Director of Public Health Report 2017

Case Study 1 - FionaI was 65 when my husband Alan died. We had been married for 40 years. We didn’t have any children and I had been a peripatetic teacher. We had enjoyed dancing and at one time belonged to our local Rambler’s group. After Alan’s death I lived in our three bedroomed house which was really a bit big for me to manage on my own. I started to get hearing loss before Alan’s death and this made it difficult for me to talk to people sometimes so Alan used to deal with tradesmen. I also developed heart failure and with Alan’s death and my communication problems I started to feel quite isolated.

One day some builders came round and told me that the roof needed fixing so I got them to do the work. I later found out that the work that had been done was poor quality and I had been the victim of fraud. I reported this to NYCC Trading Standards Team who investigated the company involved and successfully prosecuted them. They also, with my permission, referred me to the Safeguarding Team to ensure I was protected in the future and the Living Well team who were able to link me up with a local walking group run by Age UK. I was also put in touch with a voluntary group for people with a hearing loss.

This helped to increase my confidence, which had been severely knocked by this incident.

This experience caused me considerable stress at the time and over the years, coupled with the loss of my husband; I started to become depressed and anxious. My GP referred me to the IAPT (Improved Access to Psychological Therapies) service which helped a lot. However, my heart failure deteriorated over time and I started to feel unsafe at home. I also found that I was less and less able to cope at home and needed more help to carry out everyday activities. Following a referral for a care and support needs assessment, it was agreed that my needs would be best met by the local Extra Care Housing scheme which would give me a sense of security and help to reduce my isolation whilst also providing the support that I needed.

TodayAfter moving into an Extra Care facility I feel more secure, my anxiety has reduced, and I have become more active again. I have joined the residents group and have made some new friends. I have regained my confidence and have become a volunteer chairobics leader which involves organising events and making new members welcome.

To understand more about these important issues click on the links:

Hello, my name is Fiona and this is my story.

Director of Public Health Report 2017

Adults at risk, safeguarding and fraudAnyone could be at risk of abuse or neglect. A person may be more or less vulnerable at different times in their life. An adult at risk of abuse or neglect is;

• an adult who has needs for care and support (whether or not the local authority is meeting any of those needs for care and support)

• and is experiencing or is at risk of abuse or neglect

• and as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

Safeguarding means protecting an adult’s right to live in safety and free from abuse and neglect. It is about people and organisations working together to prevent and stop both the risks and the experience of abuse or neglect. At the same time ensuring that the adult’s wellbeing is promoted including, where appropriate, having regard to their views, wishes, feelings and beliefs in deciding on any actions.

If a person is in danger or immediate action is required then the emergency services should respond. However if a person is not in immediate danger concerns can be raised through the North Yorkshire County Council customer services centre on 01609 780780 (24 hour response).

Easy Read information on safeguarding can be found at What is safeguarding

Adults at risk can become victims of fraud. The Multi-Agency Safeguarding Team (MAST) at NYCC Trading Standards (TS) has been partly funded by the public health grant to tackle frauds and financial abuse of adults at risk in the County. A large proportion of this work involves frauds against older adults, aged 65 and over.

Frauds and financial abuse includes doorstep crime, distraction burglaries, investment frauds, romance frauds, mail frauds, and frauds by family, carers, powers of attorney or those in a position of trust.

The team consists of Trading Standards staff, officers from North Yorkshire Police, and a Safeguarding Officer from Health and Adult Services (HAS).

The impact of such frauds goes far beyond mere financial losses. They result in a loss of confidence and self-esteem, increased isolation, health deterioration and, in the worst cases without intervention, loss of independence.

Key characteristics of victims include loneliness and isolation, dementia or other mental capacity issues. These can lead to victimisation and repeat victimisation.

Offenders are highly professional and adept and prey upon victims’ mental confusion and loneliness. Frequently they are members of Organised Crime Groups, including international groups, who deliberately target the elderly and vulnerable.

Many victims end up in a cycle of victimisation, in a desperate attempt to recover previous losses. This is particularly prevalent in cases of mail fraud and investment fraud, where responding to the frauds can resemble a gambling or substance addiction response.

MAST has been successful with multiple prosecutions throughout 2016/17. There have also been numerous safeguarding alerts and interventions to improve victims’ health, well-being and quality of life.

The team also focuses on prevention work, carrying out talks and presentations to raise awareness with older adult groups and also older adult groups, carers and those in a position to help safeguard adults at risk, for example banks and building societies.

The team was established in April 2015. The scale of frauds and financial abuse against older and vulnerable victims which it has uncovered since then is dramatic. This is in terms of the numbers of older adults at risk, the number of frauds taking place and the levels of frauds taking place, with some victims being defrauded of tens of thousands of pounds each.

Director of Public Health Report 2017

Living WellThe Living Well service has been operational since October 2015 working with individuals (and their carers) who are on the cusp of becoming regular users of health and social care services by helping them access their local community and supporting them to find their own solutions to their health and wellbeing goals. Living Well aims to improve the health, well-being and independence of adults and in doing so reduce their use of formal support services, including emergency admissions to hospital.

Living Well supports adults who are currently not eligible for on-going social care support and who are:

• individuals who are lonely and/or socially isolated

• individuals who have had a recent loss of a support network; including bereavement

• individuals who have had a loss of confidence due to a recent change/event

• individuals requiring face to face information, advice and guidance 

This may be older people or people with physical, learning disabilities, sensory impairment or mental health needs.

The service aims to identify opportunities in the local community to help keep them as independent as possible. This includes social activities, volunteering opportunities, healthy lifestyle activities and support with practical advice and skills.

For more information follow the link Living Well in North Yorkshire

Case StudyMr and Mrs Ambrose were referred to Living Well by a worker from adult social care who was concerned about their isolation and other issues.

Mr and Mrs Ambrose rent a bungalow in a small rural village from a housing association. They were rehoused two years ago as Mr Ambrose has mobility issues and Mrs Ambrose has health issues. The village has one bus a day to the nearest town, leaving in the morning and returning later in the afternoon. Mrs Ambrose does not drive. There is no social activity in the village. Little happens at the village church, there is no village hall and no pub.

In the last year, their son in law died and Mrs Ambrose’s brother died. She had one session of counselling which left her very upset.

They were very concerned about the state of their home particularly the state of the bathroom and the lack of parking. The housing association had promised improvements but it was taking a long time.

Mrs Ambrose has a tablet but does not feel confident about using it to do online shopping.

Mr Ambrose finds it difficult to get comfortable in bed and when sitting. He can’t afford the new chair that he needs.

What do they want to achieve?Talking to the Living Well coordinator, Mr and Mrs Ambrose agreed that the most important things for them was the replacement of the bathroom, treatment of the mould, confidence in internet security and a replacement chair for Mr Ambrose.

How did Living Well support them both?The Living Well coordinators:

• Encouraged Mr and Mrs Ambrose to contact the housing association;

• Informed them about an internet security course at the library and offered to book a place for Mrs Ambrose; and

• Showed Mr Ambrose a suitable second hand chair and informed him of a shop near the library where he could buy one.

What was the outcome?The housing association fitted a new bathroom. They were both really pleased and happier due to having a home that better suited their needs. The bathroom has given Mr Ambrose more independence as he now requires less help from his wife to shower. This also gives her less concern;

• Mrs Ambrose attended another counselling session and agreed to attend some more;

• Mrs Ambrose agreed to book a place on an internet security course at the library; and

• Mr Ambrose agreed to look at buying a second hand chair.

At the end of the Living Well support Mr and Mrs Ambrose said “You have made us feel so much better. Anybody who gets to work with you two is very lucky”.

Director of Public Health Report 2017

HousingNorth Yorkshire is an attractive place to live and there is considerable demand for properties from households who work outside the County but commute from North Yorkshire, those who want to retire and who want a second or holiday home. This results in high average house prices and private rents.

A proportion of older households in North Yorkshire are ‘asset-rich, income-poor’. These are households with low retirement incomes but high levels of housing wealth as their homes have increased considerably in value. The housing stock in North Yorkshire means that these households often lack opportunities to downsize and reduce their living costs whilst increasing the liquidity of their income.

Good quality housing also has a critical role to play in creating and supporting economic growth and helping to prevent illness, injury or the deterioration of existing conditions and is especially important for older people.

The demand for housing is also changing in line with the changing demographics in the County. There are particular issues in addressing the needs of the older population across North Yorkshire. Households aged 65 and over make up one quarter of the population and this is predicted to grow. In contrast, the existing stock of housing is predominantly detached (33%) and semi detached (31%) with a smaller than average proportion of terraces and flats for smaller households, resulting in under-occupancy issues in some areas and the lack of opportunities for older households to ‘downsize’ and free up family accommodation.

Extra Care HousingIn response to the housing challenges of an ageing population, NYCC has worked in partnership with housing providers and District and Borough Councils to help develop 21 state of the art Extra Care housing schemes across the County. Extra Care housing is a solution to meet the needs of the growing older people’s population in North Yorkshire by providing high quality, specifically designed, apartments and bungalows in an environment with a care team on site that can provide care 24 hours a day, seven days a week. It provides older people with the security of having their own home, with the assurance that their care needs can be met by the on site care team. The schemes are run by not-for-profit registered housing associations that work with the local authorities in North Yorkshire to provide housing in areas for those who need it most. The model is based around promoting independence in old age and living in one’s own home, even when care needs change or increase. Living in a scheme environment actively encourages residents to become socially involved at meal times and during activities, therefore reducing the likelihood of social isolation. The extra care housing model is proven to reduce hospital admissions and social isolation whilst promoting independence in old age. By catering for a wide variety of needs, it also helps reduce admissions to residential and nursing care and frees up housing stock which can be used more appropriately.

For more information:

North Yorkshire and East Riding Strategic Housing Partnership joint housing strategy

A map of extra care housing schemes in North Yorkshire

Report recommendations

Director of Public Health Report 2017

Loneliness and social isolation in older ageLoneliness can be felt by people of all ages, but as we get older, risk factors that might lead to loneliness begin to increase and converge (Campaign to End Loneliness). Falls can have a significant contribution to social isolation and loneliness as falls and the fear of falling may limit an individual’s ability to socialise.

Older people may become lonely because they are isolated from their friends, families and communities and their overall wellbeing suffers as a result. Factors which may contribute to this include the high cost of housing making it unaffordable for local people to live and work in North Yorkshire and family members may have to move away as a result. In addition some people move to North Yorkshire from other parts of the UK, either pre-retirement or shortly after retirement as North Yorkshire is an attractive place to retire and grow old. Some older people may not have access to a private car, may be unable to drive or have to give up driving as a result of sight loss. In addition as people get older they may often develop greater difficulties with mobility. These factors can lead to social isolation especially in villages and more remote areas, where public transport is infrequent.

People experiencing loneliness and isolation are associated with a 30% higher risk of having a stroke or developing heart disease. The impact of loneliness is said to be the equivalent of smoking 15 cigarettes a day. People with a high degree of loneliness are twice as likely to develop Alzheimer’s as people with a low degree of loneliness.

Using information from the English Longitudinal Study of Ageing (ELSA) and the 2011 Census, Age UK has produced a Loneliness Heat Map Age UK Loneliness Maps

The report found that being in poor health was by far the biggest factor associated with chronic loneliness. This is followed by being widowed and living alone. Some factors normally assumed to be associated with loneliness, such as area deprivation and poverty, proved not to be significant. Rather than being an issue of rural social isolation the report highlights neighbourhoods in urban areas as having the highest risk of loneliness. The Lower Layer Super Output Area (LSOA) which covers Clotherholme Park and part of Clotherholme Road in Ripon is identified as having the highest risk of loneliness in North Yorkshire and is in the worst 2% of LSOAs in England. A map of North Yorkshire showing the risk of loneliness for those aged over 65 in the County can be found at Risk of Loneliness for those aged 65 - Age UK, 2016.

For more information:

Jo Cox Loneliness

Campaign to end loneliness

Spotlight on older people

Case StudyLoneliness and social isolation in older ageThe Wednesday Club, runs in Thixendale Village Hall. It is intended to reduce rural isolation and loneliness for older residents in the community of Thixendale and surrounding areas.

The club was given £986 from Stronger Communities in 2015 to cover village hall hire and some seating.

Director of Public Health Report 2017

Mental illness in older ageDepression, worry and anxiety can lead to confusion and poor memory. People may worry that they are suffering from dementia (a permanent loss of memory) when it is actually depression. Depression can affect 1 in 5 older people living in the community, and 2 in 5 living in care homes.

The Royal College of Psychiatrists have produced a useful leaflet called Depression in Older Adults or there is a booklet by Mind called Understanding depression

We all experience anxiety from time to time but if those feelings of anxiety are very strong, or last for a long time, it can be overwhelming and affect your ability to live your life the way you’d like to. For more information on anxiety and panic attacks see the Mind booklet at Understanding anxiety and panic attacks or the Royal College of Psychiatry web page Anxiety panic and phobias. In older people anxiety and depression can result in increasing social isolation and loneliness.

Despite Improving Access to Psychological Therapies (IAPT) services being open to all adults, older people are underrepresented amongst those accessing services. Age UK’s page: Talking treatments provides information and personal stories of older people who have benefited from psychological therapies.

Suicide in older ageAmong older individuals, the North Yorkshire Suicide Audit, covering 2010 to 2014, identified a thematic group, typified by growing despondency about the future as consequence of increased frailty, amplified by long term health issues (either diagnosed or perceived as future risks by the individual), resulting in reduced quality of life. This seemed to be exacerbated in those who had, until recently, been leading active, busy lives, but whose ability to remain active had diminished. A significant minority of individuals (41.0%, 93) were recorded as suffering from chronic medical conditions. In those aged over 70 the proportion rose to almost 80% of individuals, compared to around 20% in those aged under 40. Among the over 70 age group multiple conditions were common, with more than one illness/chronic condition evident in 16 of all 35 cases in this age group (45.7% of cases in the over 70 age group). Mind have a booklet on How to cope with suicidal feelings and the Royal College of Psychiatrists also have information for people who may be Feeling overwhelmed.

In North Yorkshire mental health services are provided by the Tees, Esk and Wear Valley NHS Foundation Trust. More information about their services can be found at Tees, Esk and Wear Valley Services.

Self-care and access to health and social care are really important. It is vital to recognise both the impact of physical illness on mental health and vice versa. Those living with mental illness such as depression or anxiety can struggle with self-care routines such as taking medication.

For more information:

Suicide Prevention

Director of Public Health Report 2017

Care provisionDuring 2016/17, there were 13,222 people who received services from Health and Adult Services (9,563 long term and 3,647 short term). For older people (65 and over) 4,302.8 per 100,000 population received long term support, compared to adults (18-64) where only 2,370.8 per 100,000 per population received support. 63% of long term support provided was for older people and includes nursing, residential and community based services (6,040 people); 90% of short term support provided was for older people which includes short term residential/nursing care and reablement services.

This means that just 6.6% of the population aged 65 and over are in receipt of care from the council. It is estimated that 71% of people receiving residential care fund themselves, with 28% funded by the Council and 1% by health. Approximately 52% of those receiving nursing home care fund themselves with 40% funded by the Council and 8% funded by health.

North Yorkshire County Council delivers care and support through:

• 140 domiciliary care providers delivering over one million hours of care every year

• 142 residential care homes with over 3,000 beds

• 45 nursing homes with over 2100 beds

• 21 Extra Care Housing schemes with over 1,100 rooms and apartments

In addition a wide range of other provision designed to support people to remain independent and living in their own homes and communities for as long as possible exists across North Yorkshire. Added to this are the range of private providers, community and voluntary sector services and those provided by families, friends and neighbours across the County.

People increasingly view themselves as consumers in terms of the care they receive – this has raised expectations around quality and approach. Timeliness of visits and continuity of care have been identified as key demands from people receiving care services in their own homes. As more than half of the care delivered is to people who are above financial thresholds for NYCC support and ‘self-fund’. This more affluent group are driving the market with many new developments focused on self-funders.

Along with other local authorities, North Yorkshire County Council is experiencing challenges in providing services for the local population:

• The care workforce is in decline and this is having an impact on ability to deliver the levels of care and support that people need especially in very rural areas

• A combination of low pay, poor perceptions of care work and a competitive labour market dominated by tourism and hospitality make recruitment a huge challenge

• Rurality makes having the right person in the right place at the right time to deliver care extremely difficult

• People with complex conditions who would have been cared for in hospitals or nursing homes in the past are now being cared for either at home or in residential homes.

These factors place additional pressure on staff and recruitment at all levels from care workers to nurses is a major issue. The map on the next page illustrates those areas where it is most difficult to find new care packages for people.

Director of Public Health Report 2017

Ease of sourcing for new care packages

Richmond

Catterick

Northallerton

Thirsk

Malton

YorkHarrogate

Ripon

Skipton

Knaresborough

Selby

Scarborough

Whitby

Relatively easy to source

Moderately difficult to source

Very difficult to source

Source: NYCC, HAS, 2016

Director of Public Health Report 2017

Sight and hearing lossSight and hearing deteriorates slowly with age and often can be imperceptible. Whilst age and genetic factors play a part lifestyle choices like smoking, alcohol or substance use, and inactivity all contribute to preventing sight loss. Regular eyesight checks (free for those 60 and over) can detect glaucoma, cataracts and age-related macular degeneration.

Hearing tests can identify any reduction in hearing capacity and identify need for hearing aids. Data predicts increasing numbers of people living with sight and hearing loss in North Yorkshire.

Preventable sight loss Source: PHE, accessed May 17

Age Related Macular Degeneration (AMD) (aged 65+) - England North Yorkshire

Preventable Sight Loss Certifications (all ages) - England North Yorkshire

Glaucoma (aged 40+) - England North Yorkshire

Diabetic Eye Disease (aged 12+ yrs) - England North Yorkshire

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For more information:

Sight loss in older people

Director of Public Health Report 2017

Director of Public Health 2017 annual report recommendationsThe aspiration is that older people should be recognised as active citizens, not passive recipients of services.

1. Age-friendly communitiesAs people get older it is important that they live in environments that help them to maintain control over their lives and make a positive contribution to their communities.

Policies, plans and services should promote healthy ageing by ensuring the contribution and needs of older people are considered, barriers to full participation and inclusion are reduced, and older people feel safe and supported to make choices about their lives.

2. Comprehensive retirement planningFinancial security, physical and mental health, and caring commitments are some of the factors that influence the work decisions of people as they get older. Many older people can expect a long period of their lives to be spent “in retirement” and wish to contribute through formal and informal work opportunities after retirement age.

Employers should facilitate workers to plan comprehensively for retirement including financial planning, ill health prevention, mental and emotional resilience, and social connectedness.

Employers should considered options that allow workers to manage their transition to retirement and allow “retired” people to maintain formal and informal links with the workplace.

3. Identifying and managing frailtyOlder people may experience physical and mental decline as they age especially when they have one or more long term conditions. However, frailty is not the only factor that influences their ability to function. Social support, health and care services and environmental factors are also important.

Health and social care practitioners should develop holistic assessments that focus on functional ability rather than physical or mental frailty. This includes sharing data with appropriate consent between services that take account of the full circumstances of the individual; including resources available to help them cope with physical and mental deficits.

Information should be made available to older people and their carers to help them to identify the factors (physical, mental and social) that predict loss of functioning so plans can be made to manage should these arise.

Health and social care practitioners should developholistic assessments that focus on functional ability rather than physical or mental frailty. Thisincludes data sharing with appropriate consent betweenall services dealing with the individual’s wellbeing that take full account of their circumstances including the resources available to help them cope with reduced physical and mental capacity.

4. End of life planningBeing able to plan with family and friends about the last stages of life ensures that older people remain in control of the choices that affect them and those they love through the end of their life. This means that they should have access to a wide range of information to plan their end of life wishes.

Services providing end of life care should to be better coordinated across the County, particularly with regards to sharing patient information and examples of good practice.

Health and social care practitioners should facilitate discussions with older people and their carers on end of life planning and support them to access information to inform their planning.

All staff involved in end of life care should receive the appropriate level of training to enable them to provide the best possible quality of care in all locations.

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