DFG Social Value
General Evidence Base for the Disabled Facilities Grant (DFG)
- Preventing people from entering residential care: (Heywood, 2001) Money well spent: the effectiveness and value of housing adaptations – Joseph Rowntree Foundation.
- Reduction in falls: New Zealand study. (Sue Adams, 2015), Cost benefits of adapting homes to reduce falls by older people: Applying the findings of international studies to the UK – Care and Repair England.
- Reducing delayed discharge
- Non-cash benefits: (Tom Snell, Jose-Luis Fernandez and Julien Forder, 2012) Building a business case for investing in adaptive technologies in England - PSSRU
- Costs of adaptations: (Care and Repair England, 2015) Disabled Facilities Grant Funding via Better Care Funds – An Opportunity to Improve Outcomes
- OTs and OT assistant costs: (HSCIC, 2015) Personal Social Services: Staff of Social Services Departments, England
- Assistive Technology: (Care Performance Partners, 2015) Telecare: Outcomes and Cost Effectiveness
- Disabled Facilities Grant allocation methodology and means test: An evaluation by the Building research Establishment (BRE) of the allocation of the DFG. (February 2011)
Cost Effectiveness of DFG
Suitable appropriate housing plays a vital role in supporting people to maintain good health, independence and improve the quality of life. By helping people live independently for longer – through programmes like the Disabled Facilities Grant (DFG) – this can help to reduce health and social care costs, improve discharge rates, reduce emergency admissions and reduce the numbers of people requiring residential care.
The analysis to assess public benefit is based on three main areas:
- removing or reducing the need for residential or community care;
- savings to the NHS through prevention; and
- non-cash benefits in the form of improvements to quality of life.
The analysis on savings to social care considers both older adults and working aged adults with disabilities, and the analysis on prevention focuses on savings to the NHS through reducing falls for a proportion of the 70% of older adult recipients of the DFG. Therefore it is likely that there are additional savings for working aged adults due to prevention, not included in the calculations. Furthermore the savings are based on the assumption that the useful life of an adaptation is 4 years. However, some studies have shown that the number of years could be as many as 6 and therefore this would make the savings higher than those projected.
Key Assumptions Underpinning the Analysis
Benefits to social care
- 10% of DFG recipients are prevented from entering residential care following an adaptation. Previous studies have assumed social care benefits from the full cost of preventing older adults from entering residential care. However, this analysis has adopted a more conservative approach and assumed that of the 10% prevented from entering residential care, 5% will still require some level of homecare.
- 25% need less homecare following an adaptation. The savings from needing less homecare are based on assuming that a person receives homecare at the average between one and two levels of intensity below their current level (low needs, medium needs, high needs, very high needs). Note, the intensity of homecare is dictated by the number of hours of homecare received.
- 18% no longer need any homecare. The saving is based on the average cost of homecare across all intensity levels of homecare. In all cases, provision of an adaptation can make the difference between an informal carer, such as a spouse, being able to care for someone with a social care need in their own home without additional support, or not.
Benefits to the NHS through prevention (falls)
- 80% of cohort of older adults that would benefit from the DFG are likely to fall each year.
- Falls can be reduced by 39% following an adaptation as shown in a study on the effectiveness of home modifications.
- Savings are incurred from reductions in attendance at A&E, ambulance call-outs, hip fractures and other types of fracture.
Quality of Life Benefits
- These are included in terms of QALY gain at a value of £1,522 per person per year. Quality of life benefits make up 23% of the total public benefits.
- The savings recorded are those to social care and the NHS which total £1,577 per telecare user. The public benefits from assistive technology account for an average of approximately 14% of the total public benefits included in the table.
- To avoid optimism bias, we have reduced all benefits by 20% to create a minimum expected benefit from increasing the DFG funding.
Within five years there will be a million more people in their 70s. By 2018, the number of people with three or more long term conditions is set to increase by 50% to nearly three million. By 2020 nearly 100,000 more people will need to be cared for at home. If we do not find better, smarter ways to help people remain healthy and independent in their own homes through community-based or home-based support, including aids and adaptations, the health and care system will be overwhelmed.
Only a small percentage of disabled and older people and vulnerable people live in specialised housing, purpose built to cater for their needs. Therefore the majority of older and disabled people will continue to live in mainstream housing.
- The annual cost for all hip fractures in the UK, including medical and social care, is about £2 billion.
- Falls account for up to 40% of ambulance call-outs to homes for people aged 65+ costing £115 per callout. In 2013/14 there were 8.47 million calls made to emergency services.
- Falls are the largest cause of emergency hospital admissions for older and disabled people, and significantly impact on long term outcomes, e.g. being a major precipitant of people moving from their own home to long-term nursing or residential care.
A Cochrane review looking at the effectiveness of various interventions in the prevention of falls among older people living in the community, concluded that home safety assessment and modification interventions were effective at reducing the rate and risk of falls.
Care and Repair England have developed findings from a recent New Zealand study of falls reductions due to home modifications. The three year study carried out in New Zealand was based on a sample of over 800 people living in similar property and in receipt of welfare benefits. Half of the sample received a package of home modifications (including handrails for outside steps and internal stairs, grab rails for bathrooms, outside lighting, edging for outside steps, and slip-resistant surfacing for outside areas) at the start of the trial, the other half had to wait three years. The home modifications received were a fairly standard package of relatively low cost adaptations installed at an average cost of $850 (£375). Injuries specific to the home modification intervention were reduced by 39%.
The most common serious injury arising from a fall is a hip fracture. Around 70,000-75,000 hip fractures occur in the UK each year. The annual cost for all hip fractures in the UK, including medical and social care, is about £2 billion (c £26,000 per hip fracture for health and social care services).
It is worth noting that because of the design of the trial the home modifications in the New Zealand study were not tailored to individual need/risk. However, it has been noted in a Cochrane review that home modification were more effective in prevention of falls when the intervention was specified by an occupational therapist who could tailor the intervention to the individual. A preventative home adaptations programme in the UK would take a far more tailored and targeted approach, in particular within the BCF as integration with primary care services and better risk stratification can improve targeting those at greatest risk, thereby likely to yield greater benefits, albeit with some higher costs of installing small and medium sized adaptations.
The aim of the DFG is to enable disabled people to live independently and safely in their homes through the provision of appropriate and cost-effective adaptations. It also supports the prevention agenda to stop a condition worsening and become more costly. The benefit of this reasonable capital investment falls into the three areas described below.
Benefits to Social Care
There are benefits through helping to prevent admissions to residential care and reducing the need for domiciliary care. By providing adaptations it enables people who would otherwise require residential care to stay living in their own home. A survey of 150 people who received a DFG adaptation showed that 1 in 10 would have gone into residential care without the intervention (Heywood, 2001). Preventing one person from being admitted into residential care can save on average £30,000 per person per year. The saving is greater for working age adults with physical disabilities at £42,700 per year. In the analysis it is assumed that the majority of DFG recipients of working age, are those with physical disabilities.
According to the most recent wave of the Personal Social Services (PSS) Survey of Adults receiving community equipment and minor adaptations (2009/10), 25% of a sample of 65,000 users of equipment and adaptations reported that they needed less help from others following receipt of their equipment or minor adaptation, and 18% that no help was needed from others. These figures have been applied in the analysis.
Benefits to NHS
The Department of Health (2009) provided an estimate of the treatment pathways and diagnoses that follow falls. According to their estimates, of 15,500 who will fall in a given year, 2,200 will attend A&E and a similar number will call an ambulance. 360 older people are likely to have sustained a hip fracture and 890 will have sustained other types of fracture. As a consequence, prevention through reducing a proportion of falls results in savings to the NHS. The finding from the New Zealand study above of a 39% reduction in falls has been applied.
The provision of suitable aids and adaptations will not prevent all falls from occurring. However, it is important to note that additional reductions in the demand for services can still be accrued where equipment-based interventions are in place. Care and Repair Cymru (2006, in Heywood and Turner 2007) suggest that the average length of stay in hospital following a fall or critical incident may be reduced by up to a week when the necessary equipment is in place at home, potentially avoiding over £1,400 in extra costs due to delayed discharge. The savings through avoiding delayed discharge have not been included in the analysis and so it is likely that the savings per adaptation may be higher than those included.
Some evidence suggests that following an adaptation disabled people needed to visit their GP less often and it was also reported that the adaptation had had a positive effect on health.
Benefits to the Individual and Carer
The Quality of Life Benefits of £1,522 per person per year is based on modelling by PSSRU (2012). Included in the calculation are the combined effects of additional deaths, acute care episodes, increased levels of institutionalisation, disability, increased fear of falls and decreased independence in cases with unmet equipment and adaptation needs. The figure of £1,522 is the mid-range estimate provided by PSSRU.
Carers are likely to be another group who benefit from adaptations through reductions in rates of injury and quality of life improvements as the adaptations may reduce the number of physical tasks which they assist. A survey of carers conducted by Henwood (1998) found that 51% of carers had suffered a physical injury such as a strained back since they began to care. However, due to a shortage of data on the benefits of adaptations in reducing the burden on carers, this has not been included in the analysis but this is likely to be substantial.