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Adapting the homes of older people: A case study of costs and savings

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DOI: 10.1080/0961321042000269429

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BUILDING RESEARCH & INFORMATION (NOVEMBER –DECEMBER 2004) 32(6), 468–483

Adapting the homes of older people:

a case study of costs and savings

Peter Lansley1, Claudine McCreadie2, AntheaTinker 2, Susan Flanagan1,

Kate Goodacre1 and AlanTurner-Smith3

1
School of Construction Management and Engineering, University of Reading, Reading RG6 6AW, UK
E-mail: p.r.lansley@reading.ac.uk
2
Institute of Gerontology, King’s College London, London SE1 9NN, UK
3
Centre of Rehabilitation Engineering, King’s College Hospital, London SE5 8RX, UK

Meeting the demand for independent living from the increasing number of older people presents a major challenge for
society, government and the building industry. Older people’s experience of disabling conditions can be affected by the
design and layout of their accommodation. Adaptations and assistive technology (AT) are a major way of addressing this
gap between functional capacity and the built environment. The degree of adaptability and the differences in the average
cost of adaptation of different types of property are large and there is major variation within property type. Based on a
series of user profiles, it was found that a comprehensive package of adaptations and AT is likely to result in significant
economies arising from a reduction in the need for formal care services. This finding is sensitive to assumptions about
how long an individual would use the adaptations and AT, as well as to the input of informal care and the nature of
their accommodation. The present study, which focused on social housing, has implications for how practitioners
specify ways of meeting individual needs as well as providing a case to support the substantial increase in demand for
specialist adaptation work.

Keywords: adaptations, ageing population, assistive technology, benefits, care services, costs, demographics, disability,
older people, public policy, quality of life, social housing, UK

Répondre à un nombre croissant de personnes âgées qui demandent une plus grande autonomie est un défi majeur que
doivent relever la société, les gouvernements et l’industrie de la construction. La vie de ces personnes qui connaissent des
conditions invalidantes peut être affectée par la conception et l’aménagement de leur logement. Les adaptations et les
technologies d’aide (AT) apportent des solutions intéressantes qui permettent de combler l’écart entre la capacité
fonctionnelle et le milieu bêti. Le degré d’adaptabilité et les différences de coût moyen de l’adaptation des différents
types de propriété sont importants et on note des variations majeures dans les types de propriétés. En s’appuyant sur
une série de profiles d’utilisateurs, on a constaté qu’un ensemble complet d’adaptations et de technologies d’aide était
susceptible de déboucher sur des économies non négligeables dégagées par la diminution du besoin en services d’aide
officiels. Ce résultat est sensible aux hypothèses sur la durée des périodes pendant lesquelles une personne aurait
recours aux adaptations et aux technologies d’aide ainsi qu’aux apports de soins officieux et à la nature des
logements. Cette étude, axée sur les logements sociaux, a des implications sur les méthodes spécifiques utilisées par
les praticiens pour répondre aux besoins des personnes et pour proposer une action en faveur de l’augmentation
substantielle de la demande en travaux d’adaptation spécialisés.

Mots clés: adaptations, population vieillissante, technologie d’aide, avantages, services d’aide, coûts, démographie,
incapacité, personnes âgées, politique publique, qualité de la vie, logements sociaux, Royaume-Uni

Building Research & Information ISSN 0961-3218 print ⁄ISSN 1466-4321 online # 2004 Taylor & Francis Ltd
http: ⁄ ⁄www.tandf.co.uk ⁄journals
DOI: 10.1080/0961321042000269429

Introduction
Many nations, with few exceptions, are witnessing a
growth in the number of older people, in part due to
people’s increase in life expectancy. The implications
for societies and for individuals are considerable. For
governments, they present significant immediate chal-
lenges. This paper addresses one of those challenges:
the enhancement of the independence and quality of
life of older people by enabling them to continue to
live in their own homes even though illness, accident
or frailty may have severely reduced their physical
and sensory abilities and, possibly, mental health.
The building industry shares this challenge of contri-
buting significantly to meeting societal needs. It has
to ensure that adaptations to the home and the intro-
duction of assistive technologies (AT)1 are feasible,
affordable and attractive in other ways (Lansley,
2001).
Many factors are combining to suggest that the adap-
tation of the home and provision of AT are becoming
increasingly important issues. Coupled with the incen-
tives arising from the increasing costs of older people’s
care, research shows that the majority of older people
wish to stay in their own homes not least those who
live alone and with chronic illness (Royal Commission,
1999; Tinker et al., 1999). Older people, some of them
very old, display a readiness to use new technology if it
addresses their needs. The Royal Commission on Long
Term Care (Royal Commission, 1999; Tinker et al.,
1999) highlighted the role of adaptations and AT in
enabling people to remain in their own home, and
policy documents have increasingly emphasized this
fact (Audit Commission, 2000, 2002, 2004, Office of
the Deputy Prime Minister, 2003a, Tinker, 2003).
UK research into well-established adaptations such as
stairlifts, level-access showers and door-entry phones
reports substantial consumer satisfaction (Heywood,
2001). Newer developments in alarm technology are
mostly confined to a minority of older people and
‘smart housing’ developments have only reached an
experimental stage (Pragnell et al., 2000). There has
been little systematic research into the implications of
a more pronounced policy focus in terms of feasibility
and cost.
The scope for an individual older person to remain in
their own home depends on many issues, but the
most relevant are concerned with the following:
. extent of their capacities, their needs and their view
of those needs
. how far these needs can be met through adapting
the home and providing AT and other specialist
equipment, and the cost
. availability of formal and informal care
Adapting the homes of older people
. costs of formal care
. acceptability of these solutions to older people
. resulting quality of life for the individual
This paper addresses the assessment of the individual’s
needs, the adaptability of properties, the costs of adap-
tations, and the extent to which these could substitute
for and supplement formal care in terms of cost. It
draws on a three-year study of the feasibility, accept-
ability, costs and outcomes of adapting the existing
homes of older people and introducing AT, specifically
in the social rented housing sector of the UK (King’s
College London and the University of Reading,
2004). The research also examined the experiences of
older people with a wide range of adaptations and
AT (McCreadie, 2004; McCreadie and Tinker, 2004).
This paper considers the following points:
. extent to which homes could be adapted and the
resulting costs
. a methodology for combining the cost of adap-
tations and AT with the costs of formal care
. experiences and opinions of older people of the
adaptations and the AT that they have used
The study
Background
There is a lack of systematic information about the
costs and benefits, and, more fundamentally, about
the feasibility of adapting homes. This is made more
complex by limited information about the installation,
maintenance and reliability of both traditional and
smart home technologies.
In social housing, several agencies are involved with
the adaptation of the home, as well as the housing pro-
vider. The requirement for adaptations is triggered by
the needs of the individual. This may lead to the need
for quite simple adaptations to improve safety
through to very complex adaptations such as those
required by a permanent wheelchair user. The assess-
ment of user needs is typically undertaken by an occu-
pational therapist, who, in consultation with a building
professional, specifies the necessary building-related
work. The occupational therapist also considers the
consequent need for formal care services.
Main research activities
The need for fundamental information about the feasi-
bility and costs of adapting the home and providing
469
Lansley et al.
AT, the relative costs of adaptations, AT and formal
care, and the acceptability of adaptations and AT to
older people provided the principal motivation for
undertaking the study.
The study comprised nine major overlapping activi-
ties:2
. Reviewing a diverse range of publications, techni-
cal literature, policy documents, legislation and
regulations relating to older people, health,
housing provision, adaptations and AT.
. Understanding the range of adaptations that may
be required and equipment that might need to be
installed (such as stairlifts) and accommodated
(such as wheelchairs and scooters) to meet the
needs of older people as well as smaller personal
items (such as adapted cutlery, special beds and
mattresses).
. Developing ‘typical’ user profiles that could be
used to benchmark the adaptability of individual
properties, ranging from users with quite modest
needs to users with very complex needs, and associ-
ating with each of these the required adaptations
and AT.
. Developing methods for auditing properties and
assessing the extent to which they could be
adapted and estimating the costs of meeting the
needs of each ‘typical’ user profile.
. Creating a methodology for assessing the formal
care input that the ‘typical’ users would need for
different scenarios, e.g. with different levels of pro-
vision, and, within the context of these, different
levels of informal care (e.g. from family and
friends); costing these different care scenarios and
then combining them with the cost of the adap-
tations and AT.
. Developing a methodology for capturing the
experiences and opinions of older people who
have had adaptations to their homes and have
been provided with AT.
. Identifying and negotiating with suitable providers
of social housing, both local authorities and
housing associations, to participate in the research
by providing properties to be surveyed and access
to residents.
. Undertaking field work in ten housing providers
(five local authorities, five housing associations)
distributed across the UK, comprising meetings
with key figures in each provider, audits of 82
properties and face-to-face interviews with 67
470
people aged over 70 years who had major adap-
tations to their homes or AT provided.
. Analysing and integrating the materials, and
reporting findings to the housing providers, advi-
sory committees, older people and more publicly.
Understanding user needs: user pro¢les
Using disability prevalence data for older people
(Martin et al., 1988; Grundy et al., 1999), seven
‘typical’ user profiles were created. Each covered a
spectrum of disabilities and included a detailed descrip-
tion of the user’s functional capacity and a list of adap-
tations and AT to address their needs. Each user profile
was envisaged at two points in time, five years apart,
with a deterioration of functional abilities between
the first and second periods. As an example, Table 1
provides a detailed description of the health and
impairments of User Profile 3, and Table 2 details the
requirements of this user in terms of the potential adap-
tations and AT. These requirements were subsequently
used to investigate whether specific properties could be
adapted to meet the needs of User Profile 3. Table 3
summarizes the health and functional impairments of
the seven hypothetical users; Table 4 gives details of
the adaptations and AT specified in the complete set
of profiles.
Building issues
There is surprisingly little published information about
the adaptation of the home to meet the needs of older
and disabled people. Most guidance applies to new
building work (Goldsmith, 1997; Carroll et al., 1999;
DETR, 1999; Housing Corporation, 2000; BSI,
2001). Whilst this guidance gives examples of what
can and should be built without any restrictions on,
for example, space and building materials, it is not
directly applicable to existing properties. Design gui-
dance specifically developed for application to existing
properties is not available on a national basis, although
local authorities have drawn up their own guidelines
(e.g. London Borough of Tower Hamlets, 2001a, b).
One of the main issues in using design guidance devel-
oped for new properties is the frequent reference to
‘sufficient space’ and ‘reasonable provision’ without
reference to any dimensions (e.g. Carroll et al.,
1999). Whilst specific design guidance exists for
many items considered by the study such as thresholds,
door widths, corridor widths, sizes of lifts, ramp gradi-
ents, handrails, hoists, and heights of switches and
sockets, there is only general guidance for key items
such as bathrooms and newer products like intercoms,
lighting, alarms and smart home technologies.
The researchers developed a set of specifications to
supplement this guidance. Critical parameters were
 Adapting the homes of older people

Table 1 User Pro¢le 3: Health and functional impairments initially and ¢ve years later

Current period ^ c Future period: ¢ve years later ^ f

Background Mrs D is 75 years old. She has been diagnosed as
having chronic obstructive pulmonary disorder
for approximately ten years. Her breathing has
become increasingly dif¢cult, which affects all
her activities. Due to an operation, she has a
reduced range of movement and strength in her
left arm and hand
Locomotion Mrs D cannot walk further than 50 yards without
stopping or without severe discomfort. Mobility
within the home: Mrs D moves through her
home unaided, stopping for a rest when short of
breath. Mobility outside the home: Mrs D needs
assistance to travel to the local shops, attend
doctor’s appointments or visit friends
Dexterity Mrs D can turn a control knob or taps with one
hand, but not with the other
Hearing No problems
Seeing No problems
Reaching and Mrs D cannot hold one arm out in front or up to her
stretching head, but can with the other arm
Continence No problems
Transferring Changing posture leaves Mrs D breathless
Personal care Getting in/out of bed: Mrs D can perform this task,
although she prefers to sleep propped up to
prevent coughing and ease her breathing.The
effort of moving from lying to standing leaves
her short of breath. Bathing: Mrs D can perform
this task, although moving from sitting with legs
extended to standing in a con¢ned space is
dif¢cult because of her reaching impairment
and the physical effort involved. Dressing: Her
reaching and dexterity impairment makes
certain items problematic, but manageable
Toileting: No problems
Activities of daily Food and nutrition: Mrs D can prepare her own
living (ADL) meals, although these tasks take longer
because of her dexterity and reaching
impairments. Shopping: Mrs D has great
dif¢culty shopping and is largely dependent on
some assistance or by using only very local
shops. Housework and washing: Mrs D can
perform these tasks, although less frequently
and rigorously, due to her reduced activity
capability and her dexterity impairment
Overall Mrs D can manage all the above activities to a
degree.The provision of assistive technology
increases the opportunity to take part in an
activity (e.g. a scooter for social interaction),
reduces the time and effort involved (e.g.
cleaning, cooking) and in some instances
increases safety (e.g. bathing)
Mrs D is 80 years old. Her mobility has decreased
due to diminished lung function and a large
increase in weight. Degenerative arthritis has
affected her other impairments.The overall
effect is that her activities of daily living are
extremely dif¢cult
Mrs D cannot walk up and down a £ight of 12 stairs.
Mobility within the home: Mrs D can move
through the house unaided but needs to stop
and rest often to regain her breath.When her
breathing is very bad, she uses a manual
wheelchair to move around the house. Mobility
outside the home: Mrs D leaves the house less
often than before but still uses her scooter to
reach local facilities such as shops
Mrs D has dif¢culty wringing out light washing or
using a pair of scissors
No problems
No problems
Mrs D has dif¢culty raising either hand above her
head to reach for something
No problems
Mrs D can transfer to and from her wheelchair
unaided, but with dif¢culty
Getting in and out of bed: Mrs D needs help with
her changing position and can no longer
perform this task unaided due to the change in
her reaching impairment, lung function and
size. Bathing: Reaching, dexterity and lung
function makes this task painful and dif¢cult to
complete. Dressing: Although achievable, this
is a task that takes an increasing amount of
time.Toileting: Mrs D ¢nds getting on and off the
toilet dif¢cult due to her reaching impairment,
size and painful knee joints
Food and nutrition: Mrs D can still prepare food for
meals, but she takes increasing amounts of
time and effort due to her size and the reduction
in her range of movements Shopping: Mrs D
can manage to take part in this activity,
although she is less independent because of
her reduced stamina and increased reaching
and stretching impairment. Housework and
washing: Mrs D requires assistance with these
tasks, but can perform some light activities (e.g.
dusting, tidying) independently
Mrs D is now less independent.The provision of
assistive technology enables her to perform
some personal care tasks without the need for
human intervention (e.g. getting out of bed,
dressing and bathing)

identified below or above which specific adaptations
would be required in response to particular user
needs. The parameters were developed from the work
of others and published guidelines, with advice from
practitioners helping to ensure that the parameters
reflected good but pragmatic practice. Whilst some of
these specifications could be applied routinely, others
needed careful interpretation. For example, although
minimum dimensions were determined for wheel-
chair-accessible bathrooms, some bathrooms failed to
meet the required width, but were much bigger in
terms of area, requiring particularly careful analysis.
471
Lansley et al.

Table 2 User Pro¢le 3: Adaptations and assistive technology (AT) required initially and ¢ve years later

Current, aged 75 years Five years later, aged 80 years

Potential adaptations and

¢xed AT
Entrances
Horizontal circulation
Vertical circulation
Personal care
Living, leisure, sleeping, food
preparation
Windows, heating, electrical,
alarms
Average cost of adaptations
and ¢xed AT for adaptable
properties (2001 costs)
First cost
Replacement at ten years
Annual maintenance
Recovery at ¢ve years
Portable AT
Cost of portable AT (2001
costs)
First cost
Replacement at ¢ve years
Annual maintenance
Recovery at ¢ve years
grab rails, lever door handles, exterior lighting, grab rails, lever door handles, exterior lighting,
door release, door intercom, ramp/short-rise wheelchair-accessible entrances (front and
platform, handrails, scooter storage and rear) including ramp/short-rise platform,
charging socket, communal lift/stairlift handrails, level threshold, door width, front
door release, door intercom, manual
wheelchair storage, scooter storage and
charging socket, communal lift/heavy duty
stairlift
lever door handles lever door handles, wheelchair accessible
including level thresholds, door width,
corridor width
stairlift heavy duty stairlift
grab rails for shower and toilet, level-access grab rails for shower and toilet, other toilet,
shower tray, wall mounted seat level-access shower tray, toilet frame,
adapted taps
none partially adapted kitchen, adapted taps, power
for recliner chair and bed
extra sockets for portable AT, radiator controls, extra sockets for portable AT, radiator controls,
additional heating, alarms: community, gas, additional heating, rocker switches, lower
carbon monoxide, smoke light switches, raised sockets, electric
window control, alarms: community, gas,
carbon monoxide, smoke
»6360 »5 038
»821 »789
»98 »74
»256 »247
dressing aids, electric tin opener, grabber, jar dressing aids, electric tin opener, grabber, jar
opener, perching stool, scooter opener, perching stool, scooter, manual
wheelchair, portable shower seat, riser/
recliner chair, variable posture bed
»2 242 »4762
no replacement »4762
»179 »381
no recovery value no recovery value

Mobility limitations create significant structural
demands on properties and generate major costs
in terms of adaptations (such as enlarged bathrooms,
widened corridors and ramps) and fixed AT to
be installed (such as stairlifts and through-floor lifts).
Other physical and sensory impairments can generally
be catered for with minimum attention to the design
and construction of the property, and at a fraction of
the cost (e.g. the use of colour contrasting décor,
raising electric sockets or installing visual doorbells),
although the AT associated with some of these disabil-
ities can be costly. The mobility-related demands on a
property are not limited simply to whether or not a
property is accessible by wheelchair. Older people
have a wide range of mobility needs. For example,
some may use an outdoor electric wheelchair and be
ambulant inside, and so only require a wheelchair-
accessible entrance and good circulation to its storage
472
location. Others may need to use an indoor wheelchair
but may be able to transfer to a stairlift rather than
requiring a vertical through-floor lift. Some wheelchair
users will require a wheelchair-accessible shower or
bathroom, but others will not.
Costing the adaptations and AT
Most previous studies of the cost of adaptations have
been based on surveys of the costs incurred by, for
example, local authority housing departments (Ernst
& Young, 1994; Netten and Curtis, 2003). Other
work has concentrated on user needs and the technical
issues of adaptation, and the costs may not be represen-
tative of a more general situation. Despite the caveats
they often attract, two price books concerned with
adaptations and small works (RICS, 2001, 2002)
provided a basis for the development of a family of
 Adapting the homes of older people

Table 3 User pro¢les: health and functional impairments of the hypothetical users initially and ¢ve years later

User Current period ^ c Future period ¢ve years later ^f

pro¢le
Age Life Initial condition Developments
expectancy1

1 80 7.0 Stroke (not severe), poor further stroke, complications

2 70
3 75
4 78
5 75
6 70
7 78
eyesight, hearing loss, following surgery to broken hip,
multiple impairments sight and hearing have
deteriorated
15.0 Multiple Sclerosis since 50 years further deterioration
11.6 Chronic obstructive pulmonary decreased lung function, large
disorder, reduced strength in weight increase in weight,
left arm and hand arthritis
9.9 Arthritis, mild sight loss further deterioration
11.6 Diabetes, mild sight loss, further deterioration, angina,
occasional fainting and occasional falls
falling, reduced strength,
some forgetfulness
15.0 Parkinson’s disease, occasional further falls
falls, hearing loss
7.9 Diabetes, loss of sensation, further deterioration, amputation of
weakness in limbs one leg below knee

Note: 1. Average life expectancy (years) from current age. Source: Of¢ce of National Statistics (2002, table 5.22).

Table 4 Summary of building adaptations and adaptive technology (AT) considered in the pro¢les

Building adaptations including:

Fixed AT Portable AT Fixed AT Portable AT

Additional heating ^ bathroom Adapted cutlery Lever door handles Scooter

Additional electric sockets Bath board Lever taps Shopping trolley/seat
Burglar alarm CCTV magni¢er Lift (communal) Smoke alarm
Ceiling-mounted hoist Commode Manual window openers Speaker phone
Colour contrast de¤cor Cordless headphones Motion detector light switch Telephone ampli¢er
Community alarm Door bell ampli¢er Partially height-adjusted kitchen Trolley
Door bell Dressing aids Platform stair lift (communal) Variable posture bed
Door-entry phone intercom Electric tin opener Platform stair lift Walking frame
Door-entry phone & video intercom Flashing telephone bell Ramp Walking stick
Door opener Grabber Floor level adaptation
Door release Hearing aid Level thresholds
Douche WC Jar openers Lowered light switches
European Installation Bus Kettle tipper Manual wheelchair storage
(surface mounted) Large-buttoned telephone
Electric curtain openers Large-buttoned remote Raised electric sockets
Electrically operated window control Rocker switches
openers Long-handled cleaning aids Scooter storage
Electronic tap controls Low air-loss mattress Wheelchair-accessible corridors
Environmental control system Magni¢er Wheelchair-accessible doors
External light with passive Manual wheelchair
infra-red sensor Medication reminder Wheelchair standard bath room
Gas and CO2 alarm Mobile hoist Wheelchair standard shower room
Grab rails Page turner Short-rise platform lift
Grab rails (bath) Perching stool Shower over bath
Grab rails (shower) Portable air cooler Stairlift
Grab rails (toilet) Portable shower seat Stairlift (communal)
Grab rails/handrails (steps/ramp) Powered outdoor Thermostatic blending valve
Height adapted kitchen wheelchair Thermostatic radiator valves
Height-adjusted bathroom Raised toilet seat Through-£oor lift
Height-adjusted cupboards Riser chair Toilet frame
Key less door lock Riser recliner chair Visual door bell
Level-access shower (gulley)

473
Lansley et al.

estimated costs for straightforward adaptations (such Table 5 Comparison of sample with national statistics
as replacing a bath with a shower) and were consulted
for the estimation of the costs of more complex Category Present study Survey of
packages of work (such as rebuilding a bathroom). English
housing,
Manufacturers provided information on the cost of 1999^ 2000 (%)
supply and installation of specialist equipment, main- Number %
tenance and replacement costs, design life, removal
costs and recovery values. Some comparisons with Small terrace 6 7.3 6.9
housing providers undertaking similar work showed houses
that initial comparisons were acceptably close except Medium and large 6 7.3 7.4
terrace houses
for bathroom-related packages. Alignment was Semi-detached and 3 3.7 13.7
achieved after the providers’ specifications for all bath- detached houses
room adaptations were adopted. Bungalows 14 17.1 21.4
Flats in converted 5 6.1 1.4
houses
Some costs were excluded. Remedial work was separ- Flats in low-rise 32 39.0 39.6
ated from adaptation work. Potential ‘knock on’ blocks
effects of adaptation were impossible to assess, e.g. Flats in high-rise 16 19.5 9.6
the need to replace all wiring, radiators and pipe blocks
work to accommodate increased loads or because Total 82 100 100
detailed investigation might reveal the electrical, gas
or heating system to be inadequate or unsafe. Estimates Source: Of¢ce of the Deputy Prime Minister (2003b), Social Housing
Sector, head of household 65 and over, Special Analysis by ACIOG, King’s
did not include any allowance for the overheads that College London, 2003.
would be incurred by, for example, an occupational
therapist when assessing the needs of an older person,
or a surveyor considering the adaptations required to
meet the occupational therapist’s recommendations.
Providers suggested overheads between 20 and increase in user requirement, more properties were
100%, some substantially more than this figure, par- found not to be adaptable. The simplest profiles
ticularly for small-scale adaptations. required the addition of grab rails, lever handles to
all doors and exterior lighting to entrances, hardly
The properties exacting requirements, which all properties could
Eighty-two properties were audited. They were accommodate. At the next levels various, additional
broadly representative of the range of accommodation needs were introduced, e.g. an over-bath shower, a
occupied by older people owned by the housing provi- level-access shower, further grab rails, ramps and
ders. Half of the properties were classified as sheltered rails, scooter and wheelchair storage, wider external
housing (using the definitions used by the Department doors, stairlifts in two-storey properties and com-
of the Environment; McCafferty, 1994) and of these munal lifts in flats with communal areas. At subsequent
about half were conventional mainstream properties levels, there were more challenges, e.g. the need for
in which community alarms and grab rails had been wider corridors and a wheelchair-accessible shower
installed but without other adaptations. When com- room with gully shower. At the highest level, there
pared with national statistics, the types of properties was the need for a wheelchair-accessible bathroom,
under-represented (semi- and detached properties) a through-floor lift and a fixed hoist from bedroom
were those that are more easily adapted (e.g. due to to bathroom. At this level, only 43 properties were
more generous internal space standards and external adaptable.
space available for ramps, lift shafts, extensions and
similar requirements). Over-represented properties Discussions with healthcare specialists suggested that
included those difficult to adapt, for a wide variety of a desirable level of adaptability would be meeting
reasons, e.g. flats in converted houses and properties the needs of an individual who uses a wheelchair or
in some high-rise blocks (Table 5). The sample under- scooter outside the home and a wheelchair inside, but
represented properties built between 1945 and 1964 who can transfer to a stairlift. This would include the
and over-represented properties built before 1919 occasional wheelchair user, whereas a permanent
and from 1985. wheelchair user is likely to need a through-floor lift.
The proportion of properties meeting these require-
ments varied greatly between, on the one hand, bunga-
lows, and ground- and upper-floor flats in both
Findings: feasibility low- and high-rise blocks, of which 96% could be
Adaptability adapted, and, on the other hand, other types of
All 82 properties could be adapted to meet the require- property, largely those with two stories, of which
ments of the most modest user profiles. With each only 68% could be adapted.
474

Costs
The amount of work required to meet the needs speci-
fied in the profiles varied greatly. However, even within
each type of property, costs ranged from almost zero,
reflecting the need for very little work, to considerable,
and in some cases, adaptation was not possible. Differ-
ences were largely explicable in terms of whether a
property was of a single or of two storeys, but for
some profiles other structural features were found to
be important. The number of adaptable properties
for each of 11 types of property and the average cost
of adaptation for those properties that were adaptable
for each combination of user profile and current and
future time period are given in Table 6.
Adaptability indices
An estimate was made of the number of individual pro-
files that can be satisfied for a specific cost level. This is
illustrated in Figure 1, where the following four
budgets have been used:
. no cost limit: if feasible, adapt at all costs
. £25 000: corresponds to the current upper limit of
the Disabled Facilities Grant available in the UK to
disabled people living in both rented and owner-
occupied properties
. £12 500: half the above limit – a level that social
housing providers have indicated is a not unreason-
able amount to spend on adaptations
. £6250: one-quarter of the above limit – a very
modest level
For example, when the lowest cost limit of £6250 is
applied to bungalows, on average about seven user
profiles can be accommodated out of a maximum of
14 compared with an average of about 13 when there
are no cost limits. This figure illustrates that some
property types achieve a high level of adaptability
even at the lowest cost limit. Indeed, this is generally
the case for one-storey properties (except for flats in
converted houses), whereas it is not for two-storey
properties. Increasing the budget can increase the
adaptability, but, as noted above, some property
types are inherently difficult to adapt.
Ground-floor flats and bungalows were the most
adaptable as well as properties with at least two bed-
rooms. Adaptable properties were characterized by
combinations of the following: accommodation on
one level – no vertical circulation; a spacious layout
with rooms separately approached from a hall or
landing; internal stud partitions and timber floors;
large bathrooms or space to enlarge an existing bath-
room; and large walk-in cupboards.
Adapting the homes of older people
The least adaptable properties were usually flats in
converted houses, maisonettes and flats with either
no lift or an inadequate lift, and one-bedroom proper-
ties and bedsits. Often they had the following: changes
in floor level within the same floor; a restricted accom-
modation layout; small bathrooms and no scope for
enlargement; and restricted spaces around the
property – limiting space for ramps, scooter stores
and extensions.
Another perspective on the variability of the cost of
adaptations is given in Figure 2, which shows the distri-
bution of cost of adaptations for two groups of prop-
erty: houses and maisonettes; and bungalows and
flats. It also illustrates that as adaptations become
more extensive, so relatively more houses and maison-
ettes are not capable of adaptation compared with bun-
galows and flats, and that except when requirements
are simple, the adaptation costs are much higher.
Context of care
Even if the profiled users were provided with all
required adaptations and AT, some would not be
able to live completely independently, but would rely
on care from others, family and friends (informal
care), or formal care services or a combination of the
two. Increasingly there has been interest in whether
and to what extent these two kinds of provision –
human and non-human input – might substitute for
one another (Audit Commission, 2000). The most rel-
evant work in this area is that undertaken in the US by
Mann et al. (1999) and Agree and Freedman (2001).
The seven user profiles (Table 3) specified the func-
tional abilities of older users currently and five years
later, and a range of adaptations and AT that they
required. For each user profile, three assumptions
were made about informal care, a co-resident carer
assumed to provide personal care and domestic help;
a non-resident carer assumed to provide domestic
help, but no personal care; and no carer (no help of
any kind). For all but User Profile 2, it followed that
formal care would not be needed if there was a co-resi-
dent carer. For this user, the alternative would be to
live in a residential home. User Profiles 3 and 4
would not need formal care if there was a non-resident
carer, but other users would need such care. However,
for all users without informal care, personal care and/
or domestic help would be needed. Since some adap-
tations and AT can reduce the need for care, it was
also assumed that the amount of care required would
differ depending on the level of adaptations and AT
provided. ‘Full’ formal care would be appropriate
with minimal adaptations and AT, and ‘reduced’
formal care would be appropriate when adaptation
and AT provision is more generous. It was further envi-
saged that the adaptations and AT described above
475
476

Lansley et al.
Table 6 Number of properties that could be adapted and average total cost of adaptations and ¢xed assistive technology for each user pro¢le

User pro¢le All property types Small terrace house Medium/large Semi detached Bungalow Flat in converted
terrace house house house

n » n » n » n » n » n »

n 82 6 6 3 14 5
1c 82 994 6 1158 6 1 406 3 1158 14 853 5 1 207
1f 71 11 391 5 15 990 4 14 883 3 13 867 13 9 826 0 ^
2c 64 15 354 4 23 746 4 24 881 3 19 549 13 14 003 0 ^
2f 43 18 954 3 24 760 1 25 631 2 27 557 10 18 437 0 ^
3c 77 6 360 6 7 830 6 9 913 3 6 722 14 3 891 2 6 205
3f 72 9 792 5 12 469 4 14 346 3 10 857 14 8 173 0 ^
4c 82 748 6 966 6 1 214 3 966 14 661 5 924
4f 78 9 867 6 12 008 6 14 600 3 11 315 14 7 686 3 13 220
5c 82 4 804 6 5 495 6 5 678 3 5 934 14 4 465 5 5 285
5f 77 15 553 6 18 787 6 21154 3 18 321 14 12 892 2 15 903
6c 78 4 116 6 5 451 6 6 448 3 4 372 14 1 887 3 2 215
6f 78 8 576 6 10 157 6 12 701 3 9 402 14 6 992 3 11 586
7c 77 3 577 6 5 001 6 6 433 3 4 143 14 1 634 2 3 024
7f 71 14 364 5 18 791 4 17 561 3 16 678 13 13 429 0 ^

User pro¢le Low rise block High rise block

Ground £oor £at Maisonette Upper £oor £at Ground £oor £at Maisonette Upper £oor £at

n » n » n » n » n » n »

n 15 5 12 4 3 9
1c 15 881 5 878 12 961 4 923 3 1140 9 939
1f 13 8 223 5 13 731 12 11 407 4 8 327 2 22 060 8 11 705
2c 8 11 079 1 20 818 12 13 446 4 11 790 2 29 790 8 14 320
2f 15 14 308 0 ^ 8 18 066 4 15 499 1 41 583 6 18 843
3c 15 4 208 5 10 389 12 6 862 4 5 098 2 14 441 8 6 192
3f 15 6 797 5 14 854 12 9 807 4 7 454 2 16 962 8 10 085
4c 15 598 5 686 12 655 4 702 3 872 9 645
4f 15 6 983 5 12 796 12 9 924 4 8 226 2 17 671 8 9 093
5c 15 4 598 5 4 408 12 4 581 4 4 410 3 5 302 9 4 515
5f 15 12 626 5 19 890 12 14 997 4 13 306 2 25 136 8 14 796
6c 15 2 302 5 5 969 12 5 494 4 2 098 2 13 304 8 4 774
6f 15 5 746 5 11 437 12 8 734 4 7 180 2 15 828 8 7 801
7c 15 1 302 5 7 055 12 4 210 4 2 213 2 12 604 8 3 263
7f 15 10 903 5 17 922 12 14 224 4 10 230 2 24 814 8 14 577

Note: c ¼ current period, f ¼ future period.

Costs shown for the future period are those that would be incurred if no adaptations were carried out for the current period.

Figure 1 Feasibility of user pro¢les with different cost limits
could be divided into three levels (basic, care reducing
and good practice), which would combine with the two
levels of care to form three alternative packages:
. Basic – basic adaptations and AT with full formal
care: formal care would be accompanied by basic
adaptations and AT consistent with an individual
being able to remain in their own home. Thus,
for several of the users with the most severe mobi-
lity impairments, the basic adaptations and AT
Figure 2 Distribution of costs of adaptation. The distribution of
the costs of adapting 23 houses and maisonettes (h & m) and 59
bungalows and £ats (b & f) for three user pro¢les described in
Table 2 is shown; 2f is a user with a high level of disability and
with a complex set of requirements (indicated as H); 6f has a
moderate disability level and modest needs (M); 4c has a low
disability level and simple needs (L). For each group of
properties, the costs have been ordered from lowest to highest
so that each line shows the percentage of adaptable properties
within a speci¢c cost limit. Except for L, there are properties that
cannot be adapted to meet the requirements. Thus, the
maximum adaptation cost also gives the percentage of
adaptable properties. For L, the distribution of costs is very
similar, with those for bungalows and £ats marginally less than
those for houses and maisonettes
Adapting the homes of older people
would include a wheelchair and wheelchair-
accessible entrances and circulation space.
. Augmented – basic plus care-reducing adaptations
and AT with reduced formal care: formal care
would be reduced as a consequence of the pro-
vision of care-reducing adaptations and AT that
would enable the individual to accomplish some
tasks that otherwise would be undertaken by
another person.
. Maximum – basic plus care reducing plus good-
practice adaptations and AT with reduced formal
care: this would extend the previous package by
the addition of good-practice adaptations and AT
to enhance quality of life by supplementing the
same level of care.
Care costs
Unit costs (Ernst & Young, 1994; Royal Commission,
1999; Netten and Curtis, 2003; Laing, 2002) were used
to calculate the annual cost of formal care input for
different combinations of user profile and informal
care.3 The estimation of these costs involved identify-
ing the extent to which each user could undertake
specific activities (getting in and out of bed, bathing,
dressing, toileting, food and nutrition, shopping,
safety and security, social life and participation).
Users were judged either to be able to manage indepen-
dently or to manage with difficulty, or to need help.
These capacities were translated into estimates of the
nature and extent of care required. Several services
were allowed for (e.g. meals, community nursing, day
care), but the predominant service was home care.
An example for User Profile 3 is given in Table 7.
This user was estimated to require domestic help only
currently and both domestic help and personal care
in five years. For all users, an augmented package of
adaptations and AT is expected to reduce the amount
of formal care needed. However, without the
maximum package, User Profile 2 would require resi-
dential home care.
Combining the costs
The ingredients of the combined packages of formal
care adaptations and AT incur different costs at differ-
ent times. Care costs are incurred on a daily basis. For
adaptations and AT, there is an initial cost, and those
of maintenance and, possibly, replacement as well as
removal costs and recovery values. For User Profile 3,
the average adaptation costs and the cost of AT are
given in Table 2; and the cost of formal care are
given in Table 7.
The combination of the costs of a package of adap-
tations, AT and formal care used discounting
methods to convert the flows of expenditure to a
477
Lansley et al.

Table 7 User Pro¢le 3: Care costs with assumption of no informal care

Services Full formal care (provided in conjunction Reduced formal care (provided in
with basic adaptations and assistive conjunction with either augmented or
technology) maximum adaptations and assistive
technology)

Hours per day Hours per week Hours per day Hours per week

Current time period aged

75 years
Home care: domestic ^ 3 ^ 1
Annual cost (2001 costs) »1612 »520
Five years later aged 80
years
Home care:
Domestic ^ 5 ^ 2
Personal 2 14 ^ ^
Days per week Days per month Days per week Days per month

Day care 1 4/5 1 4/5

Annual cost (2001 costs) »4940 »2548

Note: Within each category of home care, costs vary according to services required.

capital value (termed present value). A discount rate of
3.5% was used following recommendations from
H.M. Treasury made in late 2002 (H.M. Treasury,
2003). However, other discount rates did not have a
substantial influence on the outcome.
Figure 3 shows the average present values for ten years
for the combined cost of adaptations, AT and formal
care for the three packages assuming no informal
care, for six user profiles. User Profile 2 has been
omitted because for this profile the basic and augmen-
ted packages are replaced with residential care. Similar
relationships between the costs are revealed when con-
sidering non-resident informal care situations.
Although these analyses should be interpreted with
care because of the assumptions involved, a number
of conclusions follow. These are based on comparisons
of the costs that would be incurred by a combination of
housing, social and health services over ten years. They
do not include estimates of the value or cost of informal
care:

. As would be expected, there is substantial cost vari-

ation between different user profiles that is to some
extent related to level of disability.

. User 2, the most severely disabled, has estimated

care costs of over £200 000 due to residential pla-
cement. The user would be able to reside in his/her
own home only under the maximum package. In
this case, residential care is cheaper than remaining
at home if there is no carer.

. Other profiles demonstrate that the cost of providing

Figure 3 Cost of packages over ten years. User pro¢les are
arranged according to the level of disability. User Pro¢le 2 is
excluded as the basic package is replaced by residential care
(»198 500 over ten years). For this user pro¢le, the cost of the
maximum package over ten years is »240 000. Similar
relationships are revealed when there is a non-resident carer.
Costs are present value for ten years using a discount rate of
3.5% and based on 2001 costs
478
care in the home can reach 40% of the equivalent
residential care cost, but generally, it is much lower.
. With a basic package, average costs over ten years
range from little more than £20 000 to about
£80 000. For the augmented package, the range is
between a little above £10 000 and about
£65 000. For the maximum package, it is
between £15 000 and £80 000.

. For all profiles (except for User 2) and combi-
nations of informal care, savings result from the
introduction of care-reducing adaptations and
AT, that is the augmented package. These savings
vary but are of the order of £10 000– £27 000
over the ten years.
. Whilst these savings are reduced when the good-
practice adaptations and AT are introduced under
the maximum package, to between £3000 and
£24 000, these can be funded by the savings
achieved through introducing care-saving adap-
tations and AT.
Costs over varying periods
The period of use of adaptations and AT and care services
has an important bearing on the outcome of any com-
parison. Generally, savings begin between the sixth and
ninth years. User 2, under the assumption of a co-resident
carer, achieves savings much earlier, but there are none
when there is no carer. Users in easily adapted accommo-
dation achieve savings two to three years earlier than
average, and for difficult-to-adapt properties, savings
are made three to four years later. These points at
which savings are achieved should not be confused with
the time to recoup an investment in adaptations and
AT through reducing formal care costs, which is generally
between one and three years for the care-reducing
adaptations and AT, and between two and five years
for good-practice adaptations and AT. Consideration of
users’ estimated expectation of life, using current life
expectation data (Office of National Statistics, 2002,
table 5.22), suggests that on average savings are achieved
in a period less than the average life expectancy.
In practice, there are a number of reasons why the costs
might be overestimates. Most individuals are unlikely
to want all the recommended good-practice adaptations
and AT; equipment usually lasts longer than the design
life assumed; and the earlier that adaptations and AT
are provided, the greater the likely savings. In this case,
comparison between the augmented and basic packages
may be more appropriate. This shows that for most
combinations, savings are achieved in periods shorter
than three-quarters of the average life expectancy.
However, there is a danger of focusing too strongly on
financial cost–benefit analysis as other issues are
equally important, especially those relating to indepen-
dence and quality of life, and an even bigger danger of
over interpreting individual cases. Rather, the value of
these analyses is to suggest that overall there are no
unexpected or worrying cost implications arising
from a policy of encouraging the more widespread
adoption of adaptations and AT. Indeed, adaptations
and AT may provide an opportunity to contain care
costs, which are increasing as a result of greater longev-
ity and a rise in the absolute number of older people.
Adapting the homes of older people
Older peoples’ views and experience of
adaptations and AT
The final section of the present paper is to summarize
older people’s views of adaptations and AT, based on
interviews with 67 people aged over 70 years. The
respondents had varying disabling conditions, some
quite modest but many very severe, and they had a
range of adaptations and AT, mostly traditional. Posi-
tive comments about the value of adaptations and AT
far outweighed negative ones and were associated
with the ability of adaptations and AT to enable
control over as many of their day-to-day activities as
possible. Negative comments were largely concerned
with issues relating to poor design creating difficulties
in using the items (e.g. fiddly buttons), poor workman-
ship (e.g. incorrect positioning of grab rails) and
reliability (e.g. smoke alarms that went off too easily,
and stairlifts that broke down).
The most important comments, however, were those
about emancipation from functional limitations pro-
vided by, for example, stairlifts, which enabled indi-
viduals to go up and down stairs as they wanted, and
showers that afforded privacy to the individual who
when using a bath would need the help of others.
The interviews generated a strong body of evidence
about the contribution that adaptations and AT
could make to the quality of life and feelings of well
being, not least because they enhanced the indepen-
dence that many of the respondents wanted to retain
for as long as possible, preferably in their present
homes. Some comments made during the interviews
illustrating various aspects of the design of homes
and the benefits and otherwise of adaptations and AT
are given in Table 8.
Other bene¢ts
Other implications flow from this greater indepen-
dence. Arguably, the rate of decline of physical and
mental health is reduced and so the time at which the
individual needs additional care, adaptations or AT
or has to enter a residential or nursing home may be
delayed. As has been shown, the cost of residential
care is much higher than the cost of packages con-
sidered in this study, except for the situation where
the individual is very disabled.
Adaptations and AT not only contribute to the general
well being of an individual, but also contribute to the
safety and security of older people in their homes and
enables them to summon help more quickly. These
too should have implications for cost savings through
the reduction in accidents, especially falls, and the con-
sequent hospitalization and subsequent institutionali-
zation. This study has not attempted to estimate these
savings, but they could be substantial (Mann et al.,
479
Lansley et al.

Table 8 Some comments by respondents about their homes, adaptations and assistive technology

Topic Typical comments

Housing facilities ‘A lot of these £ats have got small baths . . . All right, they’ve given me a seat, across, but I’ve still got the
problem of getting my legs in. And it is getting a problem. I’ve asked the Manager, and we’re hoping that
Age Concern will do something about that I want the bath taken out and a shower putting in.’Cos it’s the
bath that’s the problem.It’s so high . . . I’ve not been able to get in a bath for years’. Mrs Steller, aged 71, has
arthritis and a slipped disc
Housing design ‘It’s a bit awkward.You can’t get the chair into the toilet. So . . . I get close to the toilet as I can, and he has to
grab hold of one rail, try and force himself up, and grab hold of . . . it sometimes takes about 20 minutes
doesn’t it? . . . ’ Carer of Mr Bernard, aged 86
Technology design: ‘It’s all right if you’ve got nimble ¢ngers, but that lady who showed me how to work it, it was all right, because
fall detector she’s got nimble ¢ngers, but I haven’t. See, it comes out and it stands on that wee stand up there . . . I says
to her when I put it on, you talk about Spiderwoman, I says I feel like her [chuckles] I look it . . . it is a good
thing if you fall and you’re helpless, or even if you feel dizzy and you don’t feel steady on your feet. I would
say it’s a good thing . . . ’ carer of Mrs Shanks, aged 84
Reliability: vertical lift ‘[We use the lift] morning and at night, like.Twice a day you can say. And, what is it, I think it’s twice on a
Friday and twice on a Monday ^ that’s shower day . . . They’re a good thing, I’ll give that you, but you want
it in working condition don’t you? . . . Social services should come and check it to make sure that it is a
perfect ¢nish. Especially for one of them to go on (the lift).’ Spouse carer of Mrs Black, aged 81
Reliability: stairlift ‘Anyway the last time it went ¢nally at the top of the stairs . . . So anyway, a man came last week, he was
here for ¢ve-and-a-half hours . . . and then all the fuses blew . . . And when he looked at the wiring, he
found it was only telephone wire, instead of proper. So he had to solder them all up and put some
insulating in . . . Anyway he got it going to the fact it would go up, but it wouldn’t come down.’ Mrs
Morrison, aged 83
Some negative ‘Sometimes the smoke detector is a blessed nuisance . . . if we put the grill on.’ Mrs Bradley, aged 76
experiences ‘There is a problem with the community alarm.When they speak to Mrs Joyce it’s not loud enough, and she
can’t hear them.’ Carer of Mrs Joyce, aged 86
‘I can’t use the shower stool because I slip off . . . ’ MrsTodd, aged 75
‘That hoist’s a waste of time, isn’t it?’ Carer of Mr Bernard, aged 86
Positive experiences ‘Now, if it weren’t for those bed levers I wouldn’t be able to turn over on my own.’ Mrs Clark, aged 79
‘I couldn’t use the taps before.’ Mrs Parkinson, 70
‘You see how wonderful the Window opener is.’ Miss Carr, aged 81
‘I wouldn’t be without that shower’ Mrs Knight, aged 75
‘The door-entry system is a very good thing.’ Mrs French, aged 85
‘The community alarm is a Godsend, it is really.’ Mr Castle, aged 85
Bene¢ts ‘Oh the shower’s great for me. Makes us independent, y’know. It’s great for me. I can more or less do it
myself. No, I couldn’t do nothing, if I hadn’t the shower.’Cos I couldn’t get in and out of the bath.’ Mrs Royle,
aged 77
‘Well I mean my (stair)lift is a lifeline to me really. I could never go up. I would have to have a £at if I hadn’t got
that. I’d hate to leave my little house,’cos I like it.’ MrsTate, aged 79

1999). Clearly, if as a result of the provision of adap-
tations and AT for whatever reason an individual’s
entry into a residential home is delayed, savings
would accrue and the potential burden on healthcare
budgets reduced.
More generally, these savings would add to the many
other benefits that would ensue from enabling older
people to remain in their own homes with the enhanced
prospect of arresting further deterioration, and pro-
moting the capacity to maintain independence. The
achievement of this level of independence is being
sought especially by those societies confronted by a
rapid growth in the number of older people, limited
healthcare budgets, a declining level of informal care,
and a demand for better quality of life and higher
levels of inclusion of older people in society.
Whilst social housing and healthcare systems vary
greatly between countries, the methodology summar-
ized in this paper provides a way of developing
480
estimates of the relative costs of different care strat-
egies. The approach could easily be modified to
reflect the characteristics of different housing stocks
and sources of funding of adaptations and AT.
Through incorporating national profiles of the charac-
teristics of housing and older people, this approach
could benefit strategic debates on future types of
housing and healthcare provision.
Conclusions
A methodology has been introduced for auditing, analys-
ing and costing the adaptation of properties including
the provision of fixed AT to meet the needs of older
people and an approach to comparing the costs of
packages of care, adaptations and AT. The methodology
involved the development of two explicit sets of assump-
tions. One concerns the dimensions, space and configur-
ation that enable decisions to be taken about the nature
of the adaptation and its installation. The other is con-
cerned with the constituents of packages of care.

The need to adapt properties and the extent of work
required to achieve the adaptation necessary to meet
the specific requirements of a user varies greatly both
between and within property types. The main influence
on the extent of adaptation required is determined by
mobility needs, which principally incorporate the use
of mobility aids when getting into a property, moving
around, moving to upper floors, and using bathrooms
and shower rooms. Limitations in space within a prop-
erty affect the adaptability of a property as significantly
as factors relating to property type or construction
type. Thus, when the cost of adapting an individual
property is considered in place of an average, cost effec-
tiveness can be quite different. Clearly, knowledge
of the unique characteristics of a property is important
to understanding the likely cost of the required adap-
tations and the potential savings.
As user needs become more extensive and complex, so
the costs of adaptation rise and more properties are
encountered that cannot be adapted to meet user
needs. So, although the differences in feasibility of
adaptation and the cost of adaptation are not substan-
tial where user requirements are modest, the differ-
ences are significant where users need to use a
wheelchair inside the home and for more complex
user needs, e.g. the need to use a hoist for transfers.
Except for extreme cases, the provision of adaptations
and AT combined with formal care to older people in
their own homes is much less costly than residential
care, and for many other reasons distinctly preferable.
There are also considerable cost differences between
different combinations of adaptations, AT and formal
care largely contingent on the role played by informal
carers.
Considerations of cost are dramatically influenced by
length of use linked to life expectancy. Adaptations
and AT are most appropriate when considering
the long rather than the short term. This economic
conclusion has to be reconciled with the finding
about the acceptability of adaptations and AT. It is
little use installing a preventive long-term package
unless the older person sees the various components
as useful and helpful to them at the current time. By
paying attention to the needs of users and the nature
of the property in which they live, and provided that
the users remain in that property for a reasonable
time, then for most users adaptations and AT are
very worthwhile in both cost and human terms. This
cost effectiveness is likely to be enhanced further with
newly developed sensor technologies extending the
opportunities for greater security and independence for
even more people. The study points towards the
need for a sensitive understanding of user needs and
of properties so that adaptations and AT can be appro-
priately specified. There is the opportunity to achieve
considerable savings by identifying properties that are
inherently easy to adapt, and over the longer term
Adapting the homes of older people
ensuring that these are occupied by those people
likely to need adaptations, whilst at the same time
avoiding placing older people in difficult-to-adapt
properties.
These conclusions provide some pointers to the way in
which UK policy-makers could encourage the wider
adoption of adaptations and AT. First, they suggest
that in many situations, adaptations and AT could be
an attractive substitute to the provision of home care,
although not always eliminating the need for it, and
in more extreme cases of residential care. This option
has advantages in terms of both cost to government
and the enhancement of quality of life of the individual.
Thus, they lend support to what both government and
society see as desirable as an approach to supporting
older people and specifically to the positive develop-
ments that are occurring at a national level, such as
increased recognition of the centrality of housing to
community care policies, the development of inte-
grated community equipment, the awareness of the
importance of adaptations and increased funding for
AT. Second, they indicate that if the wider adoption
of adaptations and AT is to be effective, then there
needs to be a strengthening of the knowledge and
skills of health and housing professionals directly
involved with older people and the adaptation of
their homes. Third, the conclusions suggest that adap-
tations and AT should be viewed as integral to commu-
nity care packages and not as useful supplements. This
is particularly important when considering new tech-
nology. Encouraged by the many positive develop-
ments with smart home and alarm technologies, there
is a danger of these being seen as separate rather than
as part of a whole range of technology that can help
people stay in their own homes. Yet, often basic adap-
tations to a home and traditional AT can cost far more
than novel technology, which usually meets only part
of an individual’s needs.
Although the empirical analysis has considered
housing and care within the UK, it is likely that the
findings will have significance for those countries
with similar housing and care services. Indeed, given
that reputedly in the UK the cost of building work rela-
tive to the cost of care services is relatively high, it is
possible that for other countries there would be even
greater advantages to be achieved through policies of
wide-scale adaptations and provision of AT. This
calls for replication of the study in other national set-
tings and cross-national comparisons of costs and ben-
efits; certainly, the methodology would be appropriate.
Such comparisons would need to include a broader
investigation of the benefits of adaptations and AT to
the individual, their families and their communities.
This would both enable comparison of cultural differ-
ences in terms of availability and acceptability of par-
ticular types of adaptation and AT and help to
counter what otherwise would be a rather narrow
481
Lansley et al.
cost-benefit perspective. Such a broader investigation
of the context and experiences of users did form part
of the study herein, but space has precluded all but a
small reference to the findings. Importantly, however,
the study was not able to follow the histories of older
people and the processes leading up to and following
their adoption of AT. Such longitudinal investigations,
working with health and housing practitioners to
understand how adaptations and AT are prescribed,
procured and used, would be immensely valuable to
developing effective strategies for the wider deploy-
ment of adaptations and AT.
The findings also have direct relevance to the build-
ing industry. They suggest that the industry could
make an important contribution to improving the
quality of life of older people. The market for adap-
tations, which is already strong, will continue to
develop in response to both demographic trends
and the rising expectations of older people and
society, and will be given a further impetus by the
development of cheap and reliable smart home tech-
nologies. However, it is a challenging market, which
relies on approaches to design and redesign homes in
a manner sensitive to the individual’s needs as well as
to the constraints and possibilities offered by a prop-
erty, where site work has to be very well organized
and sympathetic to the user, indeed where good cus-
tomer relationships are at a premium, and yet offer
services that are clearly cost effective. More impor-
tantly, the type of adaptation service implied in this
paper is that where timeliness not only should bear
heavily on developing a suitable business approach,
but also is critical to the quality of the lives of
those who could benefit from it.
Acknowledgements
The authors gratefully acknowledge the support of the
housing providers that participated in the research, the
support of EPSRC (Grants GR/N 33249/01, GR/N
33270/01, GR/N 33218/01), and the contribution of
their colleagues, Keith Bright (University of Reading),
Alex Bialokoz and Donna Cowan (Centre of Rehabili-
tation Engineering, King’s College London), Rachel
Stutchbury (Institute of Gerontology, King’s College
London) and Alan Holmans (University of Cam-
bridge), and the comments of referees and the Editor
on an earlier version of the paper.
Endnotes
1
The paper adopts the definition of AT used in research for the
Royal Commission (Tinker et al., 1999, p. 81), ‘an umbrella
term for any device or system that allows an individual to
perform a task which they would otherwise be unable to do or
increases the ease and safety with which the task can be per-
formed’. It covers building adaptations, items of AT that have
to be installed and fixed to a building (which in the present
482
paper are collectively termed adaptations) and portable AT –
all items of personal equipment used by an individual.
2
For further details about the study’s methodology, see King’s
College London and the University of Reading (2004).
3
All costs considered in the present paper are those that could be
incurred in various ways by the social housing provider, social
services and health services and met by the state. The costs of
informal care have not been estimated, nor have contributions
by the individual, for example, towards the purchase of AT.
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