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Roots of recovery: Occupational therapy at the heart of health equity

Housing

Observation shows that poor quality, unaffordable housing disproportionately impacts certain groups, including those from lower income households and people from minority ethnic backgrounds. Living in housing that is not fit for purpose increases the risk of a range of preventable health conditions, such as respiratory and cardiovascular diseases, as well as mental health conditions such as depression and anxiety.51 Conversely, safe and warm homes and good neighbourhoods improve physical and mental health and wellbeing and build strong communities.52

There is a need to increase the supply of purpose-built accessible housing, but 80 per cent of the homes that we will live in by 2050 already exist.53 Fewer than 10 per cent of homes in England have design features that make them ‘visitable’ by people with disabilities, whilst around 400,000 wheelchair users are living in homes that are unsuitable for them.54 Nearly half (47 per cent) of disabled respondents to the UK Disability Survey reported having at least ‘some difficulty’ getting in and out of where they live.55

Occupational therapists are integral to the provision of home adaptations. They have expertise in designing and adapting homes that can enable people to remain independent and safe, especially those with complex health and social care needs. Adapting people’s existing homes enables them to remain within communities, which may be important in meeting their social, cultural and support needs. Home adaptations are valuable in overcoming environmental barriers arising not just from physical disabilities, but also from cognitive, neurodevelopmental, sensory and psychological needs.

Around two thirds of Disabled Facilities Grant applications are for people aged 60 and over. With more than 90 per cent of older people living in mainstream housing, the implications of our ageing population on demand for adaptations is significant. As more people live for longer, often with multiple long-term health needs, it is important to take an integrated and holistic approach to housing needs, considering all the ways in which people’s safety, independence, health and wellbeing are affected by their homes. This includes fire safety and security from crime.

Housing also affects children. Those living in poor or overcrowded conditions are more likely to have physical and mental health problems in the short and long term. There is also a long-term impact on children’s life chances, with greater likelihood of lower educational attainment, unemployment, and future poverty.56 Recently, the need for home-schooling during the COVID-19 lockdowns, inevitably increased the education gap in children who did not have a suitable learning environment.

Everyone has the right to a home in which they can thrive. This belief closely aligns with the principles of occupational therapy. There are already housing departments and housing associations that benefit from employing or working in partnership with occupational therapists to provide expertise in designing and adapting homes to meet needs, increase independence and safety, and provide access.57

Key elements to maximise impact

Establish and support occupational therapists where they can:

  • Develop greater and more holistic understanding of people’s needs among multidisciplinary colleagues involved in the delivery of home adaptations or home safety.
  • Promote understanding and early consideration of building regulations related to ease of access, safety and use by the elderly and people with disabilities.
  • Work with local planning departments and have a clear process for receiving proposals at the pre-planning or an early stage for input, comment and re-design, to ensure the best design, and reduce the need for compromise later.
  • Provide expert information and advice, specifying home adaptations for people with complex health and support needs.
  • Complete post-occupancy/post-adaptation audits and outcome measures to capture the impact of good design on individuals and their families, to inform planning and adaptation processes.

Return on investment

  • Once developers and registered providers work with occupational therapists on a scheme, the learning can be applied to future projects, thus minimising occupational therapy involvement, saving time and money but still resulting in better homes
     
  • Accessible, warm, decent housing is a fundamental contributor to enabling people to remain living well and independently at home.58 Integrating services across social care, housing and health can achieve this, preventing or delaying the need for further costly care and support services.
     
  • Home adaptation has significant returns on investment in falls prevention with older people. Even non-serious falls that do not require medical or social intervention can affect peoples’ lives, for example by causing increased anxiety, functional decline and social isolation. The 20 per cent of people whose fall is deemed serious may go on to Accident and Emergency, be admitted, then discharged to a care home or their own home with ongoing social care support, all incurring significant costs.59
     
  • The provision of home assessment and modification reduces the number of falls that require a hospital admission. For every £1 invested in providing assessment and modifications, £2.17 is saved in care costs and the quality of life benefits are equivalent to £7.34, indicating there is a positive return of £6.34.59

Case study - Re-housing wheelchair users in Tower Hamlets

Awareness
Tower Hamlets has one of the most diverse populations in the UK. The employment rate is below the national average, levels of poverty are high and there is an increasing need for in-work welfare support. Healthy life expectancy is below the national average and residents have a higher-than-average need for social care services.

Action
The Project 120 initiative was launched in 2012. Its intention was to rehouse all 120 of the wheelchair users then waiting for accessible housing, to accommodation that was built to meet their needs. Since then, over 290 wheelchair users and their families have been rehoused across the borough.  

A team of five occupational therapists and one therapy assistant have expertise in accessible design and are skilled in identifying person-centred solutions to meet the occupational needs of people with complex health needs and disabilities.

The team works closely with developers, architects, the council’s own affordable housing team and housing associations to ensure the right properties are built to the right specifications and people are moved into them quickly.  They work with residents to ensure that their individual needs will be effectively supported by their home environment.

Advocacy
The local authority exceeds the requirements of the London Plan to ensure that at least 10 per cent of newbuild social housing is fully wheelchair accessible from the outset. The project has made savings for the council as the occupational therapy team contribute to designing lower cost wheelchair accessible properties instead of the council adapting less suitable properties, which is a more expensive process.60

References

51.  Town and Country Planning Association (2020) The Healthy Homes Bill: a bill that transforms the regulation of the built environment to ensure that new homes and neighbourhoods support their residents’ health and wellbeing. London: TCPA. Available at: https://www.tcpa.org.uk/Handlers/Download.ashx?IDMF=3ecf26b8-a418-4bae-83d2-3ec1b624d3e6

52.  Scottish Government (2021) Housing to 2040: fairer Scotland duty. Edinburgh: Scottish Government. Available at: https://www.gov.scot/publications/housing-to-2040-fairer-scotland-duty/

53.  Nottingham Trent University (2020) ‘Dramatic’ change needed for UK homes to meet climate targets, study shows. Nottingham: Nottingham Trent University. Available at: https://www.ntu.ac.uk/about-us/news/news-articles/2020/07/dramatic-change-needed-for-uk-homes-to-meet-climate-targets,-study-shows

54.  Habinteg (2020) Forecast for accessible homes 2020. (Briefing). Bradford: Habinteg. Available at: https://www.habinteg.org.uk/download.cfm?doc=docm93jijm4n2829.pdf&ver=3554

 

55. HM Government (2021) National disability strategy. London: Stationary Office. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1006098/National-Disability-Strategy_web-accesible-pdf.pdf

56.  Shelter (2006) Chance of a lifetime. The impact of bad housing on children’s lives. London: Shelter. Available at: https://assets.ctfassets.net/6sxvmndnpn0s/4LTXp3mya7IigRmNG8x9KK/6922b5a4c6ea756ea94da71ebdc001a5/Chance_of_a_Lifetime.pdf

57.  Housing LIN [n.d.] Occupational therapists: helping to get the housing design right. London: Housing LIN. Available at: https://www.housinglin.org.uk/Topics/browse/Design-building/occupational-therapy/

58.  The Housing and Ageing Alliance (2019) Time for action. Available at: https://www.housinglin.org.uk/_assets/Resources/Housing/HAA/Housing-Ageing-Alliance-Manifesto-2019.pdf

59.  Public Health England (2018) A return on investment tool for the assessment of falls prevention programmes for older people living in the community. London: PHE Publications. Available at: https://www.gov.uk/government/publications/falls-prevention-cost-effective-commissioning    

60.  London Borough of Tower Hamlets (2016) London Borough of Tower Hamlets Housing Strategy: Building new homes and communities in Tower Hamlets. London: London Borough of Tower Hamlets. Available at:  https://www.towerhamlets.gov.uk/Documents/Housing/TH_Housing_Strategy_document.pdf