Health, Social Care and Sport Committee Inquiry into loneliness and isolation

Care & Repair Cymru (C&RC)“Improving Homes, Changing Lives”.

We are a national charitable body and actively work to ensure that all older people have homes that are safe, secure and appropriate to their needs.

Care & Repair Cymru is committed to improving the health and well-being of older people in Wales by providing advice and assistance with home improvements, adaptations and general repairs.  We work in partnership with a number of organisations including the Welsh Government, Local Government Housing and Social Care Teams, NHS, Occupational Therapists, third sector organisations such as Age Alliance Wales, the Older People Commissioner, and housing associations to ensure that older people have access to a range of housing and social solutions that enable them to live in housing that meets their individual needs.

There are 13 Care & Repair Agencies covering the whole of Wales.  Each agency provides a wide range of services and support for older and vulnerable people, helping them to remain living independently in their own homes and communities.

Care & Repair Agencies

The 13 Care & Repair Agencies in Wales operate to the same boundaries as local government, and provide housing services to some 47,000 older people every year.  The type and scale of services we provided in 2014/15 was:

Core Care & Repair Service

· 30,176 older people helped

· 60% of people helped were over 75 years old

· 11,332 (38%) of people helped received the intensive Casework service

· 898 people received help to apply for additional welfare benefits which increase household income by £4.1m

· £508,541 raised on behalf of 850 clients from charitable funds to pay for repairs or adaptations

· £12m repairs and adaptations facilitated

· 1937 older people helped to make their home more affordable to heat

Rapid Response Adaptations

· 17,739 older people helped

· 4467 of whom helped to return home from hospital

· 15,454 of whom had works that helped prevent hospital admission

· Average time enquiry to completion was 9 days

Managing Better

Following a three year investment from Welsh Government of £1.25m under the Sustainable Social Services Third Sector Grant, Managing Better has been developed through an innovative collaboration between Care & Repair Cymru, RNIB Cymru and Action on Hearing Loss Cymru.

The new service features Managing Better Caseworkers in every part of Wales, helping older people (50+) who live in poor housing, have a sensory impairment and are frail, have dementia, or are vulnerable in other ways.  The service will work with primary healthcare practitioners, GPs, hospitals, social care, and third sector organisations to reach older people most in need of help, to keep them safe, warm and independent at home.

The Managing Better Caseworkers, working out of local Care & Repair Agencies, will visit older people in their own homes, assess their needs and identify bespoke solutions to the housing problems they face

This response was composed by Care & Repair Cymru and reflects the views of the Care & Repair movement across Wales.

1. Scale and Causesof the problems of isolation and loneliness

Our Caseworkers deliver a home visiting service to owner occupiers, vulnerable families, disabled and older people, and those suffering from cold related health conditions.  Loneliness is commonly seen in older people, especially those who have no family living close by, those with poor health and those living in poor housing , unsafe and damp homes. Some don’t see anyone for weeks on end, and find it difficult to attend local groups due to being unable to drive and/or finding it difficult to access public transport. This may be due to a number of factors not limited to mobility issues, lack of confidence and/or sensory loss e.g. eyesight problems. A visit by a Caseworker means that not only support to access a wide range of services including help with home adaptations etc. but also an opportunity to actually see someone and talk to someone.

A common feature of our home-visiting services is that we are able to pick up emotional instability first hand from face-to-face assessment and thus see many people that feel profoundly lonely and are excluded from conventional social networks. It often takes sensitive discussion to highlight these issues and whereas rurality, geography, remoteness provide a natural profile, even in urban, close-knit communities the impact of bereavement, trauma, dementia and mental health can lead to loneliness and a feeling of helpless isolation. As up to 40% of our referrals can be self-referrals, we often reach people at risk during the early preventable stages of loneliness as well as the more entrenched 'cries for help”.

Our Agency in Pembrokeshire commented that the area is popular with retirees who often end up isolated from family living in different parts of the country.  There are a lot of people who are isolated because of the geography and this is exacerbated by the way communities are changing.  There are few regular buses in rural areas and neighbours can feel remote, especially when they are comprised of younger and increasingly busy or mobile families.  However loneliness is as much a feature in towns and built up areas, as many older people live on estates where they see no one regularly even though they are surrounded by people. A telling case in point is the amount of people in Pembrokeshire that cannot have a lifeline emergency alarm installed because they do not have at least two people they could name as local responders.

Demographic changes have led to deep-seated social changes, whereby attractive 'retirement communities' like Ceredigion, Conwy, Pembrokeshire and Powys have accommodated thousands from inward migration without the natural local support networks to support their independence. Services are often sparse and remote and this increases vulnerability and makes many 'hard to reach'. In many of these scattered communities, there are examples of economic depletion where younger family members have been forced to move to urban areas. In addition, and so adding Gwynedd, Anglesey and Carmarthenshire as examples, are those that prospered through farming, forestry and the national trust economy, or on small holdings, who might now be isolated and left behind as erstwhile viable ways of life have now become unviable. This might be exacerbated by the impact of Brexit on rural Wales. Powys has the highest trend of ageing in Wales, highlighted in the last census, and our under-resourced frontline services are challenged to address significant housing challenges as well as the scars of loneliness in homes literally 'up a mountain' or 'at the end of a dirt track'. We have anecdotal evidence of visits being undertaken in areas where caseworkers felt driving conditions were probably unsafe.

Another issue we commonly come across is those individuals who are living in cold and damp homes and those living in homes in a poor state of repair.  These clients will avoid social interaction due to the embarrassment factor.  They are afraid of people seeing how they live and are reluctant to invite people into their homes thus becoming further isolated and having fewer opportunities for social interaction.

Clearly programmes like Telecare, digital inclusion, social media and Skype can be of great value, but the significant challenges of responder services, poor transport and broadband coverage are all too common. A strategic focus on technological assistance is vital in these areas. Care & Repair services have a strong track record of supporting technology introduction in a sensitive, user-friendly way and making good demonstration of the benefits of keeping in contact.

2. The impact of loneliness and isolation on older people

From a physical perspective, loneliness means that as people grow older they are more prone to falls, and because they are lonely / isolated,     there are instances when these falls go undetected and unreported the risks to the individual are increased. From a mental health perspective stimulation via human interaction means a loss of confidence and response. The impact of isolation and loneliness has an effect on health and well-being in older people generally.  In terms of general well-being, in many cases this seems to have an impact on peoples’ motivation to begin with – they look after themselves with less care, become cut-off and eventually lack the confidence or means to access the support or help they may need to live independently to a good standard.   As a result their isolation causes potential deterioration in health.

Someone who is concerned or wary of falling but has a lack of responders for a lifeline may become less mobile as they begin to limit the amount they move around in the home.  The profound impact on personal resilience and undermined confidence from a fall is highlighted by the statistic that first time fallers are 50% more likely to fall a second time. It has been found that between 40% and 50% of older people with sight loss fear falling to the extent that they reduce their levels of activity (Royal College of Optometrists, 2014). Yet, evidence from RNIB indicates that early cataract removal reduces falls by 34%. Over 500 people fall in the home every day across the UK, and housing hazards are a major contributory factor. Structured exercise programmes can reduce falls by up to 37% and offer a great model for confidence-building and social interaction, but their resource is narrow and transport is a barrier in rural Wales. The burden of falls on the NHS and on the individual is more usually measured by interventions that merely address physical trauma; however the Royal College of Physiotherapy have assessed the cost in terms of quality of life is 6.4 times this burden: isolation and loneliness are part of this calculation.

A Caseworker in Pembrokeshire visited a client recently who has to stand at the door and flag passers-by down if she wants to open a jar of food – such people are inevitably going to look for convenient, but not necessarily sufficient means of nutrition.  As a similar case in point, a 97 year old client living in the middle of Pembroke Dock has to try walking to the local supermarket to get her food – but explained that if she is tired she just come back without the shopping she set out for.

In terms of those with dementia related illnesses, the isolation can be hazardous at worst and at the least, create an environment where there is no daily stimulation for the person whatsoever.  This is particularly difficult as the average neighbour or person who could potentially help may not fully understand that the person has a cognitive impairment at all – or not know how to best interact with them.

3.         The impact of loneliness and isolation on the use of public services, particularly     health and             social care

This is an added problem for public services, as the knock on effect of the issues in Questions 1 and 2 above means that more are admitted to hospitals and rely more on help from public services.  Many of the factors causing expense in health and social care (trips and falls etc) have a link in part to isolation and loneliness, although this can be difficult to quantify.   The most unnecessary expenses in health and social care costs are those that could have been prevented – and loneliness is a key contributor in the mix of deteriorating standards and safety at home.

Care & Repair services operate a safe-discharge housing intervention with all primary acute hospitals, utilising our RRAP service to address home safety. There are so many cases of older people that have been de-skilled following a trauma and are far less able to manage in their home as they did prior to hospitalisation, and this has a knock on effect for accessing the wider community. A slide into dependency on more formal care can lead to rapid loneliness, depression and even mental health issues. Keeping people active, independent and healthy is key to addressing loneliness and isolation. This in turn might well reduce the costs to the state.

4          Ways of addressing problems of loneliness and isolation in older people

Care & Repair’s face-to-face contact with older people, many of which are 'repeat clients' or 'clients for life' have a significant but unquantifiable impact on loneliness and maintaining contact. Equally, as we deliver wellbeing and prudent health messages on a Making Every Contact Count basis, we can encourage older people to seek redress for some of their problems and refer-on or signpost to other community services. The strength of 'being known' and 'being at the heart' of local communities is that many of these community links are informal and so local pensioner groups, sporting, dance, choral, artistic, lifelong learning, gardening, reminiscence gatherings or linking to memory clinics, leisure and exercise, utilising community transport will be known first hand. There are many examples of a real 'lifeline' being given to seriously depressed and lonely clients through this type of needs matching.

Befriending groups are one solution, but the barriers are transport (costs and availability, especially in rural areas). 1 2 1 befriending is a better solution, but the barriers include demand and ability to attract suitable volunteers to support and the costs of providing this service.  Structured 1 to 1 befriending delivered by the third sector is usually a free to access service but it is not a free to run service. All volunteer befrienders have to be properly trained, supervised and DBS checked which all needs to be properly resourced.  The nature of volunteering means volunteers will come and go on a regular basis so a lot of time, effort and expense goes into the recruitment, training and matching of suitable volunteers to people who need a befriender.  There is also a cost implication associated with a volunteer befriender getting to and from a visit or training. A balance needs to be found between the costs of a volunteer befriender visiting someone and trying to match people more locally to save costs. The priority should always be on the quality of the befriending match of volunteer to client, ensuring the best outcome for the individual who is isolated.

You also need motivated, well trained and well supported staff to recruit, train and support befrienders which has cost implications. The nature of volunteering means a high turnover of volunteer befrienders. Any effective befriending service needs a well-structured and properly resourced recruitment, training and support framework, ideally one that is quality assured (e.g. Investors in Volunteers or the Approved Provider Standard APS through the Mentoring and Befriending foundation).

The nature of current befriending funding (small scale funding and short termism) can have an impact on the motivation of staff to deliver effective befriending solutions.

Clients accessing Care & Repair agencies services definitely benefit from the home visiting aspect of our work but client demand and staff workload means there is huge pressure to provide a service and not the funding to match to support it.  Visiting clients who are lonely or isolated by dedicated caseworkers across Wales would have huge health and cost benefits.

5          The extent to which initiatives to combat loneliness and isolation experienced by other             groups may also help to address these issues for older people

The way in which many services are delivered does little to combat loneliness and isolation.  So much is carried out over the phone now rather than face to face that this does little to reinforce the individual’s sense of being an important member in society when dealing with many organisations.  Care & Repair Agencies see the majority of clients at home in a face to face situation and take a holistic interest in their whole situation.

Agencies work closely in partnership with Health, Mental Health, Social Services, Occupational Therapy, social workers, etc. who are used to referring into us for their service users who are vulnerable and need us to support them to access help.

We are working across all the community networks in Wales on a day to day basis, including working with people in the most rural areas, and collaborate across county boundaries. Making communities aware of what we offer, what help is available – speaking to clients, their families and making them aware of the referral process is crucial and Caseworkers are visiting clients on a daily basis and identifying at first point of contact those who need help / those eligible for help.

Our services have a proven track record of collaborative partnership working and there are many latent community resources that might 'volunteer' a resource to address loneliness. Police-Fire & Rescue-Ambulance, Telecare response, housing floating support, Scouts & Guides, College volunteer groups, OAP groups, WI, tenant groups, as well as more established befriending, national exercise & leisure, etc. could link as a community hub in a more joined up way to look at community wellbeing and enable key parts of Wales' innovative policy ambitions.

Clair Houston

Policy & Research Officer