Equipment and adaptations: guidance on provision

Adaptations and Housing Solutions

Improving services

The timely provision of adaptations can make a significant difference to the outcomes for an individual in relation to where they can live and the level of independence they have within their daily environment. These modifications can be critical in acting as preventative measures. They can help to reduce the number of emergency hospital admissions through falls and other accidents, and also reduce the need for home care or long-term admission to a care home. For children, adaptations can support functional, social & emotional development and can provide an improved quality of life for the whole family.

However, adaptations should be seen as one of a number of possible solutions available, and it may be that housing support, or re-housing could be a better option for long term needs.

It is therefore essential that any person or family seeking any type of disability-related adaptations, should be properly encouraged to discuss their wider housing circumstances at the earliest possible stage. It is vital that we help families consider their long-term housing needs at an early stage, and proactively support them to identify solutions that could minimise the need for more extensive adaptations, and disruption, in the future.

It is also essential that there is an understanding of the depth and breadth of this agenda, recognising that adaptations and inclusive housing environments, are required for a broad cross section of people of all ages and with different physical, sensory, cognitive, mental health & neurodiversity needs. General accessibility issues become more pronounced where people are wheelchair users.

The 2018 report by Horizon Housing Association and the Chartered Institute of Housing (CIH), Still Minding the Step?, is a review of their original 2012 report, produced to estimate the housing needs of wheelchair users in Scotland, and to recommend a range of improvements.

The report emphasises the requirement for a strategic approach and better planning, noting that their review of the 32 local housing strategies indicated that a quarter of authorities do not plan for housing to a wheelchair standard. The authors also criticise the application of the medical model of disability, which is still in evidence across the housing sector, and the practice of categorising the needs of wheelchair users as 'specialist' provision, rather than acknowledging the need for accessible housing as a standard. The overall aim is one which mainstreams an 'Inclusive design/living approach. The report lists a number of recommendations that call on action from government but also should help inform local housing, health and social care partners in their strategic planning.

The growing prevalence of Dementia has been recognised as a pressure in health & social care, with over 90,000 people estimated as living with the condition, but also has an impact on housing. The Scottish Housing and Dementia Framework was published in Oct 2019 and aims to support the housing sector to articulate its contribution to supporting people living with dementia to stay at home for as long as practically possible.

Although the framework has been primarily designed to be applied by the housing sector, with specific support in place to assist housing organisations to sign-up to this, it can also, usefully be adopted as a tool to review local strategy and arrangements between housing and health and social care partners.

Policy context

There have been a number of policy & legislative developments since the original guidance, which have shifted the tone of the discussion around adaptations, to widen the perspective in terms of the need for effective strategic approaches, embedded and aligned with the developments in health & social care. These recognise the need to move away from reactive provision, and instead encourage better planning for the needs of people, in our communities.

In addition, in the wake of The Independent Review of Adult Social Care, there is a renewed interest in fundamentally improving the processes and infrastructure which deliver services, to offer greater emphasis on preventative and anticipatory responses, and removing barriers in the systems.

Adaptations Working Group and Adapting for Change

This context offers an opportunity to revisit the work previously carried out by the independent Adaptations Working Group (AWG), (and the subsequent Adapting for Change programme), which reported in Dec 2012, with recommendations which are still very relevant but, have as yet, with the exception of the Housing Solutions programme, had little support in terms of large –scale roll-out, which was the original aim.

The clear messages from the AWG highlighted the need for:

• A person-centred approach to Adaptations;
• Prevention as a key focus, with early consideration of alternatives to adaptations, which may provide a better solution e.g. move to more suitable housing;
• Providing equity in the system, removing tenure as a barrier – requiring a 'tenure neutral' approach;
• Effective integrated strategic planning, and governance with involvement of all key partners;
• Pooled budgets, and avoiding budget driven service provision.

Adapting for Change (AfC)

The Adapting for Change programme, was initiated to identify and deliver improvements to the provision of Adaptations for people living across all tenures in our communities based on the recommendations from the 2012 report, Adapting for Change: the Adaptations Working Group's Final Report. Its remit was to explore ways to achieve the best possible outcomes for older people and disabled people from investment in housing based solutions. It made a number of recommendations in the main report and in an additional report, Planning Ahead: Living at Home which focused on promoting opportunities for self-help and forward planning to help avoid the need for crisis responses.

The Adapting for Change (AfC) report highlighted a number of opportunities to improve housing adaptations but concluded that more fundamental action was needed. In 2016 and 2017 the Scottish Government worked with health, social care and third sector organisations, to support the testing of innovative approaches to these challenging issues, with the aim that recommendations from the evaluation of the programme, and the ongoing outputs from the test sites would provide practical help to inform effective service improvement, across the country.

The AWG's recommendations were tested in five test sites across the country (Borders, Fife, Falkirk, Aberdeen and Lochaber). The full Adapting for Change evaluation report and shorter Adapting for Change learning points summary, provide detail on the outcomes and recommendations from this work.

The key principles and themes which emerged from the Adapting for Change programme include the need to:

• streamline processes;
• evidence effective Outcomes for people;
• deliver tenure neutral approaches which treated all service users equally irrespective of the type of property they happened to live in;
• provide one-stop shop/integrated approaches;
• a wider focus on all housing solutions including rehousing,
• an emphasis on prevention and early intervention strategies to help people consider their longer term housing needs, in advance of crisis situations.

Housing to 2040

Housing to 2040 sets out a vision for housing in Scotland to 2040 and a route map to get there. It aims to deliver our ambition for everyone to have a safe, good quality and affordable home that meets their needs in the place they want to be.

Housing 2040

Published in March 2021, Housing to 2040, and the document's vision and principles for the future of housing, outline what the Scottish Government wants housing and communities to look and feel like, for the people of Scotland, with actions on how to achieve this.

The principles underpinning the Vision provide a high-level guide, directing local partnerships as to how policy decisions might be shaped in the future, in order to deliver these requirements. This is Scotland's first long-term national housing strategy.

Around £16 billion will be invested to deliver 100,000 more affordable homes by 2032, with a minimum of 70% of these being for social rent. Plans for a new legal requirement for all homes to meet the same standards are also included in the strategy. The new, tenure neutral Housing Standard, will create a single set of quality and accessibility standards, and the proposals will also review Housing for Varying Needs.

The Vision also emphasises the importance and need for homes that effectively meet the needs of people of all ages, including children, with the requirement for responsive provision of equipment and adaptations, and technology. Government has therefore also made a commitment to review adaptations within this context.

Scottish Government will publish a draft Standard in 2023 and introduce legislation in 2024-25, for phased introduction between 2025 and 2030.

Integration

Under the Public Bodies (Joint Working) (Scotland) Act 2014, responsibility for delivery of functions relating to housing adaptations and equipment (aids) now lies with Integration Authorities. Key responsibilities delegated to the Integration Authority are:

• The duty to assess for an adaptation
• Planning for and resourcing adaptations.
• The duty to provide grants of 80% or 100% for those living in the private sector, who are assessed as needing adaptations.

Financial resources previously deployed for tenants of Councils have also passed to the Integration Authority. Funds for adaptations undertaken by Housing Associations and Co-operatives (RSLs) etc. have not been passed to the Integration Authority, but the IA has responsibility for ensuring that relevant HSCP services are available to support adaptations for RSL tenants.

Despite the scope of the delegated duties above, little has changed in terms of widespread strategic planning, or improvements in the delivery of services although, encouragingly, there have been some more recent examples of tenure neutral approaches being applied, and some HSCP's working closely with Housing colleagues to progress a strategic improvement approach. These approaches are very encouraging and need to be supported

Work needs to be actioned in line with recommendations outlined below, which would properly realise the original vision and intent behind the move to shift governance under the integrated arrangements. This is articulated in a report by the University of Stirling developed as part of The Adaptations Policy and Practice Project, co-ordinated by the UK Collaborative Centre for Housing Evidence (CaCHE):

If the ambitions of key policies such as Housing to 2040 are to be fulfilled, the current adaptations system in Scotland not only needs to be reviewed, but overhauled and reset to support investment, partnership working and integration of adaptations into wider health, social care, and housing priorities.

University of Stirling
Adaptations Policy and Practice Project

Delivering change

There is now an impetus to address the outstanding issues, with the need to bring all relevant housing, and health & social care stakeholders together to create service models which remove the barriers to provision, and offer a genuine person-centred, 'tenure neutral' approach, for people living in our communities.

One of the ways of addressing inequities in the system, would be to remove the need for owner occupiers to apply for grant and instead provide 100% funding for the provision of fully assessed and recommended adaptations.

A number of services have come to this conclusion, and have been happy to implement changes for certain types of provision funded by adaptations budgets (e.g. Stairlifts), which streamline processes for owners and remove bureaucracy in the system.

However, this needs to be systematically applied more widely across partnerships, and there are good practice examples which evidence the benefits of removing the requirement for grant aid in the system, and can help other areas to review their arrangements.

Good Practice Example

Both Glasgow City and West Dunbartonshire private sector housing changed their arrangements in 2011 & 2012 to remove the requirement for a grant application for the provision of Stairlifts to owner occupiers. Instead, owners are now assessed in the same way as people living in publicly funded housing, and receive their Stairlift provision via the EquipU partnership Stairlifts contract.

This has:

• Ensured owners are treated equitably in a 'tenure-neutral' service;
• Significantly reduced timescales from assessment to installation - average 2-5 weeks;
• Delivered procurement and recycling savings with over a third of all stairlifts recycled back for use in other homes;
• Improved maintenance arrangements, as owners do not own the stairlifts, and are therefore no longer required to maintain these themselves;
• Frees up staff resources as they no longer require to process grant applications.

One of the first owners to receive a new Stairlift under the changed arrangements, Mrs F, stated that she couldn't believe how quickly she had received the stairlift, and called it her 'golden chair', advising that because it helped her now access her upstairs shower room, she "felt good about herself again, and hadn't felt that way for a long time".

The scheme of assistance is resource intensive for services, inhibits access by creating a financial barrier, is not person-centred, and considerably slows the process of provision.

Removing grant arrangements and instead encouraging partners to focus on partnership business models, which maximise procurement and recycling benefits, would establish a basis for effective tenure neutral integrated approaches and genuine equity in the delivery of services to people in our communities.

It is also necessary to remove barriers related to the assessment pathways, ensuring that direct access opportunities are maximised, for straightforward and standardised adaptation solutions e.g. shower installations in local authority and housing association properties.

• This should remove the need for occupational therapy assessment for these type of installations. As it stands there is no legal requirement for an OT assessment yet this has become a requirement as a matter of practice, by many housing providers in Scotland, as a way of managing demand and budget expenditure.

• To address these types of issues and help partners jointly manage budgets in a more strategic and planned way, partners should jointly identify the most effective mechanisms to utilise financial resources collectively, including consideration of pooled budgets under joint governance.
• These changes and improvements need to be supported by clarity of strategic direction, with robust joint governance arrangements which include a wide range of relevant stakeholders across housing (all tenures), health and social care.
• Work also requires to focus on the need for cohesive local housing plans, aligned to housing allocation policies, which promote the provision of barrier-free housing and early intervention strategies, supporting service users and their families, to review their long-term housing needs, including the needs of children with long-term conditions.

All of the above needs to be supported from government, and it is proposed that as a next stage of work, a national Adapting for Change Action Plan should be devised to compliment other policy work, and assist partnerships to drive forward these changes, and address the outstanding issues in our services.

Housing Solutions Programme

The 'Housing Solutions' change programme has been developed as an output from the AfC programme, applying the principles of Adapting for Change, and is essentially about supporting prevention, and early-intervention. This offers a framework for service improvement which would help drive forward the range of required changes identified in the earlier section above.

In most areas of Scotland, the provision of permanent ramps is a complex and lengthy process, and is often not the ideal solution where there are wider issues with the long term suitability of the home.

Good Practice Example

During April 2020 to March 2022, Angus Health and Social Care Partnership (AHSCP) agreed to take a tenure neutral approach to the use of removal ramps.

In total, 124 removable ramp recommendations were made within the trial period. Of the removable ramps that were inst.alled, there was variation in the timescales being realised, however this was much less that those incurred with permanent solutions. The delays incurred were related to issues with obtaining approval, as opposed to the design and cost information being obtained from the contractor for the removable ramp.

Throughout the test period AHSCP were able to recycle a number of ramps enabling the component parts to be reused and offsetting the installation costs of other ramps.

AHSCP identified that greater efficiency and flexibility could be realised through using removable ramps as well as enabling the opportunity of recycling ramp component parts.

AHSCP have now adopted the use of Removable Ramps across all tenures.

The HSCP identified the following Benefits:

• Equity across all tenures is being realised for the installation of removable ramps;
• Greater efficiency in delivering access solutions across all tenures. (historically delays can be encountered when awaiting landlord permission);
• Greater emphasis on Housing Solution discussions, and ability to realise short, medium, as well as long term use of removable ramps, to support this approach;
• Improved recycling, which reduces the expenditure on removable ramps over time.

This approach offers a practical and effective way of encouraging wider responsibility across our housing, health, social care and Third Sector services, for the identification and discussion of housing needs and solutions with people in our communities who need advice and support.

This is in line with the recommendation from the AWG Report which recognised the need for early consideration of alternatives to adaptations, which may provide a better solution e.g. move to a more suitable home at an earlier stage in someone's condition.

An important dimension of the Housing Solutions approach also focuses on the need to apply a tenure neutral approach, maximising business & procurement efficiencies, simplifying the systems and processes, helping staff, as well as people in our communities, make sense and navigate the pathways.

As an older person wanting to move, I can get help to move to a home which better meets my needs. My current home is no longer right for me but would be ideal for a family

Housing Solutions Service User

This approach fits seamlessly with the direction from government in Housing to 2040: Vision and principles, where it highlights the importance of supporting people to reflect on the suitability of their current housing, and the benefits this can have for the wider community.

Implementing Housing Solutions

The Housing Solutions approach encourages working in partnership with the person, empowering them with information & options to enable them to think and plan ahead. In many areas partnerships have used this approach as a wider framework which supports pathways around other local service provision e.g. Housing Options services. Examples such as the HOOPs (Housing Options for Older People) service in Glasgow City, and the Disabled Person Housing Service in Aberdeen City, are both examples of intervention to support critical parts of the service pathways related to hospital admission/ discharge.

As part of the Housing Solutions programme, a simple booklet, 'Do you want to Move or Stay? has been produced, which a number of partnerships in Scotland have customised for their own local services, and has been helpful in supporting staff, who may not have previously been used to initiating housing conversations e.g. nursing colleagues, support workers, podiatrists, third sector staff etc.

This booklet was first developed for Falkirk Council Housing Services, with help from the Make it Happen Forum and local people, and utilised as part of the AfC test site work within that area. Two examples are available on Healthcare Improvement Scotland's iHub website.

Training, and improving the Assessment pathways

Importantly, training modules to support the Housing Solutions programme, and encourage a multi-partnership integrated approach to identifying and assessing for local solutions have also been developed.

• The aim is to ensure that needs can be assessed, and solutions provided, by a wider range of front-line staff across Housing, health and social care, and third sector settings, removing the traditional requirement for an occupational therapy assessment for every adaptation solution. The core half day module (1) is for all relevant staff across all services and third sector partners. Additional modules (2&3) are available for supporting wider groups of staff to be able to assess for adaptation provision.

The Adaptations without Delay 2019 publication, commissioned by the Royal College of Occupational Therapists (RCOT) from the Housing Learning Improvement Network (LIN), was developed to demonstrate how adaptations can be delivered with the individual at the centre. The document highlights how, and when occupational therapists add value to the process, where complexity of individual circumstances dictates this is appropriate. However, the important message in this publication is clarifying that for many types of straightforward adaptation provision, an Occupational therapist is not required to assess these needs.

• The focus is about avoiding unnecessary delays, empowering housing associations to take a pro-active approach to providing straightforward adaptation solutions for their tenants with non-complex needs, without the need for an OT assessment.
• This opens up the opportunity for services and agencies to develop self-selection where appropriate and to explore the meaningful involvement of other staff and professions in the service pathways to ensure a more streamlined, responsive, and effective approach to meeting the adaptation needs of people in our communities.

The Housing Solutions approach and Adaptations without Delay are complimentary, and can be used as a catalyst for improvement. They provide a framework for all stakeholders across Social Care, Health and Housing (and third sector where appropriate) to review current service pathways and agree a strategic operational improvement plan, regardless of the starting point.

Working in partnership

An example Partnership Joint Protocol for Housing Solutions & Adaptations has been developed as a good practice tool to help partners embark on their strategic improvement work and some partnerships in Scotland have already utilised this to help them work with a wider range of stakeholders with the aim of taking forward service improvement.

The Housing Solutions approach can assist partners to collectively agree their policy in relation to circumstances which may sit outside current legislation or guidance. For example, health & social care partners require to clarify their policy in terms of supporting people in their communities who may live in a mobile home as their permanent residence. There are a range of historical issues with adapting these properties as these types of homes do not hold a title, and therefore this prevents the provision of grants, under current housing legislation.

Given the diverse range of organisations who may be involved in supporting peoples housing needs, it is essential that partnerships develop strong links with all relevant stakeholders and partners.

• In order to deliver an efficient service, front-line assessors should have clear referral routes and contact points for progressing cases and seeking professional advice. To further avoid any unnecessary delay it is essential that contact with other services, and external organisations is made as quickly as possible.
• To help facilitate this process IAs should work closely with their local housing partners to help develop fast track referral routes and pathways for housing solutions and adaptations, and should also develop local protocols, to ensure consistent and co-ordinated working practices between all different stakeholder organisations.

Key Actions

• A national Adapting for Change Action Plan should be devised to compliment other policy work, and assist partnerships to drive forward the changes recommended from the original Adapting for Change report by the Adaptations Working Group.
• To assist with the practical implementation of the Adapting for Change recommendations, partnerships should implement Housing Solutions change programmes which assist all relevant partners to develop local Protocols, and deliver training programmes, which effectively promote:
• Early intervention with full exploration of rehousing opportunities;
• Better planning for the delivery of barrier-free housing and an inclusive design/living approach;
• Robust joint governance, which provides a clear strategic direction and supports priority setting;
• Joint finance arrangements which help streamline service improvements (e.g. pooled budgets)
• Equity in the system, applying a 'tenure neutral' approach;
• To address barriers in the system, removing the requirement for grant assistance for owner occupiers and providing 100% funding for the assessed adaptations;
• Removing the need for occupational therapists to provide an assessment for standard adaptations in housing association properties e.g. shower provision; and encouraging 'direct access' arrangements.
• Maximising procurement and recycling benefits to help deliver efficiencies.