Kent in a national context. Where might it all go wrong and how do we prevent that? June 2012

1. Kent in a national context.Where might it all go wrong and how do we prevent that?June 2012

2. About IPC • We work for well run evidence based public care • We are part of Oxford Brookes University • We work with national and local government, the NHS and private, community and voluntary sectors • We work across the United Kingdom • We were formed in 1987, and have a team of 40 staff and Fellows, based in Oxford and Bath

3. The good news – we are living longer

4. The good news – we are wealthier! • Currently in England over 75% of people aged 68-74 live in property that they own. In 1945 fewer than 40% of all people were owner occupiers. Half of all housing equity is held by people aged 65 and over. • In 2008/09 pensioner couples received an average income of $564 per week, compared with £304 per week for single men and £264 per week for single women , pensioners. • Average gross pensioner incomes have increased by 44% in real terms between 1994/5 and 2008/09, well ahead of the growth in average earnings. • 59% of older people now receive an occupational pensions as compared to just 13% prior to 1945

5. The bad news • We live longer but the period of morbidity or ill health prior to death has not been compressed. • Public expenditure is in decline for at least the next three years, but probably longer and greater than we originally thought. • The state (and possibly younger people) will increasingly expect baby boomers to pick up more of the health and social care costs. • Key old age conditions are all areas of poor performance by the health service. • At times of financial hardship protectionism tends to trump partnership and sharing of resources.

6. About Kent • 1.5 million people of whom over a quarter of a million are aged 65 and over. • By 2030 that population of 65’s and over will have grown to 400,000. • Of that OP population, 97% white, predominantly home owning (80%) and around 20,000 people with dementia. • The oldest old population will increase disproportionately , those aged 80 and over will grow from 77J to 143K. • Around five and a half thousand adults with a moderate to severe learning disability.

7. Government • Les ring fencing of money, more localism. • Social care not likely to get the same protection as health and education. • The social care white paper mainly about rights and responsibilities from the Law Commission report and eventually about the future funding of care. • ‘Innovation’, ‘prevention’ and ‘individual choice’ much mentioned but not a great focus on how demand can be reduced. • Increasing challenge in the courts from consumers and from providers.

8. So what will happen if nothing changes • Demand for care amongst older people will rise, although not in proportion to the demographic rise and with an increasing proportion of care being in the private and voluntary sector. • Demand for acute sector health care will rise, of which an increased proportion will get displaced into large hospital type residential care. • Local authorities will provide a diminishing amount of funding, with people increasingly needing to make their own care arrangements or have voluntary organisations make arrangements for them. • Government will be about to consider new proposals over the future funding of care.

9. Impact of current economic situation on the social care market • Cheaper to borrow money now but harder to obtain due to banks caution. • Low interest rates mean people eat into their capital quicker. • Harder for older people to sell their property now which may make it harder for people to move. • An upturn in economic growth may; • disproportionately disadvantage the care sector. • May lead to a number of single home care owners leaving the market.

10. So what do we need to do • Proceed thoughtfully with personalisation. • Change relationships with the market. • Improve health sector performance. • Focus on outcomes. • Stimulate the specialist housing market. • Build community involvement and create communities that work for older people.

11. Personalisation • Good idea, works better and is more welcomed by some groups more than others. • Need to be sharper on what we mean by choice. • Local authorities need to stop seeing this as a way of abdicating responsibility for the future. • Need to monitor spend and outcomes. • Need to make sure its impact on the market is not to lose the very providers we most cherish.

12. Caricatures of the market- from the LA • “Private sector just about making money, not really welcome in the sector. • Members would still like all our services to be in- house. • Voluntary sector useful but not really able to run with big contracts”.

13. Caricatures of the market – from providers • “Local authorities enforce pernicious terms in contracts. • Don’t really understand how businesses are run . • They are not even handed and protect their in house services from price competition. • They pretend to consult but actually only tell you after decisions have been made”.

14. Caricatures of the market – from older people • “They only think of us in stereotypes and their approach is always patronising. • Local authorities are just focussed on cuts – they don’t really understand the impact on individuals. • They pretend to consult but actually only tell you after decisions have been made. • They don’t care about those who fund their own care”.

15. The common ground • Running a quality service • Efficiency • Desire to innovate • Giving greater choice to users.

16. The uncommon ground • LA’s need to: • Recognise we are all in this together. • Seek solutions from the sector and be more open about long term strategic commissioning directions and intentions. • Be clearer abut what constitutes good practice and work with the sector so that it can be achieved and kite marked to the public. • Recognise there is ore we could do to support providers at little or no cost

17. Improve health sector performance • Clear link between health conditions and peoples propensity for residential care and repeat hospital admissions. • 60% of all hospital beds are occupied by people aged 65 and over, 40% of whom have a dementia. • The growth in inpatient episodes in hospital for the 75 and over group is greater than the growth in all hospital episodes put together (66% growth from 1999-00 to 2009-10 in this age group as comarped to 38% growth overall). • The key conditions that older people suffer from are all areas of poor performance, falls strokes, continence, dementia.

18. Health • Falls – 4.6 million hospital bed days used in 2006/07 in England for fractures in over 60 year olds and frailty related falls in over 75 year olds. The number of admissions for falls increased by 36% between 2003/04 and 2008/09. the most common serious consequence of a fall is a hip fracture. • Dementia – Total incidence about 1:100 of UK population. Aged 80+ about 1:6. About a third of those aged 65+ will develop a dementia at some point in their old age.

19. Health • Cold – cold snaps are worse than protracted cold weather. We have more excess winter deaths than most other colder European countries. At low temperatures a 1% fall in temperature is associated with a 1.35% increase in deaths. • Stroke – 56% of all strokes occur in the 75 and over population. People aged 75 years and over have a 9 fold higher risk of suffering from a first ever stroke and a 14 fold higher risk of suffering a recurrent stroke when compared to people aged 45-64 years. Stroke patients occupy around 20% of all acute hospital beds.

20. Falls- as an example of health problems • Only 52% of fallers who attend ED or MIU are screened for future risk of falling and a mere 15% for osteoporosis. Less than half of all falls admissions are screened for osteoporosis risk. • Performance on falls has not improved over the last two audits. Royal College of Physicians report on Falls March 2011 and Nice guidelines on Falls

21. Falls- as an example of health problems • Many of the exercise programmes being provided are not evidence based. • Despite 94% of sites stating they use a tool or proforma that includes standardised gait, balance and mobility assessment only 34% of non hip fracture patients and 72% of hip fracture patients received an assessment. • 86% of services report that they provide supervised strength and balance exercise training however only 19% of non-hip fracture patients had participated in any form of exercise for falls prevention within 12 weeks of the fracture. Royal College of Physicians report on Falls March 2011

22. Falls- as an example of health problems • Joint commissioning between health and social care of community based programmes to ensure the provision of therapeutic (Otago and FaME) exercise programmes. • Stop funding non-evidence based, poor outcome delivering programmes and transfer the money to community services. • Use the cheapest, most successful means of programme delivery. • Ensure nobody leaves hospital with additionally acquired avoidable conditions. • Target care homes with a cash back scheme.

23. Outcomes • Need to start measuring success in terms of the outcome it achieves not in the volume or cost at which it is delivered. • Need to be able to measure overall impact, eg, fifteen minute visits, reablement programmes. • The sector needs to get better at providing the evidence that if we do x at y intensity for q people, then we believe z will be the result and here is the evidence to support that hypothesis. • Focus attention on those areas where good outcomes are easiest to deliver at most financial gain.

24. Stimulate the specialist housing market • Much of our sheltered housing is out of date and is inaccessible. We have low build rates of private sector housing suitable for older people. • Little government impetus behind the lifetime homes agenda or stimulating development. • Yet the majority of people are home owners. • A recent Shelter report ….Over a third of older people are interested in the idea of retirement housing or would be in the future. This equates to over 6 million people. Suggest there is much latent demand for retirement housing.

25. Stimulate the specialist housing sector • A whole range of studies have shown that good accessible housing in older age produces a positive health gain. • A recent study by Frontier Economics for the HCA, identified that the overall benefit per older person per annum to health and social care of better retirement housing would equal £444 per year. • We would crudely estimate that applying the FE model would deliver for Kent between £1-2 million per annum now for very little expenditure.

26. Stimulate the specialist housing sector • Ensure that in any role the LA plays in offering older people better information, that buying and selling housing and moving into retirement housing heavily features. • Encourage the delivery of new retirement housing through the planning system. • Examine what additional, practical assistance could be offered to older people to make a housing move much easier. • Support developers through sharing financial risk, eg, interest free loans, spread land purchase costs over time and make land available.

27. Build community involvement and communities that work • Challenge the assumption that more care is automatically good. Need to reduce the number of services going into people. • Promote a voluntary sector that encourages independence rather than creates dependency. • Assess the voluntary sector for funding by outcomes, by deflection, by value added. • Use the sector and its leaders to drive positive change. Where people have ability make sure they rise to the top. Do discriminate. • Work with the sector to explore how we encourage and make the best use of volunteerism.

28. Build community involvement and communities that work • Are our communities welcoming of older people? Do they work well and encourage people to stay put? • Do planners recognise the demographic make up of future communities and plan accordingly? • Is the right infrastructure in place for older people? To stay put older people need; shops, services, drop curbs, good street lighting, safe neighbourhoods, security and an active social life. • We not only need housing that is fuel efficient and safe, but housing that inspires and stimulates.

29. Contact us • Email http://ipc.brookes.ac.uk • Web ipc@brookes.ac.uk • Phone 01225 484088