Blackburn with Darwen Borough Council, Directorate of Public Health.

Integrated Strategic

Needs Assessment

“Communities Together,

Loneliness Never”

Loneliness and Isolation

in

Blackburn with Darwen

September 2013

Michael Rawsterne

1

Integrated Strategic Needs Assessment Loneliness and Isolation

Table of Contents

Defining the issue ...... 1 Why is this issue highlighted? ...... 4 Who is at risk and why? ...... 10 Level of Need in the Population ...... 15 Good Practice ...... 16 Current Services and Initiatives ...... 22 Gaps ...... 31 Value for Money ...... 33 Involvement ...... 34 Recommendations ...... 41 Existing strategies, plans and policies ...... 43 Where to find out more ...... 44 References ...... 44

Defining the issue

Social Isolation In the past, social isolation has been defined as simply referring to the absence of contacts.60,1,2 This assumes that all social contacts have the same function, provide the same support and have the same value. More recent investigators have noted that it includes a number of different aspects. For instance, if there are a large number of contacts which are brief and cursory, then a person might still be isolated. However, extended and meaningful contact with only one individual might well mean that a person is not isolated at all.

Loneliness Loneliness is “an individual’s subjective evaluation of his or her social participation or social isolation and is the outcome of …having a mismatch between the quantity and quality of existing relationships on the one hand and relationship standards on the other.” 3 This means that loneliness is about how the lack of satisfactory relationships makes you feel.

Defining the issue Corporate Research Joint Intelligence Unit 2

Definitions of loneliness derived from engagement activities in Blackburn with Darwen and the question “What does loneliness mean to you?”

Loneliness can be a chronic condition which gets worse as a person ages or it can occur as a consequence of various life events.

Scope of the ISNA The original impetus for the ISNA came from the 50+ Partnership and there will therefore be a substantial element of the ISNA devoted to older people. Although the proportion of older people who endure loneliness and isolation is not apparently greater than for other age groups, it is thought that it is a greater problem for older people due to their circumstances making it more difficult for them to engage in activities that would reduce their loneliness and isolation. The purpose of the ISNA is to define priority issues, research questions, assess risks and make recommendations for commissioning services.

Defining the issue Corporate Research Joint Intelligence Unit 3

The Campaign to End Loneliness has produced a “Toolkit for Health and Wellbeing Boards”4 This suggests a four step cycle in respect of developing and utilising the ISNA. The four steps are:-

 1 Gather Information  2 Feed into strategy development  3 Strengthen partnerships  4 Monitor and evaluate

This ISNA has been guided by this cycle and is part therefore of a process of continuing development, partnership engagement and evidence based evaluation.

In line with the recommendations made in the Campaign to End Loneliness Toolkit4, the ISNA includes material derived from relevant bodies within the borough, such as the 50+ Partnership, The Alzheimer’s Society, Public Health and Public Health Intelligence, housing associations, The Care Network, transport providers, neighbourhood managers/ representatives, the Clinical Commissioning Group, the Borough Council, Hospitals, Education and Fire and Rescue. National and international data will be used as well as local data that is available.

As well as these sources, The Campaign to End Loneliness Toolkit emphasises that it is also important that local voices are heard. The data from other sources is not always particular to Blackburn with Darwen so local data needs to be obtained. Further, numerical data can be significantly enhanced by material supplied by local residents communicated in their own way. Also, by its nature, loneliness and isolation means that relevant groups are unlikely to be heard through the normal channels or, in some cases, unlikely to appear in the conventional statistics. The local data will include findings derived from engagement activities with groups that might otherwise be excluded.

Target population The population of interest in this ISNA are people residing within the borough of Blackburn with Darwen who are more than 18 years old. The populations to consider will include vulnerable populations as defined by place, income, ethnicity, gender or age. These might include people living in poverty, people with a disability, ex-offenders, people living with HIV/AIDS, people with a mental health condition, people who are homeless and older people.

Defining the issue Corporate Research Joint Intelligence Unit 4

Why is this issue highlighted?

Policy Background Local Policy In the Blackburn with Darwen Joint Health and Wellbeing Strategy 2012-2015 it is noted that ……” there is a significant section of the local population that is socially isolated, and therefore at risk of loneliness”.5 It then goes on to note that “There is a clear link between loneliness and poor mental and physical health, with lonely and socially isolated adults being more likely to be admitted to residential care and individuals who are socially isolated being between two and five times more likely than those who have strong social ties, to die prematurely”. It then makes clear that there is a need to determine the extent of the situation in respect of loneliness and isolation in Blackburn with Darwen. Loneliness and isolation is therefore a key issue for the Story of Place and the Health and Wellbeing Strategy. The Blackburn with Darwen 50+ partnership requested an ISNA on loneliness and isolation as a priority for the borough. This was because loneliness and isolation is now perceived to be a significant problem in terms of health, wellbeing and quality of life and also something that results in significant costs for health and social care services and the 3rd sector.

Government Policy There is increased government interest in “Social isolation is not something that the loneliness and isolation. For instance, in Government or services can tackle on their March 2012, a “Summit on tackling own, but we can initiate action to recognise loneliness in older age” was held by the and identify the most isolated people. We must Campaign to End Loneliness and the work together to tackle social isolation. The Department of Health. This was attended work led by the Campaign to End Loneliness by representatives from the Department and the Local Government Association launched of Health, Department of Work and at the Government’s recent loneliness summit is an important contribution to this. Building on Pensions, local government, charities and the Department for Work and Pensions’ Ageing businesses. There was a ministerial Well programme, the Government will work address by Paul Burstow MP, Minister for closely with the Age Action Alliance to find Care Services and Steve Webb MP, practical approaches to improve the lives of Minister for Pensions. (See boxes) older people.” (White Paper, “Caring for our Future”)6

Following on from the 2012 social care White Paper6, a further indication of government support for the reduction of loneliness and social isolation is the inclusion of a new measure of loneliness and social isolation in the new 2013/14 Adult Social Care and Outcomes Framework. Specifically, the measure is self-reported levels of social contact as an indicator of social isolation. Although initially confined to social care service users, the intention is that the

Why is this issue highlighted? Corporate Research Joint Intelligence Unit 5

measure will be expanded to cover the general “……there is a compelling public population. In this respect, the ASCOF Reference policy need, a compelling human group (June 2013) has made two recommendations. need to do something about The first is that loneliness be measured by means of loneliness. We are on the verge the 3-item University of Los Angeles (UCLA) loneliness of, if not already living scale7 and the second is that the Active People Survey8 through, an epidemic of be used as the vehicle for the measure. The loneliness and if we do not start advantages are that the UCLA loneliness scale has to take action, it will have huge already been subjected to tests of validity and consequences for individuals and reliability and the Active People Survey samples the for our health and social care general population (500 people per local authority systems.”(Paul Burstow) aged 14+). The Active People survey is also carried out annually.

Implications Consequences of loneliness Socially disconnected older adults who are lonely give lower ratings of their physical health than others.9 Loneliness results in increased and earlier use of expensive health and social care resources and has also been found to be a predictor of the use of accident and emergency services independently of chronic illness10. The health implications of loneliness and isolation are considered more fully under ‘Loneliness, isolation and health’, starting on page 7.

Cost effectiveness Ameliorating loneliness and isolation in older people is inexpensive but results in substantial gains including fewer GP visits, less use of medication, fewer falls and reduced risk factors for long term care.11 It also results in fewer days in hospital, visits from a doctor and outpatient appointments.12 Also, following an intervention, there were fewer admissions to nursing homes and when these did occur, they did so later than they would have done without the intervention.13

Scale of the issue People Living Alone Whilst living alone, by itself, does not always result in loneliness or isolation, it often does. Furthermore, the simple fact of living alone can increase the risks associated with certain health conditions, such as those which may result in forgetfulness, unconsciousness or a fall. According to a recent ONS report14 in 2012 there were 7.6 million people living alone in UK households. 4.2 million were aged 16-64, the majority (58%) of whom were men. One reason suggested for this is that a greater proportion of men than women never marry. Beyond the age of 65, females living alone outnumber males who live alone. The suggested reasons are that women tend to live longer than men and women who do marry, tend to

Why is this issue highlighted? Corporate Research Joint Intelligence Unit 6

marry men who are older than themselves. The chart below illustrates the recent changes in the numbers and ages of people living alone (Figure 1). Figure 1

s People living alone in the UK by age group, 1996-2012 Source Labour Force Survey ONS 2012 Thousand 3,000

2,500 45-64

2,000 75 + 25-44 1,500 65-74 1,000

500 16-24 0

Between 1996 and 2001, there was a limited increase in the number of people aged 75+ who were living alone but since 2001, the number has been level at approximately 2 million. There has been a large (53%) increase in the number of people living alone in the 45-64 age group. This age group has increased in size due to the ageing of the 1960s “baby boomers”. The percentage of people in this age group who are married has decreased by 10 percentage points from 79% in 1996 to 69% in 2012. The number in this age group who have never married or are divorced has increased from 16% in 1996 to 28% in 2012. The numbers of people in other age groups living alone has remained relatively constant. Even though the absolute numbers of people living alone has risen from 6.6 millions in 1996 to 7.6 millions in 2012, there has been very little change in the proportion of people living in different types of household, including single person households, since 199614 . (Figure 2)

Why is this issue highlighted? Corporate Research Joint Intelligence Unit 7

Figure 2

Households in the UK by Households in the UK by household type (millions) 1996 household type (millions) 2012 Source-Labour Force Survey, ONS Source -Labour Force Survey, ONS

One person One person 0.7 0.2 0.8 households 0.3 households

One family One family 2.3 2.8 6.6 household: couple 7.6 household: couple One family One family household: lone household: lone parent parent Two or more Two or more 13.9 unrelated adults 14.8 unrelated adults

Multi-family Multi-family households households

Future Trends Number of people aged 65 and over living Population projections suggest that the alone in Blackburn with Darwen projected to numbers of people over 65 living on their 2020 Source POPPI own will increase, with the number of 9,000 females substantially exceeding the 8,000 Males 65+ number of males (Figure 3). 7,000 6,000 Females 65+ 15 5,000 Figure 3 (Source POPPI/ONS 2012) Persons 65+ 4,000 3,000 2,000

1,000 0 2012 2014 2016 2018 2020 Prevalence of Loneliness There is a high prevalence of loneliness in older people with 6-13% reporting that they are often or always lonely. There is also a growing percentage who report sometimes feeling lonely.16

Loneliness, isolation and health Many studies have demonstrated a relationship between loneliness and isolation and health. These include American studies17,18, and long term studies from New Zealand (The Dunedin Cohort studies).19,20 21,22, 23,24,25, 26

Why is this issue highlighted? Corporate Research Joint Intelligence Unit 8

The health effects included:-

1. early mortality 11. more negative and fewer positive 2. functional decline emotions 3. cardiovascular problems 12. psychological distress 4. earlier occurrence of age related disease “The effects of each of these 5. depression pathways endow loneliness with the 6. high blood pressure capacity to accelerate the rate of 7. high cholesterol 22 8. being overweight physiological decline with age”. 9. reduced capacity for physical 13. poorer sleep activity 14. higher levels of stress hormone 10. impaired immune response Recently, the English Longitudinal Study of Ageing39 found that in those over 52 who reported poor health, 59% said that they felt lonely sometimes or often compared to 21%

“The influence of social relationships on the risk of death are comparable with …….. smoking and alcohol consumption and exceed the influence of other risk factors such as physical inactivity and obesity.” 26

for those who reported excellent health.

Figure 4 Summary of Physical Health Effects of Loneliness

Functional High Poor sleep Cholesterol decline

Overweight High Blood Pressure

Lowered Cardiovascular Immunity disease

Premature Loneliness Earlier age Mortality related disease

Why is this issue highlighted? Corporate Research Joint Intelligence Unit 8

Loneliness and Mental Health There is also substantial evidence linking loneliness to mental health problems. Loneliness and isolation have been linked to:-

 Depression in middle aged and older adults independent of demographic and other factors.27,28  Stress All ages recovered less well from stress and reacted more badly to it if they were lonely and the effects of the loneliness increased with a person’s age .29 In a 2003 study for instance30 it was found that independently of other factors, socially isolated adults reported more powerful adverse reactions to stress including risk factors for hypertension. They also had poorer quality sleep.

Alcohol Although it is not suggested that excessive use of alcohol causes loneliness or loneliness causes excessive use of alcohol, they are nonetheless related. It is suggested that 20% of men and 10% of women aged 65 and over in the UK exceed recommended drinking guidelines.31 Excessive alcohol use in older age is associated with a number of adverse consequences including:-  falls and accidents 32  insomnia  incontinence  gastrointestinal problems33  memory loss  self-neglect and depression34

“loneliness may be significant at all stages in the course of alcoholism: as a contributing and maintaining factor in the growth of abuse and as an encumbrance in attempts to give it up” 35

The researchers indicate that those dependent on alcohol do feel more lonely than other groups of people. They also note that the degree of loneliness does not appear to be related to the alcohol user’s social situation. 35

“the feeling of loneliness appears to be more connected with a general negative perception about oneself and one's relations to other people and also with a general dissatisfaction with most things in life.” 35

The lonely alcohol misuser also seems to be resigned and unable to bring him or herself to change the situation. They will also manifest a range of other psychopathologies and will have less supportive social networks compared to people with other illnesses.

Why is this issue highlighted? Corporate Research Joint Intelligence Unit 9

Figure 5 Summary of Mental Health Factors Related to Loneliness

Anxiety Stress Fewer positive emotions

Alcohol Use More negative emotions

Depression Loneliness Dementia

Social Isolation Although loneliness and isolation tend to be considered together as a risk factor there is a case for considering them separately. Recent British research36 indicates that social isolation alone, irrespective of other factors (including loneliness), is associated with a range of poorer physical and mental health outcomes including earlier death.

 Nearly half (49%) of all people aged 75 and over live alone  12% of older people feel trapped in their own home  6% of older people (nearly 600,000) leave their house once a week or less  Nearly 200,000 older people in the UK do not receive the help they need to get out of their house or flat  17% of older people have less than weekly contact with family, friends and neighbours 37  11% have less than monthly contact (Age UK)

37 Both social isolation and loneliness were associated with higher all-cause mortality. However, social isolation was independently predictive of this outcome, whereas loneliness tended to occur in people whose existing health problems were sufficient explanation in themselves. The authors of the report go on to note that “Reducing both social isolation and loneliness are important for quality of life and wellbeing, but efforts to reduce isolation would be likely to have greater benefits in terms of mortality.”

Why is this issue highlighted? Corporate Research Joint Intelligence Unit 10

Who is at risk and why?

Older people It is not clear that age alone is a substantial risk factor for loneliness. An American study for instance found that only 10% of older people reported feeling lonely and that age was only weakly correlated with loneliness.38 The same study also reported that in older people social contact was associated with less likelihood of loneliness but the quality of the contacts was significant. The study found that friends were more instrumental in ameliorating loneliness than were adult children or other relatives. Among older people, being female, unmarried, in poorer health, or being in a nursing home were all associated with a greater likelihood of loneliness. In people in advanced old age, marital status, lack of contact with other people, health problems and female gender were positively related to loneliness, but living in an institution was not.

The English Longitudinal Study of Ageing also noted that the proportion experiencing loneliness was highest in those over the age of 80. (Figure 6)39.

Figure 6 Percentage of males and percentage of females who report being lonely often or some of the time. (Source English Longitudinal Study of Ageing, Wave 5 2009-10)

60 Men

50 Women 40

30

20

10 of the time" or "often". or time" the of

Percentage responding "some "some responding Percentage 0 52–59 60–69 70–79 80 and over All aged 52 and over

Older people in ethnic minority communities In a recent report from Brunel University, levels of loneliness were reported to be higher among ethnic minority elders (aged 65 or over) compared to the rest of the same age population.40 The same report also notes that although ethnic minority older groups had a wide social network and large household sizes, only 44% reported taking part in social activities that they enjoyed compared to 79% in the general population. Also, only 55% report that they have someone who gives them love and affection compared to 88% for the general population41. The situation varies according to the ethnic population concerned. In the Brunel study, only 7% of Indian elders report feeling lonely whereas 24% of the Chinese population do (Table 1). The study also found that levels of loneliness were similar to those reported for the same age cohort in the countries of origin. Younger people in ethnic

Who is at risk and why? Corporate Research Joint Intelligence Unit 11

minority groups report lower levels of loneliness than older people. Overall, these studies suggest that living with one’s children and extended family will not necessarily alleviate loneliness.

Table 1. Levels of loneliness in those over 65 by ethnicity. 42

Loneliness, social isolation and dementia. Although it is not suggested that loneliness causes dementia, there is evidence that it is associated with and can be predictive of dementia. For instance, a recent Dutch study43 found that in a cohort of 2173 seemingly unaffected community-living older persons, feelings of loneliness were predictive of dementia occurring three years later independently of other factors such as cardiovascular disease. There was a suggestion that feelings of loneliness might signal a “prodromal stage of dementia”.

In a recent report by the Alzheimer’s Society44 it was observed that:-  one third of people with dementia lived alone.  29 percent only see friends and family once a week or less  23 percent expect only one weekly telephone call  A third of people with dementia said they lost friends following a diagnosis  More than a third (39%) of people with dementia responding to the survey said they felt lonely. Only a quarter (24%) of over 55s in the general public said they have felt lonely in the last month.  Nearly two-thirds (62%) of people with dementia who live on their own said they felt lonely. Difficulties in maintaining social relationships and other features of dementia contributed to this. The same report also noted that the actual situation is likely to be worse as dementia is generally under diagnosed and the people who were included in this research did have a diagnosis and had come to the attentions of services.

Who is at risk and why? Corporate Research Joint Intelligence Unit 12

Lesbian, gay and bisexual people In a report produced by Stonewall45, it was noted that gay men and lesbians aged over 55 were less likely to have close social and personal relationships compared to their heterosexual counterparts. Figure 7

For instance, gay males were much less likely to be in a relationship (Figure 7).

Lesbians, transsexuals and gay men Figure 9 were also much more likely to live alone compared to heterosexual people (Figure 9).

They were also only half as likely to Figure 8 be living with their children or other family members (Figure 8).

Figure 10 Lesbian and bisexual women and gay and bisexual men were also much less likely than heterosexual men and women to have children (Figure 10).

Figure 11 They were also much less likely to be in contact with members of their biological family (Figure 11)

Gay men, lesbians and bisexuals are also more likely to drink more than their heterosexual counterparts, take drugs and have mental health issues. These and the other factors listed above, suggest that as they age, gay men, lesbians and bisexuals are at particular risk of being lonely and isolated compared to heterosexual men and women.

Who is at risk and why? Corporate Research Joint Intelligence Unit 13

Income Income deprivation affecting older people index. The older people of Blackburn with Darwen and other local authorities. Blackburn with Darwen are 60.0 LA relatively less well off than England 50.0 older people in most other Blackburn with Darwen parts of the country (Figure 40.0

12). 30.0 Index 20.0 10.0

0.0 Less deprived More deprived

Figure 12. Source - IMD 2010 data published by Department for Communities and Local Government (DCLG)46 There is evidence that in older people, there is a strong relationship between income and loneliness. In the 2004 English Longitudinal Study of Ageing which looked at people aged 50 and over47, it was noted that there were pronounced inequalities in levels of loneliness in older people aged 52 -59, in that those in the lowest economic quintile reported much higher levels of loneliness than those in the next quintile (Figure 13). For the succeeding quintiles the differences were less marked but there was a reliable negative relationship between wealth and loneliness. The overall relationship was maintained for those who were 60 – 74 and those who were 75+. As people aged and became very old, the differences in levels of loneliness related to wealth and poverty became less stark but nonetheless, better off old people were less lonely than poorer old people (Figure 13). This suggests Figure 13 - Percentage of older people who are lonely often or some of the that the time by age range and economic quintile. 47 proportion of older (Source English Longitudinal Study of Ageing 2004) people who are lonely or isolated will be greater for Blackburn with Darwen than for other boroughs.

Who is at risk and why? Corporate Research Joint Intelligence Unit 14

Gender and relationships Women were more at risk of loneliness than men (as seen earlier in Figure 6). Widowhood is a predictor of loneliness, whereas living with a partner lowered rates of loneliness, as did having friends and having contact with own children. However, having children but not feeling close to any of them is related to higher levels of loneliness than childlessness. People without friends reported the highest rates of loneliness.

Figure 14 Summary of risk factors for loneliness

Without a Poor health Partner Limited contact with own children

Low income Lack of friends

minority group Very old age (e.g., gay, BME)

Female Loneliness Living alone

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Level of Need in the Population Demographics According to ONS, in Blackburn with Darwen, there are 19,82548 people over the age of 65. If we take the Campaign to End Loneliness figure of 6-13% of older people who are always or often lonely16, then between 1188 and 2577 older people In Blackburn with Darwen are often or always lonely. We can also observe that with the high levels of deprivation in Blackburn with Darwen, the problem with loneliness and isolation is likely to be greater than elsewhere. According to the 2011 census49, in Blackburn with Darwen, there are 6229 people aged 65+ living alone.

Ethnic Minority Population Data from the 2011 census indicates that approximately 25% of the population of Blackburn with Darwen is of South Asian origin.50 According to the 2011 census data, there were 1524 South Asian people over the age of 65 in Blackburn with Darwen.51 As we have already seen, older ethnic minority groups are more likely to be lonely than people of the same age in the general population and their numbers are likely to increase in the future.

Level of Need in the Population Corporate Research Joint Intelligence Unit 16

Good Practice

Strategic Framework In “Combating Loneliness:- A guide for local authorities”, published by the Local Government Association52, the Campaign to End Loneliness suggests that strategies to end loneliness and isolation should be:-

 Undertaken in partnership  Part of a strategic approach to the wider issues facing older people

The nature of the loneliness challenge should be explicitly understood, and practical steps identified at the strategic, neighbourhood and individual level (Figure 15). Figure 15. Strategic Framework

Strategic whole system approach To achieve an overarching strategy, the Campaign to End Loneliness suggests a number of actions are required including:-  Research/data analysis to understand the extent of loneliness and isolation within the community.  Engagement with older people, including as far as possible those experiencing, or at risk of, loneliness, to assess the issue and identify and coproduce solutions.  Relationships across the local authority and beyond to bring together all those actors who can make a difference to loneliness and isolation, including health and social

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care, information and advice, housing, leisure providers and voluntary and community organisations.  A top to bottom commitment to tackling loneliness – with clear objectives and actions set out at all levels from elected members and chief officers, to community projects and front line staff.

Neighbourhood action In respect of Neighbourhood action a number of actions are required which include:-  Activity at the neighbourhood level flowing from an authority wide strategy  A tailored approach  An approach that recognises the particular assets of a community  Improvement of the physical environment  Improvement of services available  Improving the way people within a neighbourhood interact  Creating the characteristics of “age friendly communities” as described in the WHO Age Friendly Cities and as implemented in Manchester Creating age friendly communities requires action in three key domains. These are:-52

•Including the availability of public meeting places and green spaces; providing public seating, improving pavements to reduce the risk of falls; improving street safety with Places measures such as street lighting and other community safety initiatives.

•Including facilitating local social activities; encouraging intergenerational contact; ensuring local people have a voice in local decision making, for example through ward assemblies; People and encouraging volunteering and neighbourliness.

•including ensuring local bus services and community transport go to the places older people want, at times they want to travel. •Improving parking, particularly for those with restricted mobility; providing accessible Services clean public toilets; ensuring local shops and services are within reach; and providing local sources of information and advice

The Role of the Arts The Campaign to End Loneliness in conjunction with the Baring Foundation, has produced a report “Tackling Loneliness in Older Age. The Role of the Arts”. In it they illustrate the role the arts can and does play in alleviating loneliness and isolation for older people. In a series of ten case studies they cover a range of art related activities which include older people from varying circumstances. They note that the arts exemplify the “five ways to wellbeing” – connect, be active, keep learning, take notice

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and give.53 They also note that “Feeling valued, creative expression, using skills and engaging with other people all build friendships and enhance feelings of wellbeing which strengthens resilience in tough times”. Community Hubs - Bristol The Campaign to End Loneliness Toolkit54 notes that in Bristol there is a scheme to identify older people at risk of social isolation and then agree upon activities or opportunities in which they can take part. This “LinkAge” scheme has been evaluated by interviewing older people before and after they were engaged with the LinkAge community hub. The initial findings have found a significant decrease in social isolation and an increase in self-reported wellbeing and physical activity.55

Group Services These include day centre type activities such as lunch clubs and social group themes. They can be open to all or more limited and focused in their membership. They can have specific aims or depend on the group as a whole to develop activities that the group requires. They can be peer led or led by specialists or volunteers.

The findings concerning outcomes in terms of reducing loneliness and isolation by means of group services are mixed. The research that has employed appropriate before and after measures or control groups has found that groups services of certain kinds tend to work and others do not. In one study for instance, a group that was focused on developing social integration and friendship did not show any benefits in terms of reducing loneliness and social isolation compared to a control group. 56 In a “psychosocial group rehabilitation intervention” in which participants aged 75 or over who lived at home engaged in “(i) art and inspiring activities, (ii) group exercise and discussions or (iii) therapeutic writing and group therapy” 80% of participants reported reduced levels of loneliness. 57

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Wayfinders and community navigators WRVS project-manages West Moors Befrienders (Dorset). Wayfinders and community navigators are The service was originally set up as a telephone similar to befriending services (see next befriending service. The project was explicitly designed to increase self-confidence and also to reduce the pressure page) in that they typically rely on on NHS resources. These patients were making numerous volunteers who provide emotional (as well visits to the surgery sometimes with unexplained as practical and social) support. They are symptoms and were also seeking admission to hospital at night. different to befriending services in that they The scheme now offers face to face as well as telephone actively seek to improve the lonely person’s befriending. Generally, befrienders, either on the phone access to services and facilitate their or in person, offer support and reassurance. They also encourage the older people they work with to engage in participation in community activities. The social activities. exact nature of the provision varies from GPs are reporting fewer appointments for the older region to region and according to the people involved and an assessment of the GP and resources available and the client group. The unscheduled hospital visits of six of the participants prior to and post their participation in the scheme indicates evidence suggests that wayfinder and significant cost savings for the NHS (£80,000 for these six community navigator interventions were alone). successful in reducing loneliness and isolation with their target groups. 58,59 Individual intervention Individuals who are lonely or isolated are likely to be difficult to identify. In respect of working with individuals therefore, the Campaign to End Loneliness suggests “creative solutions” to the problem of identifying lonely and isolated individuals as well as simply knocking on doors, possibly in the presence of a “trusted member of the community” such as a police or fire officer. The Campaign to End Loneliness also notes that there is a need to understand the risk factors (noted above) that are associated with loneliness to enable better targeting of individuals who would benefit from an intervention. The effect of individual focused interventions In a systematic review of health promotion interventions intended to target loneliness and isolation, (and sometimes including related health outcomes)60, the overall finding was that interventions that provided group activities with an educational or support focus were effective in alleviating loneliness in older people. Other significant factors in respect of successful interventions were that they targeted specific groups, such as women, care-givers, the widowed, the physically inactive or people with serious mental health problems. They enabled some level of participant and/or facilitator control or consulted with the intended target group before the intervention. Studies evaluating the effectiveness of physical activity found that physical activity was effective in reducing loneliness.

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Befriending According to Age UK a befriending service “ …works by assigning each older person a befriender, who provides friendly conversation and companionship on a regular basis over a long period of time. This relationship not only promotes wellbeing and confidence, but can also help people in later life to remain independent in their own homes.”61 “Befriending” activities are a common method of attempting to relieve loneliness and isolation. The systematic review noted above60 did not find any general or systematic gains in terms of reducing levels of loneliness. Reasons suggested for this are that the population studied was not sufficiently lonely, the interventions tended not to be long term and the amount and intensity of contact was insufficient. It should be appreciated that such interventions are inherently difficult to evaluate (see next page), and anyway we now have evidence that alleviating social isolation is worthwhile in itself.36 The same researcher (Cattan) later evaluated a number of studies that looked at telephone befriending.62 Although there were a range of methodological issues such as the choice of participants, the exact nature of the telephone befriending, promotion of the initiative and small sample sizes, Cattan concluded that the evidence indicating that the method was useful in alleviating loneliness and isolation was strong. The evidence also supported the idea that if loneliness and isolation could be relieved, then this also led to other positive health outcomes. This initiative, because the befrienders were volunteers, was inexpensive to provide and perceived to be very cost effective.

Social Prescribing The Campaign to End Loneliness Toolkit describes a pilot study in Yorkshire and Humber where four GP practices referred 55 older people to a social prescribing service at their local Age UK. It noted that the participants reported a significant improvement in their social and emotional wellbeing. The social prescribing service provided an assessment of social, emotional and practical support needs. The older people were then helped to access the services such as fitness classes, handyman and community groups.63

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Difficulties with the research Windle (2011)64 observes that it is difficult to form firm conclusions concerning the effectiveness of interventions aimed at reducing loneliness and social isolation due to a range of issues associated with the research. She notes that much of the research is not UK based so it would be difficult to generalise findings to the UK. Further, many of the groups who are for instance befriended or who take part in group activities are not always lonely or especially lonely to begin with. Also, many of the individuals are already active in various ways and have access to a range of resources. There is therefore a suggestion that those who would benefit the most from, for instance, a befriending service, have been left out as they are not easy to reach or difficult to engage with for other reasons. There is therefore a paucity of findings concerning people who are deaf or blind or who have some other disability. The samples also have typically been women and men are therefore under-represented. There is on the whole a lack of longitudinal research, a lack of research that has employed suitable control groups or randomised trials, a failure to systematically measure loneliness and isolation (again, before and after interventions, longitudinally and between groups.) Further, while it can be supposed that interventions to reduce loneliness and isolation do so and therefore reduce the burden on the health and social care budget, there do not seem to be any reliable measures concerning the cost of interventions in relation to the amount of money saved. (Wayfinder and community navigator activities might increase access to services and therefore increase costs.) The overall finding is however that wayfinder, community navigator, group activities and befriender services are effective in reducing levels of loneliness.

Figure 16 - Summary of effective interventions

Give control to target group Long term

Consult with target group Sufficient amount

Target specific Loneliness Sufficient intensity groups

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Current Services and Initiatives

Exercise The re:fresh programme has increased levels of physical activity in adults by a significant amount especially in the more hard to reach “Efforts to increase physical groups including activity – to meet new guidelines women, ethnic minority groups and the disabled.65 for activity among the over 50s – “Participants said the initial health message got them also create opportunities to increase social interactions and interested in taking part, but it was the social and build social networks.” emotional benefits of sport and physical activity that (Campaign to End Loneliness) kept them going.” Figures for the first two quarters of 2012/13 show an increase of 53,230 attendances at an exercise venue of some kind for beeZ cardholders compared to the same period in 2011/12. (The beeZ card enables the holder to access exercise facilities for free) This is especially notable as budget cuts have resulted in a reduction in the availability of free exercise facilities. In the 50+ age group, there was an increase of 13% in the first two quarters of 2012/13 compared to 2011/12.66 Although the re:fresh and beeZ card programmes are not specifically targeted towards alleviating loneliness and isolation, some impact can be inferred because, as already noted, there was a strong social and emotional element and exercise reduces levels of depression.67 68

Caring Neighbourhood Scheme Befriending Service Age UK Blackburn with Darwen provides a befriending service for older people called the Caring “You’re invaluable to me” Neighbourhood Scheme Befriending Service (CNS). Demand for this service is high and the “needs of the scheme “It will be lovely to have a phone call on Sunday as users have continued to that is the worst day of the week” increase”69. Participants receive a weekly “Phonelink” or a visitor or both depending on their need and the service is provided to older people who are housebound and socially isolated. At the end of November 2012, there were 121 people on the “It’s worth a million pounds having scheme and during the year 2011/12, there were 82 someone to talk to” referrals to the service. At the end of March 2012 there was a waiting list of 56 people.

Referrals are also received for “It’s really lovely of her (the volunteer) to phone and people with more complex needs I think, at least someone cares” including mental health problems. There is also an

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increase in referrals due to the reduction in other services and the more stringent criteria applied to social care eligibility. In addition, due to the level of vulnerability of some users, there is a need for additional services such as a visitor and a Phonelink service. The delivery of the service is provided by volunteers of whom there are 10 Phonelink “You’ve made me laugh, which I volunteers and 35 visiting volunteers who haven’t done for a while” provided 4500 hours to support the delivery of the service.

The quotes provided here indicate that the service is highly valued by the people who use it.

Working with families

“I felt isolated – I don’t have any family in the area and having a little one adds to the isolation.”

Homestart UK is a national charity with an active local branch. Homestart works with any family that has a child less than 5 years old and a problem or problems of any kind. The engagement activity is carried out “I was very alone – I was new to by trained volunteers. Although the town and my family were not Homestart does not specifically supportive” target loneliness and isolation, when a volunteer first makes contact with a family, they ask specific questions about loneliness and isolation. Specific questions are also asked when a family feels that they no longer require the help of Homestart. This provides a useful before and after measure. 63% of families with which Homestart engaged reported problems with loneliness and isolation. This, along with being a lone parent, was the most frequent reason for referral. Of these 63%, more than 71% reported having their needs fully Fiona and children with met and a further 16% reported having their needs partially Volunteer (Tracy ) met.70

“When you have no family or friends nearby, Home-Start offers that kind of support.”

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A one parent family with a 13 year old, a three year old and a new baby which was born prematurely was referred to Homestart. The mother had health problems which became more severe during pregnancy. Following the pregnancy, the mother could no longer work which led to emotional and financial problems and the family was referred to Homestart by the Health Visitor.

The mother had become extremely isolated and was in a low mood. She was unable to access community groups and services as walking was difficult. With two young children, it became almost impossible for her to get out of the house. She had lost contact with her support networks and felt guilty about not working.

The Home-Start volunteer helped the family access benefit advice and assisted with applications for DLA. The family now have a disability car. She is now much less isolated and this has made a huge improvement to the whole family’s quality of life. In addition, the volunteer assisted mother to take children to local playgroups.

This family were supported for 18 months, the volunteer providing essential emotional support to help improve the mother’s emotional health and wellbeing. The volunteer helped mother to access learning opportunities to support her decision for a career change, so that she may return to work part time when her youngest child is in nursery.70

Loneliness and social isolation within the BME communities in Blackburn with Darwen It was observed that there was substantial under-use of the “traditional” befriending service provided by Age UK by Asian older people with only 3% of the cohort coming from this group. The existing model was not successful with this group and following feedback from the community, the model was amended and a pilot study offering a Phonelink in the appropriate language was piloted. 71 The pilot ran from April 2009 to March 2010. By the end of the pilot 24 people were accessing the service and 22 continued to do so beyond the duration of the pilot. It was noted that even though some Asian older people lived with a family, they might still be lonely and might still spend a lot of time alone. Other issues such as lack of knowledge concerning available services were also observed. An evaluation procedure was carried out by phone and 17 out of 24 participants responded. The evaluation feedback indicated that the service was highly valued by the users leading to reduced worry and stress and improved mental wellbeing.

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Social Inclusion The Blackburn with Darwen Social Inclusion Service provides an extensive range of inclusion activities for groups who might not access facilities as easily as others. While their activities are not directed at alleviating loneliness and isolation as such, the activities and facilities

provided can be understood to make a significant contribution in this area.

The timetable on the left gives an indication of the activities provided and supported by the Social Inclusion Service and the Creative Support Team.

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Computer Tuition

“There is clear evidence that the use of modern technologies, particularly the internet, as a method for establishing and maintaining social contact is on the increase among the older population.” (Age UK) 72

Although a report by Age UK 72 indicates that computer and internet usage is increasing rapidly in the older population, there are still large numbers who are not experiencing the benefits. This is sometimes because of lack of interest and motivation and a belief that it is of no use to them personally, but frequently, the main reason is lack of confidence and skills. To combat this Blackburn with Darwen Age UK provides free tuition on computer and internet use. The tuition is available at a number of sites throughout the borough including the Age UK Blackburn office and the Darwen Resource Centre. They are currently testing out courses on Facebook and Social Networking. Blackburn with Darwen Age UK also promotes computer and internet use through their “digital champion”, a member of staff who actively supports and encourages older people who wish to develop their IT skills and knowledge. The Social Inclusion Service (see above) also provides one-to-one computer tuition.

Age UK’s Internet Champions of the Year 2013 (l-R:- Jim Perry 92 (joint winner) June Whitfield (Age UK ambassador), David Williams 64 (runner up), Chris Scruton 70 (runner up) Janet Tchamani 55 (joint winner). See their You Tube videos on http://www.ageuk.org.uk/work-and-learning/technology-and- internet/volunteer/internet-champions/

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“The use of technology for enabling social contact and participation can be very successful, but many older people need help at the start and some need ongoing support or reassurance.” (Age UK)72

The Silver Line Helpline Pilots in the North West Region At the end of November 2012, the Silver Line Helpline for older people was launched. It aims to provide the following functions:-  a sign-posting service to link older people into the many, varied services that exist around the country;  a befriending service to combat loneliness;  and a means of empowering those who may be suffering abuse and neglect, if appropriate to transfer them to specialist services to protect them from harm. Housing In June 2013, the Housing Learning and Improvement Network (LIN) produced a report detailing the benefits (and possible drawbacks) of extra care housing.73 The report observes that extra care housing can be summarised as ergonomically designed independent housing units that usually feature common spaces, facilities and care services. The model can be summarised through three key tenets defined by some as: (i) flexible care, (ii) self-contained dwellings and (iii) homeliness.74 One of the most distinctive features of extra care housing is the availability of 24 hour on- site care, something that is generally unavailable in the community care provided by Local Authorities. Thus, extra care housing is marked out as constituting independent housing with the provision of flexible care, which can be round-the-clock where needed, and successfully straddles the divide between general purpose housing and residential care.75 There were an estimated 43,300 extra care properties in England in 2009.76 For older people who move to extra care housing, there is evidence that social lives and relationships strengthen, consequently lowering the risk of loneliness.77 The findings indicate that among almost 600 residents of extra care housing who had been resident for twelve months, over four-fifths (82%) described their social life as ‘good’ or ‘as good as it can be’. Three-quarters reported that their time was filled with activities that they chose to do, while less than one-in-ten said that they hadn’t made any friends at the scheme and only six per cent reported that they never met up with friends (within and beyond the scheme). At twelve months many residents reported that they had come to view new friends and neighbours at schemes as sources of social support, with 42% reporting that they would turn to friends in extra care housing for advice and help respectively, and 17 per

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cent reporting that they would turn to friends on the scheme for advice. Such gains in social life matched the expectations of residents on moving to extra care housing – over two- thirds of residents moving into extra care housing expected their social life would improve and that they would socialise more, thereby enhancing their ‘environmental richness’.76

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Community Wellbeing Coordinators In August 2013, Adult Services recruited 3 Community Wellbeing Coordinators to support the department’s growing focus on prevention and early intervention. The Community Wellbeing Coordinators are currently working with community centres to set up good neighbour schemes, the first of which is called ‘Good Morning Infirmary’ which is due to begin in early November. The wellbeing coordinators are working with isolated people in the Ewood ward to try and get them involved in their community by signposting them to activities at Ivy Street Community Centre and other local services. The Council is helping to identify people for them to help, and the team are also getting referrals from Police Community Support Officers who are based in neighbourhood teams. The team is also hoping to get referrals from doctors (with the patient’s consent). They are also posting leaflets through people’s doors in that area. Their focus is on early intervention and prevention, and helping people who don’t meet the department’s eligibility criteria.

Once signed up to the Good Morning Infirmary scheme people will get a weekly telephone call to check on their general wellbeing. The team will work on building up people’s confidence with the aim of helping them to attend groups at Ivy Street Community Centre as well as accessing other local services. The wellbeing coordinators will accompany people to groups and activities at the beginning to help them settle in if they are feeling nervous. Once at the community centre the volunteers will help to build up the person’s self-esteem and see if the person has any skills, such as cooking or crafts, that they could pass on to others and contribute back to the community.

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The Campaign to End Loneliness The Campaign to End Loneliness recently produced a report that highlighted the progress made by Blackburn with Darwen78 (see box). Further, the Charities Evaluation Services recently produced a report79 that observed that the Blackburn with Darwen Health and Wellbeing Board was one of only 8 out of 152 to receive a gold award from the Campaign to End Loneliness for having a strategy that “contain(s) measurable actions and/or targets on reducing loneliness in older age or for the whole population”.

“The Blackburn 50+ Partnership worked closely with the local Health and Wellbeing Board and supported the development of their strategy. Social isolation and loneliness were quickly identified as key issues. The challenge, however, was to evidence cause and effects. So a workshop was held to explore the matter further, which resulted in an agreement to research it further in an Integrated Strategic Needs Assessment (ISNA). As part of this, a series of community meetings to collect individual stories of social isolation and loneliness to feed into the ISNA were held. A public event to raise awareness and gather local views and suggest possible solutions also took place, and the Campaign took part in this event. Based on this process, a series of recommendations were put together which were then presented to a joint CCG and local authority commissioning group. This led to the beginning of a more joined up programme of commissioning and fundraising with a better informed partnership approach to meet the needs of vulnerable lonely people in Blackburn with Darwen.” Reproduced from the Campaign to End Loneliness Report, “Loneliness Harms Health. One year on.78

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Gaps

Measurement Loneliness and isolation within the borough needs to be measured in several ways. It would be useful to know how many people are affected by loneliness and isolation. It would also be useful to know who the people are who are affected by loneliness and isolation and where they might be found. Unfortunately, loneliness and isolation by its nature is very difficult to identify and measure. On the other hand, the risk factors for loneliness and isolation are known and can frequently be identified. In the Campaign to end Loneliness Toolkit4, it is reported that, using these risk factors, Essex County Council has developed an “isolation index”using commercial demographic data. Using Mosaic UK (a unique consumer classification based on in-depth demographic data), eleven common factors – identified by research as drivers of isolation – were selected as variables, defined at household level and then combined to create an index. These included:

 Single pensioners

 Widowed

 Retired

 Unlikely to meet friends family regularly

 Unlikely to interact with neighbours

 Poor health

 Suffering from depression

 Suffering from poor mobility

 Visually impaired

 Hard of hearing

 Struggling financially Different scenarios were explored by weighting the relative importance of the common factors, for example one scenario focused on older people that are widowed and in poor health. Another scenario placed emphasis purely on contact with friends, relatives and neighbours. The variables were then mapped at a Lower Super Output Area (LSOA) level to identify clusters of households that are potentially vulnerable to loneliness and isolation.80 Any authority which wished to implement this technique would require the relevant licence from Mosaic or similar. Sensory Impairment Although it is frequently asserted to be the case that sensory impairment leads to social isolation and loneliness, there is a dearth of research that actually investigates the

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relationship. Further, despite the large numbers involved, sensory impaired groups seldom feature in research on loneliness and isolation. One study which has looked at the issue in 2011 indicated that loneliness was higher in visually impaired Dutch older people than a matching non-visually impaired group. 81

Loss of vision In respect of loss of vision, the problem of loneliness and isolation associated with loss of vision could be especially problematic in Blackburn with Darwen as the percentage of older people who are registered blind or visually impaired is much higher than the national figures. Indeed it is more than twice as large for registered partially sighted. Table 2 - Percentage age 65+ with vision or hearing impairment. Blackburn with England Darwen Registered Blind 1.77 1.26 Registered Partially Sighted 2.73 1.32 Deaf .22 .27 Hard of Hearing 1.59 1.59 Source:- West Midlands Public Health Observatory82 Loss of hearing The figures for deaf and hard of hearing are not significantly different to the national picture but the proportions nonetheless indicate substantial numbers of older people who are deaf or hard of hearing and potentially at risk of loneliness and isolation because of the condition. In their report “Hidden Crisis”83 the Royal National Institute for the Deaf (RNID) made the following observations:-  Hearing loss made some participants withdraw from certain social activities, particularly those involving large groups.  Even where participants continued to take part in these types of activities, their difficulties hearing could result in a sense of isolation. In a report concerning the effect of hearing loss on people and their partners, both participants with hearing loss and their partners reported feelings of loneliness. However, hearing partners, in particular, spoke of feeling lonely and felt that they were missing out on companionship.84

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Value for Money

GP Visits The average cost of a visit to a GP is £36 and to a nurse £12.85 Clearly, if the number of visits can be reduced, this will result in a cost saving. A study supported by the Medical Research Council was carried out in Glasgow. After controlling for sociodemographic and socioeconomic variables and health, loneliness was significantly associated with frequency of consultation at the surgery but not with the frequency of home visits.86 This study indicated that lonely people of middle and older age made more frequent visits to a GP than people who were not lonely and this was independent of other factors. That is, loneliness alone is predictive of a higher than average frequency of visits to a GP.

Emergency Department (ED) Visits Studies from the USA have observed increased ED visits to be linked with loneliness, vulnerability and lack of access to family support.87,88,89 That is, social isolation as well as loneliness contributes to ED visits. Among older people without a family network, one study found that the likelihood of ED usage increased sevenfold.90

Care Home Admission An Oxfordshire county council report91 recognized loneliness as being a cause for care home admission. “Isolation and lack of social contact were mentioned in a number of instances as factors which contributed to an older person’s deteriorating health and well-being”. This particular study did not identify costs or savings that might be made if care home admissions are prevented or delayed. It also noted reasons other than loneliness or isolation as being the primary cause of care home admission. It can also be observed that the people who were admitted into care homes had already been attracting costs for support which they were receiving at home. It might not be the case therefore that reducing loneliness and isolation would reduce costs in terms of care home admissions as such interventions would not necessarily have any effect on the other causes for admission, and admission to a care home would result in a saving of the costs of home support.

In Blackburn with Darwen, residential home fees range from a basic £408 per week to £432 for dementia places or £547 for nursing homes.92 This suggests that any care home admissions that are prevented results in an approximate saving of between 400 to 550 pounds per week minus the cost of care or interventions that were being received at home. There might also be other savings such as, for instance, those associated with falls. In addition, Adult Social Services in Blackburn achieved an 18% reduction in admissions to care homes by means of “reablement” and “telecare” interventions.92 It is not possible to know what the extent of loneliness and isolation is in the population who might become residents of a care home but the results of a survey are to be published in November 2013 that would clarify this.92

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Befriending Although studies such as those above indicate that there are significant savings available if loneliness and isolation are reduced, there is very little evidence of actual cost effectiveness as very few studies have included this as an element of their research (see for instance Windle 200859). However Knapp93, in an analysis which included formal and informal factors, concluded that a befriending service would cost about £83 per year per person and would result in a saving of about £300 per year derived from reduced needs for treatment and support and an increase in quality of life and reduced depression. A community navigator type intervention would cost about £480 per person and would result in savings (partly brought about by for instance a move into employment) of £900 in the first year.

Two studies94,57 have shown that “closed group activity” based interventions result in significant savings in the intervention compared to the control group.

Involvement

Following on from the suggestions in the Campaign to End Loneliness Toolkit4, intelligence and data were obtained by a number of means from a range of stakeholders. These included case studies, focus groups, conferences and seminar events. 50+ partnership events In October 2012, the 50+ Partnership organised a Social Isolation and Loneliness Workshop which aimed to scope this ISNA. This was the first of three events. 18 people attended representing a range of organisations that had a stake or interest in loneliness and isolation in relation to older people. The discussions covered:- 1. The key issues for individuals, services, friends and relatives. 2. Issues around minority ethnic groups. Following on from this, a further event was held on February 26th, 2013 called “Communities Together, Loneliness Never”. This consisted of two workshops, and an address by Marianne Symons of the Campaign to End Loneliness. As well as a number of professionals engaged in various relevant areas, the event was primarily attended by older residents of the borough who were the main contributors to the workshops. The first workshop dealt with:-

 1.“What are the different ways we connect with other people?” and “How are these connections important to us individually and collectively?”

 2.”What can make these connections break?” and “What is the effect on individuals?”

 3. “Can you suggest ways to prevent connections breaking?”, “Are there any warning signs?” and “What support systems might help?”

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In respect of Question 1, a long list of possibilities was produced including shared interests, faith venues, family, neighbours, volunteering etc. and these connections were important in respect of health and wellbeing, information, self-esteem, keeping in touch and social interaction. For the second question, ”What can make these connections break?” and “What is the effect on individuals?”, connections could be broken by loss of relationships by way of, for instance, bereavement or families moving away, geographical distances and loss of public services, financial reasons such as loss of income or by poor health, failures of communication and loss of transport. The effect on individuals could be impaired mental health, poorer physical health and social losses such as loss of independence. For question 3, ways of preventing connections breaking could include good neighbour schemes, luncheon clubs and befriending schemes as well as remaining tolerant and keeping open public amenities, helplines such as Silver Line and bereavement support. Warning signs could include symptoms of depression and self-neglect and anti-social behaviours. The support systems that might help included Skype, cheaper transport and the Samaritans. For the second workshop the questions

 1. “What groups do we belong to? And “why are they important?” Marianne Symons  2. “What things might hinder us in taking part in activities?”

 3. “How do we encourage those isolated for different reasons to get involved?” were considered. Self-esteem, enjoyment, health and wellbeing, social inclusion and information and education were the themes that emerged from the first question. For the second question, the themes that emerged were transport, finance, confidence, health/disability, weather, responsibilities, location, language barriers, and timing (time of day). The themes for the third question were professionals (such as area co-coordinators) individuals (someone to go with), communications, projects (e.g., befriending), transport, venues. Other items included incentives and intergenerational activities. A fourth item that developed was “Have you any ideas for what sort of activities might engage people?” The responses included support (to, for instance, build confidence), advertising, social activities, transport, volunteers, educational and “other” including intergenerational activities.

Other comments to emerge that don’t quite fit into the categories above were to use PCSOs, discover and challenge barriers, “how do you find help without a computer?”, leisure centres on prescription, and something to get up for (a focus).

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Loneliness and isolation roadshows In addition to the activities noted above, the 50+ partnership has carried out a series of twelve roadshows. This involved meeting with local groups and sheltered housing schemes to “speak to residents about their experiences of loneliness and isolation”. Each of these accounts is unique and often very personal. Some of the accounts with personal and identifying details removed are presented below under the following headings – Bereavement, Illness, Carers, General.

Bereavement

Vera (69) shared the story of her sister whose husband died suddenly leaving her alone 6 years ago. She has become quite unhappy and is having health problems. Although her friends take her out quite often, it is mainly in the evening for a drink and during the day she doesn’t go out much at all. Occasionally Vera takes her sister out but it is becoming a problem with her husband who doesn’t always want his sister-in-law with them when they go out. Vera is finding this difficult to deal with and doesn’t know what she should do.

Maureen (61) lost her husband 8 years ago but she was lucky that she had lots of family around. One difficulty she had was that most of the social groups around were for people 70+. She couldn’t find anything for the 50-60 age range. A younger widows group would have been particularly useful for her.

Alan (70) lived alone for 18 years after the death of his wife. He said that he found this manageable until he retired. At that point he lost all his contacts and all his confidence. He said that he found himself alone and having very little contact with other people. This continued for a number of years. It was only after he had a hip operation that his family talked him into going into sheltered accommodation. He is much happier now and loves being around people and joins in with the social aspects of the housing scheme.

Illness

Carol has a friend that is housebound and knows that unless people go to see her she doesn’t see anyone and it worries Carol that her own health problems mean she is not always available to visit. She thinks her friend needs more help but thinks she’s a bit scared to accept any. Her mobility problems came about after a fall, and Carol thinks if she had been given a bit more support afterwards, then she might be a bit happier now.

Stan admits to being the sort of person who likes to go home on his own, lock the door and shut the world out behind closed curtains. He had a stroke and now needs regular physiotherapy to carry out basic tasks such as washing and dressing. He feels his closest family are intruding in his life and is being supported to move to a bungalow away from them. Since becoming involved with the Stroke Club he has gained confidence to join other groups including art sessions and gardening. Life isn’t easy with his disability but he is reasonably happy.

People felt that visiting those who can’t get out is important and especially those friends who had to go into care homes. More befriending and visiting is needed.

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Carers

Margaret (74) believes health issues play a big part in becoming lonely and had noticed it a lot when she was working as a nurse. A friend’s husband has recently had a stroke and this friend now finds it very difficult to get out as she’s become her husband’s carer. She has paid for carers to come in to help but it isn’t really helping her to get out. She doesn’t know what else she can do and is becoming quite lonely.

Another carer told us that when a loved one falls ill, your natural instinct is to care for them, but when the illness never goes away and becomes permanent, caring takes on a different role. Your own life goes on hold! Not only is it difficult for your loved one to accept they have a mental and physical disease, but becoming a permanent carer has its downfalls too. You feel very isolated and many times quite alone. Frustrated due to the lack of care and understanding from the medical professionals and always fighting for the 'duty of care' that is never shown - especially to the elderly and God forbid if they suffer with Alzheimer’s and vascular dementia!

General

Erica (80) and Bob (86) said that they had reached a time where all their friends were dying and they no longer had many family members around. They discussed what to do next and came to the decision to move into sheltered housing. They thought the scheme was good for them because they could manage with the help of people around them. If any of the residents were going into town they will ask the less mobile residents if there is anything that they need picking up. The residents look after each other.

Jane attends a coffee morning and told of a lady who came to the group. The lady told her that she was living alone in a large house and was finding it very difficult. She said that despite being unhappy in her home, she didn’t want to leave as all her memories were there and she couldn’t give them up. The lady hadn’t attended the coffee morning before and they haven’t seen her since. Jane presumes she is still alone in her house and remains unhappy.

Many people said that holidaying on your own can be lonely. Getting out and about during the day is fine but coming back to eat alone and spend the evening alone is hard. If you’re lucky there is someone else to sit with at meal times.

The case studies make the point that loneliness and isolation is different for everyone and

therefore it is difficult to generalise the experience and also difficult to generalise in terms of determining appropriate interventions. Analysing the case studies as a whole, there were however a number of themes that emerged. These were:- Causes and perpetuators  Transport. Lack of transport made a substantial contribution to people’s feelings of loneliness and isolation. The bus pass however was seen as liberating. In some cases, buses were not available or there was difficulty accessing them due to disability.  Bereavement was a primary cause of loneliness

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 Health problems  Communication problems. E.g. following a stroke, deafness  Safety. Fear of crime or accidents prevented people going out  Mental health problems – phobias  Discouragement of would-be volunteers and befrienders from coming forward to help by their own family and friends  Being a carer. Carers experienced a great deal of loneliness and isolation but also had very limited access to the means to reduce loneliness. Telephone befriending services were invaluable in this situation. It was difficult making professionals understand the problems faced and experienced by carers. Carers noted that they had less of an identity than the person being cared for. Carers also had very little freedom to do anything at all. Respite for carers was very important. The charity Crossroads was also very important. What prevented loneliness and isolation  Social clubs, groups, activities. Many people were socially active and members of several groups. These facilities were highly valued in terms of preventing loneliness and isolation. King Georges Hall, Windsor Suite on Wednesdays was singled out as being especially good and the Stroke association coffee mornings were seen as being particularly useful. Positive invitations were needed to groups, preferably with someone who could introduce new members rather than new members simply turning up alone. There were few if any groups for younger older people. People needed an incentive to join groups. It was important to emphasise having a good time (rather than just relieving loneliness).  Transport  Information Central information points such as doctors’ surgeries were needed to provide information about what was available.  Work is good, retirement is bad – for some people  A dog is a good thing  Good neighbours were important for preventing and alleviating loneliness  Re:fresh is very good for alleviating loneliness  Communal life, sheltered accommodation – very good for preventing loneliness  Phone, Skype and bus passes were extremely useful in respect of alleviating loneliness and their use should be facilitated.  Sociable – but not everyone likes activities. People wanted to socialise and just be with other with other people but not necessarily take part in craft activities etc.

Other points  Contact people before they get too lonely (and therefore lacking in motivation)  Not everyone is lonely – stop bothering them  Not many groups for younger people

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“Communities Together, Loneliness Never”

A further event was hosted by the 50+ Partnership at King George’s Hall on the 25th July 2013.95 This was attended by 70 members of the public and interested stakeholders. The purpose of the event was to synthesise the data and findings from previous events and to discuss the findings and implications of the ISNA. There were two workshops which dealt with a range of questions. The significant points that emerged from these included:-

 There needs to be an improvement in the provision and availability of transport  There needs to be clear jargon free information provided in a variety of venues and in different media.  There needs to be a central up to date data base of groups and organisations.  Organisations and services need to work together – services should be more “joined up”  There is a need to look at what already “The most important issue is to have clear, works well - Build on what is already there - jargon free information and to perhaps Learn from good practice begin by targeting identified risk groups.”  Young people and families need to be more involved in terms of raising their awareness and helping those who need support to make social contacts.  More venues and meeting places are needed.  More face to face and “buddying” type contact are needed in respect of invitations to events and activities. More one to one services such as bereavement counselling, buddies and support when a partner goes into care.  People who have a need of some kind need to be matched with appropriate support services.  Public and professionals need to be alert to need and be prepared to ask if someone wants help  Raise awareness of the symptoms  We need to be better neighbours  Providers must not make assumptions “…….the challenge is to reach those who  Residents could carry out surveys and feed need support in making social contact with the information to a central point others and to provide that support.”  Disabilities need to be understood

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 Services need to be non-bureaucratic  Commissioners and regulators need to build contracts carefully  Service providers should occasionally put themselves in the place of the user  Ask people what they want  There should be more opportunities for people “Again it is vital to build on existing to meet informally successful activity, to learn from good  There should be more opportunities for men to practice and to ask people what they meet want. Services need to be joined up.”  There should be more inter-generational and cultural cohesion  More one to one services such as bereavement counselling, buddies and support when a partner goes into care.  More befriending and support for people moving house  Specific volunteering opportunities could be developed that support people attending activities

Social engagement by the Corporate Research Joint Intelligence Unit The Joint Intelligence Unit has recently conducted two focus groups with groups of people who might not normally appear in the data. It is in the nature of loneliness and isolation that the most at-risk groups might not come to the attention of researchers and might not appear in commonly used sets of statistics. The groups in question therefore were a group of homeless young families who were accommodated or had been accommodated in a Twin Valley Homes (social housing) facility and a group of young homeless people also accommodated or previously accommodated in Twin Valley Homes facilities. The recurring themes that have emerged from these groups include the following:-  Transport – its cost and unavailability contributed to loneliness and isolation  Money – without it your activities or possible activities are limited  Being in a “nice” relationship was what most people wanted and would more or less banish loneliness entirely  Being in a bad relationship was a lonely and isolating experience  Mental health difficulties – depression and anxiety  Low self-confidence and self-esteem  Drug use was an isolating experience

There is also an aim to carry out a focus group in a Working Men’s Club. Taken together, this will constitute a pilot study the findings of which will form the basis of a larger borough- wide study dealing with particularly at-risk groups who might not normally be included in research findings.

Involvement Corporate Research Joint Intelligence Unit 41

Recommendations

Suggested recommendations from the Loneliness and Isolation ISNA Steering Group

Strategic

 Explore the potential of mapping analysis, to understand the extent and distribution of living alone and isolation within BwD e.g. to build on local GIS (Geographic Information System) work of Lancashire Fire & Rescue who have added to Mosaic data on household fire safety checks undertaken and location of domestic fires.  Encourage partners to work together to ensure there is no duplication of local programmes / projects for the support of those who are isolated or lonely.  Develop and implement a commissioning strategy for prevention and social building initiatives. (2030 Vision)  Detailed strategic analysis of single person households using census and other relevant data at LSOA level where available to understand the distribution and concentration of single person households in the borough  To map the agencies within the borough that already provide specific services to alleviate social isolation and loneliness to identify gaps, geographical concentration and barriers to access.  Carry out a pro-active assessment of the level of need based on the known characteristics of those likely to be socially isolated or lonely. That is, those individuals who are lonely and isolated need to be identified through public records, GPs, Emergency Departments etc.. It would be useful to have a particular emphasis on isolation and identifying those who are isolated and might have needs which are caused by or made worse by isolation.

Neighbourhood

 Produce/ adapt from elsewhere a simple briefing/ practical resource on social isolation for frontline workers, with a few key issues/ sign posting information.  Develop a training package to support those working with people at risk of isolation and loneliness.  Develop a Community Navigator scheme where local volunteers help older or vulnerable people find their way to activities or services they would enjoy or find useful.  Support the development of Good Neighbour Schemes. (2030 Vision)  Provide support to encourage smaller groups to develop whether new or established. (2030 Vision)  Ensure that neighbourhood teams and the developing Your Support Your Choice continue to develop initiatives and approaches to reducing social isolation  Explore links with local schools and colleges for potential intergenerational activities.

 Activities and interventions for particular groups such as carers or others who have a “community of interest”.

Recommendations Corporate Research Joint Intelligence Unit 42

Individual

 Use the opportunity of collecting data for the new ASCOF (Adult Social Care Outcomes Framework) indicator to identify socially isolated service users, offer intervention and track the impact.  Encourage more people to participate in social activities (bring a friend)  Develop detailed research and engagement programme to understand local perceptions of social isolation and the initiatives local people consider important  Social prescribing scheme for those identified by GP and other health services experiencing loneliness and/or social isolation.  Determined effort to identify individuals who would not normally be included in initiatives to reduce social isolation and loneliness. These might include men, the homeless, people with a disability, carers.  Develop digital inclusion including going on line, the use of tablets, PCs, smart phones and Skype.

Recommendations Corporate Research Joint Intelligence Unit 43

Existing strategies, plans and policies

Government The Government's commitment to the loneliness and isolation agenda has been summarised by researchers at University College London: “The detachment from societal activities of older people has attracted considerable attention from policymakers. This is in part due to the beliefs that older people are more susceptible to detachment and that the consequences on their health are likely to be more severe. Policies to alleviate the effects of social detachment have been outlined in the Healthy Lives, Healthy People White Paper (HM Government, 2010)96. It states that local government and central government ‘will work in partnership with businesses, voluntary groups and older people in creating opportunities to become active, remain socially connected, and play an active part in communities – avoiding social isolation and loneliness.’”97 The 50+ Partnership Outcome 6, “Social well- being and involvement”, in the 50+ partnership Blackburn with Darwen Older People Strategy 98 2011-2016 addresses Loneliness and social isolation the issue of loneliness I was very pleased to hear that a national campaign to tackle loneliness has and isolation in the older praised work going on in Blackburn with Darwen. population. Its aims are The Campaign to End Loneliness has said the borough’s commitment to tackle that older people should loneliness and social isolation is to be applauded. have good social Loneliness is a big issue that we need to tackle. There are at least 2000 lonely networks and to achieve people in the borough and probably many more. this, lonely and isolated Loneliness and social isolation, which means people do not have or have older people will need regular contacts with other people, has been linked to poor health and structured opportunities. wellbeing. Research shows loneliness can be as harmful to people's health as Efforts will be made smoking 15 cigarettes a day. It’s great a national campaign says we are on the therefore to maximise the right track but there is a lot of work to do. capabilities and energy of One of the areas we are hoping to build on is fostering neighbourliness. older people and this will Good neighbours can have a massive effect on tackling these problems. I have involve utilising the met several people through the Your Call Good Neighbour Awards who are Neighbourhoods Service tackling these issues but we need more to come forward and work with us. and Big Society ambitions. The importance of building links with younger people and the work of the Intergenerational Task Force was also acknowledged as well as the Equality and Diversity outcomes in respect of achieving this goal. The strategy also includes a number of other aims such as staying healthy, being able to get out and about and having enough money, all of which contribute to reducing the probability of loneliness and isolation becoming a problem.

Existing strategies, plans and policies Corporate Research Joint Intelligence Unit 44

Where to find out more

The Campaign to End Loneliness http://www.campaigntoendloneliness.org.uk/

Age UK http://www.ageuk.org.uk/

The 50+ Partnership http://bwd50plus.org.uk/

References

1Grenade, L. and Boldy, D. (2008) Social isolation and loneliness amongst older people: issues and future challenges in community and residential settings. Australian Health Review. 2008;32:468–478. doi: 10.1071/AH080468. Available from http://www.ncbi.nlm.nih.gov/pubmed/18666874

2 Hall, M. and Havens, B.(2001) The effects of social isolation and loneliness on the health of older women. Research Bulletin, Centres of Excellence for Women's Health. 2001;2:6–7. Available from http://www.pwhce.ca/effectSocialIsolation.htm

3 Perlman, D. and Peplau, L. A. (1981). Toward a social psychology of loneliness. In S. W Duck & R. Gilmour (Eds.J , Personal Relationships. 3: Personal relationships in disorder (pp. 31-56). London: Academic Press. Available from http://www.iscet.pt/sites/default/files/obsolidao/Artigos/Loneliness%20and%20Social%20Isolation.pdf

4 Campaign to End Loneliness Loneliness and isolation. A Toolkit for Health and Wellbeing Boards. http://campaigntoendloneliness.org/toolkit/

5 Blackburn with Darwen Health and Wellbeing Strategy 2012-2015 Available from http://www.blackburn.gov.uk/Lists/DownloadableDocuments/HWBStrategy2012.pdf

6 HM Government (July 2012) Caring for our future: reforming care and support Presented to Parliament by the Secretary of State for Health by Command of Her Majesty July 2012. Available from http://www.dh.gov.uk/health/files/2012/07/White-Paper-Caring-for-our-future-reforming-care-and-support-PDF- 1580K.pdf

7 Russell, D. (1996). The UCLA Loneliness Scale (Version 3): Reliability, validity, and factor structure. Journal of Personality Assessment, 66, 20 40. http://www.fetzer.org/sites/default/files/images/stories/pdf/selfmeasures/Self_Measures_for_Loneliness_an d_Interpersonal_Problems_VERSION_3_UCLA_LONELINESS.pdf

8 Sport England (2013) How the Active People Survey Works http://www.sportengland.org/research/about- our-research/active-people-survey/

9 Cornwell, E.Y. and Waite, L. J. (2009) Social disconnectedness, perceived isolation, and health among older adults’ Health Soc Behav 50(1 ) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2756979/?tool=pubmed

10 Geller, J., Janson, P., McGovern, E. and Valdini, A.. (1999)Loneliness as a Predictor of Hospital Emergency Department Use. Journal of Family Practice. 48 (10) http://www.jfponline.com/pages.asp?aid=2697

11 Cohen, G.D. et al.. (2006) ‘The impact of professionally conducted cultural programs on the physical health, mental health, and social functioning of older adults’, The Gerontologist, 46 (6) http://gerontologist.oxfordjournals.org/content/46/6/726.Abstract

12 Pitkala, K.H. et al.. (2009) Effects of psychosocial group rehabilitation on health, use of health care services, and mortality of older persons suffering from loneliness:a randomised, controlled trial. Journal of Gerontology:

References Corporate Research Joint Intelligence Unit 45

Medical Sciences, 64A (7) http://biomedgerontology.oxfordjournals.org/content/64A/7/792.abstract

13 Russell, D.W., Cutrona, C.E., de la Mora, A and Wallace R.B.. (1997) Loneliness and nursing home admission among rural older adults. Psychol Aging 12(4). http://www.ncbi.nlm.nih.gov/pubmed/9416627

14 Office for National Statistics (2012) Families and households, 2012 Statistical Bulletin. Derived from ONS Labour Force Survey. Available from http://www.ons.gov.uk/ons/dcp171778_284823.pdf

15 POPPI People aged 65 and over living alone, by age and gender, projected to 2030 Available from http://www.poppi.org.uk/index.php?pageNo=324&PHPSESSID=5l7icbjb81dcth84o5ppojdiq7&sc=1&loc=8295&np

16 Victor, C. (2011) Loneliness of older men and women in rural areas of the UK in Safeguarding the Convoy A call to action from the Campaign to End Loneliness. Age UK (Oxford) Available from http://www.wrvs.org.uk/Uploads/Documents/Get%20involved/safeguarding-the-convey_-_a-call-to-action-from-the- campaign-to-end-loneliness.pdf

17 Carla, M., Perissinotto, M. H. S., Stijacic Cenzer, I., Covinsky, K. E., (July 2012) Loneliness in Older Persons A Predictor of Functional Decline and Death Arch Intern Med. 2012;172(14):1078-1084. doi:10.1001/archinternmed.2012.1993 http://archinte.jamanetwork.com/article.aspx?articleid=1188033#METHODS

18 Pressman, S.D., Cohen, S., Miller, G. E., Barkin, A., Rabin, B. S. and Treanor, J. J.. (2005). Loneliness, social network size, and immune response to influenza vaccination in college freshmen. Health Psychology, 24, 297-306. Available from http://www.ncbi.nlm.nih.gov/pubmed/15898866

19 Caspi, A., Harrington. H., Moffitt, T.E., Milne. B. J. and Poulton R.. (2006) Socially isolated children 20 years later: Risk of cardiovascular disease. Archives of Pediatrics & Adolescent Medicine 160:805-811 Available from http://www.ncbi.nlm.nih.gov/pubmed/16894079

20 Danese, A., Moffitt, T. E., Harrington, H. L., Milne, B. J., Polanczyk, G., Pariante, C.M., Poulton, R., Caspi, A.. (2009) Adverse childhood experiences predict adult risk factors for age-related disease: depression, inflammation, and clustering of metabolic risk markers. Archives of Pediatrics & Adolescent Medicine, 2009 163:1135-1143. Available from http://dunedinstudy.otago.ac.nz/journals/adverse-childhood-experiences-predict-adult-risk-factors-for-age-related- disease-depression-inflammation-and-clustering-of-metabolic-risk-markers

21 Pressman, S.D., Cohen, S., Miller, G. E., Barkin, A., Rabin, B. S., & Treanor, J. J.. (2005). Loneliness, social network size, and immune response to influenza vaccination in college freshmen. Health Psychology, 24, 297-306. Available from http://www.ncbi.nlm.nih.gov/pubmed/15898866

22 Cacioppo, J.T. and Hawkley, L.C.. (2007) Aging and Loneliness Downhill Quickly? Current directions in Psychological Science. Center for Cognitive and Social Neuroscience, University of Chicago. Available from http://psychology.uchicago.edu/people/faculty/cacioppo/jtcreprints/agingandloneliness.pdf

23 Cacioppo, J.T., Hawkley, L.C., Berntson, G.G., Ernst, J.M., Gibbs, A.C., Stickgold, R., & Hobson, J.A.. (2002). Lonely days invade the night: Social modulation of sleep efficiency. Psychological Science, 13, 385–388. Available from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841303/

24Jacobs, J.M., Cohen, A., Hammerman-Rozenberg, R. and Stessman, J.. (2006). Global sleep satisfaction of older people: The Jerusalem Cohort Study. Journal of the American Geriatric Society, 54, 325–329 Available from http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2005.00579.x/abstract

25 Udell, J.A., Steg, P.G., Scirica. BM., Ohman, E.M., Eagle, K.A., Goto, S., Cho, J.I., Bhatt. D.L.. (2012) Living Alone and Cardiovascular Risk in Outpatients at Risk of or With Atherothrombosis Arch Intern Med. 2012;172(14):1086-1095. doi:10.1001/archinternmed.2012.2782 http://archinte.jamanetwork.com/article.aspx?articleid=1188041

26 Holt-Lunstad, J., Smith, T.B., Layton. J.B., (2010) Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 7(7): e1000316. doi:10.1371/journal.pmed.1000316 Available from http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000316

27 Cacioppo, J. T., Hughes, M. E., Waite, L. J., Hawkley, L.C., Thisted, R.A.. (2006) Loneliness as a Specific Risk Factor for Depressive Symptoms: Cross-Sectional and Longitudinal Analyses. Psychology and Aging

References Corporate Research Joint Intelligence Unit 46

2006, Vol. 21, No. 1, 140–151Available from http://psychology.uchicago.edu/people/faculty/cacioppo/jtcreprints/chwht06.pdf

28 Aylaz, R., Akturk, U., Erci, B., Ozturk, H., Asian, H.. (2012) Relationship between depression and loneliness in elderly and examination of influential factors. Archives of Gerontology and Geriatrics Volume 55, Issue 3 , Pages 548-554, November 2012 Available from http://www.aggjournal.com/article/S0167- 4943(12)00053-2/abstract

29Ong, A. D., Rothstein, J. D., Uchino, B. N.. (2012) Loneliness accentuates age differences in cardiovascular responses to social evaluative threat. Psychology and Aging, Vol 27(1), Mar 2012, 190-198. doi: 10.1037/a0025570 Available from http://psycnet.apa.org/journals/pag/27/1/190/

30 Cacioppo, J. T. and Hawkley, L. C.,(2003) Social isolation and health, with an emphasis on underlying mechanisms. Perspect Biol Med. 2003 Summer;46(3 Suppl):S39-52 http://www.ncbi.nlm.nih.gov/pubmed/14563073

31 Robinson, S. and Harris, H..(2011) Smoking and Drinking Among Adults, 2009: A Report on the 2009 General Lifestyle Survey. London: Office for National Statistics. Available from http://www.ons.gov.uk/ons/rel/ghs/general-lifestyle- survey/2009-report/index.html

32 Wright, F. and Whyley, C.. (1994) Accident Prevention and Risk-Taking by Elderly People: The Need for Advice. London: Institute of Gerontology, King's College London. Available from http://www.dass.stir.ac.uk/old- site/DRUGS/glasgow/elderly.pdf

33 Tabloski, P. and Church, O. M.. (1999) 'Insomnia, alcohol and drug use in community-residing elderly persons', Journal of Substance Use, 4: 147-154. Available from http://www.researchgate.net/publication/232079983_Insomnia_alcohol_and_drug_use_in_community- residing_elderly_persons

34 Woodhouse, P., Keatinge, W. R. et al.. (1989) 'Factors associated with hypothermia in patients admitted to a group of inner city hospitals', Lancet, 2(8673): 1201-1205. Available from http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(89)91803-5/abstract

35 Akerlind, I. and Hornquist, J. O. 1992 Loneliness and alcohol abuse: a review of evidences of an interplay. Soc Sci Med. 1992 Feb;34(4):405-14. http://www.ncbi.nlm.nih.gov/pubmed/1566121

36 Steptoe, A., Shankar, A., Demakakos, P., Wardle, J.. (2013) Social isolation, loneliness, and all-cause mortality in older men and women.Proceedings of the National Academy of Science of the United States of America. http://www.pnas.org/content/early/2013/03/19/1219686110.full.pdf+html

37 Age UK (April 2013) Later Life in the United Kingdom Monthly Factsheet. http://www.ageuk.org.uk/Documents/EN- GB/Factsheets/Later_Life_UK_factsheet.pdf?dtrk=true

38 Pinquart, M., Sörensen, S., Shohov, S. P.. (Ed), (2003). Risk factors for loneliness in adulthood and old age--a meta- analysis. Advances in psychology research, Vol. 19., (pp. 111-143). Available from http://psycnet.apa.org/index.cfm?fa=search.displayRecord&UID=2003-00988-005

39 Banks, J., Nazroo, J., Steptoe, A.. (October 2012) The Dynamics of Ageing:Evidence from the English Longitudinal Study of ageing 2002-10 (Wave 5) Institute for Fiscal Studies http://www.ifs.org.uk/ELSA/reportWave5

40 Victor, C. R., Burholt, V., Martin, W.. (2012) Loneliness and ethnic minority elders in Great Britain: an exploratory study. J Cross Cult Gerontol. 2012 Mar;27(1):65-78. doi: 10.1007/s10823-012-9161-6. http://www.ncbi.nlm.nih.gov/pubmed/22350707

41 Bowling, A. (2012) ”What do we know about loneliness?” Conference presentation http://www.campaigntoendloneliness.org.uk/loneliness-conference/

42 Victor, C.. (2012) “What do you expect at your age?” (Presentation) http://www.campaigntoendloneliness.org.uk/wp- content/uploads/downloads/2012/07/Victor-Loneliness-Plenary-July2012.pdf

References Corporate Research Joint Intelligence Unit 47

43 Tjalling, J.H., Darley, J.H.D., Aartjan, T.F.B., Tilburg, T.G., Stek, M.L., Jonker, C., Schoevers, R.A.. (Dec 2012) Feelings of loneliness, but not social isolation, predict dementia onset: results from the Amsterdam Study of the Elderly (AMSTEL) J Neurol Neurosurg Psychiatry doi:10.1136/jnnp-2012-302755 Available from http://jnnp.bmj.com/content/early/2012/11/06/jnnp-2012-302755.abstract

44 Kane, M., Cook, L.. (April 2013) Dementia 2013: The hidden voice of loneliness. Alzheimer’s Society. http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=1677

45 Guasp, A.. (Survey conducted 2010) Lesbian, gay and bisexual people in later life. Stonewall http://www.stonewall.org.uk/documents/lgb_in_later_life_final.pdf

46 Department for Communities and Local Government (2010) Income Deprivation Affecting Older People Index (IDAOPI) IMD 2010 data published by Department for Communities and Local Government (DCLG) Population data supplied by the Office for National Statistics 2010 Mid-2009 Population Estimates for Lower Layer Super Output Areas in England by Single Year of Age and Sex Experimental Statistics supplied to the PHOs Available from http://www.communities.gov.uk/publications/corporate/statistics/indices2010

47 Demakakos, P., Nunn, S., Nazroo, J.. (2006) Loneliness, relative deprivation and life satisfaction. In: Banks, J and Breeze, E and Lessof, C and Nazroo, J, (eds.) Retirement, health and relationships of the older population in England: The 2004 English Longitudinal Study of Ageing (Wave 2). (297 - 338). The Institute for Fiscal Studies: London. Available from http://www.ifs.org.uk/elsa/report06/ch10.pdf

48 Office National Statistics (June 2013) Mid-2012 Population Estimates: Single year of age and sex for local authorities in England and Wales. http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-310118

49 Office National statistics (2012) Table KS105EW 2011 Census: Household composition, local authorities in England and Wales http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-286262

50 Blackburn with Darwen Borough Council 2011 Census Second Release Blackburn with Darwen summary http://www.blackburn.gov.uk/Lists/DownloadableDocuments/CensusKeyStatistics.pdf

51 NOMIS/ONS (2013) DC2101EW - Ethnic group by sex by age Available from https://www.nomisweb.co.uk/default.asp

52 Local Government Association and Campaign to End Loneliness (2012) Combating Loneliness. A guide for local authorities. http://www.local.gov.uk/c/document_library/get_file?uuid=4e104158-77a2-4eb1-87a7- 53154b2d5105&groupId=10171

53 Aked,J., Marks, N., Cordon, C., Thompson, S.. (2008) Five Ways to Wellbing. A report presented to the Foresight Project on communicating the evidence base for improving people’s well-being. (the new economics foundation) http://www.neweconomics.org/sites/neweconomics.org/files/Five_Ways_to_Well-being_Evidence_1.pdf

54 The Campaign to End Loneliness. Loneliness and Isolation. A Toolkit for Health and Wellbeing Boards http://campaigntoendloneliness.org/toolkit/?s=bristol

55 The Campaign to End Loneliness (2012) Reducing Loneliness and Isolation in Older Age: Beyond the JSNA and JHWS Webinar Summary, 23 November 2012 http://campaigntoendloneliness.org/2/wp-content/uploads/Reducing-Loneliness- 23-November-Webinar-Summary.pdf

56 Kremers, I.P. et al. (2006) 'Improved self management ability and well-being in older women after a short group intervention', Aging and Mental Health, vol 10, no 5, pp 476−484. http://academic.research.microsoft.com/Paper/5644502.aspx

57 Savikko, N., et al. (2010) 'Psychosocial group rehabilitation for lonely older people: favourable processes and mediating factors of the intervention leading to alleviated loneliness', International Journal of Older People Nursing, vol 5, no 1, pp 16−24. http://onlinelibrary.wiley.com/doi/10.1111/j.1748-3743.2009.00191.x/abstract

58 Findlay, R.A.. (2003) 'Interventions to reduce social isolation amongst older people: where is the evidence?' Ageing and Society, vol 23, no 5, pp 647−658. http://www.scie.org.uk/publications/briefings/files/briefing39.pdf

References Corporate Research Joint Intelligence Unit 48

59 Windle, G., et al. (2008) Public health interventions to promote mental well-being in people aged 65 and over: systematic review of effectiveness and cost-effectiveness, Bangor: Institute of Medical and Social Care Research. http://www.nice.org.uk/nicemedia/live/11999/42401/42401.pdf

60Cattan, M., White M., Bond, J., and Learmouth, A..(2005) Preventing social isolation and loneliness among older people: a systematic review of health promotion interventions. Ageing & Society 25, 2005, 41–67. 2005 Cambridge University Press Available from http://carechat.ca/wp-content/uploads/2012/04/isolation-studies.pdf

61 Age UK Combating loneliness: Age UK’s befriending services Available from http://www.ageuk.org.uk/health- wellbeing/relationships-and-family/befriending-services-combating-loneliness/

62Cattan, M., Kime, N. and Bagnall, A. M. (2011), The use of telephone befriending in low level support for socially isolated older people – an evaluation. Health & Social Care in the Community, 19: 198–206. doi: 10.1111/j.1365-2524.2010.00967.x Available from http://www.ageuk.org.uk/documents/en-gb/for-professionals/research/low- level%20support%20for%20socially%20isolated%20older%20people%20(2008)_pro.pdf?dtrk=true

63 Campaign to end Loneliness (2012) Loneliness and Isolation. A toolkit for health and wellbeing boards. Yorkshire and Humber Age UK GP Social Prescribing Pilot. Available from:- http://campaigntoendloneliness.org/toolkit/casestudy/yorkshire-and-humber-age-uk-gp-social-prescribing-pilot/

64 Windle, K., Francis, J., Coomber, C.. (2011) Preventing loneliness and social isolation: Interventions and outcomes . Social Care Institute for Excellence. http://www.scie.org.uk/publications/briefings/files/briefing39.pdf

65 Sport England Blackburn with Darwen's re:fresh campaign Available from http://www.sportengland.org/support__advice/local_government/in_it_for_the_long_run/case_studies/blackburn_with_ darwen.aspx

66 Re:fresh. Your Health and wellbeing. 2012/13 Quarter 2 Performance Summary. Blackburn with Darwen Borough Council.

67 Hassmen, P., Koivula, N., Uutela, A..(2000) Physical Exercise and Psychological Well-Being: A Population Study in Finland Preventive Medicine Volume 30, Issue 1, January 2000, Pages 17–25 Available from http://www.sciencedirect.com/science/article/pii/S0091743599905972

68 Dunn, A. L. Trivedi, M. H., O'Neal, H. A..(2001) Physical activity dose–response effects on outcomes of depression and anxiety. Medicine & Science in Sports & Exercise, Vol 33(6, Suppl), Jun 2001, S587-S597. doi: 10.1097/00005768- 200106001-00027 Available from http://psycnet.apa.org/psycinfo/2001-01104-002

69 Shepherd, V. (2012) Caring Neighbourhood Scheme Befriending Service (CNS) Age UK Blackburn with Darwen.

70 Barrass, A.. (2013) Home-Start Supporting Vulnerable Families to Prevent Social Isolation and Loneliness. Homestart Blackburn and Darwen.

71 Shepherd, V. (2012) Loneliness and Social Isolation within the BME Communities. Age UK Blackburn with Darwen.

72 Age UK. Technology and Older People Evidence Review. http://www.ageuk.org.uk/Documents/EN-GB/For- professionals/Research/Evidence_Review_Technology.pdf?dtrk=true

73 Kneale, D.. (June 2013) What role for extra care housing in a socially isolated landscape? Housing Learning & Improvement Network http://www.ilcuk.org.uk/images/uploads/publication- pdfs/What_role_for_extra_care_housing_in_a_socially_isolated_landscape.pdf

74 Hanson, J., Wojgani, H., Mayagoitia-Hill, R., Tinker, A.& Wright, F.(2006) The Essential Ingredients of Extra Care.Health and Social Care Change Agent Team, London: Department of Health http://discovery.ucl.ac.uk/3416/

75 Riseborough, M.& Fletcher, P.(2008).Extra Care Housing: What is it? www.housinglin.org.uk/_library/Resources/Housing/Housing_advice/Extra_Care_Housing_-_What_is_it.pdf

References Corporate Research Joint Intelligence Unit 49

76 Bäumker, T., Callaghan, L., Darton, R., Holder, J., Netten, A., Towers, A.(2012) Deciding to move into extra care housing: residents’ views. Ageing and Society 32(7):1215-1245 http://www.pssru.ac.uk/project- pages/extra-care-housing/index.php

77 Callaghan, L., Netten, A.and Darton, R.(2009) The Development of Social Well-being in New Extra Care Housing Schemes.York: Joseph Rowntree Foundation http://www.scie- socialcareonline.org.uk/profile.asp?guid=05b10bae-ff91-4909-8d47-39aa91159c7f

78 Campaign to End Loneliness (2013) Loneliness Harms Health. One Year On http://www.campaigntoendloneliness.org.uk/wp-content/plugins/email-before- download/download.php?dl=57f8af19fb31ae38ede0beba2f8d1db0

79 Cupitt, S. (2013) The Campaign to End Loneliness evaluation: Health and wellbeing boards’ uptake of Campaign messages Charities Evaluation Services http://www.campaigntoendloneliness.org.uk/wp- content/uploads/downloads/2013/06/Health-and-wellbeing-boards-uptake-of-Campaign-messages.pdf

80Campaign to End Loneliness (February 2013) Loneliness and Isolation. A Toolkit for Health and Wellbeing Boards. Essex County Council. Social Isolation Index. http://campaigntoendloneliness.org/toolkit/casestudy/essex-isolation-index/

81 Alma, M. A., Van der Mei, S. F., Feitsma, W. N., Groothoff, J.W., Van Tilburg, T. G., Suurmeijer, T.P., (2011) Loneliness and self-management abilities in the visually impaired elderly. J Aging Health. 2011 Aug;23(5):843-61. doi: 10.1177/0898264311399758. Epub 2011 Mar 11 http://jah.sagepub.com/content/23/5/843.abstract

82Instant Atlas Older People’s Health and Wellbeing Atlas. West Midlands Public Health Observatory. http://www.wmpho.org.uk/olderpeopleatlas/Atlas/atlas.html

83 Echalier, M.. (2009) Hidden Crisis: Why Millions Keep Quiet about their hearing loss. http://www.actiononhearingloss.org.uk/supporting-you/policy-research-and-influencing/research/our-research- reports/research-reports-2009.aspx

84 Echalier, M.(date not available) In it together. The impact of hearing loss on personal relationships. RNID http://www.ssiacymru.org.uk/resource/a_t_In_20it_20Together.pdf

85 Curtis, L.. (2010) Unit costs of health and social care 2010. University of Kent: Personal Social Services Research Unit. Available from https://www.education.gov.uk/publications/eOrderingDownload/PSSRU-1368-230X.pdf

86 Ellaway,A., Wood, S., Macintyre, S.. (1999) Someone to talk to? The role of loneliness as a factor in the frequency of GP consultations. British Journal of General Practice 06/1999; 49(442):363-7. Available from http://www.researchgate.net/publication/12579140_Someone_to_talk_to_The_role_of_loneliness_as_a_factor_in_the_fr equency_of_GP_consultations

87 Geller, J., Janson, P., McGovern, E., et al.(1999) Loneliness as a predictor of hospital emergency department use. J Fam Pract 1999;48:801e4. http://www.ncbi.nlm.nih.gov/pubmed/12224678

88 Hastings, S.N., George, L.K., Fillenbaum, G.G., et al. (2008) Does lack of social support lead to more ED visits for older adults? Am J Emerg Med 2008;26:454e61. http://www.journals.elsevierhealth.com/periodicals/yajem/article/PIIS0735675707004305/references

89 Carret, M. L., Fassa, A. G., Kawachi, I.. (2007) Demand for emergency health service: factors associated with inappropriate use. BMC Health Serv Res 2007;7:131. http://www.biomedcentral.com/1472-6963/7/131/

90 Coe, R. M., Wolinsky, F.D., Miller, D. K., et al. (1985) Elderly persons without family support networks and use of health services: a follow-up report on social network relationships. Res Aging 1985;7:617e22. http://roa.sagepub.com/content/7/4/617.short

91 Taylor, R., Cairncross, L. and Livadeas, S.. (2010) Oxfordshire County Council’s research into preventing care home admissions and subsequent service redesign Research, Policy and Planning (2010) 28(2), 91-102 http://ssrg.org.uk/members/files/2012/01/taylor-et-al.pdf

References Corporate Research Joint Intelligence Unit 50

92 Adult Social Services Blackburn with Darwen Borough Council Personal e-mail

93 Knapp, M. et al. (2010) Building community capacity: making an economic case, PSSRU Discusssion Paper 2772, London: PSSRU. http://www.pssru.ac.uk/pdf/dp2772.pdf

94Pitkala, K.H. et al. (2009) 'Effects of psychosocial group rehabilitation on health, use of health care services, and mortality of older persons suffering from loneliness: a randomised, controlled trial', Journal of Gerontology: Medical Sciences, vol 64A, no 7, pp 792−800. http://onlinelibrary.wiley.com/doi/10.1111/j.1365- 2648.2008.04837.x/abstract;jsessionid=F905EFB7FCB90A4865C0C26DDEE856E8.d04t01?deniedAccessCustomisedMessage =&userIsAuthenticated=false

95 Hulse, Y. (2013) “Communities Together, Loneliness Never” Report of Follow Up Event – Thursday 25th July 2013. The 50+ Partnership, Blackburn.

96 HM Government (2010) Healthy Lives Healthy People. Our strategy for public health in England http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127424.pdf

97 Banks J., Nazroo, J., Steptoe, A.. (Eds) (October 2012) The Dynamics of Ageing Evidence from the English longitudinal study of ageing 2002–10 (wave 5) The Institute for Fiscal Studies 7 Ridgmount Street London WC1E 7AE Available from http://www.ucl.ac.uk/news/pdf/elsa5final.pdf

98 Blackburn with Darwen 50+ Partnership (2011) Positive about Age-An Older People’s Strategy for Blackburn with Darwen April 2011 http://www.5050vision.com/link.html?uri=http://bwd50plus.org.uk%2Fwhat-we-do%2Fthe-older- peoples-strategy.html

References Corporate Research Joint Intelligence Unit