acute in London. Adaptations for council house tenants are funded entirely separately, not through the DFG.
Nearly 9 out of every 10 applications relate to physical disabilities and 90% of adaptations provided are either level access showers, stair lifts or ramps. The average cost is around £9,000 but most work is under £5,000. This varies by region, with the highest costs in London and the lowest in the North East. Of the people who are assessed as needing an adaptation, around a third drop out along the way, usually due to financial reasons.
|Showers||Straight Stairlift||Curved Stairlift||Ramp||Extension||Other|
The initial brief for this project, previous reports, and new evidence about the current situation collected as part of this review, identified several challenges with the DFG:
- The increase in central government resources has not yet resulted in more people being helped due to reduced financial input from local authorities, lack of revenue funding, more complex cases and higher cost of work.
- Fear of triggering demand that cannot be met means that there is still little analysis of local needs and minimal advertising of the DFG. This makes it very hard for people to find out about the help available, particularly home owners and private tenants.
- The delivery process is often slow and cumbersome, with numerous handovers.
- The complexity of the DFG delivery system makes it hard for other professionals to understand it and reduces opportunities for preventative action.
- Restrictive upper limits on the cost of work and lack of contributions from health and social care can sometimes result in solutions that are not effective.
- Too many people drop out of the process, often because they must contribute to the cost.
- There is tenure inequity with a high proportion of grants going to registered providers when disabled people are increasingly in the private rented sector. The council stock remains outside the DFG which makes strategic planning more difficult.
- Reporting on outcomes is hindered by the heterogeneity of cases, staff time constraints and lack of data sharing, and this makes it hard to argue for additional resources.
- The Better Care Fund (BCF) and Health and Wellbeing Boards (HWB) could play a more strategic role but need to be focused on housing, not just on health and care outcomes.
- There has been a loss of information and advice services for people ineligible for the DFG.
- Changing expectations, new materials and advances in information technology mean the DFG needs to evolve if it is to remain relevant for the next decade and beyond.
- The challenge is to join up the process and shift the thinking from ‘welfare’ to ‘investment’ so that decisions are taken, not at crisis point, but in a more preventative way that is based on the long-term health and wellbeing of disabled people and their families.
Joining it Up - Strategically
Up and down the country there are many dedicated professionals doing their best for disabled people but struggling with processes and systems that are not fit for purpose. One of the main problems is that responsibility for the customer pathway is often split between different organisations and departments that have separate objectives and budgets. Where services work best, there is a joint commitment at a senior and strategic level between housing and social care; districts and counties. We call this the “Goldilocks Approach” because it brings together the knowledge, skills and funding required to deliver a person-centred approach that is ‘just right’.
Previous reviews and guidance have suggested that this is the way forward, but across much of the country it has not happened. We recommend that Government make it a condition of funding that Housing and Health Partnership Boards are set up (linked to existing Health and Wellbeing Boards) with responsibility for the strategic oversight and planning to meet the housing needs of disabled and older people in their locality.
This should be underlined by a new name for the grant that is up to date and easily recognisable. Services need to appeal to people of all ages including: families with disabled children, younger disabled people and the ‘baby boom’ generation who do not want to be treated as ‘old’.
- A Housing and Health Partnership Board in each area as a requirement of DFG funding with representatives from housing, health and social care.
- Each Better Care Fund/Health & Wellbeing Board to report separately on DFG funding and on a new metric ‘the number of people helped to remain independent at home’.
- Housing and Health Partnership Boards to have a similar structure to Local Safeguarding Children’s Boards.
- The DFG and Integrated Community Equipment (ICES) budgets to both be in the Better Care Fund (or its successor) to join up DFG services with equipment provision and minor adaptations.
- A single adaptations policy based on the needs of the locality, reviewed annually and signed off by the Health & Wellbeing Board.
- We need a new name for the grant, the services that provide it and the national advice organisation. That name needs to be used consistently across the country. Disabled and older people, and other professionals, need greater awareness that the grant is available.
Joining it Up - Operationally
Existing DFG systems are usually a two-part process, starting with an assessment by social care services and then a grant application to housing. For customers this can mean a long and difficult journey involving delay and frustration.
There is a growing number of integrated teams that do things differently. They bring together occupational therapists and housing staff into a single team; they have one point of contact throughout the process and they provide equipment, minor adaptations, telecare, housing options and support to move as well as the major adaptations funded by the DFG.
It’s not just about structures and systems, there’s a need for better guidance on what provision is necessary and appropriate and a more collaborative approach to decision making. A set of guiding principles for assessment should be adopted.
Nine guiding principles for installing adaptations
- Need to retain (or restore) dignity
- Need to have values recognised
- Need for relief from pain, discomfort and danger
- Need to minimise barriers to independence
- Need for some element of choice
- Need for good communication as part of giving choice
- Need for light
- Needs of children: to provide for growth and change; need for space
- Needs of other family members and of the family as a whole
When you’re working hard to meet the demand for adaptations it is difficult to commit time to redesigning how services are delivered. This requires transformation funding and using just 1% of the DFG budget will make a significant difference to help integrate services across the country.
- Integrated teams are essential in all areas to simplify and speed up customer journeys.
- Better analysis of local need to develop preventative strategies and determine levels of revenue and capital funding.
- Single point of access with ‘good conversations’ at the start and people routed down appropriate pathways.
- Regulatory Reform Order (RRO) policies have been developed in around half of local authorities and need to be adopted in all areas to provide more flexible use of the grant.
- New decision-making tools to help staff collaborate more effectively and use of 3D design and design centres to communicate better with customers.
- Better partnerships with health and care to ensure that ways of ‘Making Every Contact Count’ work more effectively so people are referred earlier, not at crisis point.
- Transformation funding equivalent to 1% of the DFG budget to enable change to happen across the country.
With a growing national programme, it is important to have a distribution formula for DFG funding that is based on readily available data as well as being transparent, intuitive and fair. The current approach is based on a confusing mix of methodologies and historical allocations.
We suggest a new formula based on the number of people with a disability, income (from benefits data), tenure split (from MHCLG data) and regional building costs. Further sensitivity analysis is required to consider the impact across regions and all local authorities.
Adopting any objective formula will inevitably lead to ‘winners’ and ‘losers’ which could be mitigated by implementing the transition over a number of years.
- That a new allocation formula is established for the next Comprehensive Spending Review and applied incrementally over the implementation period.
Updating the Regulations
The means test
The existing means test is based on the eligibility test for Housing Benefit and was designed to target funding on ‘needy’ households. It has long been criticized for being complicated, unfair and, in recent years, out of date. There is an opportunity to adopt a version of the test used to assess entitlement for social care. There would be advantages in aligning the social care and DFG means tests, as having two different tests is extremely confusing. It would also address issues of unfairness in the present test by ignoring earned income and actual housing costs. Aligning DFG and social care eligibility also creates the potential for spend on home adaptations to be considered as part of the proposed ‘care cap’. This is the maximum amount someone must pay towards their care before a local authority takes responsibility. If it encouraged more people to invest in home adaptations and improve their independence, it would be good for the person’s own health and wellbeing and it would potentially reduce domiciliary or residential care costs.
However, aligning the two tests is not straightforward. It could make it more complex, reduce the number who could be passported, and introduce local variation. The alternative option is to update the existing test by: re-establishing the link to Housing Benefit; a new formula for housing costs based on Local Housing Allowance; and updating the passporting benefits.
The option selected will largely depend upon the changes to social care finance in the 2018 Social Care Green Paper. Regardless of which test is used, there is a case for exempting applications for stair lifts and palliative care from means testing entirely due to the savings in health costs associated with preventing falls on stairs and by enabling end of life care at home.
The upper limit
Most local authorities only deal with a handful of large and complex adaptations every year (where the cost of fully meeting the needs of the disabled person exceeds the current limit of £30,000). Though small in number, the time taken to support these cases and find the extra funding can be considerable.
We recommend that the current £30,000 limit be increased in line with inflation, but also recognise that the significant variation in building costs across the country should be factored in. The benefit of proper professional support in successfully delivering these difficult building projects should also be recognised.
But simply increasing the upper limit isn’t enough. There will always be cases that cost more, but which will also deliver better outcomes and return on investment than the DFG alone could be expected to provide. It is crucial that health and social care recognise their responsibilities and jointly fund and develop the best solutions. There is also scope to use personal budgets to provide more tailored solutions.
There is also a need to rectify anomalies in VAT which is charged on ground floor extensions containing bedrooms and kitchens but not on bathrooms.
Services and charges
The DFG is currently used to pay for adaptations to an existing home, often with little consideration about whether a move to a more suitable property would lead to a better outcome. Providing support with the expense of moving can be cost effective and should be included within the list of services and charges that the DFG can support.
- Subject to what is included in the Social Care Green Paper – the DFG means test aligned with that for social care eligibility, but if not, the existing test of resources updated.
- Stair lifts and palliative care cases removed from means testing entirely.
- That the maximum amount of the DFG is raised in line with inflation, with a regional weighting based on building costs and an amount for professional fees.
- That risk-share funds are set up to deal with uneven demand for grants, and that very expensive adaptations are jointly funded by housing, health and social care.
- That the VAT rules are revisited for major adaptations.
- That the guidance is fully revised to reflect new integrated services, the expectations for local authorities and the rights of the disabled person.
That the Services and Charges Order list is updated to include support with moving.
Developing a Market
As with most of the UK construction industry, the provision of home adaptations is fragmented and has low levels of standardisation. Schedules of rates and frameworks agreements are not used in most local authority areas despite being recommended in official guidance since 2006.
However, there are pockets of good practice that could be readily adopted more widely; including an online schedule of rates that provides instant costings from local builders, ‘flat-pack’ home extension kits that cut construction times by months and stair lift recycling schemes that reduce costs and speed up installation. We need better adaptation designs that are not stigmatising.
There is potential to use the annual £0.5bn in the DFG to develop the wider market for consumers looking to adapt their home based on price benchmarking and developing common standards. For instance, by using a national accreditation scheme for builders similar to the Certified Ageing in Place Specialists that operates in North America.
Technology has always been part of the DFG, such as stair lifts and hoists. Other specialist ‘assistive technology’ has developed a reputation for failing to deliver on its promises, but with the rise in smart home technology there is a growing range of low cost solutions that are available on the high street.
Local authorities are starting to use kit like the Amazon Echo to help with medication reminders, remotely control lights and heating, and detect falls. This has clear potential to keep people independent and outside of social care systems. It also forms part of the UK Industrial Strategy to become a world leader in systems that support an ageing population. Making a smart home starter kit part of every DFG application would significantly drive adoption and generate evidence, data and learning in this area.
The majority of disabled people will not be eligible for a DFG or would prefer to organise work themselves, but it is hard for people to get reliable information on home adaptations from retail suppliers. There is an important role for local authorities and home improvement agencies to provide information, advice and low-cost handyperson services.
- A further five-year funding programme for the DFG to improve certainty and enable local authorities to invest in better procurement.
- A national accreditation scheme for builders and tradespeople.
- A smart home starter kit as part of every DFG application.
- Local authorities and home improvement agencies to provide advice, information, and handyperson services for people outside the DFG.
- Further research on what people do outside the DFG to encourage more ‘future-proofing’.
In legislation the DFG is supposed to be tenure neutral. However, in practice, access to funding and the level of service someone receives are strongly affected by tenure. Private tenants are often denied adaptations by landlords who don’t want disabled equipment fitted into their property. Lack of security of tenure can also be a barrier.
For housing association tenants, it is not clear to what extent their landlord should take responsibility for adaptations which can often lead to permission being withheld or disagreements about funding. Council tenants have the right to apply for grant, but funding must come from the Housing Revenue Account rather than the DFG. This needs further review.
When enacted, Section 36 of the Equality Act 2010 will enable disabled people to make requests for adaptations to the common parts of residential properties (such as entranceways, hallways and stairwells) which cannot be unreasonably denied.
Very few DFGs are currently approved for adaptations to common parts which makes it difficult to predict the impact of Section 36. This means that a local strategic approach is likely to be more effective than relying on DFG applications.
- Further work is needed on tenure issues, including the feasibility of a national adaptations protocol for registered providers.
- More research is also needed on ways to engage with private sector landlords and deliver adaptations more effectively in the private rented stock.
- Works to common parts should be dealt with by the local Housing and Health Partnership Board rather than in a one-off piecemeal manner using the DFG.
The aim of adaptations is to restore the use of the home so that people can regain or retain their independence and carry on living in the community. The DFG is being used in more creative ways in partnership with health and care colleagues, for example, to improve the lighting for someone with a visual impairment, to redesign a bathroom for someone with dementia or make a home safe and warm for someone returning from hospital after a fall. Having an integrated team gives an opportunity to co-ordinate the response and better tailor it to the person’s needs.
The challenge is to measures outcomes effectively to demonstrate the transformation that can occur in people’s lives when they feel in control of their home environment. Robust research is beginning to show that adaptations improve physical and mental wellbeing and reduce the fear of falling. Better local and national data on outcomes is required to demonstrate the substantial savings in health and care costs that can be generated by improving the home.
- Use of NHS number on all files, data sharing protocols, aligned IT systems and improved local and national reporting.