OP JSNA: Factsheet 12: Living independently in later life:
Needs
Summary
In 2011, there are an estimated 20,000 households with people over 65 in
Southwark, and this number is expected to rise to 29,000 by 2033.
The majority of older people want to remain independent and to remain in their own
homes for as long as possible
Factors which can impact on an older person’s ability to remain independent include:
 Ability to undertake domestic tasks and personal care
 Mobility
 Falls
 Continence
 Eyesight and hearing
 Support from a carer
 Long term conditions
 Dementia
 Poverty, isolation, and social exclusion
This factsheet covers, visual and hearing impairment, continence, falls prevention
podiatry, social exclusion and activities of daily living.
Rapid response home adaptations, handyperson services, telecare, hospital
discharge schemes are cost effective as they help avoid hospital admission. Older
people value comfortable and secure homes, an adequate income, safe
neighbourhoods, being able to get out and about, friendships and opportunities for
learning and leisure, keeping active and healthy, access to good, relevant
information.
The local picture
All public services, not just health and social care, have a role to helping older
people remain independent.
The prevalence estimates below apply national research data to the local population.
Characteristics in Southwark (such as deprivation and ethnicity) differ from the
national population so actual numbers may be slightly different.
Southwark Older People’s JSNA 2012 1
Visual impairment
A moderate or severe visual disability is defined as one where visual acuity is less
than 6/18 as this is the statutory threshold for being registered as severely sight
impaired (blind) or sight impaired (partially sighted). Approximately half of those aged
75 and over, have cataracts or refractive error (i.e. correctable sight loss), and if
these are excluded, it is estimated that 6.4% of this group have a 'registrable' eye
condition.
Visual impairment in later life arises from macular degeneration, cataracts,
glaucoma, and diabetic retinopathy. Visual impairment, or wearing glasses that don’t
correct vision fully, is a frequent contributory factor in falls.
It is estimated that currently there are over 2,200 people aged 65 and with moderate
to severe sight impairment, and over 700 people aged over the age of 75 with
registrable eye conditions. These numbers are expected to rise to 2,600 and 900 by
2025.
Although there is no local data, research from Age UK indicates that nationally nearly
two million people over 60 have not taken advantage of free sight tests in the last
two years, 42% felt there was nothing wrong with their eyes, 9% were concerned
about the cost of buying glasses, and 6% simply said they forgot to go and have a
sight test.
Hearing loss
The RNID estimate that amongst those over 70 in the UK, 71% have some kind of
hearing loss. The severity of hearing loss is also likely to increase with age.
 Around a quarter (26.7%) has mild hearing loss.
 More than a third (36.8%) has moderate hearing loss.
 6.3% have severe hearing loss.
 1.3% has profound hearing loss.
The loss of the ability to follow conversations can affect day to day communication
and social interaction, leading to social isolation, as well as a loss of stimulation and
information from the wider world. Hearing loss can impede the usefulness of
television, radio and telephone for staying in touch with family, friends.
It is estimated that almost 11,000 older people locally have a moderate to severe
hearing impairment, and 300 will have a profound hearing impairment. These
numbers are expected to rise to almost 12,900 and 360 by 2025.
Continence
Bladder control problems are more common in older people. Bladder and bowel
incontinence make continuing to live at home problematic. Urinary infections are also
more common in older people. Bladder control problems may also be caused by
particular diseases such as prostatic enlargement in men, stroke, dementia,
Southwark Older People’s JSNA 2012 2
Alzheimer's disease, and Parkinson's disease. Some diseases affecting mobility,
making it difficult to get to and use the toilet (especially where there are stairs) such
as arthritis, stroke, Parkinson's disease and dementia affect continence.
An estimated over 4,000 people aged 65 and over will experience a continence
problem at least once a week. This figure is expected to rise to 5000 by 2025.
The findings of the most recent National Audit of Continence Care (2010) undertaken
by the RCP are presented here as they represent issues that commissioner and
providers may wish to consider in developing the service. The audit found that the
quality of care (assessment, diagnosis and treatment) is worse in older people.
National Audit of Continence Care (2010)
ORGANISATIONAL AUDIT
Most continence services are poorly integrated across acute, medical, surgical, primary, care home
and community settings, resulting in disjointed care for patients and carers.
The way continence services are presently commissioned means that:
● those providing the care are not included in the process of commissioning
● many services are not set up to provide joined-up care across health care boundaries
● most lack a designated lead whose responsibility it is to organise, develop and improve the
delivery of continence care to patients
● users almost never contribute to service planning or evaluation
● provision of training for health care workers to manage bladder and bowel problems is patchy
across the nation.
CLINICAL AUDIT
Overall, adherence to national guidance (NICE) for urinary and faecal incontinence is very variable.
Healthcare professionals are not consistently:
● asking about and recording incontinence in people who are at risk of the condition
● providing assessment, diagnosis and follow-through according to standard practice
● communicating information about causes and treatments of patients' incontinence
● asking patients about their own goals for treatment
● assessing the impact of incontinence on quality of life
● making care plans to achieve treatment goals and sharing these with patients and (where
relevant) carers 1
1
http://www.rcplondon.ac.uk/sites/default/files/full-organisational-and-clinical-report-
nacc-2010.pdf Southwark Older People’s JSNA 2012 3
Local action - incontinence
A Specialist continence service offers assessment and conservative treatment, and
supports district nurses with continence care. One full time specialist district nurse
runs three clinics a week in the north, middle and south of the borough. Home visits
can also be made to assess housebound patients. Residents in nursing homes are
assessed and supported by the staff of the Care Home Support Team.
The Lambeth and Southwark specialist nurses are developing clear care pathways
using relevant NICE guidance and local information focusing on
 the use of incontinence products through low-cost interventions such as bladder
retraining, pelvic floor muscle training and the appropriate use of medications
for incontinence and ensuring that where containment products are used they
are selected and fitted correctly
 reducing unnecessary catheterisation and associated urinary tract infections
(UTI)
 managing pressure ulcers linked to poor continence care
 reducing hospitalisation for UTI, urinary retention, renal failure and faecal
impaction
 reducing care home admissions precipitated by incontinence
(RCP Cost Effective Commissioning for Continence Care)
Staff can refer for further assessment and possible diagnostics/surgery to specialist
continence/urological services at both GSTT and KCH.
Service use data is limited, however there are currently 575 men and 1188 women
living in the community, and 500 in the residential/nursing homes who have
continence products prescribed. There are also likely to be additional unquantified
people buying their own incontinence products.
Falls
Falls are more common in older age. A fall may be caused by a combination of
intrinsic factors (such as poor balance, stiff joints, weak muscles and slower reflexes)
and environmental factors (such as uneven floor or poor lighting). It may also be
triggered by an underlying health condition. In older people falls are more likely to
result in serious injury/ hospital admission, and loss of independence.
It is estimated that currently there are over 6,600 people aged 65 and over who will
fall during the current year. The figure is expected to rise to 8,100 by 2025.
Many falls are preventable. Prevention of falls includes

Promotion of bone health– through encouraging physical activity and healthy
lifestyle, and reducing unnecessary environmental hazards.
Southwark Older People’s JSNA 2012 4

Early intervention to restore independence – through falls care pathways,
linking acute and urgent care services to secondary prevention of further falls
and injuries
 Responding to a first fall/fracture and prevent the second – through liaison
services in acute and primary care settings.
A recent study conducted by Oxfordshire County Council looked at how to prevent or
delay care home admission (Taylor et al, 2010) and identified critical factors that
might lead to care home admission. Common factors were incontinence, dementia,
falls and depression.
The local picture
A fall may result in an ambulance being called, an A & E attendance or hospital
admission. In 2009-10, the ambulance was called to 2,435 people in Southwark who
had fallen. 1,677 were taken to hospital and 758 were attended to at the scene.
Rates of ambulance call out were highest for the over 75 group.
In 2009/10 716 people aged 65 and over were admitted following a fall, contributing
a total of 842 admissions for the year. Extrapolating from national data (using
POPPI) an expected 539 Southwark residents would be admitted to hospital after a
fall, so the actual number exceeded expected admissions.
Among those admitted, 155 cases were for hip fracture (as compared to 122 in
2010). Approaching half (44%) of these admissions were people aged 85 and over.
The median length of stay was eight days, with a range from 0 to 109 days. The
total cost of these admissions was £3.1 million. Admissions related to falls made up
more than a tenth of emergency admissions for the year.
Local Action- Falls
SLIPS (Southwark & Lambeth Integrated Care Pathway for Older People with Falls)
is an integrated falls service across health, social, voluntary and leisure sectors in
Southwark and Lambeth and is part of the programme of work of the Adult Therapy
Rehab Team. See http://www.slips-online.co.uk/
It provides evidence based assessment and management of clients who have
experienced a fall, are at risk of falls or are fearful of falling. Falls Clinics are
provided at Guy’s Hospital (GSTT) and the Betty Alexander Suite, Dulwich Hospital,
(KCH).
Following assessment, exercise based interventions are selected as appropriate for
the client.


3 Community exercise classes provided at Peckham Pulse; Dulwich Library
and Darwin Court
Otago exercise programme usually delivered in the client’s own home
Southwark Older People’s JSNA 2012 5


Strength and Balance exercise groups provided at the two Falls Clinics
Clients with more complex needs are usually referred for 1:1 physiotherapy:
this area of work is steadily increasing, a factor that has considerable impact
on therapist time and service capacity
In 2010-11 1,612 people over the age of 65 were seen by the Adult Therapy Rehab
Team out a service total of 1,861 i.e. 86.6%.
One of the Lambeth and Southwark CQUIN quality improvement goals
(Commissioning for Quality and Improvement and Innovation) is “to reduce the
incidence of falls resulting in harm in community settings across Southwark and
Lambeth, streamlining falls service provision, including falls prevention, by the
introduction of an evidence-based, multidisciplinary and multiagency falls pathway”.
Foot care
Foot problems are one of the major causes of walking difficulties in older people.
People aged 65 and over are especially prone to foot ulcers and painful skin lesions.
Painful feet can impair balance and functional ability and increases the risk of falls,
especially when a person has multiple foot problems.
Access to NHS podiatry is mainly restricted to higher risk patients. Users may be
referred by their GP, another health professional or may self refer. There are
currently 4,804 people aged 65+ registered as podiatry service users. Broken down
by age group this number comprises: 65 – 75 yrs- 1980, 75 – 85 yrs - 2004, 85+ 820
People who are housebound and require treatment are treated in their own home or
care home. All but a small number of housebound patients (n = 695) are aged 65+.
Of this number 522 (75%) are categorised as high risk.
Diabetes, or more specifically, poor glycaemic control, is a major cause of these
conditions amongst older people, and podiatry can improve outcomes. There is
currently a year on year increase in the number of foot ulcers.
Activities of daily living - Domestic tasks
Domestic tasks include household shopping, washing and drying dishes, cleaning
windows, using a vacuum cleaner, washing clothing by hand, opening screw tops,
dealing with personal (including financial) affairs and undertaking practical activities.
An estimated 10,400 people in Southwark aged 65 and over may currently have
problems in carrying out at least one domestic task. By 2025 that number is
expected to increase to more than 12,200.
Southwark Older People’s JSNA 2012 6
The PECCI consultation exercise involving older people in Southwark in 2011, found
that many older people expressed a concern that inability to manage simple daily
tasks, such a s shopping was a significant trigger in their perception and ability to
remain independent and healthy at home
Self-care
Self-care activities include bathing, showering or washing all over, dressing and
undressing, washing face and hands, eating, cutting toenails, managing and taking
medicines. With increased mental and/or physical frailty, formerly simple self-care
activities can become daunting and frustrating. Taking medications correctly is
important for the self-management of long term conditions.
Over 8,500 people aged 65 and over are estimated to have problems with at least
one aspect of self-care. The figure is expected to rise to 10,100 by 2025.
Mobility
Mobility activities include going out of doors and walking down the road; getting up
and down stairs; getting around the house on the level; getting to the toilet; getting in
and out of bed. Decreased mobility may lead to difficulties with household tasks and
self care, such as getting in and out of the bath. Less mobile people can have
limited access to nutrition, leisure and other activities and dependence on others for
visits to shops and using other services.
Over 4,700 people aged 65 and over are estimated to have problems with at least
one aspect of mobility. The figure is expected to rise to 5,600 by 2025. Social inclusion and well-being
Older people identify social inclusion as a key contributor to their quality of life. With
increasing age, social exclusion becomes more likely, because of poorer health, loss
of immediate family and friends, and reduced mobility.
The PECCI consultation program in Southwark in 2011, found that maintaining a
sense of social inclusion within the local community and amongst their peers was a
significant factor for older people to remain independent in the community.
It is not possible to estimate how many older people experience social exclusion in
Southwark; however research has shown that there are seven key risk
characteristics for an older person experiencing social exclusion. These
characteristics are listed below, together with estimates of the numbers of older
people potentially at risk in each category in Southwark in 2011.
 Age 80 and over ( estimated 7,500 people in 2011)
 Family type (estimated 9,200 people over the age of 65 living alone)
 Health (estimated 12,500 people aged 65 and over with a long term limiting
condition)
Southwark Older People’s JSNA 2012 7
 Mobility
 Housing tenure (67% of the 65-74 population rent and this proportion rises with
age)
 Income (in May 2011, 10,290 people claimed pension credit, )
 Telephone
These characteristics are multipliers.
What works in promoting independence
 Housing adaptations, equipment and technologies to help with the activities of
every day living, telecare and supportive forms of housing are all effective in
helping older people remain in their own homes longer.
 Social care evidence ( SCIE) Briefing 15 outlines some of the important
elements of social inclusion in practice as
 Promote and support access to social network and create opportunities for
people to make new friends
 Resolve transport issues so that they do not prevent people from participating in
the wider community.
 Build links with community projects, community centres and schools to increase
levels of social contact between people from different generations.
 Identify, respect and use people’s skills, including the skills of older people
gained in previous employment in planning, developing and delivering projects
in your service.
 Give people ordinary opportunities to participate in the wider community
through person-centred care planning.
 Involve people in service planning and ensure ideas and suggestions are acted
upon.
Home adaptations
A recent review commissioned by the Office of Disability Issues (Better Outcomes,
Lower costs, 2007) found for older people, home adaptations could play an important
part in prevention of accidents and admission to hospital, in speeding up the process
of hospital discharge or in deferring admission to residential care. More generally
appropriate adaptations improved the quality of life for the older person and their
family and carers and reduced stress and anxiety for all concerned.
“The NHS spends £600million treating people every year because of ‘category 1’
hazards in poor housing, the vast majority being associated with falls. The recent
findings from the Fit for Living Network show
 For every £1 spent on handyperson services, (which provide fast, low cost help
with adaptations and repairs), £1.70 was saved, the majority to social services,
health and the police
 Rapid Response Adaptations programmes have shown £7.50 savings were
made for the NHS for every £1 spent, due to speeded up hospital discharge,
Southwark Older People’s JSNA 2012 8
prevention of people going into hospital and prevention of accidents and falls in
the home
 Hospital discharge schemes offering housing help to speed up patient release
saving social care at least £120 a day
 The DH Older People Projects pilots (POPPs) found economic benefits from
targeted intensive interventions to prevent crisis (e.g. falls services) or at a time
of crisis (e.g. rapid response hospital admissions avoidance services) or postcrisis re-ablement services.
 Postponing entry into residential care for one year saves an average of £28,080
per person
 Adaptations and telecare can reduce the need for daily visits and reduce or
remove costs of home care (savings range from £1,200 to £29,000 a year)”
User views
Research from the Joseph Rowntree Foundation (Older People’s Inquiry, Raynes et
al., 2006) explored the experiences of older people and of professionals to identify
future areas for service improvement and development. Areas valued were:
•
•
•
•
•
•
•
Comfortable and secure homes
An adequate income
Safe neighbourhoods
Being able to get out and about
Friendships and opportunities for learning and leisure
Keeping active and healthy
Access to good, relevant information.
Local action to promote and maintain independence is covered in the next factsheet.
What still needs to be done
Visual impairment
 Ensure that older people are aware of their entitlement to free eye tests and
that frail older people are helped to obtain a free NHS-funded mobile sight test
if needed in their own home, care home or community setting as appropriate
 Ensure that people who receive guarantee pension credit are aware that they
may be able to claim an NHS Optical Voucher towards the cost of glasses.
 Ensure that eyesight and eye health are assessed and managed in Annual
health reviews and social care checkups
Southwark Older People’s JSNA 2012 9
Continence
The establishment of clear care pathways though out primary care and in social care
assessments, and capacity building in general practice, will be important in ensuring
that need is picked up at an early stage and skilled assessment and support are
forthcoming to prevent unnecessary deterioration and distress.
Commissioners and providers should review their service gaps in the current
local services in the light of the 2010 National Audit
Falls prevention
Falls prevention needs to be scaled up, given the estimate of the number of older
people projected to fall versus those accessing the service. The CQUIN quality
improvement programme is likely to result in a higher number of referrals for
assessments and interventions so more capacity in the falls service will be needed.
The difficulties to be overcome include
•
•
•
•
•
Increased complexity – older people with co-morbid long term conditions
Limited Occupational Therapy related rehabilitation.
Time therapists spend on home visits and time travelling between clients.
Lack of staffing for community exercise classes
Outdoor walking aids are currently assessed for, but not provided.
Foot care
More prevention is needed ( e.g. toe nail cutting) Toenail cutting is no longer
available from the service for clients assessed at being at low risk, yet older people
in this category may have difficulties cutting their nails because of impaired
dexterity, eyesight or dementia.
Southwark Older People’s JSNA 2012 10
References
Care Services Efficiency Delivery Programme (CSED) Projecting Older People
Information System (POPPI ) Version 6 accessed at http://www.poppi.org.uk/ on
22.11.11
English Longitudinal Study of Aging (ELSA) - reports and data accessed at
http://www.ifs.org.uk/elsa/ on 22.11.11
Office for National Statistics – NOMIS –official labour market statistics. Annual
Population Survey and DWP Longitudinal Study accessed at www.nomisweb.co.uk/
on 22.11.11
Social Care Institute of Excellence: Dignity in Care accessed at
http://www.scie.org.uk/publications/guides/guide15/index.asp on 22.11.11
Taylor, R, Cairncross, L and Livadeas, L (2010): Oxfordshire County Council's
research into preventing care home admissions and subsequent service redesign.
Research, Policy and Planning 28 (2): 91-102
The report of the Older People's Inquiry into 'That Bit of Help' Edited by Norma
Raynes, Heather Clark and Jennifer Beecham (Joseph Rowntree Fund 2006)
accessed at http://www.jrf.org.uk/publications/report-older-peoples-inquiry-bit-help on
22.11.11
Southwark Older People’s JSNA 2012 11