Ageing well 2016 to 2020

Across Hampshire, just over 1 in 5 people are 65 years and over compared to nearly 1 in 6 nationally. In real terms this means there are more than 286,000 people who are over 65 years old. This is projected to increase to over 333,000 people by 2023.

The age composition of older population varies across the County; with New Forest, East Hampshire, Winchester and Havant having the greatest proportion of over 65 and over 85 year olds. Basingstoke and Deane, Hart, Gosport and Rushmoor all have a much lower proportion of older people. The difference is stark where nearly 1 in 5 people over the age of 65 living in New Forest are over 85 years compared to less than 1 in 20 in Rushmoor.

Over the past few years the proportion of the population of older people receiving long term social care services has been 1% of 65-74 year olds, 3% of 75-84 years olds and 13% of over 85 year olds. This suggests that 87% of those over 85 years are not receiving or accessing social care support. This needs further investigation to understand if this is because they are in good health, self funding, supported by family or friends or are there unmet needs?

The ratio of people of state pension age is increasing compared to working age population. The Old Age Dependency Ratio measures the number of older people as a proportion of those of working age. This measure is forecast to increase from 35.2 in 2017 to 39.2 older people for every 100 people of working age by 2023.

Population forecasts suggest that our population will grow by 7% between now and 2023.

There are some big differences in the changes affecting different age groups. Over the next 5 years the number of 65 to 69 year olds will decrease by 10% to 78,053, the number of 70 to 74 year olds will increase by 25% to 84,214, 75 to 79 years olds will increase by 22% to 62,329, 80 to 84 year olds will increase by 14% to 44,771 and the number of over 85 year olds will increase by 20% to 59,958. This is reflective of the 'baby boomer' generation ageing.

The growth projections for over 65 year olds are expected to disproportionally affect the Hampshire districts. All districts are predicted to see a decrease in 65-69 year olds; the biggest decrease is predicted to be in Hart (14% decrease) and the smallest in Rushmoor (2% decrease). Overall the biggest increases are predicted for the 75-79 year old and 90+ year age groups with the biggest increases predicted for Basingstoke, Rushmoor, and Test Valley.

For the over 85 years olds the biggest increases are predicted to be in Basingstoke, Hart and East Hampshire, although in terms of predicted numbers of people (rather than % increases) New Forest will have the most people over 85 years by 2023, at just under 10,000.

Life expectancy is a well recognised measure of comparative health within and between populations. Life expectancy at birth is an estimate of how long a child born today might expect to live if current age and gender specific death rates apply throughout their life. Likewise life expectancy at 65 is the measure of how long a person who is 65 today can be expected to live.

The life expectancy for an area is a recognised measure of its health and wellbeing. Variation in life expectancy within and between areas highlights health inequalities.

Healthy life expectancy is a measure of the number of years a person born in an area can expect to live in good health. The healthy life expectancy for men is 65.6 years and for women is 66.3 years. Both are in line with our CIPFA neighbours and better than the overall healthy life expectancy for England.

However, in Hampshire healthy life expectancy for both men and women has not increased in line with increases in life expectancy. This means that people are living longer in poorer health.

Life expectancy for men in Hampshire has risen from 78.1 years in 2001/03 to 81.1 years in 2013/15 and is significantly better than the male life expectancy for England.

Life expectancy at 65 for men in Hampshire has risen from 17.2 years in 2001/03 to 19.6 years in 2013/15, significantly better than life expectancy at 65 for both England and the region.

Healthy life expectancy for men has stayed relatively unchanged since 2009/11 (a slight worsening then improvement with little change overall).

Life expectancy for women in Hampshire has risen from 82.0 years in 2001/03 to 84.3 years in 2013/15, significantly better than the female life expectancy for England.

Life expectancy at 65 for women in Hampshire has risen from 20.0 years in 2001/03 to 22.0 years in 2013/15, significantly better than life expectancy at 65 for both England and the region.

Healthy life expectancy for women in 2013/15 is slightly below that seen in 2009/11.

The difference between healthy life expectancy and overall life expectancy indicates increasing years of ill health; around 14 years for men and 17 years for women; therefore although women live longer than men, more life years (20.2% of women's lives v/s 17.1% of men's lives) are spent in poorer health. Although the trend for healthy life expectancy is based on only five time periods, a more detailed exploration is required to understand the cause of this effect.

There is significant variation in life expectancy across Hampshire that indicates an important inequality in health.

A more sensitive indicator for the over 65 year old population which allows comparison between local areas, such as districts, is the disability-free life expectancy. Disability-free life expectancy at 65 gives us a measure of how long someone aged 65 years now can be expected to live in good health; the difference between life expectancy and disability-free life expectancy gives an indication of the health of our older population.

In Hampshire, in 2012/14, the life expectancy of a man aged 65 years was 19.7 years, the disability free life expectancy was 12.1 years. Therefore, the number of years a man over the age of 65 years could be expected to have disability or poor health is 7.6 years, which is comparable to our CIPFA neighbours. Similarly, for women living in Hampshire, in 2012/14 the life expectancy at 65 was 22.0 years, with a disability free life expectancy at 65 years of 12.3 years. Therefore, the number of years a woman over 65 years would be expected to have a disability is 9.7 years which is comparable to our CIPFA neighbours. What is striking is that women live longer, but they are living longer in poorer health.

Understanding the impact of any changes in disability-free life expectancy and life expectancy for people over the age of 65 years over time is important for the strategic planning of health and care services to ensure that resources are targeted effectively; but it is also important to develop prevention initiatives to improve healthy life expectancy at any age.

Injuries from falls are the most common and costliest injury event for older people. The consequences of falling can be minor, but with increased frailty and osteoporosis the consequences can be significant, resulting in fractures, particularly fractured neck of femur.

It has been estimated that around 1 in 3 people over 65 and 1 in 2 over 80 fall each year and falls are the leading cause of ambulance call-outs to the homes of people over 65. In Hampshire this equates to approximately 95,000 people over 65 years falling each year, of which 49,400 are over 80 years old. Falling is often a turning point and older people recovering from a fall frequently require more continuing care from both health and social services. A 2013 Kings Fund report based on a study in Torbay, reported that falls patients account for 4% of adult social care spending and 4% of acute inpatient hospital care spending.

The proxy measures used to assess the impact of falls and hip fractures nationally come from hospital data. While hip fractures are in most cases dealt with in hospital so are a reasonably accurate measure, older people falling in their own home often goes unreported as the injury doesn't always warrant medical intervention. Therefore the figures in the indicator below will be under-reporting the true scale to the issue.

The return on investment by preventing falls is high; between £2.60 and £7.00 saved for every £1 invested (depending on the initiative and setting). Initiatives that keep people safe, improving confidence, independence and mobility reduce the risk of admission to hospital for fracture or care homes for rehabilitation/reablement.

The Global Burden of Disease Study 2010 reported that disorders of muscles, bones and joints (musculoskeletal disorders) are the single biggest cause of disability in the UK, at 31.3% of the population. Having poor bone health and weak muscles can significantly impact on health and increase the risk of falling and the severity of injury. Lifestyle factors can contribute to the prevalence of musculoskeletal conditions. Preventative measures are vitally important at both an individual and a community level. The most important risk factors to tackle are poor nutrition, obesity and physical inactivity (especially load-bearing exercise). Excess alcohol and smoking are also important modifiable factors.

Social relationships are vital for the maintenance of good health and wellbeing. Social isolation and loneliness are associated with poor mental and physical health and increased mortality. While social isolation and loneliness are closely linked, they are different. It is possible to be socially isolated and not feel lonely, or to feel lonely when not socially isolated. Both are independently linked to poorer health.

Social isolation and loneliness can affect people of any age and younger age groups are frequently neglected in discussions around social isolation and loneliness. However many of the risk factors such as bereavement and poor physical health are more common in the elderly, making older people particularly vulnerable.

In 2016 we undertook a more comprehensive review (needs assessment) of social isolation and loneliness; why it is important, who might be affected, how can we identify those at risk and what works to prevent or alleviate isolation or loneliness. This report found:

• Social isolation and loneliness are associated with poor mental and physical health, and increased mortality
• The impact on health is as significant as smoking
• Certain groups are particularly at risk of becoming isolated and lonely including, but not limited to, the older population
• Social isolation and loneliness represent a health inequality, with deprived communities being most affected 
• Social isolation and loneliness have a large financial cost on adult social care and health care services
• There is good evidence about what can be done to prevent and reduce social isolation and loneliness
• The cost of delivering programmes to prevent and reduce isolation and loneliness can be significantly less than doing nothing
• Some risk groups in Hampshire remain under-served in terms of programmes and interventions, and more should be done to support them

Unfortunately there is not one single indicator that can provide on-going information to help us identify people who are isolated or lonely, or how well we are tackling this issue. Nationally the indicators being used are based on survey reports from social care clients and their carers and while useful, do not give a true picture of the scale of the issue. Further exploration is needed to develop robust indicators that can support work to reduce isolation and loneliness.

Research indicates that loneliness and social isolation’s influence on the risk of death is comparable with well established risk factors such as smoking and alcohol consumption and exceeds the influence of other important factors such as physical inactivity and obesity. Although it was not possible to quantify the impact of social isolation on mortality rates the study concluded that social relationships influence the health outcomes of adults and we should take social relationships as seriously as other risk factors that affect mortality.

The burden of disease and impact on health of long term conditions (mortality, avoidable mortality and morbidity) is described in more detail in the Living Well section. As age is one of the biggest risk factors for having long-term conditions, then it is expected that there is a higher proportion of people over the age of 65 who have one or more long term conditions. Therefore, the greater burden of poor health is seen in older people. The mortality rate for the three main causes of death in people over 65 (cardiovascular disease, respiratory disease and cancer) are significantly below the national average, contributing to the longer life expectancy seen in Hampshire. However, one of the major challenges for health and social services for older people is dementia, with an increasing prevalence seen nationally and locally.

Dementia is a syndrome, a term for a group of diseases and conditions that are characterised by the decline and eventual loss of awareness such as memory, thinking and reasoning and often by changes in personality and mood. Dementia is a degenerative disease; the needs of an individual for health and social care will change over time with the greatest need coming towards the end of life.

Dementia isn't exclusively a disease of old age but old age is the largest risk factor for dementia and prevalence (i.e. the number of people who have the condition) doubles every decade after the age of 65. Some 68% of all people with dementia are aged over 80 and most will also have other illness or long term conditions that result in physical impairment. These co-morbidities often go undiagnosed and/or untreated. Early onset dementia refers to dementias that occur before the age of 65. In contrast to dementias in older people, dementias in younger people often present with features other than memory decline. Early onset dementias are less common than dementias in people over 65 years of age, and younger people are more likely to have rarer forms.

Alzheimer's disease (AD) is reported to account for the majority of dementias (54%); vascular dementia (16%) and mixed or other dementias accounting for the remainder. The distribution of dementias in younger people is 31% Alzheimer’s disease, 15% vascular dementia, 13% frontotemporal dementia and 12% alcohol-related dementia. There is also an increased incidence of the Alzheimer type of early onset dementia in people with Downs Syndrome which can significantly impact on the need for care.

Dementia is a leading cause of disability in people aged over 65.

• Dementia is a progressive disease, and the prognosis after diagnosis is not good. Most people die within five to eight years of diagnosis.
• Women with dementia outnumber men by two to one.
• It is estimated that 63.5% of people with dementia live in the community, of whom two thirds are supported by carers and one third live alone.
• Approximately 36.5% live in care homes.

There is growing evidence that certain dementias are preventable, particularly vascular dementia.

Our primary focus needs to be on preventing people getting dementia where possible through supporting healthy lifestyles and reducing vascular disease. However, once diagnosed, the focus needs to be on supporting people to have the best quality of life that they can and remain independent and active for as long as possible. In the final phase of the condition the focus needs to be on ensuring good end of life care.

In Hampshire, in 2015/16 the recorded prevalence of dementia was 0.88% which is above national and regional recorded prevalence and equates to 12,069 people. However the recorded prevalence for the over 65 year olds in September 2016 was 4.15% (11,464 people) which is below the national and regional recorded prevalence for this age group.

The increases in prevalence are significant but so far have been less than predicted. This may reflect that we have yet to see the 'baby boomer' generation attaining the age of majority for diagnosis. Other reasons could be a reduction in cardiovascular disease mortality. The risk factors are the same and so addressing these can impact on dementia prevalence.

Social services data show that a key issue for demand on services is the breakdown of carer support. Supporting carers is critical but what we do needs to be based on evidence of what works.

A carer is someone of any age who provides unpaid support to family or friends who could not manage without this help due to illness, disability, mental ill-health or a substance misuse problem. Carers are the largest source of care and support in each area of the UK. Carers often suffer ill consequences due to their caring role, be it financial because they have given up employment to care or ill health because they ignore their own needs. To care safely and maintain good physical and mental health and well-being, carers need information, support, respect and recognition from the professionals with whom they are in contact. Improved support for the person being cared for can make the carer's role more manageable.

Carers in their caring role are often "invisible" to services because their caring role is often not recognised or flagged up on notes or files. Very little is therefore known about carers and their needs. In respect of health needs, little data is available and therefore these are difficult to assess. In addition, there are likely to be significant numbers of carers in a caring role who have not been identified by commissioners or providers and therefore are not receiving crucial support.

From 2011 Census data, 1 in 10 Hampshire residents reported providing unpaid care. New Forest has the largest population of people who provide unpaid care, at 11.93% (as seen in the Map). This is above the South East average of 9.98%, the Hampshire average of 10.22% and the England average of 10.39%. Fareham, Havant and Test Valley districts are also above the national average.

More than 3 in 4 unpaid carers reported being in good or very good health in the 2011 Census; just under 1 in 20 regard their health as 'Bad' or 'Very Bad' (4.76% compared to the national average of 6.58%). Unpaid carers in Havant report higher levels of 'bad or very bad' health (6.14%). In line with poorer health being reported in older people, older unpaid carers also report higher levels of poor health; about 2% of young unpaid carers (0-24 years) compared to 40% for unpaid carers over 65 years. While the level of reported poor health of unpaid carers is small, the impact of poor health in unpaid carers on Health and Social Care can be significant. Analysis of social care data in 2015-16 showed that carer breakdown was a significant reason for reassessment and additional care needs.

The age profile of the carers in Hampshire appears to have significantly shifted since the previous survey, with a greater proportion of 50-74 year old carers. If this is a real effect, then the changing profile of the carer could have implications for the type of information, advice and services required by carers in future years.

These figures are based only on people already known to the local authority and therefore are likely to be a significant underestimation of the true position. A new Carers Strategy across Hampshire is being developed by partners, including the Council, Health and the voluntary sector, ensuring good information and advice is widely available to support unpaid carers in their role.

Given the projected increase in the older population and a corresponding increase in the number of older carers, and against the tightening of resources in local authority, the role of carers will become increasingly pivotal in ensuring that people maintain independence and are supported to live in their own homes.

Consideration needs to be given to how carers can be more effectively identified and where required assessed, in line with the strength based approach that is being introduced in Social Care.

People need healthy places to live healthy lives. The physical environments where people are born, live, grow, work and age have significant effects on mental and physical health and wellbeing. Planning, transport, housing, environmental and health services all have a key role to play. These social determinants of health impact on physical and mental health and wellbeing. There is strong evidence that mental ill health, cardiovascular disease, respiratory disease, excess seasonal deaths and accidental injuries are heavily influenced by these social determinants.

Older people are particularly at risk of dying during winter months compared to the rest of the population. Excess Winter Deaths (EWD) is the measure used to describe how many more people die during winter months than at other times of the year.

The UK has one of the highest EWD rates in Europe despite having relatively milder winters. This is because we tend to take fewer precautions in cold weather (such as wearing warmer protective clothing) compared to people living in countries with cold winters. Countries with milder winters also tend to have fewer homes that have cavity wall insulation and double glazing, which makes it harder to keep homes warm during the winter.

There are various physiological effects of cold weather, which may lead to death in vulnerable people, especially older people. In older people a one degree lowering of living room temperature is associated with a rise of 1.3 mmHg blood pressure. This increases the risk of strokes and heart attacks. Although the rate of EWD and fuel poverty is lower in Hampshire compared to England, it is still higher than European countries.

Fuel poverty (i.e. the ability of households to heat their homes) also disproportionately affects older households, and rural districts. Social housing and newer homes are subject to stricter regulation and are built with better insulation, meaning they tend to offer better fuel efficiency than the older privately owned or rented housing stock. Across Hampshire we know that the majority of the over 65 year old population (84%) are home owners and a further 5% privately rent.

Older People are more likely to have an underlying health condition that may make them more vulnerable to a winter death and also by virtue of age are likely to be frail.

Respiratory and circulatory diseases each account for around one third of EWDs. The level of circulating influenza can also be a major explanatory factor. A lower resistance to respiratory infections and the increased level of influenza circulating in the population in winter can lead to life-threatening complications in vulnerable groups, such as bronchitis or pneumonia. Since 2000, GPs have routinely given flu and pneumococcal vaccinations to people over 65 years. The main benefit of the flu vaccination is that it can prevent or reduce the severity of complications associated with flu. The pneumococcal vaccination is given as a one off vaccination but the flu vaccination is given annually. This is because the flu virus can change very quickly and a vaccine that is effective one year may not be effective the following year. The annual programme for flu has two elements; the first element is vaccination of those at risk (that includes all the over 65 year olds, people under 65 years but who have certain long term conditions or are a carer for someone who would be at risk if the carer got ill). Within Hampshire the rate of flu vaccinations is generally better than the national average on vaccinating the over 65 year olds but the rate is still below the target of 75%. The vaccination rate for the younger at risk population is again better than the national rate but less than the target of 75%.

As discussed in the JSNA Demography and the JSNA Living Well sections, deprivation is a key driver for poor health and the need for health and social care services. This is linked to the increased risk of long-term conditions. For example, after adjusting for age (biggest risk factor for a long term condition), people that live in deprived areas are over 3 times more likely to have more than one long term condition. There is growing evidence that it is the number of conditions someone has, rather than specific conditions, that is driving the need for health and social services. This leads to significant inequalities. Across the county, in terms of life expectancy, for men there is a 6.5 years gap in life expectancy between those in the most deprived and least deprived areas of Hampshire; for women the range is 4.9 years. The lowest life expectancy for men and women is in Gosport.

One of the biggest drivers of deprivation is lack of, or limited income.

The Index of Multiple Deprivation (IMD) includes a specific domain on income that accounts for 22% of the total IMD. This domain is measured by the receipt of income support, such that an increase in the number of people claiming benefits would denote an increase in income deprivation. An additional index for older people that is calculated separate to the IMD is Income Deprivation affecting Older People (IDAOPI). This is driven by the proportion of over 60 year olds living in income deprived families. This index is useful in understanding where our older people who are more at risk of poorer health and wellbeing live and where we need to be targeting resources to tackle inequalities. Further exploration of the drivers of inequalities for older people and how to tackle them locally is needed. Havant and Rushmoor have the most areas of deprivation for older people (11 and 16 areas in the 20% most deprived in the country respectively).

People with physical disabilities face social, environmental and attitudinal barriers, which can restrict their participation in their community. Policies that increase independence and enablement are important in supporting good outcomes amongst people with physical disabilities. Unfortunately we have very little national comparative data on disabilities in general and therefore a more detailed look at disabilities and their impact on healthy ageing is needed.

Loss of mobility can have social as well as physical consequences leading to social isolation and withdrawal. The Projecting Older People Population Information System (POPPI) applies national survey data to calculate prevalence estimates and projections of the number of people with restricted mobility. This is defined as someone who is unable to manage at least one activity on their own. 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 or getting in and out of bed. In Hampshire there are an estimated 54,000 older people whose mobility is restricted.

People aged 65 and over unable to manage at least one mobility activity on their own

Hearing loss is a common sensory deficit in older people and is usually a gradual process. It can impair the exchange of information, significantly affecting everyday life, causing loneliness, loss of independence and communication disorders.  With an ageing population a significant increase in the number of people with a hearing impairment is predicted.

Local data on hearing loss is very limited; The Projecting Older People Population Information System (POPPI) applies prevalence data from two studies to local populations to predict the number of people aged 65 years and over who have a moderate, severe or profound hearing impairment.  There are an estimated 125,500 people living in Hampshire who are experiencing some form of hearing impairment.

People aged 65 and over predicted to have a moderate or severe, or profound, hearing impairment, by age, projected to 2035

One of the leading causes of disability in older people is sight loss; older people with poor eye sight are more likely to have additional health conditions or disabilities and are more likely to become socially isolated. Sight loss can have a profound effect on access to services, for example through issues with transport or written information, which may further impact health.

Research suggests that 50% of cases of blindness and serious sight loss could be prevented if detected and treated in time. The five leading causes of preventable blindness and partial sight loss in the UK are:

• age-related macular degeneration (AMD) for which smoking is a significant risk
• diabetic retinopathy which is a complication of diabetes
• glaucoma
• cataracts
• refractive error

Research implies that the take-up of sight tests is generally lower than would be expected within areas of social deprivation. Low take-up of sight tests can lead to late detection of preventable conditions and increased sight loss due to late intervention. Risk of sight loss is heavily influenced by health inequalities, including ethnicity, deprivation and age. Sight loss can increase the risk of depression, falls and hip fractures, loss of independence and living in poverty. RNIB (2016) estimate that in Hampshire there are 4,850 people aged over 65 registered as blind or partially sighted.

The Public Health Outcomes Framework suggests that the Hampshire crude rate of sight loss due to AMD and diabetic retinopathy is significantly higher than for the rest of the country (158.8 cases per 100,000 in Hampshire compared to 118.1 for England in 2014/15 for AMD and 4.4 per 100,000 in Hampshire compared to 3.2 for England in 2014/15 for diabetic retinopathy). While this might be due to better recording of the conditions locally (the figures are based on self-certification which in Hampshire for 2014/15 was 58.5 per 100,000 compared to 42.4 for England), the levels and increasing trend are cause for concern and this does need further investigation. Sight loss in the working age population is reported in the JSNA Living Well Section.

Hampshire's population is older than the national average and ageing faster. Sight loss is significantly correlated to age and therefore predictions suggest that the number of people in Hampshire living with sight loss will increase by more than national predictions. Figure 24 presents the estimated number and predicted increase in the number of people with a sight loss eye condition.

Estimated and predicted number of people in Hampshire with sight threatening eye conditions