The Welsh NHS Confederation response to the Health, Social Care and Sport Committee inquiry into loneliness and isolation.

Contact

Nesta Lloyd – Jones, Policy and Public Affairs Manager, the Welsh NHS Confederation.

XXXXXXXXXXXXXXXXXXXXXXX Tel: XXXXXXXXX

Date:

9 March 2017

Introduction

1. We welcome the opportunity to contribute to the Health, Social Care and Sport Committee Inquiry into loneliness and isolation. The Welsh NHS Confederation represents the seven Health Boards and three NHS Trusts in Wales. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work.

Overview

2. Loneliness and isolation is a significant and growing issue amongst our population. A number of Health Board’s population needs assessment have highlighted tackling social isolation and loneliness across their populations, but particularly for older people, as a key priority. Its impacts are devastating and costly, with comparable health impacts to smoking and obesity.

3. Loneliness and isolation appear to increase with age, and among those with long-term health problems. The causes of loneliness are not just physical isolation and lack of companionship, but also sometimes the lack of a useful role in society. There are many different factors that affect loneliness and isolation, including health, mobility, housing, transport and income and the NHS is working collaboratively with a range of statutory and voluntary sector partners to address these factors.

4. The effects of social and emotional loneliness on physical and mental health and well-being are extensive. Evidence suggests that loneliness is associated with increased risk of dying, sleep problems, abnormal stress response, high blood pressure, poor quality of life, frailty, increased risk of heart attack and stroke, depression and increased risk of dementia.

5. Tackling loneliness and isolation is inherently preventative in terms of delaying or avoiding the need for more intensive support. Loneliness is ‘amenable’ to a number of effective interventions, particularly befriending. Practical, flexible and low-level assistance is often most effective and individually tailored solutions can yield the best results. Effective action to combat loneliness is best delivered in partnership and it is believed that many GP consultations may have loneliness at the root of the problem.[i] However many health and well-being services do not tend to identify those who may be at risk of loneliness and social isolation because they are not asking people if they are lonely. However, as our response will highlight, the NHS across Wales has introduced a number of initiatives and projects to combat loneliness and isolation, including the “Ffrind i mi/ Friend of mine” initiative in Aneurin Bevan University Health Board (UHB).

Terms of Reference

The evidence for the scale and causes of the problems of isolation and loneliness, including factors such as housing, transport, community facilities, health and wellbeing services;

6. It is important to recognise that although loneliness and isolation are two different concepts, they both relate to people’s sense of connection with others. As Age UK state “Isolation refers to separation from social or familial contact, community involvement, or access to services. Loneliness, by contrast, can be understood as an individual’s personal, subjective sense of lacking these things to the extent that they are wanted or needed.”^{^[ii]} We recognise that it is possible to be isolated without being lonely, and to be lonely without being isolated. The issues of isolation and loneliness can affect people at any age and is a significant and growing issue.

7. Loneliness should be viewed as a risk factor to an individual’s health and well-being. There is a wealth of evidence that indicate the scale and causes of the problems associated with social isolation and loneliness. According to Age Cymru, over 75,000 people aged over 65 in Wales (over 12% of the Welsh population who are over 65 years old) say they are often or always lonely[iii] and 46% say the TV or their pet is their main form of company. 12% of older adults feel trapped in their own home, and 9% feel cut off from society.[iv]

8. A Local Government Association report in England, Combating Loneliness,[v] published in January 2013 lists a number of potential risk factors for loneliness, including:

· Living alone. More than 75% of women and a third of men over the age of 65 live alone in Wales;[vi]

· Poor health;

· Being aged 80+;

· Loss of friends;

· Having no access to a car/ never using public transport. In Wales, two-thirds of single pensioners have no car, and so reliable local transport is extremely important as people get older;[vii]

· Living in rented accommodation;

· Living on low income or on benefits as main income; and

· Having no access to a telephone.

9. Other risk factors that been identified include;

· Single/Divorced/Widowed;

· Living in a care home;

· Bereavement;

· Carer;

· Retired;

· Ethnicity (1^st generation);

· Gay/Lesbian;

· Dementia;

· Sensory impairment/s;

· Living in high crime/high deprivation areas;

· Veterans; ex-service personal have reported that they have issues integrating back into civilian life;

· Living in sheltered accommodation; and

· Nursing and residential homes where older people feel they have no sense of purpose.

10. With the population ageing, loneliness is going to become more of a problem over time and all public services will need to identify and support people who are lonely and isolated. At the moment health and well-being services do not tend to identify those who may be at risk of loneliness and social isolation because they are not asking people if they are lonely. However, under the Social Services and Well-being (Wales) Act 2014 Health Boards are now under a duty to carry out population needs assessments and publish them and as a result many have recognised that tackling social isolation and loneliness is a key priority.

The impact of loneliness and isolation on older people in terms of physical and mental health and wellbeing, including whether they disproportionately affect certain groups such as those with dementia;

11. According to the Ageing Well in Wales Programme, loneliness and isolation can have serious impacts upon the health and well-being of older people in Wales.[viii] Loneliness and isolation has links to poor mental and physical health and the adverse effects includes;

· Increased risk of dying, loneliness increases the likelihood of mortality by 26%;[ix]

· Sleeping problems;

· Poor quality of life;

· Frailty;

· Increased risk of coronary heart disease and stroke;

· More prone to depression;

· Increased risk of dementia;

Increases the risk of high blood pressure;
Higher risk of the onset of disability;

· Abnormal stress response;

· Poor sleep;

· Cognitive decline; and

· Increased feelings of fear, abandonment, anxiety, inadequacy, desperation, depression, stress, aggression, suicidal thoughts and vulnerability.

12. Age UK[x] reports that loneliness can be as harmful to our health as smoking 15 cigarettes a day, and people with a high degree of loneliness are twice as likely to develop Alzheimer’s as people with a low degree of loneliness. The Alzheimer’s Society has identified that loneliness and isolation is a problem for lots of older people, but it is particularly difficult if people are also struggling with dementia. In fact, people with dementia tend to be lonelier than the population as a whole and a survey by the Alzheimer’s Society in 2013[xi] found 38% of people with dementia felt lonely. One of the reasons dementia could be compounding loneliness is because people don’t remember that someone has been to see them. The nature of dementia makes loneliness worse, rather than loneliness causing dementia, although there is evidence^{^[xii]} which suggests that the risk of Alzheimer’s disease more than doubles in older people experiencing loneliness.

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

13. The impact of loneliness and isolation on the use of public services is not fully understood and service providers do not routinely assess this presently. There needs to be a better understanding across public services on the impact of social isolation and loneliness on an individual’s health and well-being. We would recommend that there needs to be a recognised measuring tool to identify those who are, or who are at risk, of loneliness and isolation to better understand the impact of loneliness and isolation on public services.

14. Age UK’s evidence review in 2010[xiii] found that lonely people have more likely to use public services, particularly social care and health, than other people. Lonely individuals are more likely to:

· Visit their GP, have higher use of medication, higher incidence of falls and increased risk factors for long term care;

· Undergo early entry into residential or nursing care; and

· Use accident and emergency services independent of chronic illness.

15. Discussions with primary care teams, including doctors, nurses, ward staff, pharmacists and social workers, have identified that there may be many people who access services who may have loneliness ‘at the root’ of attendance. There is a real risk that people are given prescriptions for antidepressants (‘over medicated’) due to the lack of time GP’s have to thoroughly explore the wider determinants of health. GP’s recognise that the model currently used by many GP practices is not necessarily providing the most appropriate service for the patient.

16. There are many other options available within communities to help with lower level medical complaints, to provide support and advice to citizens before they develop a problem, and this does not require the intervention of a GP or nurse. Social support to communities and strengthening communities is central to this, including social prescribing. There is a need to focus on those individuals within our communities who at risk, giving them the support that they need to improve their health and well-being rather than ‘pick them up’ in a health setting once they become unwell.

17. While many people who are lonely or isolated visit health or social care services, research has highlighted that being isolated can impact upon older people’s ability to access services, which can then impact upon their health and well-being. In the Older People’s Commissioner for Wales’ research,[xiv] older people reported that barriers to them accessing healthcare included the following: difficulty with GP booking systems (needing to keep calling due to busy phone lines to get an appointment); consultation processes (phone consultation rather than face-to-face); getting to hospital or appointments due to lack of transport; services not meeting individual needs (e.g. cultural needs).

Ways of addressing problems of loneliness and isolation in older people, including interventions to specifically address the problems and other projects with wider aims. Evidence for what works and the outcomes for older people in terms of health and wellbeing;

18. The ways in which loneliness and isolation can be addressed are multi-faceted and will not be a ‘one size fits all’ approach. Researchers agree that there is a lack of high quality, robust evidence around which interventions are the most effective in addressing loneliness and isolation.[xv][xvi] However, research evidence has demonstrated that low-intensity support (emotional, social, practical and housing support) has direct and tangible effects in reducing loneliness and isolation. Crucially, older people need to be at the centre of decisions about what services and activities would benefit them the most, rather than the professionals assuming what they might need.

19. Group activities in particular have been seen to be helpful in enabling people out of loneliness and isolation.[xvii] This supports the view that effective interventions are;

a. Group interventions with an educational themes or specific support functions;

b. Interventions that target specific groups, for example women, carers or people with health needs;

c. Interventions where participants are involved in setting up and running the group (co-production);

d. Interventions developed within or run by an existing service;

e. Interventions with a sound theoretical basis; and

f. Interventions with a technological element, for example using video-conferencing or the internet.[xviii]

20. Identifying people at risk of loneliness can be difficult, but targeting those disproportionately affected by loneliness – lower socio-economic, groups, the widowed, the physically isolated, people who have recently stopped driving, those with sensory impairment, carers who lose their careering role and the very old – has proven most effective. Sometimes, people will require longer term support such as social care, but other times they need flexible support which just provides that ‘little bit of help’. The ‘right kind’ of help, delivered when it is needed and appropriate can make a huge difference to older people, enabling them to potentially avoid the need for more formal support, stay living in their own homes for longer and keep their independence.[xix]

21. The initiatives that have been introduced to support people affected by loneliness and isolation includes the multi-agency “Ffrind i mi” Partnership Board in Aneurin Bevan UHB. As highlighted in Aneurin Bevan UHB written response to the Committee’s inquiry, “Ffrind i mi/Friend of mine” is a partnership approach to combatting loneliness and social isolation across their communities. Led by Aneurin Bevan UHB, and chaired by the Vice Lord Lieutenant of Gwent, the Partnership Board includes a range of organisations including: the Health Board, Local Authorities, Gwent police, Age Cymru, 1,000 Lives (Public Health Wales NHS Trust), United Welsh, Coleg Gwent and GP/ Neighbourhood Care Network Leads. “Ffrind i mi” has enabled a ‘social movement’, encouraging statutory and voluntary partners and wider communities to think about innovative ways to support those at risk of loneliness and social isolation to reconnect with their community. Recognising their rich community assets, “Ffrind i mi” also aims to recruit as many people as possible as volunteers, ‘plugging the gaps’ of existing social support.

22. In Cwm Taf UHB they have used the Intermediate Care Fund to work with social services, housing, third and independent sectors to invest in projects that benefit frail/ elderly residents (65+) and their family to combat loneliness and isolation. In Cardiff and Vale UHB the “Age Connects Cardiff & the Vale” has delivered a range of projects which have demonstrated a reduction in social isolation and loneliness for older people. These include the “Friendly Advantage Project”, which reported that of the people who said they were lonely at baseline, 84% said as a result of being involved in the project their social interaction and well-being had increased. The “Healthy and Active Partnership Programme” delivered by Age Connects reported that over a 4 month reporting period, 78% of clients show an improvement in their experience of loneliness. The “Senior Health Shop” provides older people with a place to go to meet others, gather information and take part in activities, and 82% of people say that attending has reduced their isolation or loneliness.

23. Working in many of our communities are local area or community co-ordinators. These individuals, through their local contacts, often hear about or are asked to help a person who may be house bound or with no social contact. As example, the co-ordinator’s assistance could: connect the person with a health or social care professional to improve their quality of life; make referrals to a third sector agencies that can provide a chaperone for appointments or support to access shopping services; and help to make introductions with local social groups.

24. Furthermore, there are a number of social prescribing projects currently active across Wales. Social prescribing initiatives provide new life opportunities for those who need them most; opportunities to form new relationships, be creative and independent while improving both physical and mental health. Examples include voluntary work agencies, exercise classes, self-help groups, book groups, social or lunch clubs and hobby clubs among others.

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

25. There needs to be a wider scoping of current initiatives and a better understanding of their impacts on the individuals/groups they support in order to determine transferability to other groups/older people. Greater evidence is required to inform effective interventions and treatment. It is suggested that a national measurement tool to identify use of services by those affected by loneliness could be very useful.

Current policy solutions in Wales and their cost effectiveness, including the Ageing Well in Wales programme. The approach taken by the Welsh Government in terms of maintaining community infrastructure and support, and using the legislative framework created in the Fourth Assembly, e.g. the Social Services and Wellbeing (Wales) Act 2014 and the Wellbeing of Future Generations (Wales) Act 2015.

26. The current Wales legislative framework provides an ideal opportunity to try to address the impact of isolation at an early stage. The Well-Being of Future Generations Act 2015, The Social Services and Well-Being Act 2014 and the Ageing Well in Wales programme all provide a real opportunity for statutory bodies and its partners to better consider and plan for strategies that are aimed at combatting social isolation and loneliness.

27. Within the Social Services and Well-being Act 2014 a key element is for public bodies to signposting people to services and support and early intervention. This provides the platform for being able to identify older people who may be at risk of loneliness and isolation during the needs assessment.

28. As well as the Social Services and Well-being Act 2014 the well-being goals under the Well-being of Future Generations Act 2015, and public sectors responsibilities under the Corporate Health Standard, should provide the vehicle to driving forward initiatives that combat social isolation and loneliness. Some examples include:

A Prosperous Wales: better use of our community assets with an increased focus on the recruitment of volunteers from all walks of life;
A Healthier Wales: There is a real opportunity to influence innovative approaches where people’s physical and mental well-being is maximised.
A Wales of Cohesive Communities: volunteering service initiatives across communities with a wide range of partners will direct a partnership approach to innovation that enables a prudent approach to community cohesion.

29. As well as legislation, it is important that the public and communities are engaged on the health and well-being impacts of loneliness and social isolation. Community mobilisation is important and any healthcare initiatives will be readily owned by a community if the leaders, the citizens, and youth are fully engaged in mobilising the community, educating stakeholders, and implementing evidence-based interventions. Community mobilisation is a capacity building process through which community individuals, groups, or organisations plan, carry out and evaluate activities on a participatory and sustained basis to improve health and other needs on their own initiative or stimulated by others. Communities need to be enabled to help themselves and others. As well as improving well-being, this may in turn reduce reliance on public sector services, including the NHS.

Conclusion

30. As highlighted in our response loneliness and isolation are both a social and health issue. Evidence has demonstrated the impact loneliness and isolation has on physical and mental well-being but more needs to be done to identify individuals who are, or may be at risk of, loneliness and isolation. Furthermore a better understanding of the support services available at a local level needs to be developed to ensure this support is tailored to an individual’s needs and that people are engaged to enable them to access local opportunities and reconnect with their communities.