Older People JSNA | Boltons Health Matters
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Older People JSNA

Abstract

 

This is the JSNA chapter on Older People. Theme chapters summarises implications for commissioning, who is at risk and why, the level of need in the population, service provision and use, unmet needs, what works in terms of evidence, community views and priorities, any related equality impact assessments, unmet service needs/gaps and recommendations for further needs assessment work. 

Introduction

The population of the UK is ageing as a result of increased life expectancy and demographic trends.  People are living longer and there are more people reaching old age. It is a key priority for all services to plan effectively for this demographic change in order to take advantage of the opportunities this presents as well as to ensure the needs of older people can be met in the future.
Although some data is only available for older people aged 65 and over, it is accepted that the definition of older people should include those aged 50 and over.

Implications for Commissioning
• Improved identification and management of disease risk factors and management of long-term conditions.
• More in-depth review of overall service mix/capacity available for older people given increasing population.
• Continue to prioritise integration of the health and social care system.
• Develop a more coordinated approach to prevention to enable older people to remain in their own home for as long as possible including an emphasis on reducing social isolation.
• Improve information and advice to allow people to make confident informed choices.
• Improved links and shared learning between specialist and universal services with all services considering how they can support the needs of an ageing population.
• Continue to work with the voluntary sector to develop and deliver support and services to older people.
• Maximise the use of technology based support services where appropriate.
• When commissioning long term conditions care programmes or pathways for the elderly, commissioners should consider including minimum requirements for the inclusion of patient health education or health improvement strategies into contracts and service agreements with providers.
• The scope of GPs roles in dealing with depression among older people needs to transcend diagnosis, prescription and referral to include elements of: providing information and advice to allow patients to understand and manage their condition effectively; signposting to various sources of information and support inside and outside the NHS as well as coordinating the support provided by other services.
• It is important that the holistic approach to falls prevention and support after a fall is maintained to minimise the need for hospital admission following a fall and to reduce falls‐related mortality.
• Further develop the knowledge and skills of health and social care staff around end of life care.
• See also the Older People’s Housing Needs Chapter for recommendations specific to older people and housing.
Who's at Risk and Why?

Although many older people live active lives and make a positive contribution to their community there are increased risks of poor health, deprivation and isolation as age increases.  Whilst people are living longer the extra years have not necessarily been in good health or free from illness or disability.  Key issues nationally   include:
• 1.7 million pensioners (14%) live below the poverty line, with incomes less than £215 per week after housing costs (AHC) for couples and £125 for single-person households.  Of these, one million (8%) live in severe poverty (below the 50% median line AHC).  Many others have only slightly higher incomes with 1.1million on the edge of poverty;
• An estimated four million older people in the UK (34% of people aged 65-74 and 48% of those aged 75+) have a limiting longstanding illness.  This equates to 40% of all people aged 65+.  Over two thirds (69%) of people aged 85 and over in the UK have a disability or limiting longstanding illness;
• In the UK, 11% of older people describe their quality of life as very poor, quite poor or neither good nor poor;
• Depression affects 22% of men and 28% of women aged 65 or over. This would be just over two million people aged 65+ in England.  The Royal College of Psychiatrists estimates that 85% of older people with depression receive no help at all from the NHS;
• One in three people over 65 will die with a form of dementia.  It affects one person in six over 80 and one in three over 95.  In England in 2011/12, up to 54% of people with dementia did not have a formal diagnosis.  Up to 25% of all hospital beds are occupied with older patients with dementia and they stay in hospital for longer than others with similar conditions;
• About a third of all people aged over 65 fall each year (which is equivalent to over three million).  The combined cost of hospitalisation and social care for hip fractures (most of which are due to falls) is £2billion a year or £6million a day
• It is estimated that over one million older people living in the community are malnourished (10% of people 65+ UK).  One third of all older people admitted to hospital and care homes are at risk of malnutrition (32% of 65+);
• Nearly half (49%) of all people aged 75 and over live alone.  Just over 700,000 (7%) of people aged 65 or over in the UK say they are always or often feel lonely;
• 35% of the homes occupied by older people (60+) in England fail the decent homes standard (approximately 2.7 million households).  Over three quarters of a million people aged 65 and over need specially adapted accommodation because of a medical condition or disability and 145,000 of them report living in homes that do not meet their needs;
• Over-65s are estimated to spend an average of 80% of their time in the home - 90% for people over 85; 12% of older people feel trapped in their own home;
• 8% of people aged 60+ in England and Wales say they live in fear of crime;
• In the third quarter of 2012, 5.3million people aged 65 and over have never been online.
The development of complex intensive health and social care needs in the elderly and people with long term conditions are closely associated with: age, ethnicity, high levels of deprivation, low educational attainment and unhealthy lifestyles (high smoking, poor diet, low physical activity).  Key issues include:
• As people grow older, their health needs become more complex with physical and mental health needs frequently being inter-related and impacting on each other;
• Many older people receive multiple types of medication.  Any medication has the potential to cause adverse effects as well as benefits. Any new or changed treatment to help a physical condition can lead to, or worsen, mental health problems. Similarly, treatment for mental health problems can adversely affect physical health in vulnerable older people;
• Both physical and mental health difficulties can affect an individual’s ability to care for themselves independently and potentially have major implications for their way of life and their need for services;
• Doctors have known for some time that loneliness is bad for the mind. It leads to mental health problems like depression, stress, anxiety, and a lack of confidence.  There is growing evidence, however, that social isolation is connected with an increased risk of physical ill health as well.  There are suggestions it can make some diseases both more likely to occur and more likely to be fatal.  Lonely people release more cortisol – the hormone produced when we’re under stress – which can cause inflammation. If inflammation occurs long-term it can contribute towards heart disease and cancer .
A key priority nationally is to ensure people aged 65 and over are vaccinated against flu to ensure they do not develop flu complications, which are more serious illnesses such as bronchitis and pneumonia, which could result in hospitalisation.  Nationally the uptake of the flu vaccine among those aged 65 and over was 74% in 2011/12 and 73.4% in 2012/13.
A recent Care Quality Commission report   highlighted that the health and social care system is struggling to care adequately for people with dementia.  This is having an impact on hospital capacity and resources.  In more than half of CCG areas in the country, people with dementia living in a care home are more likely to go into hospital with avoidable conditions (such as urinary infections, dehydration and pressure sores) than similar people without dementia.  Once in hospital, people with dementia are more likely to stay there longer, to be readmitted, and to die there.
Nationally, almost three-fifths (58%) of alerts and 60% of referrals to Social Care Adult Safeguarding teams in 2011-12 related to people aged 65 years and over. 
Death occurs most frequently in old age.  Currently, two thirds of people die aged 75 or over, with almost three quarters of women (74.4%) dying in this age group compared with 58.4% of men.  Also, the age at which people die is increasing as people live longer.  Already one in six people die aged 90 or over .   Nationally, in people aged 75 and over in 2006–08, 58.4% of deaths were in hospital, 12.1% were in nursing homes, 10.0% were in old people’s homes, 15.5% were in the person’s own residence, 0.9% were elsewhere, and 3.1% were in a hospice.
The majority of deaths in England occur following a period of chronic illness related to conditions such as heart disease, liver disease, renal disease, diabetes, cancer, stroke, chronic respiratory disease, neurological diseases or dementia.  Analysis of palliative care register data nationally has indicated that patients are not currently being identified in the last year of life, implying that adults nearing the end of life diagnosed with chronic long-term illness are at risk of not gaining access to optimal end of life care.  This issue is exacerbated for patients with a non-cancer diagnosis.
The causes of death change with increasing age at death – Alzheimer’s, senility, pneumonia, and stroke becoming more common.  The place of death changes too, with a higher proportion of the extreme elderly, who are more likely to be women, dying in nursing or old people’s homes.  This in part reflects the frailty of many elderly people before death, which often results in the need for 24-hour care.  It also reflects the greater likelihood of older women being widowed and living alone.
There were an estimated 24,000 excess winter deaths in England and Wales in 2011/12 – an 8% reduction compared with the previous winter.  The majority of deaths occurred among those aged 75 and over; there were 19,500 excess winter deaths in this age group in 2011/12 compared with 4,500 in the under 75-year-olds.

The Level of Need in the Population

Population estimates for 2013 indicate there are 95,400 people aged over 50 years (34% of total population) living in Bolton broken down by age category as follows:
• 49,430 aged 50 to 64 (18% of population);
• 26,190 aged 65 to 74 (9% of population);
• 14,280 aged 75 to 84 (5% of population);
• 5,490 aged 85+ (2% of population).
Bolton’s population is ageing with a significant rise in the number of people aged 85+ between the 2001 and 2011 Census (from 4,500 to 5.400 people).
Bolton has a slightly younger population profile than the national and regional average (over 50s are 33.9% against 35.1% nationally and 36.1% in the North West and over 75s are 7.0% against 8.0% nationally and in the North West) partly as a result of the younger age profile of the BME population.
Overall, 52% of older people in Bolton (aged 50+) are women and 48% men.  The proportion of women increases with age due to their longer life expectancy (58% of those aged 75+ are women).  Based on national projections  the population aged 65+ in Bolton is expected to be mainly White (95%) with a small minority who are Asian/Asian British (3.7%) and other (1%).   Census 2011 data indicates there has been an increase overall in the BME population in Bolton but data by age group is not yet available. 
There are 18 Lower Super Output Areas (LSOAs) in Bolton which rank in the most deprived 5% in the country and a further 17 LSOAs which rank in the most deprived 10% for income deprivation affecting older people.   There has been a steady decline in the economic activity rate for those aged 50-64 years in Bolton over the last 5 years (from 65% in 2007/08 to 59% in 2011/12).
Estimates  (2012) provided for the Bolton population aged 65+ based on national prevalence rates  indicate:
• Almost two-fifths (39%) are living alone (15,970 people), including 50% of those aged 75+.  Over two–thirds (68%) of those living alone are female;
• Two fifths (43%) are unable to manage at least one domestic task on their own (17,607 people) including 65% of those aged 75+ (12,432 people) and 79% of those aged 85+ (4244 people);
• Over a third (35%) are unable to manage at least one self-care activity on their own (14,475 people) including 47% of those aged 75+ (8,997 people) and 67% of those aged 85+ (3,633 people);
• Over half (57%) have a long-term limiting illness (23,494 people);
• 9% are expected to have depression (3,817 people) with 3% expected to have severe depression (1,204 people);
• 5% are predicted to have a longstanding health condition caused by a heart attack (2,167 people);
• 2% are predicted to have a longstanding health condition caused by a stroke (1,016 people);
• 2% are predicted to have a longstanding health condition caused by emphysema/bronchitis (750 people);
• More than a quarter (28%) are predicted to have fallen within the last 12 months (11,639 people) with 885 people expected to be admitted to hospital as a result of a fall (80% aged 75 or over);
• 17% (7,167 people) are expected to have a bladder problem at least once a week and a further 3% (1,408 people) are expected to have a bladder problem less than once a week;
• Almost one in five (9%) are predicted to have a moderate or severe visual impairment (3,798 people) with 6% of those aged 75+ (1,229 people) predicted to have a registrable eye condition;
• Two fifths (44%) are predicted to have a moderate or severe hearing impairment (18,082 people) with 476 people expected to have a profound hearing impairment;
• A fifth (19%) are expected to be unable to manage at least one mobility activity on their own (7,880 people);
• More than a quarter (28%) are expected to be obese or morbidly obese (11,755 people);
• 13% are predicted to have Type 1 or Type 2 diabetes (5,548 people).
Local estimates based on the Bolton Health & Wellbeing Survey 2010 generally indicate that local prevalence is likely to exceed national prevalence rates for most conditions.  In 2013, among those aged 65+ there were likely to be:
• 27,576 people with high blood pressure (60%);
• 4,964 people that had had a heart attack (11%) and 7,537 people who reported suffering from angina (16%);
• 3,999 people that had had a stroke (9%);
• 9,422 people with diabetes (20%);
• 1,838 people with Chronic Obstructive Pulmonary Disorder (COPD) (4%);
• 7,997 people with a chronic cough (17%) and 4,780 with chronic bronchitis (10%);
• 14,340 people with shortness of breath with wheezing (asthma) (31%);
• 11,490 people who are sedentary (no physical activity in a week) (25%);
• 5,193 people that smoke (11%);
• 7,583 people that drink over the recommended level (16%);
• 8,686 with a Body Mass Index Obese (19%) and 1,517 people who are underweight (3%);
• 4,320 people with low mental wellbeing (9.4%);
• 10,111 people with a possible mental health problem (22%) and 9,192 people with depression (20%);
• 6,894 people that have experienced severe pain over 4 weeks (15%);
• 31,758 people who have pain or stiffness in their joints (69%) and 19,763 people with recurring or constant backache (43%);
• 9,284 people with a long term limiting illness or disability (20%);
• 6,342 people who are caring for someone else (14%);
• 23,899 people with no access to the internet at home (52%);
• 11,950 people who are unable to heat their home as well as they’d like in Winter (27%).
The Dementia Partnerships Dementia Prevalence Calculator  indicates there are currently 2,012 people aged 65+ living in the community with dementia in Bolton and 869 living in residential accommodation.  The severity of dementia is expected to be mild for 55% (1,588 people).  There are expected to be 926 people (32%) with moderately severe dementia and 367 people (13%) whose dementia is severe. 
Using estimates from the Campaign to End Loneliness there are likely to be between 3,670 (6%) and 4,705 (13%) people over 60 years who often or always feel lonely in Bolton in 2013.  Those at highest risk include: lone pensioners, older carers, people over 75, recently bereaved older people, older people with sensory impairment including dual sensory impairment, older people receiving help with bin collections, people over 65 living in a materially deprived area.
Planning4care predicts the potential numbers of people who will be in need of some form of social care based on the social care needs classifications in the Wanless Social Care review . This estimates that in 2013 among those aged 65+ there were 19,650 people with social care needs (42% of population, slightly higher than the North West average (40%) and considerably higher than the England average (33%)). Of these:
• 4,450 have low needs i.e. people who have difficulty in performing instrumental activities of daily living (shopping, laundry, vacuuming, cooking a main meal, managing personal affairs) and/or have difficulty with bathing, showering or washing all over but not other activities of daily living;
• 5,520 have moderate needs i.e. they have difficulty with one or more other activities of daily living (getting in/out of bed, use toilet, get dressed and undressed, feed self);
• 4,130 have high needs i.e. they are unable to perform one activity of daily living without help;
• 4,290 have very high needs, physical i.e. they are unable to perform two or more activities of daily living due primarily to physical impairment;
• 1,270 have very high needs, cognitive/functional i.e. they are unable to perform two or more activities of daily living due primarily to cognitive impairment (including people with dementia).
The Planning4care model suggests that in 2013 there are likely to be 16,700 people aged 65+ in need of formal care services in Bolton; 2,440 of those people are likely to be receiving care funded by the local authority (1,480 of these have 'very high' needs).  In addition, 6,340 people with high or very high care needs are likely to be either unsupported or funding their own care (3,620 of these have 'very high' needs).
In 2010/11, 300 people aged 65 years and over (the majority over 75 years) in Bolton were referred to the adult social care Safeguarding team.  This reduced to 145 people in 2011/12, although this is a new data collection so there will be more consistent recording in future.
An Index of Potential Care Need was developed for Bolton in 2011/12 combining a wide variety of local data sources to identify geographical areas where there is a higher concentration of vulnerable older people.  This identified 5,030 older people in the highest needs category.
There were 12.3% more deaths in Bolton in winter in 2010/11 compared with the non-winter period.  This was lower than the North West (15.6%) and England (17%) averages.  In comparison, Bolton’s excess winter death index was higher than the North West and England averages in the previous two years.
A significantly higher proportion of deaths occurred in hospital in Bolton (58.3% annual average 2008-10) than the England average (54.5%), although the proportion of people that died in their own home was similar to the national average (19.7% compared with 20.3%) .  A smaller proportion of deaths in Bolton occurred in care homes (15% compared with 17.8% nationally).  The large majority (91.2%) of deaths in hospital in Bolton were emergency admissions in 2008-10.
There is a relatively high suicide rate among older people in Bolton  in comparison with the national average, particularly amongst men aged 75+ years and women aged 65-74.  The overall mortality rate for this cause was 14.8 per 100,000 for those aged 65-74 (compared with 7.2 nationally) and 10.6 per 100,000 for those aged 75+ (compared with 8.2 nationally).

Current Services in Relation to Need

Key services in ensuring the health and wellbeing of older people in Bolton include the following.

Primary Care
Health services that play a central role in the local community including GPs, community nurses, health visitors, school nurses, pharmacists, dentists, optometrists and midwives. Relevant priorities include health screening and identification of risk to patients developing disease, and provision of care packages to avoid unnecessary hospital admission.  There are also a range of specific community health services relevant to older people e.g. Community Stroke Service, Falls Service and Community Therapy Team, Parkinson’s Disease Clinic, Podiatry, Continence Service, Diabetes Service.
The uptake of flu vaccination among those aged 65 and over in Bolton in 2011/12 (74.4%) was slightly higher than the national average and although figures are provisional is in line with the national average in 2012/13.

Targeted Prevention Pilot
The Staying Well pilot project aims to systematically identify individuals (age 65 and over) at high risk of future social care need and provide advice, support, and assistance to enable people to remain healthy, happy, and independent for longer.  Six GP Practices across a mix of geographical areas have been selected to take part in the feasibility project.  The project is carefully targeted at older people who are not currently receiving services but have a high risk of needing support in future.  Appointed Wellbeing Coordinators are undertaking a person centred home-based conversation with the identified cohort of patients then actively supporting individuals to find and take up appropriate services, information, advice and support.

Secondary Care
Older people are the greatest users of secondary care services such as hospitals.  Royal Bolton Hospital provides 671 inpatient beds, 32 day-case beds, and 15 endoscopy beds.  This includes inpatient beds for older people with mental health conditions.  The majority of patients who are admitted either for emergency or elective care are over the age of 65.  In 2010/11 there were almost 9,500 attendances to A&E; and 30,200 admissions to hospital among people aged 65 and over in Bolton.  The total number of hospital admissions for people over 65 years increased by 26% from 2006/07 to 2010/11.  Some specific issues of note are:
• Key performance indicators show that the rate of admissions and readmissions to hospital for  people aged 65+ in Bolton are generally low in comparison with other North West areas;
• There was a 40% increase in the number of admissions for falls for people aged 65+ from 2006/07 to 2010/11 to 1,517 (5% of all admissions), much higher than would be expected based on national prevalence rates;
• An analysis of 2011 acute inpatient data  indicated that 9.9% of non-elective bed days were used by patients with dementia, close to the Greater Manchester average (10.1%).  However, the average length of stay for patients with a primary diagnosis of dementia was 62.7 days for Bolton CCG, the highest in Greater Manchester (average of 40 days).
Reducing hospital admissions is a priority across all health and social care services not only in terms of costs but also in terms of the frequently negative impact on the long-term health of older people.  Bolton's Long-term Conditions Strategy aims to address many of the relevant issues.
Urgent care
Bolton Community Unit is based on the hospital site and has a multi-disciplinary team that assesses the needs of patients who have referred themselves or have been brought in by ambulance to the A&E department and who do not have a clinical need to be admitted to a hospital bed.  Most patients seen in the unit are over 65 years of age.  Some patients may be referred for Intermediate Care, delivered either at home or in a specialised community based unit.  There are also several domiciliary and residential rehabilitation services that can be accessed via the Referral and Assessment team.
A review of urgent care provision in Bolton is currently underway.

Mental Health
The diagnosis rate for dementia in Bolton is estimated to be 53.7%, considerably higher than the national average of 42%, and a significant increase since 2010 when the diagnosis rate in Bolton was estimated to be 42.7% .  There are still, however, an estimated 1,368 people with dementia currently undiagnosed and not receiving treatment locally.

Bolton’s integrated dementia action plan 2013-15 clearly sets out how partners will improve outcomes for people with dementia.
A new Suicide Prevention Strategy will begin to be drafted shortly based on the new national strategy.

Social Care
The Council directly provides and commissions a wide range of social care services including residential care, home care, equipment and adaptations, sensory services, day care, and other forms of community support.  In 2011/12, 2,857 people aged 65+ received ongoing support paid for at least in part by Adult Social Care (means tested).  Adult Social Care also provided equipment and other short term support (not means tested) to 3,553 people aged 65+ in 2011/12.  The total number of older people receiving ongoing support from the Council reduced by 17% between 2009/10 and 2011/12 as a result of a change in the eligibility criteria for receipt of social care – the Council no longer provides support to meet moderate needs.  The number of people receiving short term support from Adult Social Care has, however, remained consistent over the last three years.
The most significant community based service provided to those over 65 is home care, although there was a significant increase in Direct Payments in 2011/12.  The ongoing implementation of Self Directed Support will increase choice and control for service users. People with physical disabilities and their families will have control of how the budget allocated to them is used to meet their care and support needs.  This is likely to impact on the range and choice of services available and hopefully will improve outcomes for individuals.
The total number of people admitted to residential care paid for at least in part by the Council in 2011/12 was 1,150.  The number of permanent admissions to registered residential and nursing care accommodation per 100,000 population over the last three years indicates that while the rate of admissions has remained fairly consistent (810 per 100,000 people in 2011/12) there has been a recent reduction in the number of nursing care admissions and a corresponding increase in residential care admissions.  The rate of admissions to residential and nursing care in Bolton is above the England average but is lower than many other North West authorities.
Many older people with social care needs are either supported by informal carers or pay for their own care (self-funders).  There is currently no information on the total number of self-funders in Bolton.
Planning4care estimates that currently approximately one quarter of all home care hours required by older people aged 65+ in Bolton with high or very high needs (53,730 hours per week) are publicly funded by the Council.  Also, one quarter of all residential care (or care with housing) places required by the population aged 65+ (3,330 places) are publicly funded by the Council.
Voluntary sector
A wide range of voluntary sector groups provide support and health and social care services for older people in Bolton including social and leisure activities, carer support, advice and information services and befriending services.  Time-2-Communities is a new time banking organisation in Bolton that aims to get people together to help develop communities into supportive, safe, healthy, and prosperous places to live and work.  Bolton Council for Voluntary Services provides support to third sector organisations locally with a well-supported Health and Care Together Network.  Bolton Council has a Targeted Prevention and Carers Grant scheme which supports a range of local organisations to provide services to people aged over 65 years. 

Housing
The Council's Strategic Housing Services Team sets out the overall direction for improving the quality, choice, and range of housing in Bolton.  A range of different services are provided for older people including sheltered and extra care accommodation, housing advice services, 'find a home' team, Floating Support services, technology based services such as Careline and Bolton Care and Repair partnership.
Bolton Care and Repair is a partnership of organisations working in Bolton to assist older people and people with disabilities to repair, improve, maintain, or adapt their home. Partners include Age Concern, Bolton Council, Bolton at Home, Bolton NHS and more.  Bolton Care and Repair aims to help people maintain their independence and remain living in the comfort of their own home.  The primary focus is the repair or adaptation of people's homes and in support of this provides a range of services depending on the individual's needs and circumstances.  See Older People’s Housing JSNA Chapter for more information.

Community Assets
Strong networks and connections in an area is an important community asset which can help older people to avoid loneliness and promote their general wellbeing.  The Bolton Health and Wellbeing Survey 2010 showed that older people aged 65 and over in Bolton were more likely to feel they belong to their local neighborhood (76%) than those who are younger.
Nationally, approximately one third of people aged 50 and over are regular volunteers  which is a considerable asset to local communities and is likely to have positive impacts on the health and wellbeing of those that participate.  In Bolton, 24% of people aged 65 and over were regular volunteers in 2008/09.

 

Projected Service Use and Outcomes

The population aged 50 and over in Bolton is projected to increase by 8% over the next five years (2013 to 2018) from 95,391 to 103,140.  This growth is not, however, uniform across all age groups with steeper rises in the oldest categories as follows:
• The 65+ population is projected to grow by 10%, from 45,962 to 50,739;
• The 75+ population is projected to grow by 14%, from 19,773 to 22,450;
• The 85+ population is projected to grow by 14%, from 5,491 to 6,246.
Planning4care estimates the population aged 65 and over will increase by 17% over the next 10 years and by 41% over the next 20 years.
Although the growth in the older population is in line with national and regional trends the proportion of Bolton's population in the older age groups is projected to remain slightly below the national and regional averages.
An ageing population will have considerable implications for services in Bolton.  In addition, all services will need to tackle age discrimination and the promotion of dignity.
Projections of the numbers of older people with health and mental health problems and disabilities are available from POPPI and Planning4care.  Key issues highlighted over the next 5 years include:
• A 10% increase in the number of people aged 65+ with a limiting long-term illness (26,614 people by 2018);
• An 11% increase in the number of people aged 65+ with a longstanding health condition caused by a heart attack (1,352 people by 2018);
• A 12% increase in the number of people aged 65+ with a longstanding health condition caused by a stroke (1,165 people by 2018);
• A 10% increase in the number of people aged 65+ with Type 1 or Type 2 diabetes (6,301 people by 2018);
• An 11% increase in the number of people aged 65+ with Bronchitis/emphysema (853 people by 2018);
• A 9% increase in the number of people aged 65+ with severe depression (1,352 people by 2018);
• A 14% increase in the number of people aged 65+ with dementia (3,394 people by 2018 including 1,493 people aged 85+);
• A 13% increase in the number of people aged 75+ admitted to hospital as a result of a fall (824 people by 2018);
• An 11% increase in the number of people aged 65+ with frequent continence problems (8,161 people by 2018);
• An 11% increase in the number of people aged 65+ with a moderate or severe visual impairment (4,358 people by 2018);
• A 12% increase in the number of people aged 65+ predicted to have a profound hearing impairment (541 people by 2018);
• A 12% increase in the number of people aged 65+ with a mobility difficulty (8,988 people by 2018);
• A 10% increase in the number of people aged 65+ with social care needs (21,520 people by 2018).  
Planning4care has provided detailed projections for the number of people likely to need formal social care services and the number likely to be funded by the local authority or funding their own care.  The rise in the number of people with social care needs in Bolton will be in line with the North West and national average.  It suggests that over the next 5 years:
• The number of people potentially in need of formal social care will increase from  16,700 in 2013 to 18,290 people by 2018 (5,580 with very high needs);
• The number of people likely to receive care funded by the local authority will increase from 2,440 in 2013 to 2,680 by 2018 (based on current service characteristics);
• The number of people that are unsupported or funding their own care will increase from 14,250 in 2013 to 15,610 by 2018.

Evidence of What Works

A wide range of guidance is available from the National Institute for Clinical Excellence (NICE) in relation to older people including mental wellbeing, accidents, falls, and physical activity.  Work is also ongoing to develop guidance on mental wellbeing of older people in residential care, older people with multiple morbidities, discharge planning and post discharge care, and primary, secondary, and tertiary interventions to promote mental wellbeing and independence of older people.
In order to tackle social isolation among older people evidence suggests we need to invest in proven projects .  ‘Wayfinder’ or ‘community navigator’ interventions have been effective in identifying those individuals who are truly socially isolated or lonely and in ensuring signposting to appropriate services; there is good evidence that befriending services are effective in reducing depression and cost-effective when compared with usual care.   Creative groups tailored for differing interests and needs lead to reductions in loneliness and re-engagement with the wider community, and demonstrate that “the deteriorating health effects of loneliness may be reversed by an intervention which socially activates lonely, elderly individuals”.  It indicates that good practice needs to be embedded in relation to issues such as the selection and training of volunteers and ongoing support and encouragement for participants to stay engaged.  Another key feature highlighted is the need for older people to be consulted and engaged in the design, delivery and review of projects ensuring they are built on their needs and interests.  When planning services to reduce social isolation or loneliness, strong partnership arrangements need to be in place between organisations to ensure developed services can be sustained.
The Joseph Rowntree Foundation ‘A Better Life Programme’ aims to increase our understanding of what can help older people with high support needs now and in the future, whatever setting they live in.  The programme is due to complete in 2013 and will provide recommendations for policy and practice.  Some information is already available via the website about the benefits and potential of options based on mutuality (people supporting each other) and/or reciprocity (people contributing to individual and group well-being) along with housing and care solutions and residential care.
The four top priorities considered by Department of Health as likely to have the greatest local impact for people with dementia are:
1. Good-quality early diagnosis and intervention for all;
2. Improved quality of care in general hospitals;
3. Living well with dementia in care homes;
4. Reduced use of anti-psychotic medication.
Successful or promising interventions to prevent falls in the community include :
• Exercise programmes: There is good evidence for the effectiveness of exercise programmes that encourage aerobic activity or improve strength, flexibility and gait in reducing the rate of falling among older people, particularly when activity types are combined;
• Encouraging safety behaviours: Amongst those most at risk of falling, home safety interventions that assess risks in the home and recommend the use of safety equipment (e.g. stair rails, mobility aids) can reduce the number of falls experienced by older people;
• Medical interventions: Supplementing the diet with Vitamin D can reduce the risk of falls and fracture, but only with higher doses, calcium co-supplementation and among those with lower levels of Vitamin D.  Additionally, although research is limited, reviewing medication and minimising the use of drugs that increase dizziness and impair cognition (e.g. psychotropic drugs) can reduce the risk of falling;
• Multi-strategy interventions: Although results have been inconsistent, both multi-component interventions and multi-factorial risk assessment and intervention have been shown to reduce numbers of falls.
The Partnership for Older People Projects (POPP) were funded by the Department of Health to develop services for older people, aimed at promoting their health, wellbeing, and independence and preventing or delaying their need for higher intensity or institutional care.  The evaluation  found that a wide range of projects resulted in improved quality of life for participants and considerable savings, as well as better local working relationships.
There is only limited local evaluation of specific initiatives or services for older people beyond statutory performance monitoring.  Evaluation is built in to Staying Well GP based targeted prevention pilot to inform the future approach in Bolton.

Further key sources for information on effective interventions and evidence-based policy are highlighted on Bolton’s Health Matters by clicking here.

Community Views and Priorities

Although there is some feedback from the wider population of older people on some specific services there has not been any wider consultation on overall priorities. 
Recent qualitative research carried out by Ipsos MORI  to inform Bolton’s approach to targeted prevention for older people indicated there is limited awareness of the services that are available to support older people to remain living independently at home among those older people most likely to be at risk of needing social care.  Some people also feel they should not ask for help until they reach crisis point – the concept that seeking help earlier may help you to stay independent for longer was not widely accepted.  The research helped understand the different market segments among older people in Bolton in order to inform the approach to helping them to remain as independent as possible for as long as possible.
Regular surveys are carried out with social care customers and their carers on behalf of the Department of Health and also to focus on specific services locally.  The key issues identified are:
• The majority of customers and carers are satisfied with their care and support;
• The care and support provided helps people to maintain their quality of life, although there are some customers who are more likely to have unmet needs;
• An increasing proportion of customers and carers have found it difficult to find the information and advice they need, however, once they do find it the information and advice is generally good;
• The large majority of customers and carers agree it was quick and easy to arrange care, gave them a choice about how their needs were met and enabled them to find the right kind of care.  Some carers indicated, however, there is a need to improve the speed and ease of arranging residential care.
A recent survey carried out by Bolton LINk  indicated the majority of people receiving home care in Bolton were satisfied with the service but there are a number of areas where the service could be improved.

Equality Impact Assessments

 

No recent local equality impact assessments have been carried out that we are aware of.  If you are aware of any such work locally please let us know at Bolton Health Matters

Unmet Service Needs and Gaps

• A large number of older people with care needs are either unsupported or funding their own social care. It is currently unknown to what extent this impacts on costs of hospital and other health care services.
• There is evidence that older people with depression may not be assessed or treated.
• There is a need to continue to improve the diagnosis rate for dementia.
• There may be potential to increase the number of older people that regularly volunteer in Bolton which could have a positive impact on social isolation.
• Improve information so that older people and their carers are easily able to find the advice and services they require as needs arise.
• Ensure the needs of all minority groups are met by care and support providers.
• Increase the number of patients who die in their place of choice and increase the number of people who are able to die in the community setting rather than the acute setting.

Recommendations for Further Needs Assessment Work

• Analysis of hospital admissions data for older people and improved understanding of avoidable admissions.
• Continue to develop forecasting approaches so that robust projections of needs for specific services can be readily provided.
• Develop whole system (health and social care) modeling tools to identify the most effective use of resources for older people.
• Better understanding of older people’s priorities and preferences including minority groups.
• Further use of market segmentation data e.g. Acorn to understand and identify needs.
• Mapping community assets to support socially isolated people.

Key Contacts

• Andrew Walton - Older People’s Commissioning Manager, Bolton Council
• Ruth Molloy - Senior Health Improvement Specialist (Older People), Bolton Council

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