As Chair of the Campaign to End Loneliness I recently returned from sharing ideas with the AARP in the US, about how to make social isolation a public health issue. With 36 million members the American Association of Retired Persons (AARP) is a formidable advocate for seniors in the US across a huge range of issues that affect their health, wealth and self. Their latest research with Stanford University is looking to establish a new platform for their work – that social isolation should be addressed as a key public health priority.
This important research examines the impact of social isolation on Medicare spending – the federal health insurance programme for 46m people ages 65 and over in the US which pays for physician visits, prescription drugs, preventive care, hospital care, rehabilitation and social care amongst other services.
The research found that a lack of social contacts among older people is associated with an estimated $6.7m in additional Medicare spending annually and for each isolated older adult (controlling for other factors) $1,608 annually. This additional spending is comparable to what Medicare pays for certain chronic conditions like high blood pressure and arthritis. Although the study found that those who were socially isolated were not significantly more likely to use inpatient care, they did find that once admitted they accounted for more spending – either staying in hospital longer, or needing more skilled nursing facility caring (either at home or in a care home) for rehabilitation afterwards. In addition, the research shows the subsequent risk of death was 50 percent higher than for those who were not socially isolated. This difference in death rates suggests that isolated individuals may have poorer health trajectories than those who enjoy better social connections.
This research chimes with the evidence base upon which the Campaign to End Loneliness built its ‘Loneliness harms health’ campaign over the last 7 years. Pulling together evidence from across the globe we have been able to capture the imagination of the public, service providers and statutory agencies alike. Loneliness is as bad for your health as smoking 15 cigarettes a day and more harmful than excessive alcohol use, lack of physical activity and obesity – headlines made by the research carried out by Julianne Holt-Lunstad et al, and underscored by their further recent work [Holt-Lunstad, Robles & Sbarra, American Psychologist, 2017]. As a result of our work, highlighting the costs, tools to identify those at risk and how to commission and evaluate effective services, 80% of Health and Wellbeing Boards have made a commitment to tackle loneliness, 83% of English local authorities have commissioned new services and 95% of the members of our learning network say they have improved their services.
This spotlight has helped stimulate health economic analysis that shows that lonely older people are 1.9 times more likely to visit their GP, 1.6 times more likely to visit A & E and 3.5 times more likely to enter local authority funded residential care [Investing to tackle loneliness, Lauren Fulton and Ben Jupp, Social Finance 2015] – research that formed the basis for the pioneering social impact bond funded Reconnections Service, delivered by Age UK Hereford and Worcestershire. Further work by the LSE (Making the economic case for the costs of loneliness, D. McDaid, LSE, 2017] has found that the cost of loneliness to be around £8,000 per individual over 10 years for their use of NHS services – which does not include the increased risks and costs of social care services.
And since 2014 there has been over 500 media mentions a year of our work with the effect felt ever more widely in the campaigns run by Jo Cox MP in the Yorkshire Post, ITV’s a Million Minutes, the John Lewis Man in the Moon ad for Age UK and many others including thinkers like George Monbiot. When we started out, many people mocked the notion that loneliness was anything more than a personal issue or that it had any relevance to policy makers or commissioners of services. That is no longer the case, despite our care to ensure that loneliness in older age was neither inevitable or deserving of pity. And in many cases, the most powerful advocacy of all was simply older people themselves telling their stories. Their willingness to admit to what we imagine to be a social stigma. The dreaded L word.
The compelling work of the Jo Cox Commission has shone a light on the issue for all ages and we now have a Minister for Loneliness and a commitment to a national strategy, ONS measurement and an Innovation fund. We have come a long way indeed.
In the US the AARP are using their research findings to present an opportunity to policy makers along with the private sector to identify promising interventions to alleviate isolation. Some of the approaches that they are advocating are:
- creating a reliable tool to patients for social isolation and to implement it as part of annual Wellness checks with physicians,
- funding testing of interventions to measure their effectiveness bearing in mind the differing requirements for different cultural communities, socio-economic status, mental and physical health status etc,
- elevate the understanding of social isolation in the public health community and as a social determinant of health.
So how relevant are these recommendations in the UK – in the light of the very welcome government commitment to a loneliness strategy?
Firstly, its important to note the different use of language. Since its inception the Campaign has (clearly) focused on loneliness, partly because of the focus of the academic research that we were influenced by, and because as campaigners for older people we were driven by the emotional impact of feeling deeply isolated, disconnected and uncared for. We made the connection with the stories older people told us about feeling worthless, lacking purpose and the pain of missing social and emotional support. But we also understand the linked notions of isolation, (the quantity of relationships), social connectedness (the quality of relationships) and the subjective feeling of loneliness – the difference between the contacts you have and those that you would like to have.
Yet despite the difference in focus with the AARP we are fundamentally talking about the same problem and concepts. Not because of the downstream costs to health, but because of an ambition that everyone should have the quality of life and social contacts they would like to have, and to be able to contribute to the social capital of their communities whatever their age.
The other key factor in the context of government policy is how to address loneliness across the life course.
Apart from my experience of meeting isolated older people through Independent Age’s services, one of the biggest spurs of my interest was Sue Bourne’s Channel 4 programme ‘My Street’. In the programme Sue simply set out to discover the lives of everyone who lived in her street, not just her immediate neighbours and the families she knew from school. One of the most isolated individuals, a young man with Tourettes whose relationship with his family had broken down, tragically died during the making of the film. It was heart-breaking and profound.
Since 2011 Campaign to End Loneliness has focused on loneliness in older age – not just because we were set up by older people’s charities but because we recognised that in older age there is a greater likelihood of risks combining. These risks include transitions from work into retirement, into caregiving (and out of that role when the person being cared for dies), and bereavement, with the loss of partners and friends. Risks also include the onset of major illness or disability, sensory impairment, or dementia and the risk of decreased mobility, becoming housebound or moving into sheltered housing or residential care. Loneliness in old age is by no means inevitable – but the combination of risks and transitions enhances the risk that a transitory experience of loneliness could slide into a long term chronic condition, with the potential impact on psychological well-being, confidence and resilience.
But anyone working with isolated older people will also recognise that for some the experience is not associated with old age – it has been a lifelong condition sometime compounded by mental health issues. As the recent research by Holt-Lunstand alludes to, this could be because of a number of factors – heritability (people born into families with poor social connections are more likely to be isolated themselves), poor social skills in terms of forming and sustaining friendships and relationships, and weak confidence and resilience. So its impossible to speak of loneliness in older age without recognising that it can be a lifelong condition and one that could have it roots in childhood.
Indeed, putting isolation and loneliness on a par with addressing obesity, fitness and nutrition, would suggest starting in childhood and school education – on a par with 5-a-day, ‘One You’, ‘This Girl Can’ and other sexual health campaigns targeting young people. How can we embed socialisation and relationship skills at a young age and promote the benefits of ‘safeguarding your convoy’ of friendships throughout your life? Could something further be built into the Personal, Health, Social and Economic lifeskills (PHSE) curriculum in schools and what are the most effective ways to do this? And what role could Relate, the Samaritans, Childline and Silverline have in developing relationship health and supporting those in crisis?
In addressing loneliness at all ages we need to build a body of evidence about prevalence, risks and impact, and what works et each transition phase through the life course, in the same way that the Campaign has been doing through its Research and Policy hub, and Learning network. So for instance, with younger people we need to understand better the impact of adolescence in an age of social media, who is most at risk and what interventions work best. And we need to better understand the impact of the stigma of loneliness in youth. Other key life course transitions carry risks too that we better need to understand – whether the move from primary to secondary school, from school into work or college, becoming a mother for the first time, losing a job, or the onset of disability, unemployment, bereavement, retirement. All may carry the risk of transitory loneliness, pain or adjustment, the secret is to find out who is most at risk and what interventions might prevent it turning into a longer term loss of confidence and connections – and chronic loneliness.
CEL is continuing to build a good body of understanding about ‘what works’ as interventions for loneliness in older age – from signposting and community navigator models, to reconnections, social prescribing and ageing better schemes; social groups, circles of support and lunch clubs; befriending and ageing in place schemes including shared lives plus, homeshare and creative care homes schemes like a Choir in Every Care Home, Cocktails in Care Homes, Henpower and Artists in Residence schemes. We also know that there are many specific schemes focused on bereavement and for particular communities like Men's Sheds and those for the LBGTI community.
However, we are only too aware that there is huge geographical variation in the availability of schemes and commissioning practice and particular gaps in psychological support, CBT and counselling for older people (despite strong evidence that it is most effective with that age group), in reciprocal and circles models and that we have less knowledge about the specific services targeted in BME groups and intersectional needs within those communities. A further gap in our understanding is how digital approaches might work – these are particularly problematic for the digitally excluded older old, but essential learning for younger and more digitally literate age groups. And the scene is always shifting with the emergence of new social enterprises and for profit services – and as with any innovative solutions, high failure rates.
Some of the key features of those interventions that work are those that build on existing operational expertise like safeguarding or volunteer vetting, that engage older people at an early stage in design, that utilise asset based approaches that access both the assets of the individual and the community, that sweat the assets of existing frontline services like GPs, social services, libraries, the police and fire service and most importantly that are embedded in communities, accessing every touch point in older people’s lives from barbers and hairdressers, to pharmacies and cafes, faith groups and clubs. Because fundamentally isolated older people are, well, isolated. And hard to reach.
But what of the other recommendations AARP are exploring? Should we also be requiring GPs to carry out screening tests for loneliness with their most at risk clients, what tools should we use (there are a multiplicity in use from UCLA in its many guises, to De Geirveldt, to CEL’s tool, to the Dukes, and other Wellbeing tools like WEMWBS)? And once activated what happens next?
Despite our huge success in reaching Health and Wellbeing Boards and local authorities there is a whole world of CCGs and STPs who may not be as committed to tackling loneliness and it would appear, that where they do, social prescribing has become the most favoured model. But before we endorse this one approach its important we evaluate social prescribing alongside the other reconnections or community navigator type interventions and ascertain the best next step solution. One model the AARP are considering is a team based model like the Diabetes teams they have seen proliferating, in the UK frailty teams have had similar successes. If we were to establish a national model, backed by DH guidance, we should explore the best proven triage route and at the same time ensure that it addresses the very different levels of need and causes and recommend ‘horses for courses’ solutions. These pathways should separately address:
-moderate to high pathways
- preventive pathways
For the most chronically lonely and those with multiple disadvantage a whole person approach built around CBT psychological support and confidence building, backed by befriending and multi-agency input might be most appropriate. Since stepping into the home of someone housebound, with poor nutrition, heating, home adaptation, financial wellbeing and personal care and simply asking about their loneliness might seem both naïve and ultimately unhelpful.
Whilst someone with high to moderate needs might benefit from some psychological support and reconnections or social prescribing type intervention.
And for those with lower levels of need, what about a ‘nudge’ toolkit that invites people – like those facing moving to college, maternity leave or retirement – to consider all the features of their wellbeing [the New Economics Foundation 5 features of wellbeing] and encourages behaviours that reinforce them – take notice, connect, stay active, learn and give!
But most importantly, when designing these differentiated pathways wouldn’t it be great if every interaction was designed to increase the beneficiaries agency, confidence and sense of self worth rather than medicalise them or make them feel done to? Since that sense of agency is the very power tool that enables people to connect and create friendships.
In addition to these individual interventions we should also invest as communities – in mayor funds for small grass roots organisations, in developing connected communities and encouraging neighbourly public action. In the coming year the Campaign to End Loneliness will be pioneering these latter two approaches, but there is much more that we can do to all make ‘Loneliness everyone’s business.’ Reducing loneliness can never be solely the business of government. We have responsibility for ourselves, our families and friends, our neighbours and communities. And no one age group will ever benefit from a kinder and more caring community where everyone can contribute their skills, wisdom and passion. We all will.
There are so many opportunities and many more ideas to explore! And I’m sure many more lessons to be learnt from across the globe.