JOINT STRATEGIC NEEDS ANALYSIS - OLDER PEOPLE TOPIC PAPER
1. OVERVIEW OF CURRENT AND FORECASTED NEEDS
Opportunities and challenges of demographic change
‘Live Well in Later Life’, Edinburgh’s Joint Commissioning Plan for Older People 2012-22 (p23) sets out the challenges and opportunities presented by demographic change.
The opportunities include people living more healthily for longer. Almost 90% of those aged 65+ are not in receipt of health or care services. Older people also contribute substantially to society. A significant amount of caring for children, adults with disabilities or learning difficulties and older people is provided by people over retirement ages, and many community assets and activities depend on the voluntary contributions of this age group.
There are also challenges. With increasing age there is also an increase in the number of people living with long-term conditions, disabilities and complex needs. Whilst healthy life expectancy (i.e. the length of time people live in a healthy way) has been increasing, overall life expectancy has been increasing faster. This means people are living longer but people in the oldest age groups are more likely to require support for complex health and social care issues for longer periods than in the past.
The term ‘older people’ is sometimes applied to people over 65, based on pensionable age, but changes in life expectancy and lifestyle mean that many people do not associate themselves with this term. Whilst the term ‘older people’ is used for care planning purposes and in service criteria, services are based on need rather than age alone and people accessing services are increasingly from older age groups. The probability of accessing health and social care services increases dramatically with age. The graph below shows that the allocation of health and social care resources increases significantly with age (see section 4.1 of JSNA for further detail).
Figure 1: Total NHS and Social Care Spend per Head (2012-13) by Age Group – Edinburgh, Lothian and Scotland
Deprivation also has a significant impact on health and ageing, shown by the difference in life expectancy between areas of relative deprivation and affluence. Many older people with low income live out-with areas of deprivation. The effect of socio-economic disadvantage can be increased by reduced income after retirement and older people can experience very low income despite having significant assets.
The graph below shows the increased likelihood of multi-morbidities with age and deprivation.
Figure 2: Proportion of patients with Multimorbidity by deprivation quintile (SIMD) within 10 year agebands for Edinburgh CHP. Quintile 1 (Q1) = most deprived and quintile 5 (Q5) = most derived. (Data Source: Lothian IRF 2012/13)
People who are older may also have physical or learning disabilities, mental health or substance misuse issues. In addressing these issues, we need to ensure that care and support arrangements are tailored to individual needs, are not restricted by the labelling of people into categories and the transition between services as people age is well managed.
What conditions are more likely with age?
Dementia is an umbrella term for a range of illnesses and disease symptoms, which affect the brain. Although the risk of dementia increases with age, people under 65 can also develop dementia. In Edinburgh, it is estimated in that 7,823 people have dementia – around 7,536 people over 65 and 287 people under 65[1]. It is thought that around a third of those have not been diagnosed yet which means they are not receiving treatment and support. Of the most common long term conditions, dementia is most likely to have the highest resource cost for health and social care services[2]. It is estimated that the average cost of dementia per person is £27,647 per annum[3].
The experience of dementia is subjective, unique to each individual and can include a wide range of symptoms. This can make dementia challenging for people living with the condition, their families, carers and services that support them. Health and social care services need to have the time and appropriately skilled workforce to provide good quality care and support for people living with dementia. People with dementia may have involvement from different agencies which requires good joint working arrangements.
Long term conditions are conditions that last a year or longer, impact on a person’s life, and may require ongoing care and support. Common long term conditions include epilepsy, diabetes, some mental health problems, heart disease, chronic pain, arthritis, inflammatory bowel disease, asthma and chronic obstructive pulmonary disease (COPD). The risk of people developing long-term conditions increases with age as does the number of long term conditions that an individual is likely to have (table 2).
Loneliness and isolation are increasingly recognised as having a significant impact on health and wellbeing; research suggests that loneliness can have a greater impact than obesity and smoking. Whilst loneliness can affect people of all age groups, it is often linked to ageing as people are more likely to face the loss of friends, family and connections as they get older. Mobility and health conditions can also lead to people being less able or confident in getting out and about and continuing to make social connections. The availability of affordable and accessible transport is a key issue for older people in order to remain connected to community activities.
How many older people will there be and what is the projected demand for services?
The number of people over 85 in Edinburgh is expected to almost double by 2032 to 19,294. The number of older people who will require intensive levels of support is expected to increase by 61% over the next 20 year due to demographic factors alone.
The number of people living with dementia is projected to increase in line with demographic change. In ten years time the number of people living with dementia is likely to rise by 25% to 9,765 people and in 20 years the number could rise by 65% to 12,944 people.
There are estimated to be around 65,000 unpaid carers in Edinburgh, with around 10,600 of these aged 65+[4]. With the population of Edinburgh continuing to age, the number of older carers is expected to rise further along with the support needs of this group, who as well as support with their caring responsibilities also need support to ensure they take care of their own health and wellbeing. As more older people are supported to live at home, this puts additional demands on unpaid carers who are a key part of the health and social care workforce. Many people do not have carers that live close by and are able to provide support as they get older. Edinburgh has 26,320 single person households aged 65+[5].
Age and geography
The age profile varies across the city with concentrations of ‘younger’ older people (65-74 years) in the east and west of the city.
There are concentrations of people aged 85+ in the south central area of the city
These patterns are likely to be influenced by factors such as housing and socio-economic factors. For example, in relation to the over 85 populations, these are highest in areas of relative wealth, where people live longer, and also where there is a concentration of care homes for older people.
Policy direction
A key policy for older people’s services is to ‘shift the balance of care’ from institutional to community based settings, as set out in the national Reshaping Care for Older People strategy. This is based on national and local consultation which tells us that older people want to remain at home in the community where possible. In order to support this aim, we need to ensure that suitable accommodation and joined up services are available to support increasing numbers of frail older people in the community. This will require a shift in resources which are currently focused around acute and hospital based care, to community based services, including the role of the third sector. More people being cared for in the community relies heavily on the care provided by unpaid carers such as family, friends and neighbours and support for unpaid carers is therefore essential in delivering this aim.
Preventing avoidable and costly admissions to hospitals is essential in order to deliver sustainable health and social care services in the future and to improve outcomes for individuals, particularly people with dementia[6]. Recent day of care audits have identified people in hospital who could be cared for elsewhere in the community if the appropriate services and supports were available.
Levels of need and the ‘balance of care’
The prediction of future needs must take account of changes in models of care. In Edinburgh, the percentage of older people with high level needs who are cared for at home has increased from 14% in 2002 to 35% in 2015. The average number of hours of care at home services has risen, reflecting the increased needs of people living in the community. Within care homes, people with the lowest dependence has almost halved to 22% of the resident population, whereas those with the highest needs has increased from 8% to 13%. Whilst the balance of care has shifted considerably, this has not been matched by a commensurate shift in resources which has led to community services that are unable to meet demand.
Predicting future needs depends on how much further the balance of care is ‘shifted’ to the community, the examples below show how the projected demand for services would vary based on a balance of care of 40% and 45%.
Figure 3: Service movements required by 2018 to achieve 40% and 45% balance of care, based on estimated numbers of older people with high level needs.
Changes made to any part of the health and social care system have an impact on other areas which also impact on how predictions of future needs are modelled. For example, changes in the criteria in NHS inpatient complex care beds may lead to more of these patients being cared for in care homes or the community.
Needs of older people with protected characteristics
It is imperative that all health and social care services are accessible, appropriate and inclusive of and sensitive to the needs of those with protected characteristics and that consideration is given to barriers that can limit access for particular groups.
It is estimated that between 5-7% of the population are lesbian, gay or bisexual, which would be between 24,000 – 34,000 people in Edinburgh, of whom between 3,000 – 5,000 are aged over 65. Lesbian, gay, bisexual and transgender (LGBT) older people are likely to face many of the same issues as other older people, but research suggests that older LGBT people are also:
· 2½ times more likely to live alone
· twice as likely to be single as they age
· 4½ times more likely to have no children to call upon in times of need
· 10 times more likely to indicate that they have no-one to call on in times of crisis or difficulty.
Whilst LGBT older people have an increased need for support, there is a greater reluctance to access services due to concerns over discrimination, fear of harassment and loss of privacy. These fears are greater for older populations, many of whom have lived through severe discrimination – homosexuality was illegal in Scotland until 1980. 76% of lesbian, gay and bisexual people are not confident they would be treated with dignity and respect in a care home[7], while 81% of transgender people avoid certain situations due to fear[8]. Older people also have to deal with prejudice from their peers, who are significantly more likely to hold discriminatory views about LGBT people than younger generations[9]. This means that many older LGBT people find it difficult to access services, and may also hide their identity when they do.
Within Edinburgh LGBT Age project has produced a film and other materials that raise awareness of the challenges that LGBT older people can face when accessing health and social care services. The project has provided training and materials for services to help them to become more inclusive, including an audit tool and ‘ten top tips’ document.
Edinburgh hosts a multicultural society. There are around 1,100 older people from ethnic minorities in Edinburgh[10]. Older people from ethnic minorities can face barriers related to language and culture which make it difficult to access mainstream services.
2. PROFILE OF ACTIVITY
‘Live Well in Later Life’, Edinburgh’s Joint Commissioning Plan for Older People 2012-22 (p14) provides an overview of the range of services provided for older people in Edinburgh, which include:
Key areas of service include:
Preventative services
The voluntary sector are important providers of low level, ‘preventative’ services and support. NHS Lothian and the City of Edinburgh Council allocate over £4 m per year through grants to voluntary sector organisations providing preventative services for older people.
EVOC recently identified over 2,000 activities taking place for older people every week from walking groups to singing clubs, from dominos to Tai Chi. LOOP (Local Opportunities for Older People) networks have been established in 4 sectors of the city to help link people to organisations providing these activities for older people.
Housing
It is estimated that 88% of people aged 65 and over in Edinburgh live in mainstream housing, 8% live in sheltered or amenity housing, and less than 4% live in care homes. Edinburgh has the second highest proportion of flats in Scotland at 65% which can be difficult for people with mobility problems to access, especially flats above the ground floor. Nearly half (48%) of all homes in Edinburgh were built before 1945 compared to the Scottish average of 36%. Older homes can be more difficult to maintain and adapt and it can also be more difficult and expensive to improve the energy efficiency of older homes and help reduce fuel bills.
In addition to support for older people to adapt and remain in their homes, a range of housing options, including housing with care, is required in the city to meet people’s needs as they get older. Information and advice is important in assisting people to plan ahead to avoid crises due to inappropriate housing.