How Disabled Facilities Grants can reduce upstream demand by preventing falls

Background

Disabled Facilities Grants (DFGs) provide householders with one-off funding to adapt their homes in order to meet an assessed need. DFGs are most commonly used to provide small-scale adaptations (including items such as handrails, accessible showers and wheelchair ramps) totalling less than £5,000 on average per home. Older people are the most frequent recipients of this funding, although age is not itself a consideration when entitlement is decided.  

A maximum six-month period between an application being made and a decision issued by the local authority is set out in law, yet some local authorities fail to meet this legal limit, while no statutory waiting times exist for the actual completion of adaptations funded by a DFG. Many of those in need are therefore waiting months or years longer than necessary, increasing their risk of a serious medical incident such as a fall in the meantime. 

As Lord Darzi stated in his recent review of the NHS: “Everybody knows that prevention is better than cure. Interventions that protect health tend to be far less costly than dealing with the consequences of illness.” The DFG process has the potential to save the NHS significant resources while simultaneously reducing the numbers of older people who suffer the shock, indignity, pain, loss of independence, decline in mobility and , on occasion, death, which can all result from falling in the home. This was recognised in the October 2024 Budget, in which the government announced an £86 million increase to the DFG ‘to reduce hospitalisations and prolong independence.’

This briefing examines the current application process for DFGs, the clinical benefits of home improvements, the scale of the waiting times currently endured by many applicants and the potential impact of these delays on the NHS and social care. Although home adaptations and the grants that fund them are a statutory responsibility of local authorities, the financial and human costs of the current process affect all areas of the health and social care system. 

How are home adaptations funded and arranged?

Home adaptations – including grab rails, accessible showers and stairlifts – are a proven and cost-effective means of ensuring future savings for both health and social care by preventing common, but serious, negative outcomes for patients. Incidents such as falls in the home can be avoided through the timely installation of such equipment, which not only allows residents to stay in good health but also allows them to remain independent in their own homes for longer.

However, lengthy waiting times for these small-scale interventions have been condemned for more than a decade by practitioners and disability rights organisations alike. Although the picture varies across the country, some areas see waits frequently exceed six months, with one- or two-year waits not unprecedented for the completion of essential home adaptations.

Under the provisions of the Housing Grants, Construction and Regeneration Act 1996, local authorities are responsible for providing DFGs. These fund capital improvements to an applicant’s home to adapt the property to the resident’s needs, most commonly where poor mobility restricts access or makes essential household tasks, such as washing or cooking, difficult. 

A clinical referral is not required to submit an application for a DFG. Instead, an applicant will be assessed by an occupational therapist (employed by the local authority) who will examine the nature and extent of the disability in question and recommend what alterations, if any, are needed to a property. This assessment phase, which concludes with a local authority accepting or rejecting an application for DFG funding, must by law take no more than six months.

If accepted, the works set out in the application will then be funded by a DFG and implemented. However, given the range of adaptations that can be facilitated by a DFG – and the need for local authorities to contract private sector companies to complete the alterations in question – no statutory time limit exists for this implementation phase.

The average amount provided through an individual DFG is £5,000, a figure which has remained stable for over ten years. However, as application numbers have risen, so has public expenditure on DFGs, with the £625 million allocated nationwide in 2024/25 representing a 184 per cent increase since 2015. There is evidence to suggest that this growth in funding from Westminster may be offsetting some of the reductions in spending from local authorities driven by the increased pressure on their own budgets.

Since 2015, DFG monies for local authorities have been allocated through the Better Care Fund (BCF). Created to improve integration between health and social care spending, the BCF was proposed as a means to bridge the gap between services provided through the NHS and those that remain the responsibility of local government. The BCF's planning requirements recognise that, while local authorities remain statutorily responsible for the DFG process, the impact of both the NHS and the social care sector should also be considered when delivering this funding.

How can home adaptations improve clinical outcomes?

Although the DFG can be deployed to adapt homes for a range of conditions and is not bound by age limits, the majority of those who receive alterations through its processes are elderly. Consequently, the most common forms of interventions provided through the DFG – grab rails, safe showering facilities and stairlifts – are designed to manage the impact of frailty, above all in order to prevent falls.

Falls pose a serious risk to older people, representing the most common cause of death from injury in those aged 65 and above. Falls are set to become an ever-greater public health issue as the population continues to age, with 75 per cent of deaths from falls occurring with an individual’s own home and 10-25 per cent of all ambulance calls-outs to older adults relating to falls. Those who suffer a hip fracture face a 20 per cent chance of death within four months, or 30 per cent within the year. Moreover, the psychological impact of falls often results in a collapse in a person’s confidence, reducing their capacity to live independently and precipitating moves into residential social care.

At the same time, a growing body of evidence demonstrates how capital installations in residents’ homes lead to a ‘significant decline’ in the annualised rate of fall-related injuries. Broad analyses indicate that home adaptations can reduce the risk of falls by around 20 per cent overall, with this increasing to 39 per cent for those already identified as at a high risk. The interventions in question – bathroom and toilet grab rails, outside lighting and level access improvements – are comparable in both scale and cost to those facilitated through the DFG.

For example, in one study across seven British local authorities 40 per cent of those who had received home adaptations had either already fallen or were at a serious risk of doing so in the immediate future. Following the scheduled alterations to their properties, almost all of these risks were removed, thereby reducing the chances of the resident falling in future.

Moreover, by making homes safer through adaptations that remove potential risk factors, residents can remain physically able to live independently for longer. This can amount to up to an extra four years of life at home before the need to move into residential care, even among cohorts whose life expectancy remained the same. 

The scale of delays to Disabled Facilities Grants

Waiting times within the DFG process vary around the country. As of 2023, an average waiting period of 22 weeks (eight for assessment and 14 for a finished installation) was recorded nationwide. However, in some areas this could extend to a year or more. Indeed, almost half of all local authorities had cases where applicants had waited more than two years for the process to be completed, while over three-fifths of councils admitted to missing the statutory six-month assessment period limit at times.

A number of bottlenecks in both the approval process for DFGs and the implementation of the works scheduled explain these lengthy delays. With local authorities nationwide experiencing acute budgetary pressures, their ability to recruit or train more occupational therapists (OTs) in line with a rising demand for DFG assessments, is severely limited.

More than three-quarters of OTs now report that their team lacks the capacity to meet demand, while 86 per cent of practitioners reported an increased need for their services within the previous 12 months. In addition, even as the amount of capital funding for home alterations has grown, this has not been mirrored in an expansion of resources for local authorities to be able to process increased numbers of grants and referrals. A lack of suitable contractors to implement adaptations has also been identified as a further stumbling block. 

As a result of these factors, thousands of applicants are having to endure pain, discomfort and indignity while awaiting vital but often small-scale adaptations to their properties. Frequently, it is health and care settings that must then intervene to mitigate the clinical consequences of these delays. 

The potential return on investment offered by home adaptations

Falls cumulatively cost the NHS more than £2 billion each year and occupy more than 4 million bed days, chiefly in acute settings. Avoidable falls also lead to higher rates of ambulance conveyance, greater acute bed occupancy, and increased need for elective and non-elective procedures. These in turn contribute to delayed discharge, as patients who no longer meet the criteria to reside await the completion of home adaptations to allow them to leave hospital, exacerbating existing pressures on patient flow.

As a result, home adaptations as funded by DFGs offer a significant return on investment. In one analysis, Public Health England (PHE) estimated an ROI of £3.17: £1 rate of return on such investment – greater than any of the other possible interventions recommended to prevent falls, including targeted balance and exercise classes. The scale for potential cost avoidance for the NHS and social care alike is sufficiently great as to ‘deliver a health and wellbeing return that is worth far more than the costs of the DFG in first year savings alone’. As stated by PHE: ‘…the majority of these returns are not expected to be cash releasing but rather are opportunity cost savings (e.g. freeing up hospital beds due to a reduction in inpatient admissions)’. 

For those at the highest risk, the potential savings are even greater: adapting the ‘100,000 homes where a serious fall is otherwise likely to occur’ could generate an ROI of up to 34.8:1, provided the properties in question could be identified. With the Department of Health and Social Care estimating the unit costs of a hospital bed per day to range from £345 for a standard bed to £2,349 for an elective bed, each avoided admission and/or delayed discharge can provide substantial efficiencies.

Likewise, prompt home adaptations through the DFG may also reduce some of the resource pressures on the care sector. By maintaining a person’s independence for longer, home adaptations can lead to up to a four-year reduction in the amount of time spent in residential care. In this context, the one-off expenditure of £5,000 on average per approved DFG, contrasts sharply with the median annual cost of £29,000 for a residential care home placement.

Savings may also be achieved in domiciliary care through appropriate alterations in the home. Care and Repair England has estimated that every year of delay to necessary home adaptations can increase homecare costs by £4,000, the equivalent of providing safe showering or bathing facilities. Additionally, further homecare needs can be avoided through timely home adaptations, as residents can maintain their independence for longer and thereby require less assistance with daily tasks such as washing and cooking.

Conclusion

Home adaptations, as funded by DFGs, are an effective means of preventing falls and thereby reducing demand for acute care, as well as residential and domiciliary social care. Alongside the cost savings this represents for the NHS, there is also a moral imperative to allow as many older people as possible to live independent, confident lives without the pain and fear that can result from a serious fall in the home.

Although DFGs do not solely cover the elderly and can be used to address a range of needs unrelated to falls prevention or the effects of frailty, this example demonstrates the scale of benefits that can be drawn from comparatively low-cost, one-off improvements to the home. Other research is providing further example of where this approach can deliver comparable results. For example, where homes need to be adapted to accommodate residents with spinal cord injuries.

In this context, a more rapid process of assessment, approval, and implementation could allow for resources to be left-shifted out of expensive, late-stage interventions such as hospital admissions or residential care, into a model of care more focused on prevention. Consequently, a greater number of the negative clinical outcomes which stem from falls could be prevented at a lower cost per person that is presently possible. As the population ages, the potential benefits from such an approach are set to become ever-more compelling.