Surveying the perceptions of health

Barnet Citizens’ Panel – Public Health Report (2006)

Barnet Citizens Panel is made up of 1000 residents aged 18+ recruited to be representative of the adult population of the whole borough based on ward, age, gender ethnicity, disability and socio-economic status. Additional respondents are also recruited among hard-to-reach groups (i.e. those residents who are traditionally viewed as being less likely to take part in this type of consultation exercise) identified by Barnet Council.

The Panel is recruited through a selection of recruitment techniques. There are also two booster panels for BME communities (150 recruited through a postal survey) and a more personalized recruitment process for the panel with disabled people.

A survey was completed in August 2006 to inform Barnet Primary Care Trust and Barnet Council on the health priorities identified by residents and suggestions of how these should be addressed. The survey was designed with, and approved by, a consultant in Public Health at the PCT, and covered the following areas:

What is the current health status of residents and what health problems do they experience?

What behaviours do residents display that may have a positive/negative impact on their health?

Which health areas (if any) would residents like to see a change in funding allocations

Emerging trends from the data revealed the following perceptions:

A belief across all communities that health had deteriorated significantly since the previous survey in 2000

35-44 year olds were most likely to rate their own health as (very) good (85%) compared to 63% for those aged 18-24 years and 59% for those aged 55+. None of those aged 18-24 years rated their own health as being (very) poor

Respondents of “White” overall ethnicity (73%) were more likely than respondents of “Non White” origin (59%) to rate their own health as (very) good

Unsurprisingly respondents without a disability (76%) were almost twice as likely to say their health was (very) good, as compared to respondents with a disability (39%)

Of those respondents (31%) who said they would like to mention any specific health problems they have, the top five health problems were:

o Arthritis (19%); High blood pressure (18%); Asthma/Hayfever (14%); Back Problems (12%) and Mobility (11%)

The top five issues were believed to have the most beneficial impact on health conditions were:

1

o amount of exercise (59%); Food you eat (54%); Fresh air (43%); Making it easier to get healthcare (32%) and Situation at job and Standard of living (both 28%)

Explanations for deteriorating health included:

o Taking less exercise; increased pressure at work, increase in stress levels generally; weight increase/eating too much/wrong foods eaten; onset of old age

Questions relating to emotional well being, feeling happy and not depressed revealed that almost one-third of respondents had felt unhappy, sad or depressed for more than two consecutive weeks in the past year. Of these, young people aged between 18-24 were significantly likely to have this feeling.

TellUs 2 Survey

The TellUs2 Survey is …………………………………….

In the TellUs 2 Survey 37% of pupils rated themselves as being ‘very healthy,’ this figure is higher than the national average of 31%. Furthermore, 9% of pupils said they were ‘not very healthy’; this is the same percentage as the national average.

Satisfaction with healthcare services

It was notable that across most services satisfaction was higher for those of White ethnicity, those with a disability, female respondents, older respondents, and those in lower socio-economic groups; the corollary was that satisfaction tended to be much lower for BME respondents, those without a disability, male respondents, younger respondents and those in higher socio-economic groups.

3.1.1 GPs in Barnet - Use and Satisfaction

Take up off GP services in Barnet is nearly universal with 93% of respondents using a GP in the two years prior to the survey (summer 2005 to summer 2007. Satisfaction with GPs in Barnet is extremely high (76% overall and 82% amongst users). The Citizens’ Panel results clearly show that the GP is seen as the first point of contact for accessing all NHS services - therefore understanding satisfaction with GP services is vital to understanding satisfaction with NHS services in Barnet more generally. Satisfaction is particularly high amongst females, white respondents and those in lower socio-economic groups but is significantly lower for males and BME respondents. The patterns of satisfaction found in this survey confirm much previous research on the subject in other geographical locations and in national studies.

The satisfaction figure for all Barnet residents with GP services of 76% is almost identical to the 77% who were satisfied in a survey of all London Boroughs commissioned by the NHS and carried out in 2006 (MORI 2006). This survey of 7,036 London residentsi showed that 83% had visited a GP in the

i The question was ‘from your own experience or from what you have heard or read, to what extent are you satisfied or dissatisfied with local doctors / GPs’; the Citizens’ Panel question text was ‘If you have used the following services over the past two years, how satisfied were you with the service you received (GP Practice)’?

last year compared to 93% in the Citizens’ Panel surveyii); the difference may be explicable in terms of differing definitions of users rather than any real difference in usage of the service. The Citizens’ Panel survey did not capture satisfaction with issues around appointments with GPs but Barnet data from National GP Patient Access Survey (2007) suggest that satisfaction is quite high and in line with national averages. For example 75% of respondents nationally said that they were able to get an appointment with a doctor more than 2 full days in advance on the last attempt – in Barnet the equivalent figure was 74%.

The lower satisfaction levels of some ethnic minority groups with GP services have been noted in previous research. National GP Patient Access Survey (2007) found that (for example) in response to the question ‘Last time you wanted to, were you able to get an appointment with a doctor more than two full days in advance?’ 43% of those of Asian / Asian British ethnicity replied ‘no’, compared to just 25% of all respondents.

A study of 10,000 adults (which included a sample of 1,104 Barnet residents) in the former North West Thames Health Authority (NWTHA) in the 1990s found that 90% of respondents in the NWTHA were satisfied with GP services ranging from 91% satisfied in those of European ethnicity to 87% amongst those of Asian ethnicity. 12% of African males were dissatisfied with GP services compared to 9% of Asians and 7% of Africans. These are relatively small differences but in such a large sample may well be significantiii. (Nzegwu 1993:107, 1993: 234).

The reasons for the lower satisfaction of some segments of the BME population are likely to be complex, relating to expectations shaped by culture and different perceptions of the extent to which they are listened to, and receive appropriate referrals and prescriptions from the GP. Differing levels of satisfaction may also be a reflection of being treated differently by health professionals as a consequence of intentional or unintentional racism. There is also some evidence that BME patients are less likely to experience continuity of care (i.e. they are less likely to see the same GP on each visit). The National GP Patient Access Survey (2007) found that 23% of Black African respondents and 28% of Asian / Asian British respondents has been unable to make an appointment with the GP of their choice on the last attempt compared to just 12% of respondents overall. A lack of continuity in care may have a pronounced negative impact on satisfaction. (Fan et al. 2005) Language barriers may also impact on satisfaction.

The extent to which services (including GPs) are used is also an important driver of satisfaction. Generally speaking, those who use a service tend to be more satisfied than those that do not (which was not captured in the current survey) and those who use more frequently are more satisfied than those who use occasionally (not captured in the current survey). It is possible that different patterns of satisfaction to some extent reflect different patterns of use. In some cases, Over-representation of BME respondents in lower socio-economic groups cannot account for the differences in satisfaction since, with regard to many services, satisfaction is higher amongst lower socio-economic groups and lower amongst BME respondents. However material deprivation (such as lack of access to a vehicle), may effect frequency of visits to GPs which may in turn result in lower satisfaction. There is some evidence that BME use of health services, including primary care, may be less than other groups because of suspicion of, and alienation from, those delivering health services (Nzegwu 1993:46). In the case of Black African males this particularly relates to negative experiences of mental health / psychiatric services (as detailed in The Blofeld Report 2003).

The finding of higher satisfaction with GPs amongst lower socio-economic groups found in the Citizens’ Panel survey replicates other research such as the National GP Patient Access Survey

ii The Citizens Panel survey asked about use of GP in the last two years; the MORI survey asked about use in the last year.

iii Significance calculations are not provided for this aspect of the analysis

(2007) and Nzegwu (1993) although the differences are not as pronounced as in the Citizens’ Panel survey. Again, the reasons for this are likely to be complex; perhaps partially due to lower expectations in lower socio-economic groups in contrast with higher expectations and a more ‘critical’ approach amongst respondents in higher socio-economic groups. Similarly, the tendency for female respondents in The Citizens’ Panel survey to be more satisfied with GP services) replicates findings by Nzegwu (1993:104) although the overall differences are smaller than in the Citizens’ Panel survey.

Satisfaction with the GP out of hours service is low (44%) – the reasons for this are not explored in the Citizens’ Panel survey but there is evidence that practices providing an out of hours service directly have higher satisfaction than those who use a deputising service (McKinley et al. 2002).

Healthy lifestyle

During the public consultation in 2008, the respondents were asked what were they likely to undertake in order to improve their health. The responses to this question are shown in Table 1 and Table 2.

Table 1: What respondents said they would do in order to improve their health (Ipsos MORI and Better Health in Barnet surveys)

Barnet PCT Consultation 2008

Improve Diet

Increase level of exercise

Reduce levels of stress

Lose weight

Reduce alcohol intake

Give up smoking

Improve sexual health

Other

535

24%

515

23%

361

16%

343

15%

98

4%

76

3%

44

2%

23

1%

Ipsos MORI

Improve Diet

Increase level of exercise

Reduce levels of stress

Lose weight

Reduce alcohol intake

Give up smoking

Improve sexual health

Other

54

42%

82

63%

51

39%

56

43%

12

9%

6

5%

5

4%

9

7%

Table 2: The top 5 healthy lifestyles which respondents indicated they would do to improve their health

Better Health in Barnet Healthcare for London

Improve diet

Increase level of exercise

Reduce levels of stress

Lose weight

Reduce alcohol intake

Increase level of exercise

Lose weight

Improve diet

Reduce levels of stress

Reduce alcohol intake

Alcohol consumption in Barnet

The Citizens Panel survey 2006 revealed that 5% of respondents drunk alcoholic beverages every day, whilst 11% were drinking 4-6 times a week. Nevertheless, 20% of respondents indicated that they were drinking less than once a month and 17% never drunk alcoholic beverages.

Barnet Council’s 2006 Citizens Panel Survey showed that, generally, younger people drink alcohol more frequently than older ones. This is shown in.

It was found that White respondents were more likely to drink frequently (19%) compared to BME groups (6%). Respondents who indicated that they had a disability were less likely to drink alcohol (25%) compared to the general population of Barnet (15%). The data did not reveal any correlation between alcohol consumption and income. However, the highest alcohol consumption was in £10,000 -£19,000 income group.

Figure 1: The number of people reporting drinking 5 or more units of alcohol and the frequency of doing so

The result of the TellUs 2 survey1 indicates that alcohol consumption among young people in Barnet is lower than the national average. Table 3compares the results of this survey with national data.

Table 3: Results regarding alcohol consumption in TellUs 2 survey

Barnet National

Never drink alcohol 61% 42%

Get drunk once/twice a week

9% 12%

Get drunk three or more times a week

4% 7%

The Exeter survey2 found that there was a rise in the number of pupils who drunk at least one alcoholic drink in the last week which was 30% compared to 26% in 2001. Nevertheless, the number of female pupils indicated that they consumed over the recommended units of alcohol (14 per week) had decreased from 15% in 2001 to 13%.

Healthy eating

The populations surveyed by both Barnet Counciliv and Barnet PCTv identified healthy eating as a factor for improving health. Barnet PCT’s survey found that 535 (24%) respondents wished to improve their diet. Furthermore, the Citizens Panel showed that respondents were eating more healthily: 26% said that they ate 5 or more pieces/portions of fruit and vegetables in a day. However, 2% stated that they did not eat even one portion of fruit or vegetables in a day.

Women in Barnet appear to have healthier eating habits than men. 34% of women indicated that they ate “5 or more” fruit and vegetable portions as compared to only 17% of men.

iv London Borough of Barnet 2006 – Citizens Panel Surveyv Barnet PCT Public Consultation Survey 2008– Delivering Better Health in Barnet – “Your NHS, Your Money,

YOU help Decide”

1 London Borough of Barnet 2007 - TellUs 2 Survey2 School Health Education Unit 2007 A report on the Health Related Behaviour of Young People in Barnet.

0

10

20

30

40

50

60

70

80

90

100

18-24 25-34 35-44 45-54 55-64 65+

Nu

mb

er o

f re

spo

nd

ents

0-1 per month2-4 per month

2-3 per week

4-7 per week

0

10

20

30

40

50

60

70

80

90

100

18-24 25-34 35-44 45-54 55-64 65+

Nu

mb

er o

f re

spo

nd

ents

0-1 per month2-4 per month

2-3 per week

4-7 per week

0-1 per month2-4 per month

2-3 per week

4-7 per week

When Black and minority ethnic groups were compared to respondents from White ethnic origin, only 15% of them groups indicated that they ate five or more fruit and vegetables a day compared to 30%.

Other areas that were highlighted by respondents in this survey included: reducing high blood pressure, reducing cholesterol levels, visiting the dentist, avoiding drug use and starting dancing.

As well as identifying what respondents were more likely to do in order to improve their health, they were asked what the NHS could do to help them make the changes. The respondents indicated that they thought that the following would help:

stress reducing classes;

well-being classes;

Adults with mental health problems are the most disadvantaged and socially excluded group in society. Addressing barriers to social inclusion forms the wider agenda for mental health services (mental health and social exclusion report 2004). The Layard report 2005 (PM Policy Unit) identified ‘mental health is the biggest social problem of our country as it affects people with mild and moderate mental health problems’. The mental health agenda requires a broad whole system focus which moves away from a focus on mental health specific policy targeted at specialist mental health services. Although in development higher quality support is still needed at home and this is reflected as a specific target within the Barnet LAA to take account of the fact that Barnet has lower numbers of acute beds than neighbouring boroughs however higher numbers of people are living in registered care.

The predicted demographic growth in people of 65 years and above within the Borough over the next ten years is below the national average rate for older people. However the post war generation (referred to as the baby boomer generation), will by the end of the period, begin to feed into the 75+ age group resulting in a 25% growth in older people. This age group is where

leaflets on stress relief techniques;

get fit sessions (free) like stop smoking sessions;

crèche so parents can partake in exercise;

make gym use cheaper, particularly for people who are unable to afford it e.g. those on low incomes;

regular check-ups with GP or other health professional for advice and monitor progress;

more awareness for school children;

more information from radio / TV;

advertising, promotions in health centres, surgeries; and

greater access to dietitians.

The Healthcare for London consultation found that 101 people (78%) strongly agreed or agreed that they would welcome advice on staying healthy when they came into contact with healthcare professionals. (E.g. advice on losing weight or stop smoking).

there is known to be increased demand on health and social care services. Therefore improvements in developing a more preventative approach over the next ten years will lay a good foundation for managing a significant predicted growth in older people in the latter period of this strategy and beyond.

Currently Barnet has the second largest population over 65 and over 85 in greater London. Older people are more likely to suffer from chronic and long term conditions and are also more likely to suffer from falls / factures which bring them into contact with health services. Older people represent the largest proportion of users of NHS services, however can and do get better after a period of rehabilitation and convalescence. It is vital that these episodes of acute/ medical treatment are used as opportunities for people to optimise their functioning and return home safely.

It should be noted that it is possible that the projections in the table below overestimate the percentage rate of increase in the Barnet population in view of the large scale residential developments that will be providing new accommodation over the next ten to fifteen years and which may be acquired more readily by younger age groups.

Percentage changes from 2007ONS sub-national population projections 2004200820092014201920242029England65+1.46%3.20%16.21%26.12%36.75%50.64%England75+0.94%1.87%10.54%22.39%45.49%59.97%Barnet65+0.89%1.78%10.69%18.49%28.95%43.43%Barnet75+0.00%0.00%3.88%9.48%25.86%37.93%London65+0.13%0.39%6.50%11.

70%19.92%33.17%London75+-0.09%-0.26%2.86%6.88%19.84%28.83%However the continued rise in the numbers of people living longer is likely to have an impact on demand for social care services and in particular for positive interventions for people with dementia as prevalence increases with age. The significant bulge predicted in the number of people over 85 from 2017 onwards in Barnet, in common with the national picture, will greatly increase the chances of demand on social care services. The older population will become more ethnically and socially diverse, more consumer aware and this will have an increasing impact on the demand for types of services. In addition there will be more single older person households. In 2008 there were an estimated 3,549 persons with dementia in Barnet. By 2025 this number is expected to increase 10% and by 2015, 36%.

The invaluable contribution of informal carers to meet needs

It is worth noting that in the Citizens Panel Survey (2006), 49% of respondents gave a number of reasons why their health had become worse over the last seven years. These are summarised in Table4.

Table 4: Reasons given for people’s health deteriorating

Reason Number of people citing this

Taking less exercise 24

Increased pressure at work 14

Increase in stress levels generally 13

We know that the majority of caring for disabled and older people is undertaken by informal family carers and that caring can affect carers’ health and wellbeing. Almost all carers at some time need some help and support to enable them to continue to care. At a national level we know that:-

Women are more likely to be carers than men A large and growing proportion of carers are over 60 years of age Three-fifths of carers are looking after someone with a disability 855,000 carers provide care for more than 50 hours per week Three-fifths of all carers receive no regular visitor support services at all Two thirds of working-age carers are in paid employment Carers are regularly in touch with the NHS and have two main health

problems - physical injuries such as a strained back, and stress-related illness since becoming carers. Carers are twice as likely as non-carers to have a mental health need

Carers’ needs are currently only being met patchily and we can expect increasing demand for care, caused by the growth in the numbers of old and frail people living in the community

Research estimates suggest that there are between 20,000 and 50,000 young carers nationally. Some young carers or their parents may fear that, if they draw attention to their situation, they will be taken into care. Children in families where a parent suffers from mental illness can be at risk of developing mental health problems. In families where alcohol or drug abuse is a problem, children can be faced with a caring role which can create great anxiety.

It is estimated that 60% of the population will care for someone at some point during their lives. In Barnet almost 10% of the population are carers, of which at least 2000 are 75 years or older, with nearly 5000 providing 50 hours or more of care per week. The 2001 census indicates significantly higher numbers of carers providing over 50 hours a week care in the more deprived wards of the borough. Appendix showing breakdown by area, amount of care provided & location

Barnet council contributes significant funds to the local Carers Centre which has over 4000 carers from across the borough registered with them. However a Barnet is an increasingly ethnically diverse borough, black and minority ethnic carers are among the ‘hidden’ carers and this brings the requirement to ensure that carers support is culturally sensitive and competent in order to ‘reach out’ across all sections of the community.

Weight increase/eating too much/wrong foods eaten 11

Onset of old age 10

Progressive worsening of existing condition 10

Air pollution/Smoking in public places/Cars 8

Mobility more difficult due to health problems 8

Increased household bills/Increased cost of living 6

For the increasing number of people living longer in their own homes, with shorter and shorter hospital admission time, we can expect for there to be a greater impact on families and informal carers, especially in the context of knowing that many carers are older people themselves.

Social care and support services in Barnet –activity, demand and trends

During 2007/08, Barnet Adult Social Services dealt with 6119 referrals for adults of which over 3400 resulted in assessments of individual need. This activity has increased steadily over the last 5 years for each of the care groups, however with a decrease in 2007/8.

Table 1 Referral and assessment volumes 2003-2008 Barnet Adult Social Services

Referrals and Assessments Adult Social Services

6119 5133 5734 4680 4799

3406 5310 4932 3183 2388

2217 2835 3626 2022 2438

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2007/08 2006/07 2005/06 2004/05 2003/04

New assessments leading to service

Passed for further assessment

Dealt With at point of contact

The type of activity relating to adults in contact with social services has changed according to how the system has managed demand. In general there has been an increase in ‘signposting’ to alternative sources of help. In common with the national picture for councils, Adult Social

One of the highest responses in both surveys was the recognition that exercise was required to improve health. Responses to PCT survey indicated that 23% of people wished to increase their level of exercise. Moreover, the Citizens Panel survey 2006, revealed that 29% of respondents stated that they took the recommended level of physical activity a week i.e. 30 minutes or more of physical activity a one day, five times or more a week. It was found that only 17% of respondents indicated that they exercised less than once a week to rarely or never.

The responses from the Citizens Panel Survey 2006, indicated that Barnet residents who took the recommended level of exercise per week was below the national average

Currently 120 out of a potential 700 adults with learning disability in Barnet are known to take regular sports and exercise activities more then once a week. Barnet Council is keen to increase the numbers participating in sport to three sessions which last for 30 minutes. However, barriers to participation in sport include:

a lack of clubs where people can learn a sports skill necessary to enable them to access mainstream;

no accessible list of inclusive activities;

a limited number of sessions to meet the increased participation; and

little promotion or awareness of the benefits of sport within this community.

The evidence of specific health problems within the community of people with learning disability also makes concerning reading: Research for the Disability Rights Commission investigation Equal Treatment: Closing the Gap (September 2006), found that the rate of respiratory disease was significantly higher (20% more) than in the remaining population (16%). It was found that 80% of people with learning disability engage in levels of physical activity below the minimum recommended by the Department of Health. Furthermore, people who had lower ability and who live in more restrictive conditions are at risk of increased physical inactivity.

Services has developed more filtering mechanisms for screening people at the point of referral so that some people have been excluded from services at an earlier stage. There has been greater reliance on the voluntary sector to offer low level support and interventions where direct referral by the council is not necessary. The council has continued to strengthen relationships with the voluntary sector through a steady funding stream and the numbers of people helped through the grant funded sector have increased.

What is not fully known is how people with ‘low or moderate needs’ are able to get their needs met and what level of unmet need there is in the general population. It is important that more is known about the consequences of unmet need both in terms of assessing the outcomes for those individuals and their families, and in terms of predicting the numbers of adults who may develop care needs which are ‘substantial and critical’ over the next 10 to 20 years and where an earlier intervention may have prevented referral to social services, acute or specialist care for longer.

The data shows that the number of new assessments each year which led to a service provision has varied from year to year and from client group to client group for example historically Barnet has always had high numbers of ‘self funders’, particularly older adults, many of whom in the past would have contacted social services for an assessment. Increasingly there are alternative sources of help and advice for people who pay privately for care and an increasing consumer awareness of private equity schemes and other types of financial arrangements. However the total activity levels in terms of referrals and assessments have increased by 32.5% over the period 2003/04 to 2007/08 the cumulative impact of which is increased demand on care management and assessment capacity and purchasing budgets.

The Citizens Panel Survey 2006 revealed a clear negative relationship between level of income level and level of physical activity. It was found that the recommended amount of physical activity was undertaken 38% of the time by respondents who were on incomes below £10,000, but only 17% by those on income of £100,000–£150,000. However, 50% of those with an income in excess of £200,000 said that they undertook regular physical activity, whilst the least physically active were those on incomes between £40,000 to £200,000.

The Barnet PCT consultation found that only 3% of those surveyed thought that giving up smoking was one of their first three priorities in order to improve their health. Nevertheless, the Citizens Panel survey showed that there were 14% of smokers in their survey population and 68% indicated that they wanted to quit smoking whilst 20% indicated that they had a strong desire to do so.

New Assessments leading to Service

213288

17 36 49 23 29

616

180

421

15921518

2666

2278

1703

213253

490

272281

0

500

1000

1500

2000

2500

3000

2003/04 2004/05 2005/06 2006/07 2007/08

No

of

Ass

essm

ents

Physical & Sensory

Learning Disability

Mental Health

Adults 65+

More analysis is required of referral patterns for social care and support services by ward / locality, however there are some identifiable trends in needs and demand by location. Use of services by older people tends to be spread across the borough however with higher demand in the more deprived wards. A recent analysis of homecare referrals showed that there was a lower turnover of service users in deprived areas indicating that people may start using services earlier because of higher rates of illnesses and the lack access to alternatives sources of support for those individuals. Appendix showing map of homecare service users?

The demand for mental health services correlates with wards known to be more deprived. The Joint Commissioning Strategy for mental health is targeting interventions in the wards of Burnt Oak, Colindale, West Hendon and Coppetts where there are known to be higher levels of mental illness.

Non-smokers made up the largest group of those surveyed (n=461, 62%), followed by those who had quit smoking for more than two years (n=148, 20%). As giving up smoking is the most significant thing that someone can do to improve their health (and it is better not to start), this is very encouraging.

Table 3 Sources of referrals to Barnet Adult Social Services

2007/082006/072005/062004/052003/04Primary care16121466162712781377Secondary health care26743532356126051487Self

referral1919176015881373741Family/friend/neighbour16391649154513801046Barnet Adult Social Services49452257534Housing 2002091739984Local Authority240351541427346Criminal Justice

Agencies5018637415366Other677716506377571Not known20521761681465There has been an overall increase in referrals from healthcare services, reflecting trends in hospital care for shorter stays and more rapid discharges and the need for a joined up response across health and social care. The importance of this has been reflected through the inclusion of a performance measure related to intermediate care in the Barnet LAA. Demand for intermediate care services, equipment and rehabilitation /enablement have increased as a result as set out below

Number of people funded by the council receiving intermediate care in a residential setting (rapid response) to prevent hospital admission2003-042004-052005-062006-072007-082008-09 PlanBarnet610894246IPF

Data375249403741Number of people funded by the council receiving intermediate care in a residential setting (supported discharge) to facilitate timely hospital discharge and / or effective

rehabilitation.Barnet34384332482530IPF Data7091105130162166Number of people funded by the council receiving non-residential intermediate care to prevent hospital admission.Barnet194206163181823905IPF

Data214205219256313336Number of people funded by the council receiving non-residential intermediate care to facilitate timely hospital discharge and / or effective rehabilitation.Barnet568603684843523575IPF

Data440449461519512527Number of places funded by the council in non-residential intermediate care schemes.Barnet50658595130143IPF Data125149165164170178

Increased focus on upstream interventions across health and social is essential to reduce longer term dependency on health and social care. The prevention of falls remains a key priority due to the associated mortality, physical injury, loss of function and loss of independence experienced by older people. Falls are a major contributor to hip fractures and are also associated with a significantly increased risk of many other fractures, including wrist, pelvis, and upper arm. As the average age for a fracture of the hip is 83 years; 80% of such people are likely to be women and 68% of patients will have fallen within their own home we can expect without upstream interventions for a higher demand for health and social care services related to falls. More effective prevention of falls will reduce the demand for acute and community health care and on social care services such as homecare and residential care.

It is also interesting to note the considerable increase in self referrals and from informal carers. These have grown in line with changes in access to social services supported by developments in advocacy and more recently the introduction of self assessment tools and a policy of increasing access to advice and services for carers.

The above table also demonstrates that referrals to Adult Social Services from housing have also increased as people wish to remain living in their own homes in the community as opposed to a move into more formal care settings such as registered care requiring access to

personal care and housing related support.

Housing and care and support

The traditional definition of care services is changing and one main aspect of this is the increasing link to housing need as reflected in the increased levels of referrals from housing for Adult Social Services. Need and demand analysis for care and support services is therefore inextricably linked to the analysis of accommodation in the borough and the availability in particular of suitable housing for disabled and vulnerable adults. The Housing Needs Survey 2006 also appears to show the link between support needs and the quality of accommodation and status of tenure.

The 2006 Housing Needs Assessment estimates that 4.14% of all households, or 5294 households (see table in appendix), suffer from ill-health due to the condition of their home and which is linked to forms of tenure, and geographical location. For example 15.3% of households living in council rented accommodation suffer from ill-health because of the condition of their home and 7.36% of households in Hendon suffer from ill-health because of house condition.

The assessment also estimates that these households are more likely to contain no older people and to have support needs. Further work is required on reviewing the reasons why people said their house condition was causing their ill-health. It might be that they are under notice of eviction or that the house is difficult to heat or that the home suffers from major disrepair.

The Housing Needs Assessment also estimated that there are 18,734 households with support needs and that 73.6% of the households require support because of physical disability and 24.2% because they are frail/elderly. A majority of support needs households contain older people and most requirements relate to needs and adaptations. Some of these households must also suffer from ill-health because of the condition of their home and more work needs to be done to identify and link the data on support needs households and ill-health households.

21.4% of all households in Barnet contain only older people and almost all households containing older persons only are comprised of one or two persons only. There is an increase predicted in the numbers of older people living alone in common with the national picture and therefore likely increased demand for support and adaptations to their home.

Housing related support funded through the Supporting People programme is focused on maintaining independence and supporting stable accommodation arrangements for adults in the community who experience a range of difficulties including disability, mental health problems, domestic violence, substance misuse and homelessness. There has been a recent

rise in the numbers of people supported through these arrangements, some of which act as alternatives to care services. This is reflected in the Supporting People activity data:

A total of 1446 new client record forms were received for 2007-08, an increase of 479 on last year’s figure of 970, and an improvement of 49%.  The overall number of new service entrants in Barnet was 55% higher than the London borough average although Barnet receives 20% less SP grant than average. These figures reflect increasing volumes of people from a range of groups receiving short term support; where 79.5% of the client record forms were for floating support (the support goes to where the need is) in Barnet compared to a London average of 45.6%, however this should be set against 4.2% for supported housing (support is linked to specific housing options) in Barnet against a London average of 31.4%. A breakdown of activity for 2007/08 for supporting people in Barnet compared to London and England is set out in the appendix.

Trends in Social Care Service Delivery

Services funded by Social Services following assessment include ‘one off’ short term and long term services from the provision of an equipment aid to daily living, professional support and short term homecare through to longer term rehabilitation provided at home, a long term homecare package and residential or nursing placements either on a long term or respite basis. The length of time someone needs a funded social care service varies from days to years.

The table below shows all provisions being provided in each year for each care group within the categories of community provisions (services to people living in their own homes, and carers support) and residential and nursing care provisions. Community provisions include Direct Payments allocated to service users to purchase and arrange their own care. The community provisions include supported living which has increased steadily as an alternative to care homes and is predicated on the availability of suitable accommodation for adults with disabilities.

Table 4 shows the total number of service provisions funded in each year over the last 4 years by Barnet Adult Social Services and indicate the changes across the categories as well as the changes in overall volume.

Table 42007/82006/72005/62004/5Total Total Total Total Physical & sensory impairment8317655122801743351970465529145425074213Learning Disabilities6874282776716418327170042730725884972981Mental health998910844110310021142105392913745964901324Older Adults48053757859361496949693813969518739331072421502138101110429

Community provisionsResidential placementsNursing placements

Volumes of service provision are only one indicator of level of needs and of the costs of meeting that need. There has been a general rise in the complexity of need for individuals who

are referred to social services and living at home. This is due in part to people with long term conditions living longer and general increases in life expectancy. This has a knock on effect to the care homes who are now meeting much higher levels of need.

In line with the national picture there has been a significant fall of permanent residents in care homes supported by the council and an increase in community provisions. The drop overall in older people using services in 2007/8 is in line with a national reduction in the numbers of older people using services reported for March 2003 to March 2006 by CSCI as a result of increasingly tight application of eligibility criteria (ref. The state of social care in England 2006/7, September 2008) at a time when the over 75 population has increased by 3%.

The pattern and delivery of community provisions has changed significantly in Barnet and reflects an increase in professional support, Direct Payments, community equipment and breaks for carers. More data is required about patterns and use of services including changes in the lengths of stay in care homes and particularly about the impact of changes in health provisions and the impact on demand for social care services.

Care Market in Barnet

Most people receive care and support through informal arrangements and growth in demand is expected to impact on carers and communities as more and more families and households will be affected by carrying out caring responsibilities for short or long periods. We also know that people who care for long periods are especially vulnerable to physical and mental ill health which creates an individual personal burden, increases demands on health and social care services and undermines the viability of informal care arrangements. ref. National Carers strategy. There are some gaps in support for carers, including respite care and emergency home based respite which are set out further in section 4 of the JSNA.

Apart from informal care, the care market in Barnet is dominated by residential care. Historically there have been a high numbers of people who fund their own care arrangements in Barnet reflecting the economic profile of the borough in particular of retirees. This has stimulated a large provision of private care homes and to a lesser extent domiciliary care agencies. However it is not clear that these self funders always have good access to advice and support which enables them to exercise choice of care arrangements and which would stimulate demand for alternative provisions.

The latest demand analysis shows us that the Local Authority and local Primary Care Trust combined purchase less than 50% of the placements locally, although the proportions a higher for younger adults. Appendix to dimensions report.

Occupancy levels of care homes are falling in line with the national picture. The market is accessed by a number of outside boroughs and PCTs which presents a number of risks which need to be locally managed. There are particular risks currently associated with this market as several of the larger asset based companies are affected by the economic climate and with lowering occupancy levels this increases the risk of relatively sudden care home closures.

There is a need for more self contained accessible housing with 24 hour support and access to good quality homecare services which can support younger and older people with complex care needs. This has been reflected within the Barnet LAA in respect of people with mental health needs known to secondary mental health services.

Personal Dignity and Respect

The experience of abuse and neglect is likely to have a significant impact on a person's health and well being. By its very nature, abuse – the misuse of power by one person over another – has a large impact on a person’s independence. Neglect can prevent a person who is dependent on others for their basic needs exercising choice and control over their fundamental aspects of their life and can cause humiliation and loss of dignity.

Vulnerable adults in receipt of social care services experience a higher prevalence of abuse and neglect than the general population. The Local Authority has the responsibility for establishing a multi-agency partnership to lead on Safeguarding Adults which needs to ensure that under the local Safeguarding procedures every adult is supported to retain their independence, well-being and choice and to access their human right to live a life that is free from abuse and neglect. While the Local Authority leads on this, all appropriate statutory agencies are responsible for achieving it.

Levels of referrals into the Safeguarding Team have been lower than expected for the population of Barnet. In 2007/08 with targeted focus to improve Safeguarding arrangements levels of referrals are moving more in line with what would be expected. During 2007/08 there were 258 people referred under the Barnet safeguarding arrangements. The chart below sets out the source of the referrals and the types of alleged abuse. Table: Safeguarding referrals per client group for 2007/08 per 10,000 18-64

Older PeopleLearning DisabilityPhysical and Sensory ImpairmentMental HealthHIV/AIDSDrug service usersCarersBarnet28.592.971.581.480.000.100.00IPF41.363.321.241.460.020.050.06England47.344.801.941.96

0.010.110.10Table: Total Number of safeguarding referrals were made by 'No Secrets' MAPP partners in the NHS, Police, Housing, Probation, Criminal Justice services and CSCI in 2007-

08

BarnetIPF DataEngland (Average)NHS523250Police2521Housing agencies.8510Probation and criminal justice.006CSCI.2410

Barnet has a high number of registered care homes within the Borough attracting self-funders and people placed by other Local Authorities to reside within them. Of the total safeguarding referrals of people whose circumstances made them vulnerable for 2007-08 reported 27 were buying their own care without financial support from the council, over 10% of referrals. With increased awareness of safeguarding and the introduction of new statutory responsibilities under the Mental Health Act, we expect for the increase in referrals from self-funders under safeguarding to increase further.

Linking Demand and Overall spend

The gross expenditure for Adult Social Services as shown in the chart below has increased above inflation levels reflecting the Council’s commitment to the corporate plan priority of ‘Supporting the Vulnerable.’ The gross spend on Adult Social Services has increased by 25% over the five year period 2003/04 to 2007/08, an actual gross spend increase of over £22 million. The actual increase on demand for a social care service in the same period was a 32.5% increase.

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

2003/04 2004/05 2005/06 2006/07 2007/08

Asylum Seekers

Learning Difficulties <65

Mental Health <65

Older Adults

Other Services

Physical & Sensory Impairment <65

Sum of Gross Spend £000

Year

Service Type

The breakdown of this total spend for Adult Social Services in Barnet over the 5 year period reflects the changes to the pattern of care provisions with a significant decrease in the proportion of expenditure on registered care and increasing spend on community based services. This increased spend is partially explained through increased number of community packages, but is also linked to the costs of meeting more complex needs in the community. This trend of increased costs of community packages has been influenced further through personalisation as older people are receiving more intensive home care packages as an alternative to residential care.

It is important to note that social care and support is met by a range of services and the picture of spend presented here does not include the cost to individuals of privately funded health or social care. There are a wide range of costs which include transport, some of which is met by social services, some of which is met by corporate services and other sectors.

Work has been undertaken to project the future costs for adult social care based on current patterns of demand and spend and population growth. This has been estimated as being £43 million over the next 10 year period over and above standard increases for inflation if patterns

of service delivery remain unchanged. In the context of a difficult economic climate across the United Kingdom and the challenge for social care funding given the worsening dependency ratio as set out in the Government’s consultation on the future of social care, this level of funding increase cannot be sustained. The responsibility between the state, citizen and family in the provision of social care over the next 10 years will need to be fundamentally redefined.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003/04 2004/05 2005/06 2006/07 2007/08

Residential & Nurising Care placements

Other Services

Home care

Direct Payments

Day Care

Assessment and care management

Sum of Gross Spend £000

Year

Area 2

User Experience of Social Care

If the future delivery model for social care needs to be set in the context of redefining the roles of the individual, family and state, it is important to understand the views of the local people in Barnet who are in receipt of social care services or potential customers in order to inform future plans.

On an annual basis, Adult Social Services conducts a user satisfaction survey to examine the experience of service users in a particular area of service. The results and feedback from the last three surveys are included in the appendix. Emerging from these survey results and feedback to other specific service consultations ie day services for people with a physical and

sensory impairment, the following themes emerge

People want and need more information about what is happening at different stages of service delivery e.g. from identifying need for equipment to installation so that they can take control of their lives

Less delays in receiving a service, and follow-up calls once they have started receiving a service

People in receipt of social care feel more socially isolated, are concerned for their personal safety and have reduce ability to travel to places that they would like to go to. This contributes to a feeling of a reduced lack of control over daily life.

That there are a wider variety of services provided locally but people need to be better signposted to them in order to access them – if you do not know what is out there you cannot be expected to use it.

Good social care should support people and carers to access employment and carers support services need to be prioritised especially breaks to allow carers to continue to stay in paid work.

Between 05/09/08 and 14/11/08, the London Borough of Barnet facilitated a public discussion on the strategic proposals to change assessment and care management practice to give people more choice and control through personal budgets. This included a questionnaire and an open debate on 02/10/08.

Getting good and reliable access to social care was a strong theme through a one stop shop approach. People want to be able to access services without the need for face to face assessments with widespread support for quite significant services, such as short breaks, home care and occupational therapy equipment being provided on the basis of the phone assessments

There was support for providing information via the internet – interestingly more people stated that they would like information online than by phone.

People appeared to see the benefit of introducing short-term ‘enablement’ packages of care. They suggested a wide range of services that could be included in such packages. Interestingly, there was a focus on services that would not sit in a normal ‘enablement homecare’ package – such as accessing occupational therapy equipment and helping people develop social networks.

People had a very balanced view of the advantages and disadvantages of personal budgets. Many people reaffirmed the belief that it would help make people more independent and give them more control and choice over their support. Common concerns about the budgets centred on the new risks they introduce for things to go wrong – either because managing them is too stressful for individuals or carers, or that the people managing them fail to cope with the responsibility and make poor care management or financial decisions. The debate showed that people needed more detail before they could be fully comfortable with the idea.

People were open to the idea of groups other than the council supporting people to plan their care. The perceived benefits of this were that it increased people’s independence, choice and control. By contrast, the perceived risks focussed on those people involved having insufficient expertise to assist people needing social services effectively. A very wide range of groups were put forward as having the ability to get involved in this process. The most commonly mentioned ones were family, friends, 3rd sector organisations, and health professionals.

Key Messages

The picture of future demand presents an ever growing financial burden to the health and social care system as well as growing personal burdens faced by individuals, carers and families. We can expect people living with long term conditions will be ever more common. There are short and long term challenges presented by long term conditions, chronic illnesses and disabilities which are often associated with care and support needs and being able to meet these within the limited resources

There has been significant shifts in the health and social care system over the last 5 to 10 years away from institutional care towards care closer to home and there has been an expansion of the range of options for people with care and support needs to remain living at home and to receive care and treatment in the community in line with the expressed wishes of service users and the wider population.

These shifts present challenges about how to achieve a movement of investment across systems in the shorter and longer term to reflect this shift, especially as costs for all types of care continue to rise, in order to continue to develop choices for people with care needs in the community and prevent excessive demand on acute and specialist services.

There is a central challenge in how to manage wider population needs against local needs - for instance ensuring local services match identified care and support needs, whilst ensuring at a wider level work is undertaken to develop services and agencies that can address issues such as rarer conditions, screening for certain conditions and developing support services that can link across local health and social care boundaries.

There are major challenges in making decisions about ever more complex and often more costly (but perhaps also more cost effective) treatments and care opportunities, whilst ensuring promotion and progress of new approaches. Investment in wellness as a prevention strategy requires good local intelligence which links across health needs and social care and support needs.

There is an acceptance of the need to provide better information for those who wish to manage their own care and healthcare needs - this has a huge impact on the way service users, carers and professionals relate to information and work together, particularly across primary care and secondary care.

The traditional definition of care is being expanded through systematic links to housing and accommodation and there is increasing recognition of the impact of design and its close links with care. Linking housing with health promotion strategies has a beneficial impact on health and therefore on demand for social care.

Future prevention strategies will need to ‘reach out’ to wider sections of the different communities in Barnet if more equality in health outcomes is to be achieved.