Martin Knapp and Margaret Perkins look at the findings of research into the importance of preventive work with older people
Five years ago the Joseph Rowntree Foundation’s Older People’s Inquiry published That Little Bit of Help, in which befriending was identified as a service that could help older people maintain independence and emotional well-being.
The report pulled together much of what was known at the time in relation to older people, but there was little research around to inform the recommendations.
In recent months new evidence has been published, giving us a better understanding of what works and the implications for increasingly tight budgets.
Two national programmes have boosted our knowledge. One was the LinkAge Plus programme, led by the Department for Work and Pensions, which comprised eight pilots involving central government, local authorities and other organisations. The evaluation report has a wealth of information about the effects on the lives of older people, on how care and support can be provided, and on costs (Davis and Ritters 2009).
Although LinkAge Plus was not only about prevention, some pilots did have this emphasis. In Devon, a new style of service was offered for older people who were experiencing a downturn in their lives. These individuals were at higher-than-average risk of isolation, social exclusion and poor health, perhaps exacerbated by their loss of confidence to go out. Mentors visited people and prompted them to become involved in stimulating creative and social activities, either in small, informal, friendly groups in local community venues or in their own homes. Among other findings, there was a significant reduction in the number of older people with depression.
The Partnership for Older People Projects (POPP) were funded by the Department of Health. Twenty-nine local authorities in England were chosen as pilot sites. Each of them set up one or more local projects to promote the health, well-being and independence of older people, and delaying or preventing their need for higher intensity care, including admission to a care home.
Some of the interventions were of the “upstream”, low-level preventive kind described in the Joseph Rowntree Foundation report. Overall, the evidence from the national evaluation of POPP revealed many positive achievements, including improvements in quality of life and cost-effectiveness. For older people receiving what the research team called “well-being or emotional interventions” – including befriending services – fewer reported being depressed or anxious after the intervention.
Kent Council funded activities including befriending services organised and delivered by local voluntary groups. The London School of Economics’ Personal Social Services Research Unit evaluated this local programme, called Brighter Futures.
The individuals who became involved in these activities – which included shopping trips and other outings, exercise classes and one-to-one befriending – expressed positive views about the value of the support to them and the links they offered. The programme also appeared to have the potential for savings because it reduced loneliness, which is a major risk factor for depression.
The latest addition to our knowledge is a systematic review of completed studies of befriending by Nicola Mead and colleagues at the University of Manchester (2010) who scoured international literature.
They did not confine their search to older people’s befriending services, but they did limit their search to randomised controlled trials published before April 2008. (Randomised trials, widely used in clinical research, allocate people to an intervention in a purely random way to compare the effectiveness of different models of care. This research design is seen as the best for finding out if, say, a new intervention is more effective than current practice.)
Even if the Manchester University team had continued their review for two more years, their inclusion criteria would have meant omitting the LinkAge and POPP pilots. The suitability of randomised designs outside clinical settings remains a subject of debate.
The authors pooled the data from the various studies to look at overall effects and focused on depression. They concluded that – compared with usual or no care – “befriending has a modest effect on depressive symptoms and emotional distress in varied patient groups”. These are short-term effects only (up to 12 months after befriending started), and it may be that longer-term impacts are worse, or they might be better.
In different ways and with different approaches, these studies offer encouraging evidence in support of befriending services.
Each of these reports and papers addresses only a few of the possible effects of befriending. The new-found confidence and increased links into the local community of older people who have received support from befriending services might prevent later complications or emergencies, for example.
As well as preventing depression and emotional distress, these services might also help older people to see their GPs, and so make sure that a range of health needs are met. These are all potential effects that might add to the case for expanding befriending interventions.
A couple of years ago, Conor O’Luanaigh and Brian Lawlor (2008) reviewed the evidence on loneliness among older people and its effects on health. The studies they found suggested that between 5% and 16% of older people in the UK are lonely. The associated risks to their mental health and well-being are well known.
What we now know is that befriending services – many of them run by voluntary and community sector organisations, and many heavily reliant on volunteers – can help to counter these risks. These services aim to alleviate social isolation, thus preventing loneliness and, in some cases, depression. The LinkAge, POPP and Mead studies all point to positive outcomes from befriending services. It is not so clear whether there are also economic benefits, although the evidence is encouraging.
Practitioners: When an older person is referred for assistance with social care and feels lonely and isolated, it may be worth considering whether befriending support would be beneficial. Qualitative research evidence shows that older people welcome such contact, feel less isolated and may be assisted to take part in other social activities, which helps them become more socially included. They can also be helped and encouraged to access other services earlier, which could prevent more serious difficulties occurring.
Commissioners: The importance of preventive measures to avert admission to hospital or residential care underpins much health and social care policy. The research shows that befriending schemes have potential for savings through preventing loneliness and, in some cases, depression. Investing in such schemes at the local level may delay the need for more costly health and social care service provision.
Directors of social services:Considering the pressures on frontline staff in older people’s teams, developing additional community-based support which may delay the need for professional input makes sense. Befriending schemes are usually run in the voluntary sector, often using volunteers, and so these activities can also help build local partnerships and promote community development.
Voluntary sector providers: The national POPPs project showed the importance of the voluntary sector in supporting older people and assisting them to remain living in the community. Evidence from that study and other research has shown that befriending schemes are rewarding for volunteers and the older people. They may also create possibilities for access to other services often provided by the voluntary sector, such as outings and shopping trips.
● Brighter Futures Group final report (2009), Kent County Council, Maidstone
●Joseph Rowntree Foundation (2005), That Little Bit of Help
● Howard Davis and Katrina Ritters (2009), LinkAge Plus, National Evaluation: end of project report, DWP Research Report No. 572
● Nicola Mead and colleagues (2010), “Effects of befriending on depressive symptoms and distress: systematic review and meta-analysis”, British Journal of Psychiatry, 196, 96-101
● Conor O’Luanaigh and Brian Lawlor (2008), “Loneliness and the health of older people”, International Journal of Geriatric Psychiatry 23, 1213-1221
● Karen Windle et al (2009), National Evaluation of Partnerships for Older People Projects, PSSRU, University of Kent
Martin Knapp is professor of social policy at the London School of Economics and Political Science, where he directs the Personal Social Services Research Unit. He is also director of the School for Social Care Research, part of the National Institute for Health Research. Margaret Perkins is a research officer at LSE’s Personal Social Services Research Unit.
This article is published in the 15 July 2010 edition of Community Care under the headline “The role befriending can play in older people’s well-being”