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Adapting The Homes of Older People: A Case Study of Costs and Savings
Adapting The Homes of Older People: A Case Study of Costs and Savings
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Adapting the homes of older people: A case study of costs and savings
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6 authors, including:
Anthea Tinker
King's College London
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1
School of Construction Management and Engineering, University of Reading, Reading RG6 6AW, UK
E-mail: p.r.lansley@reading.ac.uk
2
Institute of Gerontology, King’s College London, London SE1 9NN, UK
3
Centre of Rehabilitation Engineering, King’s College Hospital, London SE5 8RX, UK
Meeting the demand for independent living from the increasing number of older people presents a major challenge for
society, government and the building industry. Older people’s experience of disabling conditions can be affected by the
design and layout of their accommodation. Adaptations and assistive technology (AT) are a major way of addressing this
gap between functional capacity and the built environment. The degree of adaptability and the differences in the average
cost of adaptation of different types of property are large and there is major variation within property type. Based on a
series of user profiles, it was found that a comprehensive package of adaptations and AT is likely to result in significant
economies arising from a reduction in the need for formal care services. This finding is sensitive to assumptions about
how long an individual would use the adaptations and AT, as well as to the input of informal care and the nature of
their accommodation. The present study, which focused on social housing, has implications for how practitioners
specify ways of meeting individual needs as well as providing a case to support the substantial increase in demand for
specialist adaptation work.
Keywords: adaptations, ageing population, assistive technology, benefits, care services, costs, demographics, disability,
older people, public policy, quality of life, social housing, UK
Répondre à un nombre croissant de personnes âgées qui demandent une plus grande autonomie est un défi majeur que
doivent relever la société, les gouvernements et l’industrie de la construction. La vie de ces personnes qui connaissent des
conditions invalidantes peut être affectée par la conception et l’aménagement de leur logement. Les adaptations et les
technologies d’aide (AT) apportent des solutions intéressantes qui permettent de combler l’écart entre la capacité
fonctionnelle et le milieu bêti. Le degré d’adaptabilité et les différences de coût moyen de l’adaptation des différents
types de propriété sont importants et on note des variations majeures dans les types de propriétés. En s’appuyant sur
une série de profiles d’utilisateurs, on a constaté qu’un ensemble complet d’adaptations et de technologies d’aide était
susceptible de déboucher sur des économies non négligeables dégagées par la diminution du besoin en services d’aide
officiels. Ce résultat est sensible aux hypothèses sur la durée des périodes pendant lesquelles une personne aurait
recours aux adaptations et aux technologies d’aide ainsi qu’aux apports de soins officieux et à la nature des
logements. Cette étude, axée sur les logements sociaux, a des implications sur les méthodes spécifiques utilisées par
les praticiens pour répondre aux besoins des personnes et pour proposer une action en faveur de l’augmentation
substantielle de la demande en travaux d’adaptation spécialisés.
Mots clés: adaptations, population vieillissante, technologie d’aide, avantages, services d’aide, coûts, démographie,
incapacité, personnes âgées, politique publique, qualité de la vie, logements sociaux, Royaume-Uni
Building Research & Information ISSN 0961-3218 print ⁄ISSN 1466-4321 online # 2004 Taylor & Francis Ltd
http: ⁄ ⁄www.tandf.co.uk ⁄journals
DOI: 10.1080/0961321042000269429
Adapting the homes of older people
AT, the relative costs of adaptations, AT and formal people aged over 70 years who had major adap-
care, and the acceptability of adaptations and AT to tations to their homes or AT provided.
older people provided the principal motivation for
undertaking the study. . Analysing and integrating the materials, and
reporting findings to the housing providers, advi-
The study comprised nine major overlapping activi- sory committees, older people and more publicly.
ties:2
. Reviewing a diverse range of publications, techni- Understanding user needs: user pro¢les
cal literature, policy documents, legislation and Using disability prevalence data for older people
regulations relating to older people, health, (Martin et al., 1988; Grundy et al., 1999), seven
housing provision, adaptations and AT. ‘typical’ user profiles were created. Each covered a
spectrum of disabilities and included a detailed descrip-
. Understanding the range of adaptations that may tion of the user’s functional capacity and a list of adap-
be required and equipment that might need to be tations and AT to address their needs. Each user profile
installed (such as stairlifts) and accommodated was envisaged at two points in time, five years apart,
(such as wheelchairs and scooters) to meet the with a deterioration of functional abilities between
needs of older people as well as smaller personal the first and second periods. As an example, Table 1
items (such as adapted cutlery, special beds and provides a detailed description of the health and
mattresses). impairments of User Profile 3, and Table 2 details the
requirements of this user in terms of the potential adap-
. Developing ‘typical’ user profiles that could be tations and AT. These requirements were subsequently
used to benchmark the adaptability of individual used to investigate whether specific properties could be
properties, ranging from users with quite modest adapted to meet the needs of User Profile 3. Table 3
needs to users with very complex needs, and associ- summarizes the health and functional impairments of
ating with each of these the required adaptations the seven hypothetical users; Table 4 gives details of
and AT. the adaptations and AT specified in the complete set
of profiles.
. Developing methods for auditing properties and
assessing the extent to which they could be
adapted and estimating the costs of meeting the Building issues
needs of each ‘typical’ user profile. There is surprisingly little published information about
the adaptation of the home to meet the needs of older
. Creating a methodology for assessing the formal and disabled people. Most guidance applies to new
care input that the ‘typical’ users would need for building work (Goldsmith, 1997; Carroll et al., 1999;
different scenarios, e.g. with different levels of pro- DETR, 1999; Housing Corporation, 2000; BSI,
vision, and, within the context of these, different 2001). Whilst this guidance gives examples of what
levels of informal care (e.g. from family and can and should be built without any restrictions on,
friends); costing these different care scenarios and for example, space and building materials, it is not
then combining them with the cost of the adap- directly applicable to existing properties. Design gui-
tations and AT. dance specifically developed for application to existing
properties is not available on a national basis, although
. Developing a methodology for capturing the local authorities have drawn up their own guidelines
experiences and opinions of older people who (e.g. London Borough of Tower Hamlets, 2001a, b).
have had adaptations to their homes and have
been provided with AT. One of the main issues in using design guidance devel-
oped for new properties is the frequent reference to
. Identifying and negotiating with suitable providers ‘sufficient space’ and ‘reasonable provision’ without
of social housing, both local authorities and reference to any dimensions (e.g. Carroll et al.,
housing associations, to participate in the research 1999). Whilst specific design guidance exists for
by providing properties to be surveyed and access many items considered by the study such as thresholds,
to residents. door widths, corridor widths, sizes of lifts, ramp gradi-
ents, handrails, hoists, and heights of switches and
. Undertaking field work in ten housing providers sockets, there is only general guidance for key items
(five local authorities, five housing associations) such as bathrooms and newer products like intercoms,
distributed across the UK, comprising meetings lighting, alarms and smart home technologies.
with key figures in each provider, audits of 82 The researchers developed a set of specifications to
properties and face-to-face interviews with 67 supplement this guidance. Critical parameters were
470
Adapting the homes of older people
Table 1 User Pro¢le 3: Health and functional impairments initially and ¢ve years later
Background Mrs D is 75 years old. She has been diagnosed as Mrs D is 80 years old. Her mobility has decreased
having chronic obstructive pulmonary disorder due to diminished lung function and a large
for approximately ten years. Her breathing has increase in weight. Degenerative arthritis has
become increasingly dif¢cult, which affects all affected her other impairments.The overall
her activities. Due to an operation, she has a effect is that her activities of daily living are
reduced range of movement and strength in her extremely dif¢cult
left arm and hand
Locomotion Mrs D cannot walk further than 50 yards without Mrs D cannot walk up and down a £ight of 12 stairs.
stopping or without severe discomfort. Mobility Mobility within the home: Mrs D can move
within the home: Mrs D moves through her through the house unaided but needs to stop
home unaided, stopping for a rest when short of and rest often to regain her breath.When her
breath. Mobility outside the home: Mrs D needs breathing is very bad, she uses a manual
assistance to travel to the local shops, attend wheelchair to move around the house. Mobility
doctor’s appointments or visit friends outside the home: Mrs D leaves the house less
often than before but still uses her scooter to
reach local facilities such as shops
Dexterity Mrs D can turn a control knob or taps with one Mrs D has dif¢culty wringing out light washing or
hand, but not with the other using a pair of scissors
Hearing No problems No problems
Seeing No problems No problems
Reaching and Mrs D cannot hold one arm out in front or up to her Mrs D has dif¢culty raising either hand above her
stretching head, but can with the other arm head to reach for something
Continence No problems No problems
Transferring Changing posture leaves Mrs D breathless Mrs D can transfer to and from her wheelchair
unaided, but with dif¢culty
Personal care Getting in/out of bed: Mrs D can perform this task, Getting in and out of bed: Mrs D needs help with
although she prefers to sleep propped up to her changing position and can no longer
prevent coughing and ease her breathing.The perform this task unaided due to the change in
effort of moving from lying to standing leaves her reaching impairment, lung function and
her short of breath. Bathing: Mrs D can perform size. Bathing: Reaching, dexterity and lung
this task, although moving from sitting with legs function makes this task painful and dif¢cult to
extended to standing in a con¢ned space is complete. Dressing: Although achievable, this
dif¢cult because of her reaching impairment is a task that takes an increasing amount of
and the physical effort involved. Dressing: Her time.Toileting: Mrs D ¢nds getting on and off the
reaching and dexterity impairment makes toilet dif¢cult due to her reaching impairment,
certain items problematic, but manageable size and painful knee joints
Toileting: No problems
Activities of daily Food and nutrition: Mrs D can prepare her own Food and nutrition: Mrs D can still prepare food for
living (ADL) meals, although these tasks take longer meals, but she takes increasing amounts of
because of her dexterity and reaching time and effort due to her size and the reduction
impairments. Shopping: Mrs D has great in her range of movements Shopping: Mrs D
dif¢culty shopping and is largely dependent on can manage to take part in this activity,
some assistance or by using only very local although she is less independent because of
shops. Housework and washing: Mrs D can her reduced stamina and increased reaching
perform these tasks, although less frequently and stretching impairment. Housework and
and rigorously, due to her reduced activity washing: Mrs D requires assistance with these
capability and her dexterity impairment tasks, but can perform some light activities (e.g.
dusting, tidying) independently
Overall Mrs D can manage all the above activities to a Mrs D is now less independent.The provision of
degree.The provision of assistive technology assistive technology enables her to perform
increases the opportunity to take part in an some personal care tasks without the need for
activity (e.g. a scooter for social interaction), human intervention (e.g. getting out of bed,
reduces the time and effort involved (e.g. dressing and bathing)
cleaning, cooking) and in some instances
increases safety (e.g. bathing)
identified below or above which specific adaptations these specifications could be applied routinely, others
would be required in response to particular user needed careful interpretation. For example, although
needs. The parameters were developed from the work minimum dimensions were determined for wheel-
of others and published guidelines, with advice from chair-accessible bathrooms, some bathrooms failed to
practitioners helping to ensure that the parameters meet the required width, but were much bigger in
reflected good but pragmatic practice. Whilst some of terms of area, requiring particularly careful analysis.
471
Lansley et al.
Table 2 User Pro¢le 3: Adaptations and assistive technology (AT) required initially and ¢ve years later
Mobility limitations create significant structural location. Others may need to use an indoor wheelchair
demands on properties and generate major costs but may be able to transfer to a stairlift rather than
in terms of adaptations (such as enlarged bathrooms, requiring a vertical through-floor lift. Some wheelchair
widened corridors and ramps) and fixed AT to users will require a wheelchair-accessible shower or
be installed (such as stairlifts and through-floor lifts). bathroom, but others will not.
Other physical and sensory impairments can generally
be catered for with minimum attention to the design
and construction of the property, and at a fraction of Costing the adaptations and AT
the cost (e.g. the use of colour contrasting décor, Most previous studies of the cost of adaptations have
raising electric sockets or installing visual doorbells), been based on surveys of the costs incurred by, for
although the AT associated with some of these disabil- example, local authority housing departments (Ernst
ities can be costly. The mobility-related demands on a & Young, 1994; Netten and Curtis, 2003). Other
property are not limited simply to whether or not a work has concentrated on user needs and the technical
property is accessible by wheelchair. Older people issues of adaptation, and the costs may not be represen-
have a wide range of mobility needs. For example, tative of a more general situation. Despite the caveats
some may use an outdoor electric wheelchair and be they often attract, two price books concerned with
ambulant inside, and so only require a wheelchair- adaptations and small works (RICS, 2001, 2002)
accessible entrance and good circulation to its storage provided a basis for the development of a family of
472
Adapting the homes of older people
Table 3 User pro¢les: health and functional impairments of the hypothetical users initially and ¢ve years later
Note: 1. Average life expectancy (years) from current age. Source: Of¢ce of National Statistics (2002, table 5.22).
Table 4 Summary of building adaptations and adaptive technology (AT) considered in the pro¢les
473
Lansley et al.
estimated costs for straightforward adaptations (such Table 5 Comparison of sample with national statistics
as replacing a bath with a shower) and were consulted
for the estimation of the costs of more complex Category Present study Survey of
packages of work (such as rebuilding a bathroom). English
housing,
Manufacturers provided information on the cost of 1999^ 2000 (%)
supply and installation of specialist equipment, main- Number %
tenance and replacement costs, design life, removal
costs and recovery values. Some comparisons with Small terrace 6 7.3 6.9
housing providers undertaking similar work showed houses
that initial comparisons were acceptably close except Medium and large 6 7.3 7.4
terrace houses
for bathroom-related packages. Alignment was Semi-detached and 3 3.7 13.7
achieved after the providers’ specifications for all bath- detached houses
room adaptations were adopted. Bungalows 14 17.1 21.4
Flats in converted 5 6.1 1.4
houses
Some costs were excluded. Remedial work was separ- Flats in low-rise 32 39.0 39.6
ated from adaptation work. Potential ‘knock on’ blocks
effects of adaptation were impossible to assess, e.g. Flats in high-rise 16 19.5 9.6
the need to replace all wiring, radiators and pipe blocks
work to accommodate increased loads or because Total 82 100 100
detailed investigation might reveal the electrical, gas
or heating system to be inadequate or unsafe. Estimates Source: Of¢ce of the Deputy Prime Minister (2003b), Social Housing
Sector, head of household 65 and over, Special Analysis by ACIOG, King’s
did not include any allowance for the overheads that College London, 2003.
would be incurred by, for example, an occupational
therapist when assessing the needs of an older person,
or a surveyor considering the adaptations required to
meet the occupational therapist’s recommendations.
Providers suggested overheads between 20 and increase in user requirement, more properties were
100%, some substantially more than this figure, par- found not to be adaptable. The simplest profiles
ticularly for small-scale adaptations. required the addition of grab rails, lever handles to
all doors and exterior lighting to entrances, hardly
The properties exacting requirements, which all properties could
Eighty-two properties were audited. They were accommodate. At the next levels various, additional
broadly representative of the range of accommodation needs were introduced, e.g. an over-bath shower, a
occupied by older people owned by the housing provi- level-access shower, further grab rails, ramps and
ders. Half of the properties were classified as sheltered rails, scooter and wheelchair storage, wider external
housing (using the definitions used by the Department doors, stairlifts in two-storey properties and com-
of the Environment; McCafferty, 1994) and of these munal lifts in flats with communal areas. At subsequent
about half were conventional mainstream properties levels, there were more challenges, e.g. the need for
in which community alarms and grab rails had been wider corridors and a wheelchair-accessible shower
installed but without other adaptations. When com- room with gully shower. At the highest level, there
pared with national statistics, the types of properties was the need for a wheelchair-accessible bathroom,
under-represented (semi- and detached properties) a through-floor lift and a fixed hoist from bedroom
were those that are more easily adapted (e.g. due to to bathroom. At this level, only 43 properties were
more generous internal space standards and external adaptable.
space available for ramps, lift shafts, extensions and
similar requirements). Over-represented properties Discussions with healthcare specialists suggested that
included those difficult to adapt, for a wide variety of a desirable level of adaptability would be meeting
reasons, e.g. flats in converted houses and properties the needs of an individual who uses a wheelchair or
in some high-rise blocks (Table 5). The sample under- scooter outside the home and a wheelchair inside, but
represented properties built between 1945 and 1964 who can transfer to a stairlift. This would include the
and over-represented properties built before 1919 occasional wheelchair user, whereas a permanent
and from 1985. wheelchair user is likely to need a through-floor lift.
The proportion of properties meeting these require-
ments varied greatly between, on the one hand, bunga-
lows, and ground- and upper-floor flats in both
Findings: feasibility low- and high-rise blocks, of which 96% could be
Adaptability adapted, and, on the other hand, other types of
All 82 properties could be adapted to meet the require- property, largely those with two stories, of which
ments of the most modest user profiles. With each only 68% could be adapted.
474
Adapting the homes of older people
Lansley et al.
Table 6 Number of properties that could be adapted and average total cost of adaptations and ¢xed assistive technology for each user pro¢le
User pro¢le All property types Small terrace house Medium/large Semi detached Bungalow Flat in converted
terrace house house house
n » n » n » n » n » n »
n 82 6 6 3 14 5
1c 82 994 6 1158 6 1 406 3 1158 14 853 5 1 207
1f 71 11 391 5 15 990 4 14 883 3 13 867 13 9 826 0 ^
2c 64 15 354 4 23 746 4 24 881 3 19 549 13 14 003 0 ^
2f 43 18 954 3 24 760 1 25 631 2 27 557 10 18 437 0 ^
3c 77 6 360 6 7 830 6 9 913 3 6 722 14 3 891 2 6 205
3f 72 9 792 5 12 469 4 14 346 3 10 857 14 8 173 0 ^
4c 82 748 6 966 6 1 214 3 966 14 661 5 924
4f 78 9 867 6 12 008 6 14 600 3 11 315 14 7 686 3 13 220
5c 82 4 804 6 5 495 6 5 678 3 5 934 14 4 465 5 5 285
5f 77 15 553 6 18 787 6 21154 3 18 321 14 12 892 2 15 903
6c 78 4 116 6 5 451 6 6 448 3 4 372 14 1 887 3 2 215
6f 78 8 576 6 10 157 6 12 701 3 9 402 14 6 992 3 11 586
7c 77 3 577 6 5 001 6 6 433 3 4 143 14 1 634 2 3 024
7f 71 14 364 5 18 791 4 17 561 3 16 678 13 13 429 0 ^
Ground £oor £at Maisonette Upper £oor £at Ground £oor £at Maisonette Upper £oor £at
n » n » n » n » n » n »
n 15 5 12 4 3 9
1c 15 881 5 878 12 961 4 923 3 1140 9 939
1f 13 8 223 5 13 731 12 11 407 4 8 327 2 22 060 8 11 705
2c 8 11 079 1 20 818 12 13 446 4 11 790 2 29 790 8 14 320
2f 15 14 308 0 ^ 8 18 066 4 15 499 1 41 583 6 18 843
3c 15 4 208 5 10 389 12 6 862 4 5 098 2 14 441 8 6 192
3f 15 6 797 5 14 854 12 9 807 4 7 454 2 16 962 8 10 085
4c 15 598 5 686 12 655 4 702 3 872 9 645
4f 15 6 983 5 12 796 12 9 924 4 8 226 2 17 671 8 9 093
5c 15 4 598 5 4 408 12 4 581 4 4 410 3 5 302 9 4 515
5f 15 12 626 5 19 890 12 14 997 4 13 306 2 25 136 8 14 796
6c 15 2 302 5 5 969 12 5 494 4 2 098 2 13 304 8 4 774
6f 15 5 746 5 11 437 12 8 734 4 7 180 2 15 828 8 7 801
7c 15 1 302 5 7 055 12 4 210 4 2 213 2 12 604 8 3 263
7f 15 10 903 5 17 922 12 14 224 4 10 230 2 24 814 8 14 577
Services Full formal care (provided in conjunction Reduced formal care (provided in
with basic adaptations and assistive conjunction with either augmented or
technology) maximum adaptations and assistive
technology)
Hours per day Hours per week Hours per day Hours per week
Note: Within each category of home care, costs vary according to services required.
capital value (termed present value). A discount rate of omitted because for this profile the basic and augmen-
3.5% was used following recommendations from ted packages are replaced with residential care. Similar
H.M. Treasury made in late 2002 (H.M. Treasury, relationships between the costs are revealed when con-
2003). However, other discount rates did not have a sidering non-resident informal care situations.
substantial influence on the outcome.
Although these analyses should be interpreted with
Figure 3 shows the average present values for ten years care because of the assumptions involved, a number
for the combined cost of adaptations, AT and formal of conclusions follow. These are based on comparisons
care for the three packages assuming no informal of the costs that would be incurred by a combination of
care, for six user profiles. User Profile 2 has been housing, social and health services over ten years. They
do not include estimates of the value or cost of informal
care:
. For all profiles (except for User 2) and combi- Older peoples’ views and experience of
nations of informal care, savings result from the adaptations and AT
introduction of care-reducing adaptations and
The final section of the present paper is to summarize
AT, that is the augmented package. These savings
older people’s views of adaptations and AT, based on
vary but are of the order of £10 000– £27 000
interviews with 67 people aged over 70 years. The
over the ten years.
respondents had varying disabling conditions, some
quite modest but many very severe, and they had a
. Whilst these savings are reduced when the good-
range of adaptations and AT, mostly traditional. Posi-
practice adaptations and AT are introduced under
tive comments about the value of adaptations and AT
the maximum package, to between £3000 and
far outweighed negative ones and were associated
£24 000, these can be funded by the savings
with the ability of adaptations and AT to enable
achieved through introducing care-saving adap-
control over as many of their day-to-day activities as
tations and AT.
possible. Negative comments were largely concerned
with issues relating to poor design creating difficulties
Costs over varying periods in using the items (e.g. fiddly buttons), poor workman-
ship (e.g. incorrect positioning of grab rails) and
The period of use of adaptations and AT and care services
reliability (e.g. smoke alarms that went off too easily,
has an important bearing on the outcome of any com-
and stairlifts that broke down).
parison. Generally, savings begin between the sixth and
ninth years. User 2, under the assumption of a co-resident
The most important comments, however, were those
carer, achieves savings much earlier, but there are none
about emancipation from functional limitations pro-
when there is no carer. Users in easily adapted accommo-
vided by, for example, stairlifts, which enabled indi-
dation achieve savings two to three years earlier than
viduals to go up and down stairs as they wanted, and
average, and for difficult-to-adapt properties, savings
showers that afforded privacy to the individual who
are made three to four years later. These points at
when using a bath would need the help of others.
which savings are achieved should not be confused with
The interviews generated a strong body of evidence
the time to recoup an investment in adaptations and
about the contribution that adaptations and AT
AT through reducing formal care costs, which is generally
could make to the quality of life and feelings of well
between one and three years for the care-reducing
being, not least because they enhanced the indepen-
adaptations and AT, and between two and five years
dence that many of the respondents wanted to retain
for good-practice adaptations and AT. Consideration of
for as long as possible, preferably in their present
users’ estimated expectation of life, using current life
homes. Some comments made during the interviews
expectation data (Office of National Statistics, 2002,
illustrating various aspects of the design of homes
table 5.22), suggests that on average savings are achieved
and the benefits and otherwise of adaptations and AT
in a period less than the average life expectancy.
are given in Table 8.
In practice, there are a number of reasons why the costs
might be overestimates. Most individuals are unlikely
to want all the recommended good-practice adaptations
and AT; equipment usually lasts longer than the design Other bene¢ts
life assumed; and the earlier that adaptations and AT Other implications flow from this greater indepen-
are provided, the greater the likely savings. In this case, dence. Arguably, the rate of decline of physical and
comparison between the augmented and basic packages mental health is reduced and so the time at which the
may be more appropriate. This shows that for most individual needs additional care, adaptations or AT
combinations, savings are achieved in periods shorter or has to enter a residential or nursing home may be
than three-quarters of the average life expectancy. delayed. As has been shown, the cost of residential
care is much higher than the cost of packages con-
However, there is a danger of focusing too strongly on sidered in this study, except for the situation where
financial cost–benefit analysis as other issues are the individual is very disabled.
equally important, especially those relating to indepen-
dence and quality of life, and an even bigger danger of Adaptations and AT not only contribute to the general
over interpreting individual cases. Rather, the value of well being of an individual, but also contribute to the
these analyses is to suggest that overall there are no safety and security of older people in their homes and
unexpected or worrying cost implications arising enables them to summon help more quickly. These
from a policy of encouraging the more widespread too should have implications for cost savings through
adoption of adaptations and AT. Indeed, adaptations the reduction in accidents, especially falls, and the con-
and AT may provide an opportunity to contain care sequent hospitalization and subsequent institutionali-
costs, which are increasing as a result of greater longev- zation. This study has not attempted to estimate these
ity and a rise in the absolute number of older people. savings, but they could be substantial (Mann et al.,
479
Lansley et al.
Table 8 Some comments by respondents about their homes, adaptations and assistive technology
Housing facilities ‘A lot of these £ats have got small baths . . . All right, they’ve given me a seat, across, but I’ve still got the
problem of getting my legs in. And it is getting a problem. I’ve asked the Manager, and we’re hoping that
Age Concern will do something about that I want the bath taken out and a shower putting in.’Cos it’s the
bath that’s the problem.It’s so high . . . I’ve not been able to get in a bath for years’. Mrs Steller, aged 71, has
arthritis and a slipped disc
Housing design ‘It’s a bit awkward.You can’t get the chair into the toilet. So . . . I get close to the toilet as I can, and he has to
grab hold of one rail, try and force himself up, and grab hold of . . . it sometimes takes about 20 minutes
doesn’t it? . . . ’ Carer of Mr Bernard, aged 86
Technology design: ‘It’s all right if you’ve got nimble ¢ngers, but that lady who showed me how to work it, it was all right, because
fall detector she’s got nimble ¢ngers, but I haven’t. See, it comes out and it stands on that wee stand up there . . . I says
to her when I put it on, you talk about Spiderwoman, I says I feel like her [chuckles] I look it . . . it is a good
thing if you fall and you’re helpless, or even if you feel dizzy and you don’t feel steady on your feet. I would
say it’s a good thing . . . ’ carer of Mrs Shanks, aged 84
Reliability: vertical lift ‘[We use the lift] morning and at night, like.Twice a day you can say. And, what is it, I think it’s twice on a
Friday and twice on a Monday ^ that’s shower day . . . They’re a good thing, I’ll give that you, but you want
it in working condition don’t you? . . . Social services should come and check it to make sure that it is a
perfect ¢nish. Especially for one of them to go on (the lift).’ Spouse carer of Mrs Black, aged 81
Reliability: stairlift ‘Anyway the last time it went ¢nally at the top of the stairs . . . So anyway, a man came last week, he was
here for ¢ve-and-a-half hours . . . and then all the fuses blew . . . And when he looked at the wiring, he
found it was only telephone wire, instead of proper. So he had to solder them all up and put some
insulating in . . . Anyway he got it going to the fact it would go up, but it wouldn’t come down.’ Mrs
Morrison, aged 83
Some negative ‘Sometimes the smoke detector is a blessed nuisance . . . if we put the grill on.’ Mrs Bradley, aged 76
experiences ‘There is a problem with the community alarm.When they speak to Mrs Joyce it’s not loud enough, and she
can’t hear them.’ Carer of Mrs Joyce, aged 86
‘I can’t use the shower stool because I slip off . . . ’ MrsTodd, aged 75
‘That hoist’s a waste of time, isn’t it?’ Carer of Mr Bernard, aged 86
Positive experiences ‘Now, if it weren’t for those bed levers I wouldn’t be able to turn over on my own.’ Mrs Clark, aged 79
‘I couldn’t use the taps before.’ Mrs Parkinson, 70
‘You see how wonderful the Window opener is.’ Miss Carr, aged 81
‘I wouldn’t be without that shower’ Mrs Knight, aged 75
‘The door-entry system is a very good thing.’ Mrs French, aged 85
‘The community alarm is a Godsend, it is really.’ Mr Castle, aged 85
Bene¢ts ‘Oh the shower’s great for me. Makes us independent, y’know. It’s great for me. I can more or less do it
myself. No, I couldn’t do nothing, if I hadn’t the shower.’Cos I couldn’t get in and out of the bath.’ Mrs Royle,
aged 77
‘Well I mean my (stair)lift is a lifeline to me really. I could never go up. I would have to have a £at if I hadn’t got
that. I’d hate to leave my little house,’cos I like it.’ MrsTate, aged 79
1999). Clearly, if as a result of the provision of adap- estimates of the relative costs of different care strat-
tations and AT for whatever reason an individual’s egies. The approach could easily be modified to
entry into a residential home is delayed, savings reflect the characteristics of different housing stocks
would accrue and the potential burden on healthcare and sources of funding of adaptations and AT.
budgets reduced. Through incorporating national profiles of the charac-
teristics of housing and older people, this approach
More generally, these savings would add to the many could benefit strategic debates on future types of
other benefits that would ensue from enabling older housing and healthcare provision.
people to remain in their own homes with the enhanced
prospect of arresting further deterioration, and pro-
moting the capacity to maintain independence. The Conclusions
achievement of this level of independence is being A methodology has been introduced for auditing, analys-
sought especially by those societies confronted by a ing and costing the adaptation of properties including
rapid growth in the number of older people, limited the provision of fixed AT to meet the needs of older
healthcare budgets, a declining level of informal care, people and an approach to comparing the costs of
and a demand for better quality of life and higher packages of care, adaptations and AT. The methodology
levels of inclusion of older people in society. involved the development of two explicit sets of assump-
tions. One concerns the dimensions, space and configur-
Whilst social housing and healthcare systems vary ation that enable decisions to be taken about the nature
greatly between countries, the methodology summar- of the adaptation and its installation. The other is con-
ized in this paper provides a way of developing cerned with the constituents of packages of care.
480
Adapting the homes of older people
The need to adapt properties and the extent of work ensuring that these are occupied by those people
required to achieve the adaptation necessary to meet likely to need adaptations, whilst at the same time
the specific requirements of a user varies greatly both avoiding placing older people in difficult-to-adapt
between and within property types. The main influence properties.
on the extent of adaptation required is determined by
mobility needs, which principally incorporate the use These conclusions provide some pointers to the way in
of mobility aids when getting into a property, moving which UK policy-makers could encourage the wider
around, moving to upper floors, and using bathrooms adoption of adaptations and AT. First, they suggest
and shower rooms. Limitations in space within a prop- that in many situations, adaptations and AT could be
erty affect the adaptability of a property as significantly an attractive substitute to the provision of home care,
as factors relating to property type or construction although not always eliminating the need for it, and
type. Thus, when the cost of adapting an individual in more extreme cases of residential care. This option
property is considered in place of an average, cost effec- has advantages in terms of both cost to government
tiveness can be quite different. Clearly, knowledge and the enhancement of quality of life of the individual.
of the unique characteristics of a property is important Thus, they lend support to what both government and
to understanding the likely cost of the required adap- society see as desirable as an approach to supporting
tations and the potential savings. older people and specifically to the positive develop-
ments that are occurring at a national level, such as
As user needs become more extensive and complex, so increased recognition of the centrality of housing to
the costs of adaptation rise and more properties are community care policies, the development of inte-
encountered that cannot be adapted to meet user grated community equipment, the awareness of the
needs. So, although the differences in feasibility of importance of adaptations and increased funding for
adaptation and the cost of adaptation are not substan- AT. Second, they indicate that if the wider adoption
tial where user requirements are modest, the differ- of adaptations and AT is to be effective, then there
ences are significant where users need to use a needs to be a strengthening of the knowledge and
wheelchair inside the home and for more complex skills of health and housing professionals directly
user needs, e.g. the need to use a hoist for transfers. involved with older people and the adaptation of
Except for extreme cases, the provision of adaptations their homes. Third, the conclusions suggest that adap-
and AT combined with formal care to older people in tations and AT should be viewed as integral to commu-
their own homes is much less costly than residential nity care packages and not as useful supplements. This
care, and for many other reasons distinctly preferable. is particularly important when considering new tech-
There are also considerable cost differences between nology. Encouraged by the many positive develop-
different combinations of adaptations, AT and formal ments with smart home and alarm technologies, there
care largely contingent on the role played by informal is a danger of these being seen as separate rather than
carers. as part of a whole range of technology that can help
people stay in their own homes. Yet, often basic adap-
Considerations of cost are dramatically influenced by tations to a home and traditional AT can cost far more
length of use linked to life expectancy. Adaptations than novel technology, which usually meets only part
and AT are most appropriate when considering of an individual’s needs.
the long rather than the short term. This economic
conclusion has to be reconciled with the finding Although the empirical analysis has considered
about the acceptability of adaptations and AT. It is housing and care within the UK, it is likely that the
little use installing a preventive long-term package findings will have significance for those countries
unless the older person sees the various components with similar housing and care services. Indeed, given
as useful and helpful to them at the current time. By that reputedly in the UK the cost of building work rela-
paying attention to the needs of users and the nature tive to the cost of care services is relatively high, it is
of the property in which they live, and provided that possible that for other countries there would be even
the users remain in that property for a reasonable greater advantages to be achieved through policies of
time, then for most users adaptations and AT are wide-scale adaptations and provision of AT. This
very worthwhile in both cost and human terms. This calls for replication of the study in other national set-
cost effectiveness is likely to be enhanced further with tings and cross-national comparisons of costs and ben-
newly developed sensor technologies extending the efits; certainly, the methodology would be appropriate.
opportunities for greater security and independence for Such comparisons would need to include a broader
even more people. The study points towards the investigation of the benefits of adaptations and AT to
need for a sensitive understanding of user needs and the individual, their families and their communities.
of properties so that adaptations and AT can be appro- This would both enable comparison of cultural differ-
priately specified. There is the opportunity to achieve ences in terms of availability and acceptability of par-
considerable savings by identifying properties that are ticular types of adaptation and AT and help to
inherently easy to adapt, and over the longer term counter what otherwise would be a rather narrow
481
Lansley et al.
cost-benefit perspective. Such a broader investigation paper are collectively termed adaptations) and portable AT –
of the context and experiences of users did form part all items of personal equipment used by an individual.
of the study herein, but space has precluded all but a 2
For further details about the study’s methodology, see King’s
small reference to the findings. Importantly, however, College London and the University of Reading (2004).
the study was not able to follow the histories of older 3
All costs considered in the present paper are those that could be
people and the processes leading up to and following incurred in various ways by the social housing provider, social
their adoption of AT. Such longitudinal investigations, services and health services and met by the state. The costs of
working with health and housing practitioners to informal care have not been estimated, nor have contributions
by the individual, for example, towards the purchase of AT.
understand how adaptations and AT are prescribed,
procured and used, would be immensely valuable to
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