National Assembly for Wales, Health, Social Care and Sport Committee Inquiry into loneliness and isolation
1. The British Geriatrics Society (BGS) is the professional body of specialists in the healthcare of older people in the United Kingdom. Our membership is drawn from doctors practising geriatric medicine including consultants, doctors in training and general practitioners, nurses, allied health professionals, researchers and scientists with a particular interest in the care of older people and the promotion of better health in old age. BGS has 3,500 members who work across England, Scotland, Wales and Northern Ireland. In Wales our members play a key role in acute hospitals and the community in delivering effective healthcare for older people.
2. BGS welcomes the opportunity to present this written submission to the Committee’s Inquiry. We have noted the Committee’s specific interest in evidence for the scale and causes of loneliness and isolation, and its impact on health and social care services, together with evidence of what works in addressing the issues. Our submission focuses on the loneliness and isolation experienced by older people in Wales.
Evidence for the scale and causes
3. There are clear links between age and loneliness. ONS analysis of statistical data on wellbeing shows that people age 80 and above are the most likely to report high levels of loneliness (29%). The evidence of loneliness in later life, and the link between isolation and loneliness, is extensive and well documented, for example, by Age UK in their evidence review of loneliness in later life.
4. We know that the scale of loneliness and isolation is likely to grow, given that its likelihood increases with age. The number of people aged 65 and over living in Wales is projected to increase by 292,000 (44%) between 2014 and 2039 . We are therefore pleased that the Committee is conducting its Inquiry and recognises the need for a strategic approach to addressing this crucial issue now.
5. There is evidence that rural poverty is a contributing factor in social isolation . Wales has a relatively large rural area and high levels of poverty compared to the UK average which suggests that older people who also experience rural poverty may be at greater risk of loneliness and isolation. In 2011, almost 30% of the rural population in Wales was aged 60 or above, compared to 21% for urban areas.
6. Living environment. Lack of access to transport and appropriate housing are key factors that contribute to isolation amongst older people. Difficulty in accessing transport, whether because of limited public transport or fuel poverty, is likely to impact disproportionately on older people, and can present challenges in accessing primary and acute health care. A recent review of housing for older people in Wales concluded that “the housing environments in which we age can play a determining role in ensuring that people remain engaged in their local communities and maintain a sense of autonomy and independence”. Living environment is one of the key determinants in enabling older people to be discharged from hospital without delay and in regaining the ability to live independently.
7. Health status is a significant factor that contributes to people becoming disconnected from social groups. Many older people who BGS members work with have complex and multiple conditions, which can make it difficult to maintain social connections and participate actively in the community and in activities that are meaningful to them. For those older people who are in good health and are ‘ageing well’ many will be caring for a spouse or close relative: Carers UK research found that 8 out of 10 carers have felt lonely or socially isolated as a result of looking after a loved one.
Impact of loneliness and isolation on use of health and social care services
8. The impact of loneliness and isolation is well evidenced and its impact on use of health and social care services is significant. People who are lonely are more likely to:
- visit their GP
- use medication
- have more falls and need long term care
- move into residential care
- use accident and emergency services
9. There is evidence that loneliness has an effect on mortality that is similar to smoking 15 cigarettes a day, and is associated with poor mental health, cardiovascular disease, hypertension and dementia.
10. Many of the older people who BGS members work with are living with frailty: between a quarter and a half of all people aged 85 and above are estimated to be frail. This means that they are at risk of dramatic deterioration in their physical and mental wellbeing after an apparently small event which challenges their health . Being able to maintain social contact makes a significant difference to the health of older people living with frailty. The extent to which older people are able to maintain independence, and therefore have less need of social care, is in part dependent on their social networks, and support from family and friends.
11. There is a two way relationship between social isolation and dementia: people who are socially isolated are more likely to develop dementia, and people who have dementia and are more likely to become isolated and reduce or stop engaging with their social networks. Either way, the consequence is an increased likelihood of needing support from health and social care services.
12. Delayed discharge from hospital is exacerbated for older people who are socially isolated, and the likelihood of re-admission to hospital is greater without the support of family and friends. It is also greater when there are difficulties in accessing intermediate care: we know that waiting times to access intermediate care have increased significantly in the last three years as a result of a capacity gap, and that one third of the people waiting for intermediate care support are waiting in an acute bed. Whilst there isn’t clear data to show the full impact of delays in accessing intermediate care services, our view is that there may be a disproportionate impact on older people who are lonely or isolated.
Addressing problems of loneliness and isolation – evidence for what works for older people’s health and wellbeing
13. There is strong evidence and clear guidance on the provision of high-quality care and services for older people. The King’s Fund report, Making our health care systems fit for an ageing population provides comprehensive information on what we know works well. This includes both major and minor interventions, for example, “adequate treatment for ‘minor’ needs that limit independence such as foot health, chronic pain, visual and hearing impairment, incontinence, malnutrition and oral health … have significant benefits on older people’s well-being and independence” Without such interventions the risks of loneliness and social isolation, and of greater deterioration of health, may require more acute, resource intensive health and social care.
14. Comprehensive Geriatric Assessment (CGA) is a holistic, multidimensional, interdisciplinary assessment of an individual by specialists of many disciplines in older people’s health care. It includes as a core element an assessment of the social support networks available to the person, and their level of participation in activities which are of significance to them. Research shows that use of CGA in hospitals increases independence, thus contributing to an individual’s capacity to engage with their social networks . Alongside this the provision of a regular holistic medical review by GPs is an essential component in the range of support required to promote health and wellbeing in older people with frailty, and enable them to maintain social networks.
15. Health services provided by multi-disciplinary teams are essential in meeting older people’s health and social care needs. BGS and the Royal College of GPs recently published a report on innovative approaches in practice, Integrated care for older people with frailty which shows the benefits of GPs and geriatricians working together, with access to the vital services provided by other professionals, including nurses, therapists, pharmacists and social workers. It provides case studies of how it is possible to deliver improved health outcomes for older people, economic benefits and greater levels of staff satisfaction. Key features of these case studies include:
- person-centred care
- continuity of care
- proactive approaches which use:
- the electronic Frailty Index to identify patients at risk of frailty
- Comprehensive Geriatric Assessment (CGA)
- care plans for multiple eventualities
- strong communication and collaboration
16. When a hospital admission has been necessary, good discharge planning and post-discharge support are essential . There is evidence that post-discharge follow-up telephone calls are a cost-effective method of improving outcomes for older people who are socially isolated. They help prevent readmissions to hospital and can also help to identify older people experiencing loneliness and social isolation, meaning that support can be put in place”.
17. The British Geriatrics Society has developed tools based on our members experience and expertise in meeting the health care needs of older people. These include:
- Comprehensive Geriatric Assessment. Further information about CGA is available at: http://www.bgs.org.uk/cga-managing/resources/campaigns/fit-for-frailty/frailty-cga
- Fit for Frailty Parts 1 and 2, provide advice and guidance on the care of older people living with frailty in community and outpatient settings, and on the development commissioning and management of services for people living with frailty in community settings. There is some evidence that focusing community services on those with frailty rather than on those ‘at highest risk of hospital admission’ might improve quality of patient care and reduce hospital bed usage. http://www.bgs.org.uk/fitforfrailty-2m/campaigns/fit-for-frailty2/fff2-campaign/fff2-lite-vn
- The Silver Book provides practical advice on safe and effective emergency care of older people in an acute setting. It sets out standards of care and recommendations for policy makers which are based on integrated health and social care services delivered by interdisciplinary working with a person centred approach as the only means for achieving the best outcomes for frail older people. http://www.bgs.org.uk/silverbook/campaigns/silverbook
Current policy solutions to loneliness
18. BGS members in Wales recognise and value the framework of support for older people that has been developed in recent years, including the Wellbeing of Future Generations (Wales Act) 2015, the Ageing Well in Wales initiative, and the introduction of the Better Care Fund with its encouragement to local authorities to ensure that their plans include action to address loneliness and isolation.
19. However, we believe that greater investment in implementation is required if the intention of these initiatives is to be more fully realised.
20. We believe that part of the solution to loneliness and social isolation amongst older people in Wales lies with speeding up the journey towards increased integration of primary and acute care, and of health and social care services. Our view is that this shift can only be achieved in practice with increased investment to support implementation.
21. We recognise that the re-design of services for older people, so that they are genuinely person-centred and co-ordinated around older people’s individual needs, is the only effective means of ensuring maximum benefits from such investment. BGS is therefore keen to share its experience and expertise and engage with, the Assembly, the Welsh Government and others in the statutory and voluntary sectors who share our aim of promoting better health for older people in Wales.
We would be more than happy to attend an oral evidence session if that would be helpful. Please do not hesitate to get in touch.
Dr Jonathan Hewitt
Chair, Wales Council, BGS
Dr Eileen Burns
[i] Measuring National Well-being: insights into loneliness, older people and well-being, 2015, ONS https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/measuringnationalwellbeing/2015-10-01
[ii] Evidence Review: loneliness in later life, Age UK, 2015 https://www.ageuk.org.uk/Documents/EN-GB/For-professionals/Research/Age%20UK%20Evidence%20Review%20on%20Loneliness%20July%202014.pdf?dtrk=true
[iii] ONS. Census Analysis -Comparing Rural and Urban Areas of England and Wales. (2013b) 2011 http://www.ons.gov.uk/ons/dcp171776_337939
[iv] Rural Poverty in Wales: Existing Research and Evidence Gaps, Public Policy Institute for Wales, 2016 http://ppiw.org.uk/files/2016/06/An-introduction-to-Rural-Poverty.pdf
[v] ONS. Census Analysis -Comparing Rural and Urban Areas of England and Wales. (2013b) 2011 http://www.ons.gov.uk/ons/dcp171776_337939
[vi] Housing for Older People in Wales: an Evidence Review. Public Policy Institute for Wales, June 2015
[vii] Reducing social isolation across the life course. Public Health England, UCL Institute of Health Equity, 2015 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/461120/3a_Social_isolation-Full-revised.pdf
[viii] No one should have to care alone, Carers UK, 2017 https://www.carersuk.org/news-and-campaigns/alone/breaking-isolation
[ix] Campaign to End Loneliness http://www.campaigntoendloneliness.org/references/
[x] Combating loneliness, a guide for local authorities. LGA, Campaign to end Loneliness, Age UK, 2016 http://www.local.gov.uk/documents/10180/7632544/L15-431+Combating+loneliness+-+a+guide+for+local+authorities/b4b88757-2623-4696-ae04-565892a58909
[xiii] National Audit of Intermediate Care, Support Report, NHS Benchmarking, 2015 http://www.nhsbenchmarking.nhs.uk/CubeCore/.uploads/NAIC/Reports/NAICReport2015FINALA4printableversion.pdf
[xiv] Making our health and care systems fit for an ageing population, Oliver D, Foot C, Humphries R, Kings Fund, 2014 https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/making-health-care-systems-fit-ageing-population-oliver-foot-humphries-mar14.pdf
[xv] Comprehensive Geriatric Assessment (CGA), British Geriatrics Society, 2014 http://www.bgs.org.uk/cga-managing/resources/campaigns/fit-for-frailty/frailty-cga
[xvi] Integrated care for older people with frailty, RCGP, BGS, 2016
[xvii] Ibid, 2016
[xviii] Telephone follow-up calls for older patients after hospital discharge, Lewis E, Samperi S, Boyd-Skinner C, Age and Ageing journal, OUP, January 2017