Housing Adaptations: Options for Change and Improvement - An Analysis of Consultation Responses

4 views on approaches to organisational delivery

Introduction

4.1 The Working Group concluded that a more fundamental change is likely to be required to tackle some of the underlying issues with the current system to speed up delivery of adaptations and ensure that provision relates to the needs of the individual, rather than the tenure of their home. The Group has identified key themes around different approaches which could be taken:

• Where best should organisational responsibility lie for housing adaptations?
  • Local housing authority;
  • Health and social care; or
  • The individual requiring the adaptation.
• How should housing adaptations be funded?
  • Housing resources;
  • Health and social care; or
  • The individual requiring the adaptation.

4.2 Three questions were asked in relation to approaches to organisational delivery as follows:

Question 4: Which of the three approaches to organisational responsibility (through local housing authority, Health and Social Care Partnerships or the individual) do you believe would provide the most effective basis for the delivery of housing adaptations and the greatest benefits to people who need adaptations? Why?

Question 5: Are there issues or risks with any of the three approaches to organisational delivery that are not covered above?

Question 6: In the context of personalisation, what are the most important things to put in place to ensure that people who need adaptations and their carers are at the centre of the process and have choices?

Views on the three Approaches to Organisational Responsibility (Q4)

Question 4a

4.3 Opinion was varied amongst respondents regarding the most effective approaches to organisational responsibility as set out in the table below. The most common approach amongst respondents related to the local authority taking responsibility (just over one third of respondents) followed by the individual and through health and social care partnerships. Some respondents also felt that a combination of these approaches would prove the most effective.

Question 4a - Views on approaches to organisational responsibility by respondent type (% of respondents)
Respondent Type	Local housing authority	Health & social care	Individual	Through a Combination	Don’t know / blank
Housing associations (n=22)	50	18	14	14	5
Local authorities (n=20)	25	10	20	25	20
Care and repair organisations (n=9)	33	22	33	11	0
Occupational therapists (n=6)	50	17	0	0	33
Other groups & repress. Bodies (n=9)	0	33	56	0	11
Individuals (n=3)	66	0	0	33	0
Total	35	17	22	14	11

4.4 There was some variation by organisation. The local authority approach was most popular amongst housing associations, occupational therapists and individual respondents; the health and social care approach was most popular amongst other groups and representative bodies; whilst the individual approach was most popular amongst other groups and care and repair organisations.

4.5 The regional consultation events for organisations explored the different options for organisational and funding responsibility. Opinion was divided at these events, although having the individual at the centre was considered key as well as consistent and clearly defined national structures and boundaries. At the service user events, the individual approach was favoured as set out in chapter seven.

Question 4b

4.6 Where the respondent preferred the local authority approach, a variety of different reasons were provided. It was felt by these respondents that the knowledge, skills and technical expertise which exist amongst local authority housing officers would continue to provide the best option for tenants. As the strategic housing authority, the local authority approach would also enable greater co-ordination with other related policy areas such a building control, planning and investment in housing for older people. It would also ensure consistency across tenures and enable the development of partnerships at a local authority level;

“We believe that adaptations should continue to come under the scope of the strategic housing authority. The main benefits of this approach are: this will allow a strategic approach to housing adaptations that is consistent across all tenures; many of the structures and processes are already in place and only minor reorganisation would be required; one stop shop approaches could be developed more readily; and the strategic housing authority is best placed to advise on alternative housing options and address imbalances in the supply and demand for housing for older people.” (Local Authority/Local Authority representative body)

4.7 The local authority approach would also represent the simplest option organisationally given the current role in this field and it would take less time than the other options. Finally there would be consistency with existing legislation e.g. local authorities’ existing duty to ensure that housing adaptations needs are met under the Chronically Sick & Disabled Persons Act 1970.

4.8 Some respondents who favoured this option also highlighted issues with the other options; some felt that under Option 2 (health and social care partnerships) there would be a lack of property management experience and it would take the service away from people who are not in the social care system. The health and social care partnerships are also in the early stages of development. In addition, Option 3 (the individual) may be problematic for vulnerable individuals and present a number of practical and budgetary issues.

4.9 Under the local authority approach, some respondents felt that there is still a need for closer collaboration with occupational therapists, care and repair organisations and health and social care partnerships as well as consideration given to incorporating a more person centred approach.

4.10 Where the respondent preferred the health and social care approach, reasons included that the health and social care is founded on person centred principles, so this approach would promote a personalised approach consistent with the integration agenda;

“The Health and Social Care model is felt to offer the most holistic approach. It incorporates the opportunity to ensure the individual and their carer are at the centre of the process, while providing the management structure and support required to facilitate a more equitable, value for money, streamlined service. In line with Health and Social Care Integration as well as SDS principles, a much more holistic approach could be taken to the provision of support to the individual and their carers, allowing for a more preventative approach and better planning for long term management of Social Care and Health services.” (Local Authority/Local Authority representative body)

4.11 Under this option local partners could align adaptations as one part of the overall system of care and support for older people and disabled people and the involvement of occupational therapists would be retained. It may also be easier to arrange major adaptations for clients who are due to be discharged from hospital under this option and it would enable a more preventative focus. Local control would be retained under this option and it provides the management structure and support required to facilitate a more equitable, value for money, streamlined service.

4.12 Where the respondent preferred the individual approach, a variety of different reasons were given in particular that it has the greatest fit with the personalisation and self-directed support agendas. It would deliver the greatest benefits to those needing the adaptations and meet their needs, delivering what works best for the individual. This option would also result in the focus being on the needs of the individual and these would be addressed in a holistic manner, irrespective of tenure and with a single funding mechanism. It was also felt that this option will lead to an improved service being provided by organisations operating in the sector as they will need to respond to what individuals want, provide choice and flexibility and operate within reasonable timescales for the customer;

“The person-centred approach would be the most appropriate means of delivering an improved and more timely response to the needs of individuals. This model sits perfectly with the ‘empowerment’ agenda, in which people are supported to achieve outcomes that best suit their needs and preferences. This would, of course, need to be backed up by an effective and comprehensive resource in terms of information and advice and guidance to take the individuals, their carers and their families through the process.” (Other group/representative body)

4.13 Those who favoured the individual approach highlighted issues with the other options, including the complexity of the local authority system and whether health and social care partnerships are able to administer and co-ordinate the delivery of adaptations effectively within the context of other competing operational priorities.

4.14 Under this option, the individual would need access to high quality independent information and advice to assist them in the process. It was also felt that this approach may not be suitable for all individuals so some form of flexibility may be required in the process.

4.15 Some of the respondents favoured a collaboration approach whereby elements of each proposal combined would provide the most effective basis for the future delivery of adaptations or where local areas decide which the best arrangement to meet specific local circumstances is.

Views on the Issues or Risks with the Three Approaches (Q5)

4.16 The majority of respondents - two thirds - mentioned some risks with one or more of the approaches in addition to those already identified within the consultation document. The main risks noted for each of the approaches are set out below. Some of the risks identified are similar across the first two options (local authority and health and social care). The option which respondents associated the most risks with was the individual approach, reflecting the major change which this represents from the current arrangements.

Local Authority

4.17 A series of risks were identified relating to the local authority approach. The first of these involved individual needs not being met through this approach and the need to ensure that they are at the centre of the process when the approach is lead by a local authority. There were also concerns that as local authority budgets and remits are so wide, funding in this area may become ‘lost’, ‘bogged down in local bureaucracy’ or ‘be used for other local authority expenditure commitments’.

4.18 Other risks included the continued involvement of occupational therapists and care and repair services under this approach. This relates to ensuring that there is a continued involvement of occupational therapists in the assessment process and that their knowledge and expertise in this area is not lost to ensure the best outcomes for the user. Similarly, the ongoing participation of care and repair services in organisational delivery would need to be ensured under a local authority approach. This will ensure that their expertise is not lost and they are able to continue to play a role in sourcing additional funding for both clients and associated programmes which local authorities themselves may be unable to access.

4.19 As this approach is similar to how adaptations are currently organised, there is a risk that some of the issues with the current system highlighted previously (e.g. complexity and funding issues) would remain under this approach. Finally, there may be potential confusion over issues of responsibility between local authorities and RSLs and the need to agree common standards. In addition there could be conflicts of interest for local authorities between their strategic and landlord roles.

Health and Social Care

4.20 A series of risks were identified in relation to the health and social care approach. As with the local authority approach, under this option there was some concern over how a system with health and social care services as the lead body would lead to an increased emphasis on the personalisation and self-directed support agendas and ensure that the individual is at the centre of the process. There is also a need to ensure the ongoing involvement of care and repair services in organisational delivery to ensure that their expertise is not lost and they continue to work well with the social care sector and alleviate some pressure on their services.

4.21 There were various concerns raised regarding budget issues, including that any integrated budget would need to be ring-fenced to ensure that the required outcomes are achievable and that funding for adaptations are not ‘lost’ or ‘diluted’ within the integration process. The lack of continuity in provision was also highlighted - this relates to the need for new systems, policies and procedures to be put in place at a time when the health and social care sector is already undergoing significant change and re-organisation;

“The integration process will produce massive changes across many services including the need for huge financial reorganisation. It is important that adaptations are not ’lost’ or diluted within the integration process.” (Local authority/local authority representative body)

There were some concerns that many health and social care professionals may not have the detailed expertise of housing issues, the delivery of adaptations, housing legislation and the complexities of housing tenure. Linked to this, this option involves the risk that the ‘strategic housing focus is lost’; for example there may be less direct linkages to local housing strategies, allocation policies, the understanding of housing need and demand at the local level, and housing services that would exist through the local authority approach;

“The strategic housing focus is lost which will impact on landlord functions, Local Housing Strategies and the understanding of housing need and demand at a local level.” (Local authority/local authority representative body)

Also, this could result in too much emphasis being placed on the health and care needs of individuals rather than their practical housing needs.

4.22 Health and Social Care services are not best placed to take a ‘housing options’ approach as part of the assessment for adaptations, as this requires detailed knowledge on all local housing providers, housing legislation and the housing market.

4.23 A final risk identified was that this model may deter some people from seeking an adaptation as they don’t wish to be identified as ‘a social care case’ simply in order to access an adaptation.

The Individual

4.24 A number of risks were identified relating to an approach based around the individual, reflecting that issues such as individual budgets represent a major change in approach albeit there is a general acceptance of the need for a focus on the individual in whichever approach is adopted.

4.25 The first risk identified relates to the ability of individuals to manage or control the process. It was felt that some people may be unwilling or unable to commit to the time and responsibility required of them. This is particularly the case where vulnerable individuals are involved and could lead to increased stresses or worries for the individual;

“The individual taking responsibility for the adaptation is laudable, but nearly 30 years of experience has shown me that the majority of clients and their families do not wish nor have the ability to take on this responsibility.” (Occupational Therapist)

4.26 Under this approach there is also the risk that outcomes could be varied and dependent on the ability of the individual to deal with the process. The self-directed support process is still at an early stage and the full issues, risks and successes with this approach are not yet clear.

4.27 Linked to the above, it was felt that under this option the most comprehensive support and guidance would need to be provided, which in turn has resource and responsibility implications. Where the organisation providing advice to an individual also provides adaptation services, there would need to be assurance that there were no conflicts;

“Consolidation of the process around the individual would be a challenge. There would need to be commitment by the individual and not all clients may wish to be involved in the process. Consistency and funding will be issues and the support mechanism would have to be comprehensive.” (Care and Repair organisation)

4.28 A number of funding issues were noted with regards to this approach. This includes ensuring that there are mechanisms in place to ensure that money is being used appropriately, the extent to which the individual would contribute and ensuring that these individual costs do not affect personal care budgets. A particular example was provided which related to how the costs of adaptations to multiple units on a shared site can be allocated to individuals when the adaptations are shared and there is an integration of technologies. There would also need to be clarity on whether there would be any penalties for the individual for the inappropriate use of funds through self-directed support especially where the individual requires further adaptations at a later date.

4.29 A final risk is that under this approach, adaptations will be focused on individual needs to the detriment of strategically planning ahead and a focus on prevention and the ‘plan ahead approach’.

4.30 Some risks were noted which relate to all three options. These include references to the tensions between providing better designed adaptations and achieving procurement savings; the impacts of welfare reform on the ability of individuals to contribute to the payment for adaptations; the different administrative boundaries used by local authorities, health and social care partnerships and RSLs; and the lack of a joint or partnership approach amongst these three options (reflecting the fact that some respondents favoured a combination of the three approaches proposed).

Views on Personalisation (Q6)

4.31 The consultation examined the issue of personalisation and the most important elements which need to be put in place to ensure that people are at the centre of the process. The issues are set out in the table below.

Question 6a What are the most important things to put in place to ensure that people who need adaptations and their carers are at the centre of the process and have choices?
Issue	Number	%
Information, advice and assistance	45	65
Providing choices for the individual	20	29
Transparent assessment process / criteria	19	28
Ensuring that the individual is at the centre of the process	16	23
Other	34	49
Blank	4	6

4.32 The main items proposed relate to the provision of better information or advice, providing choice for the individual and ensuring a transparent process Each of these is considered in turn below.

Better Information / Advice

4.33 Ensuring that the individual (and any carer) involved is provided with high quality advice and information to enable them to make informed decisions was the most common issue noted both in the written responses and at the service user events (see chapter seven). Some of the common themes referenced included having more and better information at regular points in the process, impartial and informed support, and flexible advice and assistance;

“It is important that support is provided to equip people with the necessary information to make these choices themselves and negotiate the legislative minefield. This support must be impartial, professional, and customer focussed.” (Care and Repair organisation)

4.34 In addition, some respondents noted that the personalisation agenda means that advice needs to be tailored and in a range of formats to meet the individual needs of the client rather than generic advice being provided;

“Home visits and a personalised approach are the key, with one service taking the lead. This allows people to communicate and discuss their concerns with a trusted advocate who is experienced and knowledgeable in the field and able to offer and interpret advice and information. It is not enough to provide people with written information or leaflets, as people often want a particular result and do not want to understand the whole process behind it.” (Care and Repair organisation)

4.35 The range of information and advice sought included funding, options for adaptations, and equipment.

Providing Choice for the Individual

4.36 Ensuring that individuals have a wide range of options or choices was considered to be the second most important component of the personalisation approach to adaptations. This involved providing appropriate alternatives to consider and presenting all of the realistic options open to the individual;

“Good housing options: ensuring service users have good information and advice regarding all of the housing options available to meet their long term housing needs; one system/holistic assessment: ensuring that service users’ needs are considered at the same time, by all relevant professionals, and that they are therefore at the centre of understanding all the options available to them - including to meet health, social care and housing needs.” (Local Authority/Local Authority representative body)

4.37 The quote below highlights the need to ensure that clients and carers are fully briefed on options and have choice in the adaptations process regardless of tenure.

“Through the private adaptations the client and their carers are fully consulted and advised through the whole process along with the recommendation and support of the occupational therapists through the care and repair process. To replicate this process across all adaptations would ensure that the client has the choice in the consideration of the adoption and choice of contractor etc.” (Housing Association/Housing Association representative body)

4.38 In addition, it could also involve providing the option of the individual being involved in the adaptations process or it being lead by a client or care and repair organisation.

Transparent Assessment Process

4.39 For over a quarter of respondents, ensuring that there is a transparent assessment process was a key component of a successful personalisation approach to housing adaptations. This involves providing a clear, transparent and appropriate framework for assessment and the establishment of equitable criteria as highlighted in the response below;

“It would be essential to have a fair and transparent model for resource allocation (which would be tenure neutral).” (Housing Association/Housing Association representative body)

4.40 In addition, this means involving carers and individuals closely in this process as well as ensuring that the appropriate knowledge and skills are available at the assessment stage;

“The person and their carers need a face to face individual assessment of need by a professional who is skilled in considering the current and expected long term need. They need to ensure that the person and carers are consulted and given choices within realistic boundaries.” (Occupational Therapist)

Ensuring that the Individual is at the Centre of the Process

4.41 In addition to providing individuals with extensive advice and information, ensuring that individuals are at the centre of the process including consulting with them and taking on board their views was seen as central to the personalisation agenda.

4.42 Consultation was viewed as important at each stage in the process (e.g. the assessment, funding and design). This would help to ensure that the individuals’ needs and personal circumstances are the key driver for each adaptation;

“All clients and carers should be consulted at the very early stages and every option should be put forward to them. The client may be able to help fund a better option than the selected agency can afford.” (Group/representative body)

Other Responses

4.43 A series of other things were referenced as being important to put in place to ensure that people are at the centre of the process. These were:

4.44 Issues relating to professionals/organisations operating in the field include ensuring that they have an up to date understanding of the processes; that they understand that user-led solutions may be very different (and as valid) as professional-led solutions; and their performance is held to account (e.g. through the outcomes focused approach, robust service level agreements and focus on achieving ‘homes for life’ building standards).

4.45 With regards to funding issues, other points raised include personalisation not being used to implement cuts to funding for major adaptations; that resources allocated match the true costs of the installation of the adaptation and not just represent a notional budget; and that individuals are encouraged and given the ability to contribute their own resources if they wish additional features to the adaptation.

4.46 Other points raised include mitigating stress factors for the individual and making services such as care and repair available to clients across tenures.