Adapting for Change: evaluation

Chapter 4: A broader outcomes-focused service

AWG recommendation: A broader outcomes-focused service with early consideration of overall housing options.

The AWG recommended that services should take a broader, outcomes-focused perspective and, in particular, should look beyond simply providing grant funding or directly undertaking an adaptation. Specific areas that the AWG felt should be looked at included early consideration of alternatives to housing adaptations, enabling people to organise their own adaptations, tackling issues other than adaptations and realising opportunities offered by social rented sector modernisation programmes.

Key research evidence

Early consideration of housing options

The early intervention, housing options ^[15] type approach is one which the housing sector has been looking at for several years, particularly in relation to homelessness prevention. Many key stakeholders within the test sites, and particularly those from the housing sector, were very clear that the approach also offers considerable potential in terms of encouraging people whose needs are changing to give earlier thought to the housing options available to them.

The focus here was very much on the test sites looking for ways to encourage people to consider their housing situation well before any crisis is reached and, potentially, prior to the need for an adaptation. It is not necessarily about avoiding adaptations, but about giving people the time and space to make other choices if they prefer. It could also be about supporting people to consider making anticipatory changes.

There was broad agreement amongst key stakeholders that the early consideration of alternatives is not only in the best interests of the individuals involved, but will also be key to creating a sustainable package of services in which the specialist adaptations function can focus primarily on those in greatest need. Much of the work of the test sites - be it developing pathways (see Chapter 6) or considering options for a one-stop-shop for example - has been taken forward with this in mind.

Accessing adaptations-related information and advice - the service user perspective

Accessing information and advice was a subject about which a number of the service users had significant experience or clear views. This was also an area in which a small number of service users had experience of some of the changes already being made within the test sites. Beyond these direct experiences, many of the issues raised also spoke very clearly to some of the planned changes and the type of impact they might be expected to have.

In most cases a service user's decision to look for information and advice, including as to whether an adaptation could be possible or appropriate, had been at the suggestion of a third party. Although this was often a family member or friend, others cited included: Housing Officers (for social rented sector tenants); GPs; District Nurses; other primary healthcare staff; and home carers. For a small number of those spoken to, the initial conversation had been with a hospital-based OT or social worker, or with a secondary healthcare professional. In other cases, the suggestion had been made by representatives from third sector organisations, such as the local Care and Repair Service.

In a small number of cases the potentially urgent need for an adaptation had related to a hospital admission. This included someone who felt that, in hindsight, having had an adaptation to their home might have helped avoid that admission. This individual had no recollection of an adaptation ever being suggested, despite several health care professionals visiting their home. In another case, a service user had been waiting for an adaptation but there had been delays in processing the grant application.

When service users had the initial conversation with someone other than family or friends, their experiences of being given signposting information was mixed. At one end of the spectrum it had amounted to simply being told to 'ring the council switchboard'. At the other end of the spectrum, staff had made an initial call and/or arranged for someone to contact the service user.

Where the initial conversation was with an organisation with a particular focus or specialism in providing information, advice and support, and especially when it was with a Care and Repair Service, service users tended to report particularly positive experiences. Quick and easy access to an informed and personalised service was greatly appreciated.

This range of experiences points to the need for a wide-range of front-line staff to be able to refer or provide sign-posting information. It also reinforces the importance of the pathways development work being carried out (see Chapter 6). Other issues raised by service users, and which the test sites or other areas might wish to consider in taking their work forward, included:

• Information needs to be available in a range of formats and be accessible to those who prefer to access information electronically and those who do not. Service users occasionally differentiated between the way they would like to receive information, generally in hard copy, and the way those supporting them might prefer to access information, generally electronically.
• Being able to access all the necessary information and, if required, advice through a single access point was a very clear preference. This is discussed further in Chapter 5.

Accessing home move-related information and advice - the service user perspective

In terms of the importance of the early conversation about a possible house move, the experiences of a number of current or former service users pointed to its potential ^[16] . For example, many people noted that they had been aware that their needs, or the needs of a family member, were changing but that they had sometimes been reluctant to act and were not aware of available support. This was usually for a complex range of reasons but often centred around fears of losing control and of being unable to continue living in their current home.

Service users tended not to have given real consideration to moving house, sometimes noting that this could be inevitable at some point, but was not necessary at the moment. Those who had given most thought to their future tended to be living in the mainstream social rented sector and were aware of there being amenity or sheltered accommodation nearby. In some cases, they had discussed their options with a representative of their current landlord.

Those living in the owner-occupied sector tended not to have sought any information about future options. However, many felt that they had the necessary knowledge or experience, or would know where to access information or support if they needed it. This support was generally expected to come from adult children or other family members. A small number of people, and particularly those without family members to call on, identified particular issues about which they thought they might need or would welcome help. These were: finding an appropriate private sector property which would not need significant work to meet their requirements; arranging and overseeing any work that was required; and some of the practical arrangements associated with making a move, including disposing of unwanted possessions.

Only a small number of service users spoken to were living in the private rented sector; their concerns about the future were very clearly focused on being able to find a property which met their needs at a price they could afford. They tended to see socially-rented sheltered accommodation as being their best option but were sometimes reluctant to take active steps towards finding such accommodation. As with many others, this was because they did not wish to leave their current home and/or neighbourhood.

Many of the conversations with service users highlighted that considering future options is a potentially very sensitive issue and one which many people find difficult to think and talk about. Although a small number of service users felt it was something they should be considering, they often felt unready. For some, there was a real dilemma between making a move while they were still in a position to be in control and exercise choice, and a very strong desire to remain within their current, and often much-loved, home. While this range of experiences certainly points to the potential of the early intervention approach the test sites are looking at, it also highlights the need for services to be led by, and sensitive to, the needs and preferences of the individual.

In terms of issues which the test sites or other areas might wish to consider in taking their work forward, the feedback from service users suggests:

• Making significant changes in this area may require approaches which help people to feel more willing or able to initiate potentially difficult conversations.
• It can be very much easier to have a 'difficult' first conversation with someone who is already known to you and who you trust, even if they then suggest you contact another organisation.
• Those without a 'live' network of contacts within either statutory or third sector services are least likely to know where to go if looking for advice. This tended to apply particularly to people living in the private sector and who did not have an option of contacting their social landlord.

Opportunities for positive change

Along with the work around pathways (covered at Chapter 6), many key stakeholders within the test sites - and particularly housing, social care and third sector stakeholders - saw the early provision of the information and advice function as being one of the most important areas of work being taken forward and, generally, as an area in which some significant progress was being made. Examples of changes which were seen as already making a difference included the introduction of 'good conversations' incorporating supported self-assessment, raising awareness of housing options and signposting to available services. This approach was being developed across housing support services to provide guidance at the earliest stage.

For many key stakeholders, ensuring that those working across a range of key frontline services are aware of the various services available will be key to an effective, early intervention approach; there was a frequent suggestion that there is still some work to do around ensuring that staff consider having that initial, housing-related conversation. This was seen as applying particularly, but not exclusively, to those working in both primary and secondary healthcare. However, there was a hope that the new working relationships forged through the AfC process would make it much easier to address some of these gaps.

As noted, housing options was already a key consideration within all test sites and some positive developments were underway. Although generally still at early stages, the test sites' experience to date suggests that:

• Training and information sharing across agencies, and in particular for frontline staff, will be key. The focus of any training would need to vary depending on the package of services to be offered but might, for example, cover the services available and what they do, or give an overview of any self-assessment options available. However, it will be important that any training or other awareness-raising work is on-going. This will not only help ensure that existing staff have up-to-date information but will also ensure that new staff are given the information they need. It should be noted that the ihub has developed and soft tested a package of training which is due to be rolled out across the test sites. The training will be adaptable to the local context.
• There may be considerable potential in improving the quality and range of publicly-facing information available. An up-to-date and accessible package of information can be of use not only to people looking for advice themselves but also their carers or families. It can also be useful for a range of professionals, including front-line staff. This information needs to be accessible for those without access to web-based information.

While the possible benefits of an adaptation or other work to the existing home may be one option to emerge from an early consideration of future needs, for some people a move may be the preferred, most viable or only real option. Again, the one-stop-shop and pathways work was being developed with this in mind as were proposals to develop peer volunteer schemes to assist with decision making. Key stakeholders highlighting this issue also noted that this needs to be a consideration when taking forward any work around refining or standardising assessment processes, including any self-assessment models.

However, a small number of key stakeholders, including housing and social care stakeholders, noted that this early intervention, housing options-focused work will inevitably highlight some wider issues concerning the availability and ease of access to suitable alternative homes. It was an area in which AfC, and other adaptations-related work, was seen as informing, and hopefully influencing, connected agendas. There was a particular hope that the wider housing stock's readiness to meet varying needs will become an area of interest for the IJBs.

Beyond these wider, housing supply-related challenges, other challenges which had emerged, and about which the test sites (or at least some within them) had been considering how the AfC partners could respond included:

• Ways of helping people to make a move to a home which would still need to be adapted, particularly if this offered the best and most sustainable option in the longer-term. This could include making grant funding available, even if their current home had been adapted and was meeting their immediate need.
• The role of housing allocations policies and approaches. Three specific issues were raised: 1) the extent to which policies recognise wanting to stay in the existing area, even if this is not directly linked to a package of formal or informal support; 2) how those looking for a socially-rented property in an area operating Choice Based Lettings can be supported to find a home which meets their medium to longer-term needs; and 3) Ensuring that people who need to move because their current home is not suitable, and cannot be adapted, have sufficient priority to obtain an offer. This included both applicants who cannot be discharged to their home from hospital and those who have returned home but still have an urgent need for a home which better suits their needs.

Services to support people to organise their own adaptations

The focus here is on services being able to support people who are not eligible for funding, or who do not want it, to organise their own adaptations. People who think they may benefit from an adaptation to their home being able to access expert advice is generally seen as key to this approach.

This was another area in which there was a broad consensus about the potential of this approach across the test sites. One of the test areas was providing advice and assistance to owners who wanted to fund their own adaptations and others were planning to introduce a similar service or were looking at this issue. However, whilst recognising that this approach had the potential to reduce some grant-funded spend, many stressed that the approach should not be driven by this objective. Rather, it was seen as speaking very clearly to the personalisation agenda discussed further in Chapter 5.

The interviews with current and former users of adaptations services, albeit they may not have had direct experience to date, certainly suggests the approach has potential. Issues raised by these users, primarily but not exclusively those living in the owner-occupied sector, included:

• When they had the necessary resources, they would often have been very happy simply to pay, for smaller adaptations in particular. A range of reasons given included that they could afford it and felt that public monies could otherwise be better spent. Others equated paying in full with being able to access a quicker and more flexible service. Others did not wish to undergo an income assessment.
• Those who would have been willing to pay generally felt that being able to access informed and impartial advice was very important. For some this would have been sufficient, whilst others would also have welcomed support in finding a trustworthy contractor and the management of the work.
• Overall, however, the clearest preference was for the work to be carried out by a trusted and known third sector provider, such as the local Care and Repair service. This was often rooted in previous and very positive experiences of using their services.
• Most of those commenting lived in the owner-occupied sector, but a small number of both local authority and housing association tenants also suggested they would have covered the cost of smaller adaptations, particularly if this had meant the work could be done very quickly. They tended to the view that their landlord would still be best placed to carry out the work.

Whilst most key stakeholders, and particularly those from the third sector, were supportive of the concept and principles behind supporting people to organise their own adaptations, there were some concerns about raising an expectation or demand that the agencies on the ground are not able to meet. This was generally a concern about overall capacity and current funding levels. However, there were also concerns about the complexity of the issues which could arise, particularly in relation to any larger works. This was sometimes about any expectation that they would be assisting people to raise funds, including through equity release. Key stakeholders, including from within the organisations which could be delivering such a service, were also clear that an assessment from a specialist OT should still form part of the package of services where larger or more complex adaptations were concerned.

Realising opportunities to adapt housing stock

This issue relates particularly to the social rented sector and how modernisation, upgrading or regeneration programmes could be used to support older and disabled people.

Although not necessarily directly related to AfC, overall, social landlords who raised this issue were alive to the potential of using existing programmes of work to increase the proportion of their stock that can meet varying needs. However, it was also noted that a range of design, location and affordability factors can come into play. In terms of specific adaptations for an existing tenant, again, social landlords sometimes noted that they would try to arrange for the work to be carried out as part of an on-going programme of work, including one that might not otherwise have covered the property in question.

In terms of the examination of practice, or changes to practice, that relate more specifically to AfC, two main opportunities emerged. They were that:

• Landlords may be increasingly looking at ways of making properties easier to adapt, or indeed making it easier and less costly to remove adaptations. The examples cited tended to focus on bathrooms and being able to install or uninstall a wet floor shower option within minimal disruption.
• OTs, and particularly specialist housing OTs, in several of the test sites said that they were getting more involved in the design of new build, or the refurbishment of existing, social rented stock. In some cases, properties had been pre-allocated and designed to meet the needs of a particular service user, whilst also considering how the property might be used to meet the needs of others in the longer-term. The evidence from the test sites suggests there are increasing numbers of formal and informal conversations between representatives of the housing, social care and health sectors around the design of the social rented sector stock.

Increased opportunities for people across a range of organisations and sectors to share ideas, knowledge and good practice around issues such as these has emerged as one of the most positive aspects of the AfC initiative.

Summary conclusions

Much of the work of the test sites has been taken forward with a view to early intervention and encouraging people to consider their options before serious problems arise; the experiences of a number of current or former service users also pointed to the importance and potential of the early intervention approach. They also highlighted the need for services to be led by, and sensitive to, the needs and preferences of the individual.

Along with the work around pathways, many within the test sites saw the early availability of the information and advice function, supporting a preventative approach, as being one of the most important areas of work being taken forward and, generally, as an area in which progress was being made.

While the possible benefits of an adaptation or other work to the existing home may be one option to emerge from an early consideration of future needs, for some people a move maybe the preferred, most viable or only real option. Again, the one-stop-shop and pathways work was being developed with this clearly in mind.

Many of the key stakeholders saw considerable potential in work to support those who wished to pay for their own adaptation. However, there were concerns about overall capacity and current funding levels. Key stakeholders, including from within the organisations which could be delivering such a service, were also clear that an assessment from a specialist OT should still form part of the package of services, especially where larger or more complex adaptations were concerned.