Home help

Even for very disabled people, it is possible to remain at home with the help of assistive technology – equipment and adaptations such as stairlifts, wheelchairs and level-access showers. But finding out what technology can be fitted, who should pay for it and whether it is cost-effective compared to nursing home fees is often difficult.

King's College London and the University of Reading have recently finished a study addressing these issues. It was sponsored by the Engineering and Physical Sciences Research Council, and carried out by a multidisciplinary team that included building surveyors, rehabilitation engineers, an occupational therapist and social scientists.

The survey strongly underlined the potential of assistive technology to help older people stay at home in the face of increasing frailty and disability. Tweaking and adapting homes could, it concluded, meet the needs of most people.

The two-and-a-half year study focused on 82 different properties, belonging to five local authorities and five housing associations across the country. It assessed them in relation to the needs of seven hypothetical older people with different types and degrees of disability, now and in five years' time with a likely increased disability.

Can you adapt?
Aiding mobility, and particularly providing for wheelchair accessibility, was a major issue with some properties and offered more challenges than any other type of disability.

Some of the reasons were obvious – narrow doorways, small bathrooms and so on. Others were more subtle and involved detailed design issues (see "Changing rooms", opposite).

As the degree of disability increased, fewer properties could be adapted – in fact, only half of the homes could meet the needs of a very infirm person who used an electric wheelchair and needed an accessible bathroom, involving a fixed hoist from that room to the bedroom.

Some of the sheltered properties in the study were more easily adapted than others but not always – in fact, sheltered bungalows were found to be more problematic than mainstream ones. Quite often, ordinary properties that had been equipped with enough simple extras to transform them into sheltered homes were very difficult to adapt any further.

A study visit to the Netherlands revealed that it has experienced very similar problems and solutions to the UK. Interestingly, however, the very steep, winding stairs typical to Dutch homes can be provided with a stairlift in Holland while this is not common practice in the UK.

All part of the package
Assistive technology is, of course, only one part of the story. Whether the person accepts and uses it is another – they may not believe they need it, for example – and it cannot be divorced from the rest of what older people experience, including other services and the involvement of their families.

Physical aids form just part of a package of care for most older people, so the study considered the interplay between the two main ingredients: technology and formal care such as personal and home care, community nursing and meals.

The cost of combined assistive technology and care that would be needed to keep older people of varying degrees of disability at home were studied. These were considered over varying periods of use and taking into account initial and maintenance costs, the expected normal life of products, their resale value and replacement costs (see "Enabling costs", below).

Surprisingly, in general, it appeared that the higher the level of disability, the sooner savings are achieved and the more money is saved. These savings appear to be achieved regardless of whether there was no informal care at all or some informal care, such as a non-resident carer.

For moderate disability levels, the investment in adaptations and technology to substitute for care was recouped within one to three years by reduced care costs, and the investment in supplementary adaptations and assistive technology was reclaimed in two to five years. Thereafter, major savings accrued.

At very high levels of disability large savings can also be achieved, especially where the alternative would be a care home. For these cases the nature of the informal care was important, with feasibility and savings being enhanced with a co-resident informal carer but very depressed without one.

When the average life expectancy of the users was considered, in most cases savings could be shown for both the augmented and maximum packages. However, the study also made some conservative assumptions about how long individuals might use the adaptations and technology. In nearly all cases, even with reduced life expectancy, the augmented packages showed savings over the traditional ones. And in about half of the cases implementing large-scale changes in the home showed savings.

Mixed messages
Assistive technology is a very ambiguous subject. The terminology can be confused and different professional groups use it to imply quite different technologies. Relevant information is often inaccessible for particular professionals and users, or may be described with wrong words and associations – for example, many older people do not consider themselves "disabled".

Aids that have been assessed as necessary for tenants or their carers, and for which they are eligible, must be provided free of charge, as must all minor adaptations costing £1000 or less (which includes the cost of buying and fitting). Luckily, the Department of Health increased the funding available to help with the cost of this in June 2003. But it is not always clear who is liable to pay for assistive technology – whether it is a responsibility of the housing provider, social services, health services or the individual.

There are also particular difficulties in ensuring that users and professionals are able to access information about opportunities for assistive technology. Another risk is that assistive and "smart home" technology, which uses computer systems to make homes sensitive to a tenant's behaviour patterns and can call for help if a worrying aberration occurs, are seen in the same light: as newfangled, sci-fi solutions. In fact the ideas underlying these systems are really quite simple and just need to be demystified.

Plus, the supply of much equipment is over-dependent on advice from manufacturers with vested interests in their own products and a building industry that in general is neither knowledgeable about overall needs, nor interested in the installation and maintenance of assistive technology.

As a result it often appears to be installed as a response to a particular health problem, drawing on whatever information is available at the time, with little thought given to an individual's changing health or their subsequent needs.

Assessors and providers need to take a more holistic and longer-term view of the person's needs than that.