Connecting the socially isolated to improve health
Professor Chris Drinkwater, president of the NHS Alliance and director of HealthWORKS, explains how his area has tackled social isolation to improve health
Any way you look at it, the predicted figures of the costs to the NHS of our ageing population are daunting.
By 2025 it is estimated the number of over-65s will have grown by 42%, with the number of people with at least one long-term condition rising from three million to 18 million. Add to those health costs the projected costs of social care, and you are looking at long-term conditions as the driver for £7 in every £10 spent by the NHS.
We are seeing ever-increasing numbers of frail elderly who may be living alone or lacking family support systems, and it is clear we need to start doing something differently.
Social isolation is a fundamental problem of ageing that primary care has not yet got to grips with. We have started to think about how we manage middle-aged and older people with long-term conditions and mental health problems, but we are still focusing on the biomedical.
Newcastle is the 37th most deprived local authority area in England, with a culturally diverse population of 270,000.
We have high levels of people with long-term conditions and generally poor health – with more than half of the local over-65s suffering from a limiting, long-term illness. Addressing higher than average levels of mental ill health is also a priority for the city.
But what has become clear – through a variety of projects – is that care for these patients under the old way of thinking cannot be sustained.
What we need to do is integrate services properly, avoiding duplication and overlap, be person-centred and, most importantly, place greater emphasis on keeping older people active and part of the community.
Resources need to be targeted to prevent vulnerability turning into dependency.
One of the key determinants of whether people go into hospital is around social isolation – which can be as dangerous as smoking and alcohol for older people.
Primary care needs to get better at identifying vulnerability before it gets to be a problem, but also knowing what to offer patients whose social isolation puts them at risk.
GPs recognise the problem of social isolation, but in most cases can only offer a medical response, such as antidepressants.
In the early 1990s, we set about trying to create a service that would address the needs of socially isolated patients.
The practice I was working at applied to redevelop space at an old shopping centre that would incorporate office space for health trainers, a community gym and a kitchen for cooking lessons. It was to be a prototype for a new breed of healthy living centres. Funding was obtained from a government City Challenge programme and regional health funding. HealthWORKS began as a voluntary-sector organisation with a workforce of five or six and a turnover of £120,000.
The doors opened in 1996 – or in fact were opened by the then-leader of the Labour party, Tony Blair.
Having close links with local GP practices from the start, HealthWORKS has since expanded to absorb a second centre in Lemington, Newcastle, and offers a range of programmes around nutrition, exercise, weight management, family health, coping strategies and community engagement.
We are a registered charity and social enterprise with a current annual turnover of £1.3m, over 70 staff and more than 80 volunteers.
Our work – all centred around working with communities to tackle health inequalities – includes the community health trainer contracts for Newcastle and the running of a Sure Start children's centre.
Through the services we provide and the signposting we do to organisations that complement our work, we aim to support people to develop personal and community resilience in improving their health and wellbeing.
Around 65% of our income comes from contracts with the NHS and local authority, 25% from earned income and the rest comes from grants.
Communities for Health
In 2008, we were provided with Communities for Health funding to develop and then roll out a model to provide a range of accessible social activities for vulnerable older people and those with long-term conditions for whom loneliness or isolation was a problem.
Communities for Health funding came from the Department of Health, but was allocated to local authorities in a bid to strengthen partnerships between healthcare and local authorities to tackle a range of health issues including isolation.
The project began with two pilots. In the Lemington Centre pilot, three local GP practices were asked to refer anyone aged between 25 and 70 with one of or a combination of heart disease, diabetes or obesity, plus low mood and who was socially isolated to the physical activity team.
The HealthWORKS physical activity team's role was to signpost patients to a wide range of services that we already provided, including exercise on referral, aromatherapy, support groups and social groups.
In the second pilot, also linked with three general practices, patients were referred to the existing community health trainer team at HealthWORKS Newcastle if they were over 65 years of age and with low mood and/or socially isolated who were offered the same service as in pilot one.
Two other existing services, offered by charities, were brought on board – Search, which offers community health activities for the over-50s as well as benefits and access advice for the elderly, and West End Befrienders, who help frail, older and disabled people to live more independently within the community.
A single referral form was developed to make the process simple for GPs.
For both projects, patients had an initial appointment to assess factors such as mood, social contact, relationships, money, pain, ability to carry out daily tasks, confidence in exercising, healthy eating, hobbies and managing health, before an action plan was put in place based on the goals the patient wanted to achieve.
After being granted further funding to extend the pilot, we rolled out the scheme to the whole of west Newcastle and developed a uniform referral criteria. Patients must be over 50 years of age, suffering from low mood and/or social isolation, with any long-term condition. We worked out that up to 650 people in west Newcastle would meet all the above conditions.
Since the project started in 2008, there have been more than 500 referrals to Communities for Health. Two-thirds were women, which is to be expected given that more women are living alone and suffering isolation, and more women are prone to suffer from poor mental health.
The total costs for running the schemes plus the Search project and West End Befrienders was £388,110 in 2010 – which has been calculated as £244 per person per year for high-level support with regular reviews or £70 for those who may just need pointing in the direction of existing community services.
This compares with £277 per year the NHS spends just for medication on every person with diabetes.
Focus groups and surveys have shown overwhelmingly positive responses from patients who have been referred.
This quote is typical of those taking part in the scheme: ‘I now have a much better outlook on life. My mood has lifted and I am able to cope when I get low without relying on medication. I am taking responsibility for my own health, which makes it even more rewarding.'
Getting the isolated engaged
Our programme offering GP referral for people with long-term conditions who were socially isolated has shown the strategy could have a large sustainable impact on locking people into social networks through health improvement programmes.
But there are a variety of other ways we get vulnerable people through our doors.
In June 2010, Newcastle PCT commissioned Staying Steady, a falls prevention exercise programme that provides 160 exercise places per week in community centres across the city including HealthWORKS Newcastle and the Lemington Centre. Referrals can be from health professionals or self-referrals.
A report published after Staying Steady's first year showed the average person taking part was 79 years old and around three-quarters were female.
In addition to the measurable outcomes of physical improvements in balance, gait and endurance, one of the real wins of the scheme has been the improvement in the social networks of those taking part.
Many participants cite the increased social contact as a benefit and it helps to increase self-esteem and confidence.
Participants are also referred to other services and third-sector providers for social contact, and we ensure the venues we use provide social groups for older people.
Initial figures showed 65% of those completing the programme continued with other exercise classes, which backs up questionnaire surveys showing how important the social aspect of the scheme was to participants. Comments included: ‘The support given is fantastic and motivating' and ‘It is nice to meet other people and the classes are enjoyable'.
One of the criticisms of a home-based programme offered to participants was the lack of opportunity for social contact – something that has since been remedied after it was found this aspect helps people stick to the programme.
One woman who took part because she had osteoarthritis in her knees said the programme had increased her confidence to the level that she was going to the gym despite being on a waiting list for a knee replacement – something she would not have felt able to do before. The support of the group and the friends she has made have meant she can attend the gym at the same time as people she knows.
The cost per participant is £370 compared with £4,000 for a hip replacement or £7,000 or more if a frail elderly person falls and ends up needing social care.
Activities for men
Our community health trainers are not just looking to get people exercising and eating healthily. They want to lock people into social networks to help cement the brief lifestyle interventions they can offer them.
We have developed a variety of services targeted at particularly vulnerable groups.
The Newcastle NDC baseline mental health survey showed that of men aged between 45 and 55 years, 49% are living alone and 58% are economically inactive and have associated high levels of smoking, alcohol use and obesity.
One programme we have developed to engage with this group is a weekly fishing session on the Newcastle quayside with equipment provided for the first five sessions.
Some of the men from this group also take part in the cooking sessions run by our food and nutrition team.
The benefits of these types of schemes are the discovery of a supportive social network and people become more physically active. They also develop better ideas about nutrition and improved mental health. This scheme can be linked in with other programmes on cutting out smoking and alcohol, and health education on subjects such as diabetes and prostate problems.
Exercise on referral
Exercise on referral is another option offered through our community gyms. This is done through either assessments and goal-setting with a tailor-made programme or supported gym sessions and classes.
Participants – who can be referred by any health professional – get gym visits at the discounted cost of £1 per session for the first three months, then £1.50 for the rest of the year. After that the cost is just £2 per session.
Three-quarters of clients report that their social contact has increased due to their participation and we try to ensure that ‘like-minded' people are grouped together and are introduced to each other when they come to the gym sessions.
Among the social groups we run, one of the most successful has been Pin Pals. This is a group of about 14 regulars, mainly men, some of whom have learning disabilities and who need support from a carer, who meet weekly at the 10-pin bowling arcade.
Community health trainers attend the group to support with one-to-one goal setting and increasing socialisation.
Our route to creating a solution to tackle isolation has been assisted by various government grants that were available in the 1990s, but the big three challenges for CCGs will be long-term conditions, mental health and the elderly.
Without addressing the issue of social isolation that so compounds all of these issues, they will break the bank.
Professor Chris Drinkwater is president and public health lead at the NHS Alliance, director of HealthWORKS and chair of Newcastle West CCG
A social enterprise charity that employs 70 staff in a building accommodating a community gym and training kitchen and 80 volunteers.
Around 65% of income is from commissioning contracts with the PCT and local authorities to provide services to address social isolation – a key determinant in hospital admissions.
There are several routes to connect patients with the service, including by GP referral, a falls prevention service and self-referral.
The service runs several schemes to address social isolation including a men's fishing club that also trains men to cook their catches, a 10-pin bowling group for people with learning disabilities and a community gym that costs £2 a session.