Scottish Government

Contents

Introduction

Key Facts & Statistics

The Housing Contribution

Financial benefits from providing equipment and adaptations

Case Studies

Annex A

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The dramatic increase in life expectancy is changing the shape of Scottish society, and will necessitate a similar change in the shape of future care provision across the country.

In 1856 the average life expectancy was 40 years. Today it is 84.4 for women and 81.6 for men, and there are now more people over retirement age than children under sixteen. [1]

Research has shown that the majority of older people wish to live independently in their own homes for as long as possible, able to get out and about in their local area and take part in community life.

Suitable housing and housing related support, such as equipment and adaptations, in partnership with other care services, can improve health and reduce demand for more costly health and social care services, enabling the full benefits of other services to be realised. [2]

Assistive technology has been observed to increase choice, improve quality of life, reduce pressure on carers and maintain independence, giving the individual the dignity and independence they desire, and the power to enjoy living in their own familiar environment for much longer.

As a society we are all going to have to do more for ourselves, and for each other. This has implications for all services. The number of people living with long term conditions, or some form of vulnerability, is increasing. Attitudes to risk will have to change and new expectations as to where and how people will live and receive their care and support encouraged.

This paper provides some evidence, in the form of case studies, of the potential savings that could be made through the provision of equipment and adaptations. It is hoped that this evidence can encourage more innovative thinking and encourage partnerships to look at alternative models of care within a community setting.

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The following statistics set the scene for the need to look for alternative models of care that will enable partnerships to meet the increasing demands of our changing society.

Estimated population by age and sex, 30 June 2008

Changing Demographics [3]

• In Scotland, the over 65 population is projected to rise by 21% between 2006 - 2016.
• By 2031 it will have risen to 62%
• The over 85 age group is projected to increase by 38% by 2016
• Rising to 144% by 2031

Considering these demographic changes, any policy with the ability to reduce the cost of health and social care and enabling resources to go further, whilst at the same time ensuring individual independence within a healthy and safe environment for as long as possible, is welcomed.

Falls - The Financial Costs [4]

• 8,033P falls recorded by over 65s at home during 2008/09
• 6,295 of these people were aged over 75
• Up to one third of over 65s suffer a fall each year, costing the NHS an estimated £4.6m per day and £1.7 billion per year. [5]
• The commonest injury from a fall is a hip fracture, affecting approximately 60,000 people per year in the UK at a cost of £1.7 billion to the NHS, and results in up to 14,000 deaths [6]
• In 1999 in England there were 190,000 A&E attendances resulting from falls by people with a visual impairment. The associated costs to hospitals were £270 million. [7]
• 89% of the falls and the majority of costs related to people aged 75 and over. Nearly half (90,000) happened as a direct result of visual impairment (cost £130 million).4

Falls - The Human Costs

The effect of falls on society is not just of a financial nature, for many older people a fall can be a life changing episode. As well as the physical effects of a fall such as discomfort, pain and the possibility of long term disability there are the social and psychological effects to consider. These can include loss of independence, social contacts, confidence and a decreased quality of life

Falls can often result in a 'long lie' for a person who is unable to get up from the floor. This can have potentially serious consequences such as hypothermia, broncho pneumonia and pressure sores. A 'long lie' of 12 hours or more can seriously affect a person's recovery from a fall.

2005/06 Scottish Household Survey [8]

Around a third of all households (34%) contain at least one person with a long-standing limiting illness, health problem or disability.

Households with low net annual income are most likely to contain someone with a long-standing limiting illness, health problem or disability.

• 41% with a net annual income of £6,000 or less, and
• 51% with a net annual income of £6,001 to £10,000

53% of older smaller households and single pensioner households are most likely to contain someone with a long-standing limiting illness, health problem or disability.

Households with at least one person who needs regular help or care because they are sick, disabled or elderly are more prevalent in social rented housing than any other tenure type.

• 54% of local authority/Scottish homes
• 56% of Housing Association/Co-op homes

Just over a third (35%) of adults with a long standing illness, health problem or disability have equipment or adaptations (41% of 60-74 years and 56% of 75+).

The most common forms of equipment and adaptations currently held are:

• Handrails 54%
• Walking sticks/crutches 50%, and
• Bath/shower seats 41%

18% of adults with a long standing illness, health problem or disability needs additional equipment and adaptations (21& of 60-74 years and 19% of 75+)

The most common forms of equipment and adaptations needed are:

• Handrails 23%
• Stairlifts 17%
• Bath/shower seats 17%

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There is much that housing providers can do to improve health outcomes for people and reduce the uptake of health and social care services. For example, by providing more accessible homes or adaptations housing can become a formalised part of the care pathway. The National Housing Federation's report Health and Housing: worlds apart? highlights the contribution of Housing Associations to health and social care. By providing rapid home adaptation services, floating support and step-down services, housing organisations (in England) have played a key role in minimising delayed discharges and avoidable admissions to hospital.

Housing based solutions, such as extra care housing; housing based services for people with dementia - such as telecare - lifetime homes, adapted properties and warders all go some way to reducing the burden on health and social care budgets.

When considering the design of new 'healthy housing' consideration needs to be given to the lighting and ventilation and insulation of the build. It is also essential that properties are accessibly built, and are easier to adapt if the resident becomes ill, disabled or frail with age.

Home modifications in the absence of other interventions may be effective for people with a history of falls. However, it is most likely to be effective when integrated within a wider package of care services that focus on education, exercise, hydration and nutrition. [9] Despite the importance of installing grab rails, lighting stairwells and avoiding hard surfaces, this alone will not reduce falls. [10]

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Money Well Spent: The effectiveness and value of Housing Adaptations, Frances Haywood 2001

1. Reports the findings of a research project, carried out during 1999-2000 by professionals from seven local authority areas in England and Wales, in partnership with the research coordinator and two disabled researchers.
2. Findings are based on direct interviews with 104 recipients of major adaptations and 162 postal questionnaires returned by recipients of minor adaptations.
3. The aim of the project was to gather evidence on the effectiveness or otherwise of large and small adaptations.
4. The following examples relate to major adaptations.

One of the most economical ways of reducing the burden on the public purse is to give timely support to unpaid carers. A total of 39 respondents said this was an outcome in their case. For these 39 cases, the adaptations had been in place an average of 3.57 years (2,227 weeks) and had cost an average of £10,569. If this is broken down into weeks it amounts to an average of £4.74 a week to reduce the burden of care on either a family carer or paid carers - less than the cost of providing one hour's home care.

In [the study] sample there were 13 cases in which the adaptation was benefiting an extra disabled person, and the average time the adaptation had already been in use was 2.7 years. At an average cost of £10,861. This equates to a cost of £6.40 per week for a single person, but only £3.20 if the second beneficiary is taken into account.

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Service User A

Extract from Exploring the Cost Implications of Telecare Service Provision; Newhaven Research: February 2010

Service User A is a 59 year old male who has multiple sclerosis. He lives alone in a property adapted with a ramp, level access shower and a tracking hoist.

A is immobile and uses an electric wheelchair. He has environmental controls which allow him to operate:

• All home entertainment
• Lights and lamps
• Curtains
• Hands free telephone
• Door intercom/door release
• A door opener, which is also linked to a community alarm unit.

A has carer support 4 times a day (2 each time) to aid with washing, dressing, toileting, transferring, food preparation and housework. He has a catheter fitted and a District Nurse attends at least once every 6 weeks to change this. He also has incontinence pads on his bed.

The tables at Annex A summarise the total annual costs of the care package being provided for service user A. Local authority costs are highlighted in yellow, NHS blue and joint costs in green.

The cost of providing the specified care package annually is approximately £42,000, with some £31,000 of the costs falling to the local authority, and £11,400 to the NHS.

If service user A was not being supported in the community, the alternative care package would be centred on admission to a high dependency care home, the cost of which would be met on a 50/50 basis by the NHS and local authority. This would raise the overall care costs to over £72,000, with the local authority paying £38,700 and the remaining £37,500 falling to the NHS.

Service User B

Extract from Exploring the Cost Implications of Telecare Service Provision; Newhaven Research: February 2010

Service user B is an 89 year old male who lives with his elderly wife. He has a deep vein thrombosis and osteoarthritis, and has had several falls in the past.

B has recently been diagnosed with dementia and has exited his home at night on occasions in an inappropriate state of dress. His wife is also unsteady on her feet, has diabetes and has a brain shunt in place.

Smoke and gas alarms have been installed and his wife calls for assistance using her pendant if B should fall or wander. Mobile wardens respond to all calls from installed equipment. A minimal home care input and a range of occupational therapy equipment has been provided.

The table at Annex A summarises the total annual costs of the care package being provided for service user B.

The principal care package for service user B costs in the region of £6,500 in total, with around £500 of this met by the NHS. The local care group advised that an appropriate alternative would involve admission to a care home specialising in dementia care, which would raise the cost of the care package being provided to almost £33,000. This would involve a very significant increase in costs for the local authority to meet, although the NHS cost would fall a little, as falls assessment would no longer be required.

Service User C

Extract from Better Outcomes, Lower Costs; University of Bristol for the Office of Disability Issues, DWP

After assessment of 30 year old service user C, investment was made in step-lifts; power adjusted seating systems, adapted bathroom, hoists, computer-based writing and environmental control systems. If this had not happened when Service User C's mother died he would have had to enter residential care for the rest of his life.

This was not just because of the physical help he needed but because, before the adaptations, he had no autonomy and had become used to a life of complete dependency. The adaptations not only relieved the physical burden, they changed the man's life and abilities.

Assuming a life expectancy of 50, and weekly residential care costs of £800. the cost of residential care would have been £41,600 per year (at 2006 prices) and £2 million over 20 years.

Compared with three sets of adaptations/equipment at £30,000 over 20 years and housing costs of £104,000.

A saving of around £1.9 million could be achieved. If, in living independently he still needed some support, a £200 per week care package over 20 years would still achieve savings of £1.6 million compared with residential care.

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References

[1] ONS (2006) General Household Survey

[2] Bolton J (2009) The use of resources in adult social care: A Guide for Adult Local Authorities. DH: London

[3] www.gro-scotland.gov.uk/statistics/high-level-summary-of-statistics-trends/index.html

[4] Source: ISD Scotland (SMR01)

P Provisional (Nov 09)

[5] Don't Mention the F-Word, Help the Aged 2005

[6] Older People's Experience of Falls and Bone Health Services (England), Royal College of Physicians, 2008

[7] Fully Equipped, Audit Commission 2000

[8] Scottish Household Survey 2005/06 - http://www.scotland.gov.uk/Publications/2007/08/01084217/0-2

[9] DH (2009) Falls and fractures: Effective Introductions in health and social care. SO: London

[10] Gillespie LD et al (2009) Interventions for preventing falls in older people living in the community. Cochrane Review Issue 4

[11] Costs from Unit Costs of Health & Social Care, PSSRU 2008

[12] Not included in official study