Older Adults and Health Inequalities in Lancashire and Cumbria

9.30 – 11.20 Wednesday 27th October 2021

Overarching message:

• Systemic issues (e.g. funding, priorities, performance indicators, lack of joined-up working, communication around service availability) need to be addressed to enable organisations to deliver long-term equitable preventative interventions that deal with the social causes of ill health and hospital admission amongst older adults
• Need to change the narrative around older people and retirement to one that focuses on active, positive, healthy lives that values people, their contribution and involvement in local communities and society.

Actions:

• Sayyed to follow-up with Tammy for conversation on private rental sector and what can be done from BwD perspective
• Anne send some information about the retirement workshops
• Tammy to liaise with Donna about their ED-based service is set-up to address social causes of hospital admissions/ED attendance and follow-up with Teri/Vicky about potentially mapping what similar services are, and are not, being commissioned by the NHS

Key points for each question (see appendix for verbatim nearpod contributions):

1. What are the key local issues for Older Adults and their health in Lancashire and Cumbria?

Top issues from the nearpod:

• Individual physical issues e.g. malnutrition, hydration, physical deconditioning (esp. for people shielding)
• Environmental issues e.g. poor-quality housing, fuel poverty, poor rural transport
• Social and emotional issues e.g. loneliness, isolation, mental health (related drug and alcohol use), debt, overwhelmed/overworked for carers, less family around to support with care,
• Service issues e.g. digital exclusion, reduced engagement with GPs, lack of support services for dementia post-diagnosis
• NB: All issues compounded for some groups e.g. LGBTQI+, ethnic minority groups, people with dementia

Key concerns discussed by the group:

• Health inequalities related to Covid-19 and older people clearly reflected the intersection of poor housing, poverty, ethnic minority status

In terms of housing:

• Policy reforms has tipped the balance to increasing numbers of older adults in private rented sector
• Reduced housing condition surveys/regulation also means that there are hidden issues in terms of standards and quality
• The withdrawal of the Supporting People Grant has had a massive impact on people’s ability to live independently, as have the parallel reductions in support services
• Owner occupiers need also to be considered as they are often ‘cash poor’
• Challenges across the board (but especially private rented sector) in terms of ensuring that housing is fit for purpose or can be adapted if needed following (e.g. a fall, hospital stay) especially in old style homes – Need a Lifetime Homes Standard
• In terms of GP engagement and digital exclusion
• Real concerns that problems that would have been picked up haven’t been due to the issues that older people have had engaging with GPs (for a range of real and perceived reasons) – will lead to greater problems down the line
• Missed opportunities for referral of older adults to preventative programmes (e.g. falls prevention, memory clinics)
• Emphasis in health services on apps and platforms not complemented with additional support for people with digital inclusion needs

2. What actions are working and what actions should be taken for better health and wellbeing for OAs? Who should be responsible/leading this?

Example initiatives from nearpod:

Physical activity buddy programme to address deconditioning (newly established); Living Longer Better programme; advice services; Winter Warmth Fund; activities run in local facilities; Men in sheds; U3A; WI; Cosy Homes; VCSFE services generally; Dementia Hubs; digital support/inclusion services; pre-retirement planning workshops; telecare; Care Network's Healthy Homes programme; BwD Food Resilience Alliance; optimal ageing pilots from Active Lancashire; better use of Town and Country Planning Act; hospital aftercare services; refresh programme in BwD

*Conversation slipped into barriers here – see point 4.

3. What message would you send to the HEC that you feel would make the greatest changes for OAs to improve health inequalities?

The HEC needs to:

• Amplify the importance of digital inclusion for older adults
• Encourage/support policy reform to address shortcomings in key determinants (e.g. housing quality; enabling people to stay in the workplace for longer)
• Encourage consistent commissioning of preventative services that do engage with the social causes of ill health amongst older adults and hospital admissions (e.g. hospital aftercare services, ED based advice/support services)
• Support VCFSE services that engage in prevention and action on the social causes to demonstrate their contribution not just to reducing NHS spend, but the moral imperative to not let people find themselves in hospital due to loneliness or as a measure of last resort
• Change the narrative around ageing as ‘slowing down’ in ‘retirement’ – advance a more positive and active notion of ‘rewirement’ that values people’s strengths, attributes, values
• Redress the balance of NHS focus from acute services to strengths-based/asset-based community approaches that focus on ‘place-making’ and repairing eroded fabric that has harmfully impact older adults involvement in their communities
• Connect ambitions to climate crisis agenda e.g. sustainability cities and transport
• Consider Age friend regions
• Consider what differences in life expectancy mean for different communities
• Not reinvent the wheel and recognise and value what is established (e.g. Older People’s Partnerships)

4. What are the barriers that prevent you from making a step change in health inequalities?

Lack of longer-term, consistently funded prevention:

• Some but not all of the services listed in point 2 above are commissioned – others relying on grappling for bits of funding, or ad hoc delivery as and when it is possible to pick up different issues for people
• Where there is funding it is minimal (e.g. dementia advice services commissioning covers less than 2 full time posts to cover large footprint)
• Voluntary sector constantly “holding its breath” about whether funding will be renewed – very uncertain way to work (which is itself a symptom of the uncertain funding landscape for local government)
• Commissioning infrastructure not user-friendly or geared towards smaller organisations – feels like the same few big players who are commissioned to deliver services across the patch, leading to an undervaluing of VCSFE members and in particular grass roots BME groups – further money incoming to ICS for reducing inequalities (20+5) but how are voluntary sector supposed to access? Under/non-funded voluntary services undermines the premise of models such as social prescribing

• Commissioners need to engage with voluntary sector at design stage – such a missed opportunity otherwise
• Lack of joined up working between organisations on similar issues (e.g. food poverty)
• So often, older adults are not aware of what services are available and limited comms resource to address this persistent problem

If the targets are not changed, behaviours will not change:

• The system is oriented towards NHS and acute care
• Despite rhetoric, prevention is not given priority nor funding
• There were examples in the past of mechanisms with decent indicators (e.g. Comprehensive Performance Assessments) which should be revisited
• Sayyed has had some recent success getting admissions avoidance included as a performance indicator in the measures for the Better Care Fund

• Important who is calling the shots on what matters and how older adults are being involved in decision-making

5. Where are the greatest opportunities for improvement?

• Fund VCFSE
• Fund prevention

 

Appendix: Contributions from nearpod

1. What are the key local issues for Older Adults and their health in Lancashire and Cumbria?

• Malnutrition and hydration
• Physical de conditioning particularly as a result of extended shielding
• Poor quality housing affecting physical and mental health
• Loneliness and isolation
• Perceived reduced access to GPs prevents early diagnosis or preventing decline in conditions
• Access to good quality, affordable food
• Motivation for self-care impacted by pandemic
• Culture of a 'stiff upper lip' may prevent older people from seeking help
• Mental health has increased in the last 18 months
• Hoarding dramatically increased in our properties
• Drugs and alcohol are prominent; social isolation - fear of going out now
• Debt causing stress- increase visibility of doorstep lenders
• Deconditioning especially since the pandemic
• Fuel poverty
• Issues in rural locations around access to health, retail, services, limited accessible transport
• Lots of older people in Cumbria living alone. Also higher proportion of older people compared to national average and set to grow
• Cumbria has a lot of old stone homes and in some urban areas poor housing stock
• Lack of access to digital, causing difficulty with GP appointments
• Long waits on the phone to make GP appointments puts people off, so issues not being found until more developed and serious;
• Telephone appointments for people with dementia not always appropriate (engaging in this way may not work for them), so they either don't get the same access or it's not confidential as they need to involve someone else; Not knowing how to cook healthy food at affordable prices
• Carers not having time to prepare good quality food, leaving older people surviving on quick and often unhealthy/unbalanced diets
• Carers being overwhelmed and perhaps not always asking for the support that's needed, or the support not being available/affordable
• Accessing digital health services
• Marked differences in choice as a result of inequalities and deprivation, impacting on access to services and support. Since Austerity gap has widened and pressures driving modernisation and efficiency means a lot of communities more excluded
• Changing family dynamics impacted by COVID. More people isolated with major challenges in transport, places to go, friends, activities and universal support
• Inequalities impacting harder on older ethnic minorities. Sectors lack cultural competencies and these are exacerbated by many service providers not employing or being representative of the services they serve
• Breakdown of traditional family structures resulting in more people needing assessed support packages
• Reduction in universal benefits resulting in Direct payments being seen as another source of income/benefit. Open to abuse and misuse

• Digital literacy and digital capability is a big challenge. Add to that sensory challenges including arthritis, dexterity and eye sight

• Isolation and lack of daily structure / activities impacting on earlier onset of dementia

• Inability to adapt older poor quality housing, means limited opportunity to remain at home

• Social isolation for those with English as a 2nd language

• Everything that has been stated in the other notes but amplified for those with language and cultural issues

• Lack of spaces that are accessible to older people and affordable transport
• Lack of community transport or poor public transport links
• Under recognition of mental health amongst some communities leading to under reporting
• Faith can be a real positive but it can also be a hindrance to seeking professional health
• Over reliance on clinical interventions
• Hidden issues with alcohol and substance misuse and services not accessible/appropriate
• High levels of digital exclusion contribute to increased inequality across the whole piece
• Post diagnostic support for people living with dementia. It is the only condition I am aware of that people are given a diagnosis and just sent home to deal with it. This has been exacerbated by the pandemic restrictions
• Management of long-term conditions and support to self-care
• Poor quality housing - owner occupied - is exacerbating long term conditions such as respiratory as people dont have the money to make their homes safe and warm
• Transport to day services
• Loneliness and isolation leading to depression
• Carers looking after their loved one and having their own health challenges
• Under acknowledgment of carers being expert partners means carers are reluctant to ask for support. Older carers feel it is their duty to manage
• Health anxieties are much higher following Covid
• Telephone appointments rather than face to face and digital exclusion
• Longer waiting lists for operations as a result of Covid
• It is important to include LGBT people as we often 'fall off the radar'. The Health Behaviours JSNA conducted by Lancashire County Council, found that LGBT people were one of the 4 groups of most concern regarding physical and mental health
• See also recent research from PHE and Age UK re ageing in coastal and rural communities found high levels of social isolation and barriers accessing services for older LGBT+ people -this is backed up by work of Lancashire LGBT with 50+ beneficiaries
• Women from some cultures are reluctant to access medical services for live threatening conditions as they are worried about the affect on family if, for example, they have an operation and can not then look after family. More awareness needed

2. What actions are working and what actions should be taken for better health and wellbeing for OAs? Who should be responsible/leading this?

• We are about to launch a physical activity buddy programme offering tailored strength based support to encourage people who have been deconditioned to be more physically active
• services and activities need to be delivered in neighbourhoods/places to remove some of the transport barriers
• We need to embed positive ageing into our workforce approach
• Increased digital inclusion support for people - this needs to be the business of all public services
• In terms of employment there is lots of evidence that people are leaving the workplace earlier as they are not supported with managing health conditions - if employers had more supportive policies this would improve both health and economic position
• We are working with the ICS to deliver the Living Longer Better programme encouraging positive and active ageing
• Consistent post diagnostic support for dementia needs to be commissioned
• Our Age UK advice service supports older people to claim in excess of £1million each year in benefit entitlements - just BwD. This is not a funded service - we scrabble around each year for grants to support
• CCF organise a Winter Warmth Fund offering one off grants each winter to try and tackle fuel poverty
• Local facilities such as village halls can offer a vital link in rural communities. Lunch clubs, drop-ins, exercise classes, educational talks. Men in sheds also works well
• There are some amazing supportive groups such as WI, U3A etc that can become important support groups for individuals
• Benefit advice remains important
• Befriending/ Handyman services important for socially isolated older adults
• Addressing issues has to be joined up to help ensure coverage of issues with wide representation and funding
• Cold to cosy homes in Cumbria through Cafs

• The VCSFE does some fantastic work but there is a heavy reliance on funding which in most cases is not long term or sustainable

• Use an asset based approach in commissioning services

• Dementia Hubs can provide vital information & support to support people with dementia and their carers
• Digital support that provides kit, broadband and support for use. We run a digital support service that provides all of this, but it's resource hungry and needs ongoing financial support
• We run pre-retirement planning workshops, which help people plan for their retirement. Covers various aspects of retirement helping people to identify key issues for a good and healthy retirement
• Allow LCC Telecare be accessible for all - currently it has excessive criteria
• Our Digital Inclusion Service is helping older people access services but far more investment needed to meet need. Starting to work with NHS DigitalChampion scheme to get older people online for gp appointments etc.
• Improved training for GP receptionists is required. So many people report blocking of contact with GPs and attitudes which lead to desperate people being reluctant to telephone surgery
• Workforce development to promote active ageing across all frontline staff who are in contact with older people, their carers and their families
• 'Doing with' not 'doing too' is so important. Change the perception of getting old = slowing down
• Promoting active environments for older people - ensuring toilet and rest stops
• Some support groups can be seen as not accessible for some communities - need to work on making them accessible
• Care Network's Healthy Homes programme in BwD (commissioned by Public Health) supports older people to live safe, clean and warm homes
• Cosy Homes in Lancashire – ChiL
• BwD Food Resilience Alliance takes a strengths based approach to supporting access to food in a dignified way. Taking a joined up approach wherever possible
• There should be more funding for VCSFE sector from local sources - at the moment funding for innovative schemes comes from grant funding - usually projects, which are short-term
• Active Lancashire supporting local authorities and optimal ageing pilots in Blackpool and West Lancs with sport england funding around physical activity and empowering adults to become more active. Working with the libraries around physical activity
• Workplace Health/ Business Health matters
• Strength based, asset based solutions. Empower people
• Town and Country Planning Act - create local communities to re-engage a sense of society and community. be forceful in Place shaping. This would encourage people to walk to get local services, have conversations and build networks.
• Retirement should be a key part of employee well being. This has to start with embedding positive habits/cultures and bahviours.
• Engage more people in volunteering. and get away from the notion of people are 'old' when they retire, keep people's mindset 'Young'. Change the rhetoric
• Rewire society to see older people as assets. They have massive skills and life experience and want to be bale to give back on their terms. We should enable a huge 'paid' volunteer movement
• https://www.ageuk.org.uk/lancashire/our-services/retirement-planning/

3. What message would you send to the HEC that you feel would make the greatest changes for OAs to improve health inequalities?

• Things need to be done everywhere and we have to move away from postcode funding, which continues the inequalities
• People must be able to access health services in a way that's suitable for them, face2face, digital, telephony in recognition of their individual circumstances and capabilities
• We need to keep older people active in mid body and soul for as long as possible. To do this we need to re-imagine society and use 'Place' making a primary driver for inclusion. We need enabling funding, transport and sectors to change their mindset
• We could be radical about community heat and power to ensure that we hit climate and also address issues of poverty
• What alternative description would you use instead of 'older people' - i personally dislike the description older people
• We need to start the conversation MUCH earlier - don't wait for pre retirement or retirement
• Increasing physical activity is key in reducing health inequalities
• Ensure housing for older people is appropriate - considering insulation and fuel poverty
• Need an equitable approach the whole footprint - patchy commissioning invites a post code lottery
• Change the conversation from 'care' to 'coach' with the strengths based approach
• Promoting an Age friendly place through policy, strategy, commissioning, infrastructure and delivery
• Stop spending all the funding on trying the medically treat the problem and work with local communities much earlier to stop or delay health issues in the first place
• Think of older people as a positive asset to communities
• The NHS needs to be serious about funding support to tackle the wider determinants of health not just assuming that someone else will - for example measures to improve housing conditions/fuel poverty
• We are keen to work with organisations to encourage people as young as 20 to think about their retirement as so important.
• Early intervention
• Policy/strategy decisions are usually driven by available data - LGBT+ people do not often appear in data collection and this often results in strategies which are not inclusive
• Think about the most vulnerable people. Issues for people are multi-layered. Solutions should work well and help address multiple issues - partnership working is key

4. What are the barriers that prevent you from making a step change in health inequalities?

• Funding
• Under recognition of specialist services the VCFSE can offer and the perception we are not professional
• Being target/ output driven instead of impact driven and understanding that sometimes we cant measure the impact as its not "instant"
• Austerity and inability to plan long-term
• Too many priorities competing with each other and for resources.
• Short termism
• Uncertainty around funding prevents long term planning
• Constant focus on funding for NHS
• Resistance to change from the community - fatalistic attitude towards ageing
• I don't think people understand the impact todays choices will have on later lives - a barrier is a lack of awareness of impact of behaviour
• A lack of knowledge about what help and support is available and how to access it
• A barrier is a lack of planning for later life, or understanding what planning needs to be done for a good one
• Inconsistent and short-term funding arrangements
• The VCFS not being seen as equal partners or having equal voice
• Some of our local populations have low expectations about quality of life and therefore dont expect things to improve
• Ageing population in Cumbria is set to grow and the needs are wide. Partnership working is important - but needs to be met with funding
• Fragmentation of funding opportunities across the county. As a pan-Lancashire charity supporting LGBT people who are approx 5% of population, we struggle to get funding across Lancashire for all our beneficiaries. It is often at District level
• Hospitals dominate health agenda/leadership/resource management

Indicators:

• We need to measure people feeling happy and well
• Ageing well measure
• People feeling like they are valued and add value
• There are validated measures available that measure levels of wellbeing and loneliness that many in the VCFSE sector used. Measures which track management of LTC's or admission avoidance could also be used
• Active ageing measure for participation in physical activity for 30mins or more 3 times a week. Participation in an activity supporting volunteering more than x times a week. Lifelong learning participation/university of third age
• Have a cost value measure for prevention in the same way NHS attribute cost to bed blocking?

5. Where are the greatest opportunities for improvement?

• Supporting our VCFS to work in the heart of communities through adequate, long term and secure funding
• Using the resources that already exist. We have an exceptional network of organisations across the county who can truly work together to improve lives across the spectrum of need.
• Prevention not crisis response. An opportunity to listen to people and learn
• Prevention prevention prevention!
• Be proactive not reactive