Preventive services for older people should boost independence and prove cost effective if the evaluation of Popps is anything to go by, writes Louise Tickle
Most people who play an instrument start to learn as a child. But Gwenda Stanton began learning the violin at the age of 81, and only then because her community outreach worker encouraged her to give it a go.
“She asked me if I had a hobby,” says Stanton. “Well, I love the theatre and art, and I like music. So she asked if I’d like to do some art classes. But the rough path to the church where they were held was too much for me and I had to say no to that. So then she asked, ‘what about something else?’ And I thought, well, I’d always wanted to play the violin.”
A second-hand violin was found for £25 and East Sussex Council’s Partnerships for Older People Projects (Popps) gave Stanton a small pot of money to pay for lessons.
“It’s run out now, but I did learn a few tunes,” she says. “It gave me an interest, and made me feel I wasn’t so old and useless, and that even at my age I could learn something new.”
Relationship of trust
The effects, it seems, go far beyond the sense of achievement gained by being able to play a tune: Gwenda Stanton has now built a relationship of trust with her community outreach worker that will stand her in good stead for using future services. She’s already been put in touch with her local “trusted handyman” scheme: a newly raised toilet seat and a wobbly grab handle that’s been securely fixed to the wall means she’s now able to use her bathroom safely. She says the reduced risk of falling has given her confidence that she can manage her basic needs without injuring herself.
Encouraging and supporting relatively low cost services such as these has become an important part of some councils’ and primary care trusts’ investment in their communities. Alongside these well-being services, many councils are introducing preventive services which reduce the demand on acute care and save resources. The DH-funded Popps programme, which is being trialled in 29 sites, is evaluating the impact of both well-being and preventive services.
Older people frequently come to the attention of healthcare and social services at a time when they are in a crisis. Prevention and early intervention have not been prioritised with the same degree of urgency that acute illness, a debilitating fall or a major breakdown in mental health would typically prompt. But the government is shifting the focus to what works in terms of preventing crises for the country’s older population, particularly as the numbers of older people are going to greatly increase over the coming decades.
For these reasons the recent evaluation report on Popps will have made interesting reading for policymakers and service commissioners, particularly the emerging evidence that joined-up community support can reduce admissions to hospitals and residential care. Popps national evaluator Karen Windle who has reviewed 11 pilots so far, says: “We can say, for the first time, that we’re seeing that a preventive project is cost effective.”
LinkAge Plus is another pilot scheme, this time funded by the Department for Work and Pensions, that aims to help people remain independent for as long as possible.
At Nottinghamshire Council, which undertook an extensive consultation in preparation for its LinkAge Plus project, programme manager for older people John Hannam says that easier access to information was what respondents emphasised they needed most.
In response, the LinkAge team set up a “first contact signposting scheme” that has joined up a range of services which now require minimal effort to access. It means that whichever service visits an older person first – be it a firefighter to advise on smoke alarms or a police officer about security – they are all trained to ask 10 simple questions, designed to establish whether any other support is needed. The professional then contacts other relevant services on the older person’s behalf to gain that support.
Low level support
There are also one-stop information shops and outreach workers whose job it is to search out the most isolated people and inform them of the services available. A part-time co-ordinator has been employed as a central point of contact in each of Nottinghamshire’s seven districts, and the whole scheme has worked so well in getting services to the people who need them that other councils are now looking to implement similar schemes.
None of this low level but crucial support is going to work if your home is so cold and damp that you become ill, or if it’s so physically unsuitable for your needs following a hospital stay that you swiftly give up and request residential care. Given that older people spend up to 90% of their lives at home, their living environment impacts greatly on their continuing health and mental well-being.
But the small, vital, practical adjustments that can make all the difference to an older person maintaining their independence – being able to bathe themselves, use the toilet, cook a meal, manage the stairs – after illness or injury are all too often not installed until it is too late. A bad stumble after recovering from a fall can knock someone’s confidence and make them feel more vulnerable than is necessary, were they just given a little more practical help.
Sue Adams, director of Care and Repair England, a charity set up to improve the housing and living conditions of older and disabled people, says more than half of those in residential care go straight there from hospital. “So the two big challenges are to find a way of really speedy delivery of those interventions – it should all happen before they go home – and preventing the need for that urgent intervention in the first place,” she says. “What that means is that if someone knows they’re going to have surgery, doing the adaptation stuff in advance of them going in. And that doesn’t happen very often at all.”
Work is now underway to predict the risk of admission to residential care in order to put in place holistic interventions and preventive measures. In 2007, the King’s Fund published predictive modelling around the risk of hospital admissions and upstream interventions. This was followed by a Nuffield Trust study that is still ongoing. But the question of who should pay for these preventive measures is always the sticking point. Residential care is costly. But so too is bedspace for an older person making multiple long-stay trips to hospital.
“There needs to be a wake-up call in the medical world as to the impact of housing on health and admissions,” says Adams.
No council-run scheme is going to make Gwenda Stanton’s life perfect, of course. When asked how confident she is about continuing to live in her own home over the coming years, she admits to “fits of getting frightened”.
What would help? “What I need is someone here who I can call on,” she says. “I have a pull cord thing and they send an ambulance, but you don’t always need an ambulance, do you? You may need someone to come and give you a hug and have a cup of tea.”
So family, friends and neighbours are all desperately needed. But projects that aim to reach people before they hit rock bottom have a vital part to play, and although unlike a hug they’re not free, they could yet prove more beneficial, and cheaper, than the alternative of a residential home or a hospital bed.
Key messages from the Popps guidance
The savings effect seems to be most pronounced where interventions are specifically focused on “hospital avoidance”, such as intermediate care/rapid response and hospital in-reach.
Some interventions will generate significant savings while others will focus on improving well-being. Both are vital to delivering the kind of transformation envisaged within Putting People First. It is important to be clear about what is being commissioned, and why, in order to deliver a balanced system.
Other public services are crucial to promoting well-being – housing, transport, community safety, leisure services, public health.
Involving older and disabled people in the planning and monitoring of services is crucial to ensuring that they are developed appropriately.