Tackling loneliness and social isolation: the role of commissioners

SCIE Highlights No 3
Published: January 2018

With one million people aged 65 and over in the UK reporting they are often or always lonely, few would refute the need to tackle this issue. (1)
However, loneliness and social isolation are conditions that are difficult to identify, complex to address and hard to resolve. The evidence base for interventions to address the problems of loneliness and social isolation is emerging but inconclusive at this stage.

Introduction

In September 2017, SCIE and Renaisi organised a seminar with commissioners, local authorities and third sector representatives to explore the opportunities and barriers faced by commissioners seeking to address social isolation in older people. This was part of a three-year evaluation that SCIE and Renaisi are undertaking of a new national programme to help address isolation in older people through reading-based interventions.

This Highlights briefing draws on the discussions from the seminar, and previous research and evaluations in this field including Preventing loneliness and social isolation (SCIE, 2011) and the evaluation of North and South London Cares (Renaisi, 2016). It:

• identifies the evidence that points the way to a better understanding of effective interventions
• provides examples of practice emerging in different parts of the country
• examines what needs to happen next in order to create a more conducive commissioning environment.

The impact of loneliness and social isolation

Loneliness can affect people at any age, but the focus of this report is on older people. There are many ways to define, and differentiate between, loneliness and social isolation. Loneliness is the ‘subjective, unpleasant and distressing phenomenon stemming from a discrepancy between individuals’ desired and achieved levels of social relations’. (2) Social isolation is ‘an imposed isolation from normal social networks caused by loss of mobility or deteriorating health’. (3) A way of clarifying the difference is to say that ‘a person can be lonely in a crowded room’ but they are not socially isolated.

The impact that loneliness and social isolation can have on the physical, mental and social health of isolated older people is well documented. The Campaign to End Loneliness points to research which shows that lacking social connections is as damaging to health as smoking 15 cigarettes a day. (4) Lonely individuals are more likely to visit their GP, use more medication and have a higher incidence of falls. (5) They are also more likely to enter early into residential or nursing care. (6)

What works to help address loneliness and social isolation?

The landscape of interventions is diverse including direct one-to-one or group-based support and signposting to other services. The emphasis is often on creating opportunities to bring people together, maintaining and creating networks and friendships, and promoting activities that help to overcome the risks faced by and poor health outcomes of many individuals who are lonely and socially isolated.

† In early 2018, SCIE will publish an updated version of a 2011 briefing on preventing loneliness and social isolation.

In the field of health, there is a focus on measures such as delayed transfers of care that can be captured objectively in contrast to softer processes that track the changes that people say they experience. Assessing interventions that are fundamentally about people, feelings and relationships is challenging. For example, the notion of ‘enjoyment’ is crucial, but this is a difficult outcome to measure and quantify.

The main message from the seminar was that it is impossible to identify one ‘magic’ intervention for all lonely adults. The states of loneliness and isolation may be context-specific, so while an intervention in one setting works for one person, in another it might fail them completely. Also, individuals often respond differently depending on their circumstances. A ‘holistic approach’ is required when designing and commissioning services focused on individuals. Solutions need to be flexible enough to respond to individual preferences, expectations and aspirations.

What are the challenges faced by commissioners and those delivering interventions?

The importance of a ‘smorgasbord’ of interventions for use in primary, secondary and tertiary settings has been emphasised. The Campaign to End Loneliness has developed a framework which sets out the full range of interventions needed from stakeholders across the community, health and social care sector to support older people experiencing, or at risk of experiencing, loneliness. It suggests a strategic approach that combines identifying and using community assets, at neighbourhood level, using volunteers and fostering a positive attitude to ageing.

However, this has inherent challenges for commissioners in local authorities and clinical commissioning groups (CCGs) in a context where the drive to be cost effective can take precedence. Commissioners need to feel confident that the services they commission avoid duplication and are efficient. Many organisations working to address social isolation are operating at a small scale and are funded for short-term projects, and may not even be on a commissioner’s radar. While services offered by larger national charities are undoubtedly a crucial part of the picture, the current system risks excluding smaller providers, and missing out on innovation and the chance to take a risk on pilot approaches.

Challenges and barriers experienced by commissioners in the current system

Commissioning challenges:

• Local authority systems are set up with the expectation that the activity under contract can be monitored against agreed benchmarks.
• Commissioners require evidence of effectiveness that summarises impact and enables them to demonstrate how they are helping to grow the local market in line with Care Act requirements.
• Systems may not be flexible enough to enable the commissioning of small amounts of service provision – ‘block procurement’ is often a more practical solution.
• Local authorities may have certain requirements for insurance cover or health and safety procedures.

Challenges and barriers experienced by smaller organisations in the current system

Provider challenges:

• A smaller organisation may be unable to respond as required as their monitoring and accounting procedures may fall short of public sector expectations – and they lack time above project delivery to fulfil the requirements.
• Smaller organisations may not have knowledge and data that commissioners need to inform their commissioning decisions – particularly on longer-term outcomes.
• Volunteers often primarily staff small services and schemes, making it hard for them to promote their services and to respond quickly and comprehensively to project proposals.
• Smaller providers may struggle to consider or prioritise these requirements due to lack of funding above and beyond project activities.

How can these challenges be overcome?

Despite some of the wider challenges in the commissioning landscape, there are numerous examples of ‘brave commissioning’ of services.

Some of the commonly identified enablers that help commissioners to overcome barriers and support different approaches include:

• Political and leadership support – where there is commitment from the top, and existing structures such as Health and Wellbeing Boards support joint approaches across local authorities, the NHS and other parts of the public sector.
• Honest dialogue – co-producing services and solutions with local residents to ensure that a range of interventions are in place that meet people’s needs.
• Using Better Care Funding (and other financial levers) to prioritise preventative approaches to loneliness and social isolation.
• Committed individuals with the flexibility and support to push through different approaches.
• Being pragmatic – accepting that some new initiatives need longer-term funding to give them time to embed.

Examples mentioned in the seminar included:

• Lambeth Council Community Connectors. These posts, jointly funded by the council and the CCG, are managed by Age UK and supported by volunteers. People self-refer or come via their GP or a social worker to access services. Community Connectors link people in their local community with activities and organisations that can help improve their quality of life. This can include connecting people with relevant wellbeing and health services, local community groups and organisations and social groups. See Lambeth’s Evaluation of Phase 1.
• Social Finance Reconnections Project. Launched in May 2015, Reconnections is aimed at reducing loneliness and isolation for 3,000 people over the age of 50 in Worcestershire. It provides one-to-one tailored support for lonely older people who co-develop an action plan to establish ways in which they can (re)connect with a variety of local support networks. The commissioner is Worcestershire County Council (as lead) along with three co-commissioners from Redditch & Bromsgrove, South Worcestershire and Wyre Forest Clinical Commissioning Groups. It is funded by a Social Impact Bond, and is being evaluated as part of the Commissioning Better Outcomes Fund evaluation. Find more information from Worcestershire Reconnections Social Impact Bond .
• Friends of the Elderly (FOTE) provide a range of services including Befriending, in the Woking area. A paid worker coordinates the service. Volunteers commit to a onehour weekly visit although in practice many do more and build sustained relationships. For the past three years, they have held coffee mornings in a sheltered housing scheme where there are no longer wardens to support older residents. The local authority is looking to recommission the service run by FOTE.
• Local area coordination is a long-term, asset-based approach where people are supported to stay connected, build links, find practical solutions and pursue their goals. There are no eligibility criteria and coordinators have time to work with people in depth. Wigan was mentioned as one example of good practice where an asset-based approach extends across the whole area. Find more information from the Local Area Coordination Network .

What needs to happen next?

Commissioning does not take place in a vacuum. High-density living, difficult economic conditions and negative societal attitudes can exacerbate the situation of isolated older adults. Without changes in other parts of society, even the best services will never be able to meet their needs.

Developments required include:

• Reducing or limiting the stigma around isolation and loneliness. Many people do not want to burden family and friends or to access services as they feel it would label them as ‘failing’. Activities and interventions which are engaging and enjoyable will make it more likely isolated older people will want to participate, but this is not easy to achieve.
• More staff with the psychological skills to support lonely older people so that ‘every contact counts’. However, ensuring services are scaled up either with trained paid or volunteer staff is a costly challenge.
• Holistic approaches such as age-friendly cities and public awareness campaigns to push the issue up the social agenda. A civil education programme similar to Dementia Friends would ensure the wider public learn about causes of and ways to address loneliness and isolation in older adults.
• Engaging different parts of the community to identify and tackle loneliness. For example, those in organisations who come into regular contact with older people (such as pharmacists, hairdressers or faith groups) are well placed to identify lonely older adults and to point them in the direction of information and services.

However, there are a number of steps that commissioners can take and where their actions can have a direct influence. To help navigate this complex landscape, participants at the seminar suggested that it might be useful to think about particular subgroups of isolated older adults, and what configuration of services might help address their needs. Investing in transport was also highlighted as being crucial to the success of many projects. Sometimes even a small investment in transport costs will enable a service to continue or thrive – either to support access for participants, or enable volunteers to fulfil their roles. There was also willingness for local authorities to learn from each other and discuss good practice, within a system where it is all too easy to operate in geographical siloes due to the lack of time and capacity to share creative approaches.

At a recent event on loneliness, a panel member offered her personal experience of dog owning as the intervention that reduced her loneliness and isolation. The woman said she had to get out of bed each morning to walk her pet, and because the dog was appealing, people stopped to talk. This happened most days and the woman said she no longer felt isolated and lonely. She chuckled: Would local commissioners be willing to add to his/her budget sheet the cost of purchasing a dog for a lonely local older woman?

Pet ownership is not the solution for everyone. But it illustrates what the evidence tells us. The causes of loneliness and isolation are various – and so are the solutions. Flexibility is needed if we are committed to making a difference to the lives of lonely older people.

Key messages for commissioners:

• To move away from commissioning block contracts for a ‘whole service’ towards a willingness to ‘micro-commission’ to support existing groups and enable the establishment of new ones.
• To identify and map existing assets in the local area, which will help to sustain knowledge and build on expertise.
• To make it clearer and easier for smaller organisations to respond to commissioning tenders. Response times and tender requirements should be proportionate to the organisation’s size and capacity.
• To promote services which are willing to work closely to produce a seamless offer. This will help avoid duplication, ensure cost effectiveness, and potentially provide routes into areas of poverty and deprivation that will help local authorities tackle other priorities at the same time.
• To invest ‘upstream’ in the community to reduce the likelihood of people becoming isolated, for example following bereavement.
• To devolve budgets to local area coordinators to free up new approaches within an assetbased framework.