ph1 april 2015 - y&h edition

PH1….Far From Neutral

FOCUS ON LONELINESS AND SOCIAL ISOLATION

Welcome to the April 2015 edi�on of PH1 which is themed around the issue of loneliness and

social isola�on.

This issue has been put together by public health trainees in Yorkshire & Humber. As a region we

have chosen to adopt the theme of loneliness and social isola�on for 2015, and as such we have

commi&ed to raise the profile of this important public health issue both locally and na�onally.

PH1 provides a great opportunity to highlight the impact of loneliness on health and wellbeing to

a public health audience.

Social isola�on as measured by the Adult Social Care Survey and Carers Survey is one of the indi-

cators of the Public Health Outcomes Framework (1.18). Na�onally, Public Health England has

worked with The Campaign to End Loneliness and a number of other partner organisa�ons to

iden�fy and share best prac�ce examples of strategies to tackle the issue.

In true public health style we have set the context by taking a look at the issue in more detail,

how it is defined, who is at risk, what the evidence tells us and how we can measure the impact

of loneliness. Read registrar Nick Leigh-Hunt’s informa�ve ar�cle on page 2.

One way we, as a region, are raising the profile of the impact of loneliness is through our formal

partnership with the na�onal Campaign to End Loneliness. You can read an interview with the

Director of the Campaign, Laura Alcock-Ferguson, on page 6. In it she talks about the role public

health can play in ensuring that loneliness is recognised as a public health priority by Health and

Wellbeing Boards across the country.

Chronic loneliness affects 800,000 older people in the UK, but its effects are not only confined to

the over 65s. In our Frontline Perspec�ves ar�cle on page 9 we have interviewed staff working

on the frontline about how they iden�fy loneliness and how they think it should be tackled. The

ar�cle highlights the diverse range of people who can be impacted.

As the profile of this issue grows, a number of local authori�es and CCGs are considering ways in

which they can tackle loneliness. The Big Lo&ery Fund has awarded funding to 15 areas in Eng-

land and Wales to tackle loneliness and social isola�on in older people. In Yorkshire, Sheffield

and Leeds were successful in their lo&ery bids and you can read more about their plans on page

5.

Dr Sophie Egerton gives a powerful insight on into the rela�onship between social isola�on and

long-term condi�ons both from an academic and personal perspec�ve. Read her ar�cle, star�ng

on page 12.

Many of you will have heard of Silverline, the helpline launched by Esther Rantzhen to provide

support to older people experiencing loneliness and social isola�on. The current director talks

to one of our Registrars, Ma&hew Neilson on page 18

We hope you find this edi�on of PH1 helpful and informa�ve.

April 2015 Health Educa#on Yorkshire &

Humber

Public Health Specialty Registrars

INSIDE THIS ISSUE

Loneliness & Social Isola#on

— Facts and Figures ............ 2

Tackling social isola#on in

Yorkshire & the Humber ...... 5

Interview with Laura Alcock-

Ferguson, Campaign to End

Loneliness ........................... 6

Frontline Perspec#ves on

Loneliness ........................... 9

Social Isola#on and Chronic

Illness ……………………………...12

Tackling Loneliness: A case

study ……………………………….14

Loneliness & Isola#on: An

Academic Perspec#ve ……..15

Chronic Illness and Social Iso-

la#on: Beyond Theory …….16

The Silver Line …………………18

Final Thoughts ……….……….20

“Loneliness and the feeling of being unwanted is

the most terrible poverty” (Mother Teresa)

1

“ Lonely individuals have been es�mated to have a greater risk

of developing clinical demen�a, depression , Alzheimer’s and

undergoing cogni�ve decline”

What are the Risk Factors?

Social isola�on can occur throughout life, but is much more common in the elder-

ly, due to reduced mobility and the loss of family or friends through bereave-

ment. It has been reported that more than half of nursing home residents may

feel lonely. Women make up a greater propor�on of lonely individuals since the

ra�o of women to men increases with age. Apart from age and gender, other risk

factors include: physical and mental health; socio-demographic factors, such as

household composi�on, being a carer, or poverty; and the social environment,

such as the place of residence, driving status, access to transport, or the built

environment. In children and young adults loneliness and social isola�on are

related more to bullying, lack of outdoor areas to play, and paren�ng styles.

LONELINESS & SOCIAL ISOLATION - FACTS AND

FIGURES

What is social isola�on?

It is important to dis�nguish between

social isola�on and its sister concept

loneliness. Loneliness is defined as the

subjec�ve feeling of the absence of a

social network (social loneliness) or a

companion (emo�onal loneliness); social

isola�on is defined as an objec�ve lack

of interac�ons with others or the wider

community.

Some defini�ons of social isola�on bring

the two concepts together by consider-

ing both the quality and the quan�ty of

social interac�ons, with loneliness

viewed as part of the former. However

while the two may be closely associated,

it is possible to be lonely but not socially

isolated and vice versa, or experience

Popula�on sub-

groups

There are rela�vely few

studies on the importance

of ethnicity in social isola-

�on; there may be li&le

difference between differ-

ent ethnic groups in mid

life, but in later life these

become pronounced with

older Chinese individuals

being three �mes lonelier

than older Indian individu-

als.

Geography is also an issue,

as social exclusion in the

elderly is two and a half

�mes greater in densely

populated areas compared

to those less dense. How-

ever the older rural popu-

la�on in the UK is set to

increase in coming dec-

ades, which will present

challenges in terms of

elderly individuals being

able to access social and

support groups, given the

poorer transport links.

2

By Nick Leigh-Hunt. Public Health Registrar

Data & Trends

It is difficult to ascertain accurate figures as many individuals do not admit to being

lonely. However the most recent survey by the Office of Na�onal Sta�s�cs iden�fied

that 17% of all individuals over 80 years were oHen lonely and a further 29% were

lonely some of the �me; this is significantly different to the figures of 9% and 25%

respec�vely for individuals aged over 52.

The propor�on of older people repor�ng that they are lonely has remained rela�vely

constant over �me in the UK; three separate studies from 1948, 1954 and 2005

showed that a li&le under 10% reported feeling lonely all the �me, but the propor�on

of older individuals who reported feeling lonely some of the �me increased from 13%

in 1948 to 25% in 1954 to 32% in 2005. However compared to other European coun-

tries, the UK is a less lonely place for older people.

Loneliness is not confined to older adults; a survey by the Mental Health Founda�on

found that 12% of 18-24 year olds were oHen lonely with 45% lonely some of the �me.

A survey of pre-teens iden�fied that 41% had experienced loneliness.

Importance for the individual

Whether loneliness is a cause or effect of ill health is difficult to ascertain as most

research on the subject involves cross sec�onal studies. Much of the research

considers the rela�onship with mental health since there is a strong associa�on

between loneliness and general sa�sfac�on with life. Lonely individuals have

been es�mated to have a greater risk of developing clinical demen�a, depres-

sion , Alzheimer’s and undergoing cogni�ve decline. Associa�ons with aspects of

physical health include adverse affects on blood pressure and a greater all cause

mortality for those suffering from loneliness or social isola�on. A meta- analysis

of 148 longitudinal studies including around 300,000 individuals followed up for

the greater part of a decade on average showed that those with good social links

had a 50% greater likelihood of survival, which is akin to the effect of smoking up

to 15 cigare&es a day for those more socially isolated.

There are several theories as to how a lack of social support leads to physical

disease, in par�cular those considering the development of cardiovascular dis-

ease. It has been hypothesised as being mediated through adverse effects of the

nervous system and adrenaline on heart rate, blood pressure and the repair of

blood vessel walls or through the lack of protec�ve hormones such as oxytocin

which are released on close physical contact with others. Health behaviours are

equally implicated in the associa�on between lack of social support and cardio-

vascular disease, as strong rela�onships are linked to healthy behaviours while

those who are socially isolated may take up harmful behaviours.

Causes of Loneliness in four neighbourhoods in Yorkshire. Source: Joseph Rowntree Foundation

3

Importance for Society

Social isola�on has an impact

on service u�lisa�on as affected

individuals are more likely to

undergo early admission into

residen�al or nursing care. It

may also contribute to a large

part of primary care workload,

with 1 in 10 individuals visi�ng

their GP poten�ally doing so

because of loneliness. Among

the elderly, it has been associat-

ed with increased emergency

hospital admissions and hospi-

tal re-admissions.

Na�onal context

Social isola�on as measured by the Adult Social Care Survey and Carers Survey is one of the indicators in the Public

Health Outcomes Framework (1.18). Public Health England has worked with The Campaign to End Loneliness and a num-

ber of other partner organisa�ons to iden�fy and share best prac�ce examples of strategies to tackle the issue. The Big

Lo&ery Fund is currently suppor�ng approaches to reduce social isola�on in 15 areas across England and Wales.

Measuring & Evalua#ng

It is difficult to quan�fy loneliness and social isola�on, partly because there are no universally accepted defini�ons of the

concepts, but also because different aspects of them are used to generate metrics. Both vary across the life course and can be

temporary or of long dura�on which will have differing effects depending on the age of subjects being studied. There are also

cultural and gender differences with respect to how prepared individuals are to admit to being lonely or discussing it.

A range of tools have been developed some of which are based on self report ques�onnaires on subjec�ve feelings while

others are based on the degree of social contact or networks. Examples of some of the tools are:

• The University of California, Los Angeles Loneliness Scale, a 20 item self report ques�onnaire which aims to measure self-

perceived isola�on, and rela�onal and social connectedness.

• The De Jong Gierveld Loneliness Scale, an 11 item self report ques�onnaire which aims to measure overall emo�onal and

social loneliness, including the sense of emp�ness, missing having people around, feeling rejected and the presence or

absence of people to rely on, trust or feel close to. A shorter version has been developed for use in surveys.

• The Lubben Social Network Scale, a 10 item ques�onnaire developed to assess the level of social support available to an

elderly pa�ent in order to iden�fy those in need of assistance. It contains ques�ons on family and friends, close rela�on-

ships, living arrangements and the degree of caring ac�vity.

• The Medical Outcomes Study Social Support Survey, a 19 item self report ques�onnaire ini�ally developed to assess

individuals with chronic medical condi�ons. It covers areas such as emo�onal, tangible and affec�onate support and

posi�ve social interac�on.

• The Mul�dimensional Scale of Perceived Social Support, a 12 item self report ques�onnaire which measures percep�ons

of support from family friends and a significant other, and has been adapted for use in other languages.

• The Friendship Scale, a 6 item self report ques�onnaire which assesses the ability to share feelings or be in�mate with a

significant other, relate to others in a meaningful way, ask others for help when needed, and iden�fies the presence of

social networks or feelings of being isolated from others in social seLngs or loneliness.

References

1. Drageset, J., Kirkevold, M. and Espehaug, B. (2011). Loneliness and social support among nursing home residents without cogni�ve

impairment: a ques�onnaire survey. Interna�onal Journal of Nursing Studies, 48, p611–9.

2. Office of Na�onal Sta�s�cs (2013). Measuring na�onal well being, older people and loneliness, p4.

3. Victor, C., Burholt, V. and Mar�n, V. (2012). Loneliness and ethnic minority elders in the UK: an exploratory study. Journal of Cross-

Cultural Gerontology, 27, p65-78.

4. Age UK (2009). Social exclusion in later life, an explora�on of risk factors, p13.

5. Victor, C. (2005). The Social Context of Ageing: A Textbook of Gerontology.

6. European Social Survey (2006-12). European social survey loneliness figures. h&p://www.europeansocialsurvey.org/

7. Griffin, J. (2010). The Lonely Society. Mental Health Founda�on

8. h&p://www.mentalhealth.org.uk/content/assets/pdf/publica�ons/the_lonely_society_report.pdf

9. Ac�on for Children (2009). Stuck in the middle: the importance of suppor�ng six to 13 year olds. www.ac�onforchildren.org.uk

10. Fra�glioni, L. et al (2000). Influence of social network on occurrence of demen�a: a community-based longitudinal study. Lancet, 355,

p1315–9.

11. Cacioppo, J.T. et al (2006). Loneliness as a specific risk factor for depressive symptoms: cross-sec�onal and longitudinal analyses. Psy-

chology and Aging, 21 (1), p140-51.

12. Wilson, R.S. et al (2007). Loneliness and risk of Alzheimer disease. Archives of General Psychiatry, 64 (2), p234-240.

13. James, B.D. et al (2011). Late-life social ac�vity and cogni�ve decline in old age. Journal of The Interna�onal Neuropsychological Society,

17 (6), p998-1005.

14. Hawkley, L.C. et al (2010). Loneliness predicts increased blood pressure: 5-year cross-lagged analyses in middle-aged and older adults.

Psychology and Aging 25 (1), p132-41.

15. Holt-Lunstad, J. et al (2010). Social Rela�onships and Mortality Risk: A Meta-analy�c Review. PLOS Medicine, 7 (7): e1000316.

16. Russell, D.W. et al (1997). Loneliness and nursing home admission among rural older adults. Psychology and Aging, 12 (4), p574-89.

17. Ellaway, A. et al (1999). Someone to talk to? The role of loneliness as a factor in the frequency of GP consulta�ons. Bri�sh Journal of

General Prac�ce, 49, p363–7.

18. Molloy, G.J. et al (2010). Loneliness and emergency and planned hospitaliza�ons in a community sample of older adults. Journal of the

American Geriatrics Society, 58, p1538–41.

19. Public Health Approaches to Social Isola�on and Loneliness h&p://www.campaigntoendloneliness.org/phe-approaches-loneliness/

4

TACKLING SOCIAL ISOLATION IN YORKSHIRE

AND THE HUMBER By Ma>hew Neilson. ST3 in Public Health

Increasingly, social isola�on and loneliness is being recognised as a priority by policy

makers and funding bodies, and important work is being done in a range of seLngs

to start to tackle this problem. We asked organisa�ons around the region what they

were doing, and heard about some really interes�ng and innova�ve projects.

Social Prescribing in Doncaster

GPs are in a key posi�on to iden�fy and

support socially isolated people. In Don-

caster a recent ini�a�ve, jointly funded

by Doncaster Council and NHS Doncaster

CCG, aims to enable this.

GPs are taking part in a pilot scheme to

iden�fy pa�ents and refer them on to a

community organisa�on that will sign-

post to the appropriate local services.

Par�cipa�ng GPs have been given a

dedicated “social prescrip�on pad.”

A team, run by a partnership of South

Yorkshire Housing Associa�on and Don-

caster CVS assess the pa�ent in their

own home, and refer them to the appro-

priate provider organisa�ons.

Staying Well in Calderdale

The ageing popula�on is a public health

priority, and loneliness and isola�on

affects use of health and social care.

The Staying Well project aims to: reduce

loneliness and social isola�on; create

more connected communi�es; improve

coordina�on between sectors and or-

ganisa�ons.

Community hubs micro-commission new

schemes. The Local Authority has em-

ployed staff to support hubs and coordi-

nate individuals and neighbourhood

workers. Five GP prac�ces are pilo�ng

social prescribing. Calderdale CCG fund

the project which is being evaluated by

the University of Lincoln.

Time to Shine in Leeds

Leeds City Council and third sector or-

ganisa�ons, led by Leeds Older People’s

Forum, were awarded Big Lo&ery fund-

ing to reduce social isola�on and loneli-

ness in people aged 50+ in Leeds. The

Time to Shine project is a six year pro-

gramme which aims to reach over

15,000 people.

Projects will include: social prescribing;

digital inclusion IT; building senior net-

works ; provision of social and cultural

ac�vi�es.

Time to Shine will also work to raise

awareness of social isola�on through

outreach work with the public, and

health and social care professionals.

North Yorkshire County Council

This is a predominantly rural popula�on,

presen�ng a par�cular challenge in tack-

ling social isola�on. The County Council

and partners have iden�fied social isola-

�on as a priority issue, and it features in

their Joint Strategic Needs Assessment.

The council’s Innova�on Fund provides

small grants to community and third

sector organisa�ons and a key aim of

the fund is “reducing loneliness”.

Funded projects include the Community

Café “on tour”, where a community

informa�on service is taken to rural

areas. Other projects t arget young peo-

ple with disabili�es, and the homeless.

Ageing Be>er in Sheffield

Sheffield was awarded Big Lo&ery fund-

ing aimed at reducing social isola�on

among older people. The consor�um

running the Ageing Be&er project is led

by South Yorkshire Housing Associa�on.

Planned projects include: development

of a “neighbourhood toolkit” to iden�fy

and support isolated people; suppor�ng

innova�ve ideas to tackle isola�on; pop-

up events to raise awareness; an inter-

genera�onal skills swap, where young

people are paired with isolated older

people; peer mentoring to help older

people cope; counselling services; and

training “access ambassadors” to help

older people tackle their isola�on.

The role of public health

Social isola�on represents a challenge

for health and social care. In addi�on to

its role in emo�onal wellbeing, it has a

direct effect on wider aspects of health

and can increase service use. There is a

clear role for public health - to iden�fy

those at risk and effec�vely target re-

sources. There is also a clear role for the

public health in local authori�es, Public

Health England, and other seLngs in

developing an evidence base.

Many of the projects men�oned here

have had valuable input from public

health, but there is clearly more that can

be done to reduce the impact and bur-

den of loneliness and isola�on across

the region and the country.

5

CAMPAIGN TO END LONELINESS

Laura Alcock-Ferguson is Director and founder of the Campaign to

End Loneliness, a national partnership which aims to raise awareness

of loneliness and its impact on the health and wellbeing of older people

in the UK. Since its launch in 2011 the campaign has grown rapidly,

and now has over 2000 supporters. Here Laura talks to PH1 about

the long-term aims of the campaign and the role public health can

play in tackling this important and growing issue.

6

Campaign Director Laura Alcock-Ferguson talks to Eleanor Houlston, ST3 in

Public Health

How did the Campaign to End Loneli-

ness get started?

Loneliness is a complex and personal

ma&er affec�ng 3 million older people

today and with life expectancy on the

increase, and divorce rates increasing, in

the future this figure is expected to rise.

Whilst there is much academic research

that could help improve front-line ser-

vices, historically there was a lack of

transla�on of this research into prac�ce.

There was also li&le coordinated ac�on

to share evidence and good prac�ce in

tackling the loneliness felt by older peo-

ple among frontline organisa�ons. It

was this opportunity to create be&er

understanding and coordinate ac�on to

tackle loneliness in older age that led

our partner organisa�ons to launch the

“Campaign to End Loneliness” in 2011.

The Campaign is led by five organisa-

�ons, Age UK Oxfordshire; Independent

Age; Sense; Manchester City Council;

and Royal Voluntary Service (previously

WRVS). Together with our 2000+ sup-

porters, and many new organisa�ons

and ini�a�ves that have started since

2011 to tackle loneliness, we have all

achieved a huge step forward in the four

years since we were founded focusing

on both campaigning for loneliness to be

priori�sed as a health issue and by

spreading the learning on what really

works when it comes to tackling the

blight that loneliness and isola�on

brings to the lives of older people.

Have you been involved from the start,

or did you join when the campaign was

established?

I have taken the idea of the Campaign

from a piece of paper to where we are

today: since launching in 2011 the Cam-

paign has grown to over 2000 support-

ers, with research and prac�ce contacts

across Europe and worldwide. We have

moved the debate about loneliness from

one where social contact was seen pure-

ly as a “nice-to-have” community bonus

to an issue that needs urgent ac�on due

to its impact on health.

Loneliness and social isola#on can

affect a wide range of people. Can you

describe the main groups that you work

with/campaign on behalf of, and the

issues they face?

Loneliness can be caused by a wide

range of circumstances - for example,

bereavement, re�rement, moving home

or the onset of ill-health. These things

are more likely to overlap in older age,

leaving those in later life more at risk of

loneliness. In the UK, almost 4 million

(37%) of those over 65 say they are

lonely “some�mes” or “always” and,

with a growing older popula�on, there is

a risk that this number could grow to

almost 6 million by 2030.

This number may be further increased

by changing demographics - for exam-

ple, more people aged 45 -65 are divorc-

ing or living alone and these are major

risk factors in becoming isolated and

lonely in later life. Living alone is not the

only risk leading to loneliness: research

shows that socially excluded groups –

including LGBT communi�es, minority

ethnic groups and people with physical

or learning disabili�es – are also more

likely to feel lonely in older age. Loneli-

ness and isola�on have been shown to

be as harmful to health as smoking 15

cigare&es a day and loneliness is linked

to a wide range of mental and physical

health problems.

What is the ul#mate aim of the Campaign to End Loneliness?

The Campaign inspires thousands of people and organisa�ons to tackle loneliness and

create the right condi�ons so that people in later life have the number and quality of con-

tacts that they want.

WHAT DOES THE CAMPAIGN

DO?

The Campaign to End Loneliness

inspires thousands of people and

organisa�ons to do more to tackle

loneliness in older age. We work

through community ac�on, shar-

ing good prac�ce and evidence to

ensure loneliness is acted upon as

a health priority. The improve-

ment of direct service provision

for older people is at the very core

of what we do – and we work with

hundreds of front line chari�es as

well as local authori�es to help

them create the right condi�ons

in their local area for older people

to avoid loneliness. Our main

ac�vi�es currently include:

Learning Network: We share

learning about how to best reduce

loneliness both with our 2000+

supporters and beyond, through

our events, media coverage, case

studies, research bulle�ns, publi-

ca�ons, webinars, online Learning

Network and online forum, regu-

lar updates, Twi&er and other

social media.

Convincing commissioners to in-

vest in ac�on to reduce loneliness.

Ensuring the voice of older people

is being heard.

Service Improvement: We are

currently working on two key

areas to help front line organisa-

�ons improve:

1. Developing a measurement

tool to measure effec�veness of

interven�ons to reduce loneliness.

2. Suppor�ng the iden�fica�on of

those most at risk of loneliness

Our publica�on Promising Approaches to Reducing Loneliness and Isola�on offers a

route to help commissioners recognise the complex and individual experience of lone-

liness and to ensure they do not seek a ‘one size fits all solu�on’. In par�cular, the

new framework in the report (see above) features four dis�nct categories of loneliness

interven�on that could be put in place to provide a comprehensive local system of

services to prevent and alleviate loneliness.

“We have moved the debate about loneliness

from one where social contact was seen purely as

a “nice-to-have” community bonus to an issue

that needs urgent ac�on due to its impact on

health. “

7

8

“We want to inspire change in both those in posi�ons of power and influ-

ence and in those working directly with anyone in later life. By 2020 our

aim is for at least 75% of health and wellbeing boards to have priori�sed

loneliness or isola�on.”

How are you measuring the effec#veness of the Campaign to

End Loneliness?

We have a robust evalua�on based on the change we seek to

create - our outcomes - by an external evaluator – the Chari-

�es Evalua�on Service. Our evalua�on results show the

changes we have created within organisa�ons: both organisa-

�ons that fund others (local authori�es) and organisa�ons

that help older people directly. This evalua�on is s�ll ongoing

and will also track the longer-term results of these service and

funding changes for older people themselves, with results

expected from 2016 onwards.

In the mean�me, our latest evalua�on report shows that we

are on track to deliver our long term impact. Some of these

outcomes can be seen in our three year evalua�on report:

h&p://www.campaigntoendloneliness.org/wp-content/

uploads/downloads/2013/12/CES-impact-evalua�on-of-the-

Campaign-to-End-Loneliness.pdf

As Director, what changes would you like to see implement-

ed to address loneliness and social isola#on by the year

2020?

We want to inspire change in both those in posi�ons of power

and influence and in those working directly with anyone in

later life. By 2020 our aim is for at least 75% of health and

wellbeing boards to have priori�sed loneliness or isola�on.

We would also like hundreds of organisa�ons to be reaching

out to those most at risk of loneliness, by using be&er iden�fi-

ca�on tools, and hundreds more organisa�ons to be able to

prove their effec�veness by using our new Loneliness Meas-

urement Tool.

Public Health Specialty Registrars in Yorkshire & Humber

have chosen to focus on loneliness and social isola#on as a

theme for 2015. As part of this, they have formed a partner-

ship with the Campaign to End Loneliness to raise the profile

of the issue in Yorkshire & Humber and beyond. What do

you think are the poten#al benefits of a partnership like

this?

Loneliness is a public health issue and needs to be squarely on

the public health agenda. The Campaign has argued that local

authori�es have a key role to play in taking the lead on ad-

dressing this issue across their community. Our supporters

(including academics, commissioners and front line services)

have a wealth of knowledge and exper�se on this issue and

together we have produced a range of materials, tools and

case studies to support local authori�es in finding ways to

tackle loneliness. In fact, in June the Campaign will be launch-

ing an online tool providing guidance for commissioners to

take ac�on in their communi�es. We also have the voice of

over 700 front line services behind us, all of whom are work-

ing hard to try to support people at risk of loneliness.

However taking our messages to every local authority and

geLng these messages heard is not always easy. Working

with Public Health Speciality Registrars who understand the

key issues and are able to communicate them to key decision

makers in local authori�es, ensures that our message is heard

by many more people who are in a posi�on to ensure this that

loneliness and social isola�on is addressed in their communi-

�es.

What can individual public health registrars/consultants do?

Many individual registrars work with public health teams in

local councils. They understand the risk factors that can lead

people to becoming lonely and the poten�al health conse-

quences of loneliness. They are in a great posi�on to use

their knowledge of the issues to influence their own prac�ce

and the prac�ce of others.

Individuals can become champions in the workplace to raise

awareness of this issue in their local area as well as influenc-

ing back upwards to na�onal public health bodies to encour-

age them to give this issue greater priority.

9

Andy. Clinical Assistant in A&E and ST2 in Public Health

In your experience, how does loneliness and social isola#on impact on your pa#ents?

Loneliness decreases anybody's resilience when dealing with any health or social challenge.

Something that we might consider to be a small health problem can become a major hurdle

without that natural support, and something quite serious can quickly become overwhelming

without someone to turn to. In the A&E se(ng it's especially difficult as the turnaround of

pa�ents is so quick that we don't feel we have the �me (or exper�se) to help with this element of a health or social problem.

But it's not just A&E that feels under pressure from lack of �me and resources, and so nowhere are these people ge(ng

properly helped - we all should be helping ... including in A&E.

What are the common reasons that lead to your pa#ents experiencing loneliness or social isola#on?

The most common are perhaps the ones we would intui�vely iden�fy - 1. old age with loss of a spouse and other family mem-

bers, 2. mental health problems that make social interac�on difficult. But there are many others, lots of life circumstances can

result in undue isola�on - moving to a new town or country where we don't have social connec�ons, chronic illness that might

make it hard for us to interact in 'normal' ac�vi�es, young people bereaved of friends or family, unrecognised mental health/

behavioural health/social health problems that can quickly turn someone into an apparent 'outsider'. I think we are very quick

in society to decide someone doesn't 'fit' and use that as an excuse not to make an effort to interact .

More and more people are facing loneliness & social isola#on. How does this match with your experience?

It's difficult to say without knowing this area in more detail - is it really true, or are we just be4er at iden�fying this and the

related mental health problems? I think it could be - we know that people are living longer which means there's more �me to

be lonely, we know that we are in a funny transi�on where social media is everywhere but not everyone quite knows how to

use it to their benefit. I do think, we need to improve how our society, social and health care systems respond to loneliness as a

problem that can be fixed.

Please describe which of your pa#ent groups are most affected by this issue

Asylum seekers and certain groups from overseas (although some groups from overseas are actually much be4er at more tra-

di�onal community support than our mainstream English society), the elderly (a major problem and an injus�ce we need to

address) and those with mental health problems and substance misuse issues (especially young adults).

What support, if any, are you able to offer or signpost people to?

It is ge(ng slowly be4er, but we need more. There are community support teams who will visit older people in their home

within a day or two of discharge from A&E. There are also be4er responses to people who present with mental health prob-

lems - A&E used to just assess degree of self harm, do an emergency 'suicidal risk' assessment and if neither warranted admis-

sion, we would discharge people back to the situa�on they were in before. These aren't easy situa�ons to fix, but A&E is such a

good 'pick up' place for people in difficulty that we should use it for community referral ... let's keep building this capacity!

In your view, what more needs to happen to reduce the burden of loneliness/social isola#on for your pa#ents?

We need to use the fact that lots of lonely people come through the acute health care system to iden�fy them. We should send

them home in the knowledge they will receive input and support in the community. We are far too o8en discharging people

back to the lonely places from whence they came - at worst this means missing the only opportunity the system gets to im-

prove the person's situa�on.

FRONTLINE PERSPECTIVES ON LONELINESS

“I le6 my country of origin and

with that departure, an extended

family, a career and large group of

good friends. I was le6 alone and

powerless in the UK…” Riana

(Migrant)


It mainly affects mental health. In isola�on people generally have fewer opportuni�es and I believe isola�on short-

ens life expectancy.

What are the common reasons that lead to your pa#ents experiencing loneliness or socially isola#on?

Old age and bereavement. Separa�on and divorce. In my client group (mainly new arrivals in the UK) separa�on

from family and friend support is a very big factor. It is quite common for people to have lost contact with partners

and children and not know their whereabouts or to find it very difficult to get visas for rela�ves to visit them in the

UK even when they are able to support them financially. People housed under the Na�onal Asylum Support Service

(NASS) can be housed anywhere in Sheffield . They can be miles away from people who speak the same language

and o8en cannot afford bus fare. I have met a lot of very unhappy people who have come to the UK for an arranged

marriage and find living with the in-laws very isola�ng, although that is not always the case of course. Lack of cash

can be very socially isola�ng especially if someone’s accommoda�on is unsuitable to ask others to visit them.

10

Andy. TB Specialist Nurse, Sheffield


I suspect this is true but I have no real evidence. Casual work with flexible hours, and agency working must mean that fewer

people get support from a work environment. Alcohol is not the answer but pubs closing must lead to more social isola�on

because it is a loss of public space. Cuts to public spending will inevitably lead to more isola�on, cuts to parks, youth services,

the �me carers can spend with a client…..etc


It can be anyone, but in my client group it is most obviously asylum seekers.


Focussed a4en�on for the dura�on of TB treatment. [Typically 6 months] and referral to community groups/organisa�ons.


On a macro level this is about taxa�on and the sort of society and provision that we want and are willing to pay for. On a local

level it can be hard to keep up with what is currently available because groups and funding come and go. I think a central reg-

ister of what is available would be helpful. English for Speakers of Other Languages (ESOL) provision is o8en quite poor and I

would like to see more money invested in this as it decreases social isola�on, gets people mixing on a non-ethnic basis and

saves money in the long run.

FRONTLINE PERSPECTIVES ON LONELINESS CONT’D…...

11

James. GP and Phase 3 Registrar


From a primary care perspec�ve, loneliness and social isola�on impact in different ways in

different pa�ent groups. The main manifesta�on is probably a form of low level mental ill-

health inasmuch as pa�ents will o8en experience some of the symptoms and exhibit some of

the signs of depressive illness, but not necessarily at a level that would fit with a formal diagno-

sis. In addi�on, some less mobile pa�ents will o8en “not want to bother the doctor” and be-

cause they may not have regular contact with family or friends appear to present for advice or

assistance much later than their peers who have a more resilient social network. This is par�cu-

larly no�ceable in those who have moved regionally to re�re in the area, and they are therefore geographically isolated from

their families and previous support networks.

What are the common reasons that lead to your pa#ents experiencing loneliness or socially isola#on?

In terms of older adults, the main issues that appear to lead to our pa�ents experiencing loneliness or social isola�on are o8en

around independence and mobility, either of themselves or of those in their social network who acted as the individual who

maintained the network. Unusually some of our younger pa�ents are also describing feeling lonely or socially isolated, in spite

of having a reasonable social network. Anecdotally these networks seem to be virtual using social media rather than a more

tradi�onal face-to-face rela�onship. It raises the ques�on of whether pa�ents get the same benefit from social media as they

do from a face-to-face rela�onship.


This fits with what I am seeing in clinical prac�ce, although very few pa�ents will iden�fy that they are experiencing loneliness

and social isola�on. I personally feel as though I am dealing with more “social” rather than “medical” problems. I have also

spoken to GPs in my role as a Public Health registrar who describe “spending more �me feeling like a social worker rather than

a GP”.


The pa�ent groups have in the past been older adults, especially those who are geographically isolated from their families

and/or with issues that impact on their mobility or independence. However more recently there appears to be a cohort of

younger adults/adolescents who are repor�ng similar issues but due to relying on virtual networks rather than more tradi�on-

al face-to-face networks.


In terms of older adults I o8en signpost to an exis�ng day centre on the estate, however, this is a private organisa�on and

there is a cost associated for those who are ineligible for social services support.


I am not sure that there is one thing that needs to change. The causes are complex and are o8en variable and dependent on

the individual, therefore a popula�on approach may not actually solve the problem. Ensuring that services that mi�gate social

isola�on (e.g. bus routes) are not cut will allow some to maintain their independence, but I am not sure that there is a simple

answer that will solve the problem. I guess that if there was, we wouldn’t be having this conversa�on.

“My husband died and le6 me on my own. I managed to cope with things and get by at first.

But in the last two years it got very lonely and miserable. I saw my daughter once a week,

but the rest of the �me I was on my own with nobody to talk to. I thought, ‘This can’t go on

with me by myself’.” by Joy, 88

First and foremost, we need to be sure of what we are talking about, when it comes to ‘chronic’ illness. Our wholesale adop-

�on of the word ‘chronic’ probably fails to convey what we intend to define – which is the state of experiencing the symp-

toms of a disease which is long term; not necessarily constant, possibly unpredictable and poten�ally resul�ng in significant

disability. Official defini�ons of chronic illness may fail to convey the extent of disability and disrup�on which can accompa-

ny chronic illness.

In reducing a set of condi�ons (the manifold and diverse effects of all chronic illnesses) to a single, rather trite word, we run

the risk of restric�ng how society might respond to what is a huge popula�on of pa�ents with myriad needs. We might un-

wiLngly harbour assump�ons about disability and long term suffering which are more convenient than accurate, for exam-

ple that the effects of long term illness are constant, predictable or likely to follow a linear trajectory. In reality, chronic ill-

ness tends to produce a state of fluctua�ons in illness and wellness, which are difficult to predict, plan for and resolve.

We have a good working defini�on of social isola�on: “…an objec�ve lack of interac�ons with others or the wider communi-

ty.” In considera�on of how social isola�on might arise as a result of, or adversely impact the effects of chronic illness, it is

appropriate to invoke the work of Bury and his concept of ‘biographical disrup�on’. In his seminal paper, Chronic illness as

biographical disrup�on1, which recounted his interviews with pa�ents recently diagnosed with rheumatoid arthri�s, Bury

suggested that the process of becoming unwell and receiving a chronic illness diagnosis represented a crisis in the life of an

Sophie is a public health registrar, previously a GP, who was diagnosed

with a rare gene�c condi�on 18 months ago. The condi�on is Vascular

Ehlers Danlos Syndrome, a rare variant of a connec�ve �ssue disorder

which results in weakened collagen, par�cularly affec�ng the walls of

medium-sized arteries and hollow organs like the gut.

individual, which would then have implica�ons for their role in society, their percep�ons of ‘self’ and, in turn, their rela�on-

ships with others.

Focusing on the imposed need for extra resources, in terms of help from others, we run into the problem of ‘feeling like a

burden’, which speaks to the human aspira�on to pledge reciprocity – the idea that one good deed deserves or even requires

another, in return2. Our previously ‘healthy’ person may start to worry that they cannot fulfil the social norm of reciprocity,

because they are unwell (rela�vely resource-poor) and find themselves trying to ‘calculate’ how much help it’s acceptable to

ask for, given that they cannot guarantee a return. This might become a barrier to seeking help or may lead to behaviours

based on ‘reciprocal concessions’3

– whereby an ini�al request for help might be a&enuated (to something which appears less

burdensome). The downgraded request, in turn, is viewed as a form of concession from the help-seeker; in turn evoking sym-

pathy in the chosen helper and resultant mo�va�on to provide some support. The problem with the reciprocal concessions

approach is that a pa�ent may find themselves diminishing their help-seeking so much that they start to miss out on health-

improving interven�ons (which depend on physically geLng to clinic). They may also unwiLngly withdraw from interac�ons

with their social network in order to avoid any situa�on which might lead to help-seeking or even trigger unsolicited offers of

help - this might be one reason for increasing social isola�on.

In the event of social isola�on having been a factor prior to diagnosis, the repercussions for access to help and support may

be felt much more acutely, leading to disadvantage much earlier in the illness. We know that the lack of a decent support

network has been shown to adversely impact health outcomes and wellbeing.

Another poten�al reason for increasing social isola�on is that what was once taken for granted, a healthily func�oning body,

might suddenly feel much less reliable and likely to become an embarrassment socially, in turn eroding self-confidence and

leading to avoidant behaviour.

SOCIAL ISOLATION AND CHRONIC ILLNESS

By Sophie Egerton. Phase 3 Public Health Registrar. [email protected]

12

Maslow’s Hierarchy of Needs4 is also a personal favourite, because, whilst we can argue for and against various details of the

theory, I know that my own health crisis seismically undermined my usual state. So, for example, star�ng from the premise

that, despite being varyingly unwell for twenty years, I had managed to make it all the way into the self-actualisa�on zone

(working, producing, being at liberty to use my brain for the greater good) and stay there most of the �me, I suddenly got very

sick and tumbled, eventually, right back to base camp. This withdrawal from anything more than the ac�vi�es of basic survival

compounds social isola�on and also makes a&endances for clinic appointments much more of a challenge, thereby reducing

access to therapeu�c interven�on.

Finally, the work of Elizabeth Kubler Ross has much to contribute to our understanding of the chronic disease experience, if

we assume that receiving a diagnosis represents the sort of crisis event which could result in a grief-type reac�on. The Kubler

Ross curve, which has its supporters and detractors, plots human produc�vity at various stages of an agreed grief cycle5. If we

can view that cycle flexibly, as something which individuals probably travel through in a less-prescribed way than the model

curve might suggest, then we might adapt it to chronic illness. If chronic illness disrupts life, any response to it must involve a

degree of adapta�on and change and the acceptance of a ‘new normal’. However, given that future prognosis, risks and thera-

peu�c op�ons may remain uncertain and advice from healthcare professionals may be conflic�ng, pa�ents are unlikely to go

through the stages of grief neatly, poten�ally geLng stuck in a protracted unproduc�ve state (which could mean rock bo&om

in Maslovian terms). It might appear to observers that the individual treads a very erra�c path through life for some �me - at

odds with societal sick role expecta�ons and rather difficult for others to comprehend and to respond to.

A change in produc�vity, which affects an individuals’ contribu�on to society, resul�ng from illness or grieving can become the

crisis in itself, because it can give rise to feelings of guilt especially during periods of paid sickness absence. Naturally this may

nega�vely impact ideas of self-worth. The person who is deemed too unwell to fulfil their work role may withdraw from social

situa�ons out of a sense of disen�tlement to certain ‘goods’, but this can only increase their social isola�on – where interac-

�on might be a powerful rehabilita�ve force. Many chronic illness pa�ents will have already had years of subop�mal health

before geLng a diagnosis and may have encountered difficul�es ‘being believed’; regarding symptoms which may have ap-

peared commonplace or vague or difficult to measure objec�vely (take fa�gue as an example). When does fa�gue become

disabling and therefore valid in terms of concessions to reduced produc�vity levels? Pa�ents may well have suffered s�gma

(socially isola�ng) due to others failing to understand how severely they are affected – aHer all, isn’t everyone �red? On the

other hand, this may ul�mately mean that diagnosis at least offers something posi�ve, by way of vindica�on.

References

1 Bury, M: Chronic illness as biographical disrup�on Sociology of Health and Illness Vol. 4 No. 2 July 1982

2 h&p://www.jstor.org/discover/10.2307/2092623?uid=3738032&uid=2&uid=4&sid=21106286601631

3 Cialdini, R.B., Vincent, J.E., Lewis, S.K., Catalan,J., Wheeler, D.,& Darby, B.L., Reciprocal Concessions Procedure for Inducing Compliance: The

door-in the face Technique. JPSP, 1975,31,206-215.

4 Maslow, A. H. A theory of human mo�va�on. Psychological Review, Vol 50(4), Jul 1943, 370-396.

5 Kubler-Ross, E. (1969), On Death and Dying, Touchstone, New York, NY.

Key Points

•Chronic illness is not linear

•Diagnosis has a social impact

•Limited reciprocity leads to withdrawal

•Unreliable bodies cause embarrassment

•Tumbling down Maslow’s hierarchy

•Diagnosis may cause a grief-type reac�on

13

Case Study: Health Trainers Address

Loneliness Lucy is an 83 year old re�red care-worker who cared for her husband un�l he

died two years ago.

She was ini�ally referred to the Health Trainer service in North Sheffield

(provided by SOAR) for weight management advice by her cardiac communi-

ty nurse. Lucy had a mobility scooter which she managed to get out on occa-

sionally and son who called in with shopping on a regular basis, but generally

her mood was low.

The loss of her husband and caring role in life, coupled with living alone in a

rela�vely isolated area of North Sheffield appeared to be the main reasons

for Lucy’s low mood. Lucy also had a history of heart disease and had had a

pacemaker fi&ed.

Following discussions around healthier ea�ng and taking more exercise, Lucy agreed some goals with her Health Trainer. She

was referred to an aqua-aerobics class with the support of her GP. During subsequent visits, the Health Trainer signposted

Lucy to a local luncheon club and the Door2Door service to facilitate trips to the local supermarket.

Aqua-aerobics was a huge success, both from physical ac�vity and self-esteem perspec�ve. The aqua-aerobics instructor said

that Lucy is “the life and soul of the classes and her determined a@tude puts many of the younger ones to shame!”

Lucy succeeded in losing some weight, which helped to ease her joint pain and built up her self-confidence. She mixed more

within her community and began mee�ng others in a similar situa�on.

The Health Trainer signposted Lucy to a local“Turn Your Frown Upside Down” healthy lifestyles lcourse. As a result, Lucy met

three other Health Trainer clients from her area. They have now all become friends and Lucy organises day trips and holidays

for them all!

Lucy is now able to fulfil her need to socialise with like-minded people and it has given her back her caring role in life. She is

looking forward to the future in a much more posi�ve way.

“I can’t put into words how much I appreciate your hard

work and what you have achieved for me.” Lucy

Outcomes

•Improved social contact

•Improved confidence and self-esteem

•Improved diet, mobility and physical ac�vity levels

•Mental Health well-being improved 100% (WHO5 scale)

•Diabetes, Blood Pressure and Cardiac Health indicators all improved

•Signed off by Cardiac Health Nurse Service

•The forma�on of an informal women’s social group in the local area, with Lucy at the helm.

•All four women now have reduced their social isola�on, improved lifestyles, have achieved weight loss and improved their

mental and physical wellbeing indicators

14

LONELINESS AND ISOLATION - AN ACADEMIC PERSPECTIVE By Ian Walker. Phase 2 Public Health

It is probably not surprising to find that the field of loneliness and social isola�on research is embryonic. Much of the available

research in this area has only been undertaken in the last five years. However there is an emerging evidence base indica�ng a

link between health outcomes (physical and mental) and being socially isolated, par�cularly in old age. In this sec�on of PH1

we highlight where the gaps in the research exist. For registrars interested in pursuing research opportuni�es, this may pro-

vide food for thought.

A scoping review undertaken by researchers at the Personal Social Services Research Unit (funded by the NIHR School of So-

cial Care Research) found that prescribing best prac�ce in this area is difficult because of the immature evidence base. Chal-

lenges exist due to significant gaps in the evidence and difficul�es in linking the literature on risk factors to their impact on

health and wellbeing. The significant gaps the researchers iden�fy are:

•A widely regarded conceptual model that explains the mechanisms and processes from social isola�on to detrimental health

outcomes has not yet been developed.

•A lack of robust research focusing on the use of health and social care services by those that are lonely and/or socially

isolated

•A lack of robust and repeated evidence on interven�ons to reduce loneliness and isola�on

•Only a third of studies the researchers iden�fied used a longitudinal design which can iden�fy the direc�on of causality

between health outcomes and isola�on

•Almost all research used the individual as the unit of analysis, whereas incorpora�ng ecological factors could iden�fy the

role of communi�es and neighbourhoods in this rela�onship

•Li&le research has looked at the health effects of reducing loneliness to see if improvements are possible through such

interven�ons

“Isola#on is being by yourself. Loneliness is not liking it.”

Voluntary sector service provider (Independent Age Isola#on Report)

Further to this scoping review, the Campaign to End Loneliness commissioned a review of evidence which was undertaken by

Oxfordshire Age UK. This review highlights many of those in the NIHR review but also iden�fies the following gaps -

•Robust evalua�ons of one-to-one befriending services and telecare/telehealth interven�ons to reduce loneliness

•Evidence of cost-effec�veness of interven�ons to reduce loneliness

•The impact of loneliness in ins�tu�ons and with individuals who have sight loss, hearing loss or cogni�ve impairment

It is clear this area of research has many opportuni�es for registrars interested in developing a research career or for those

who are interested in applying academic research techniques in public health prac�ce.

A range of research gaps exist in this field; from robust evalua�on of exis�ng services to theore�cal conceptual models of

isola�on (cause) to health outcome (effect).

References

Courtin, E. and Knapp, M. (2014) Health and Wellbeing Consequences of Social Isolation and Loneliness in Old Age. NIHR School for Social Care

Research. Available at http://www.sscr.nihr.ac.uk/ dev/project/health-and-wellbeing-consequences-of-social-isolation-in-old-age-a-scoping-study/

Bolton, M. (2012) Loneliness – the state we’re in: A report of evidence compiled for the Campaign to End Loneliness. Abingdon: Oxfordshire Age

UK. Available at http://www.campaigntoendloneliness.org/resources/

15

CHRONIC ILLNESS AND SOCIAL ISOLATION: BEYOND THEORY

“The last two years have been very challenging in many ways and my eyes have been opened to the daily and longer term

struggles of people with chronic illness. No one person’s experience will be the same, but I have been surprised by many

things:

I had taken for granted that there would be more understanding, from medical professionals (colleagues!) about the

human consequences of illness e.g. how living with a real risk of catastrophe impacts on being a single mum. When peo-

ple fail to ask about life beyond the clinic or simply cannot empathise or understand their pa�ent’s concerns, this in itself

can feel very isola�ng, because it seems impossible to access any shared experience or sensible advice. However, the

internet can go some way to allevia�ng social isola�on in this respect, par�cularly in the case of rare disease, sufferers

social networking bridges the geographical gaps between pa�ents and also brings expert advice within reach.

Having an ‘invisible’ illness (the onset of disability does not necessarily come with its own wheelchair) can be a source of

inverted s�gma – what I mean by this is that many people s�ll encounter suspicion and cynicism when their limita�ons

are not visually obvious. There will always be unhelpful comparisons e.g. with the person in the wheelchair who manages

amazingly well, in which case the person who looks ok but feels incredibly unwell ends up feeling inadequate, guilty, a

fraud.

There are some systems and bureaucra�c processes which are just too rigid to accommodate the needs of the individual

humanely and this can lead to feelings of disenfranchisement. Chronic illness is not uniform and should never be reified

thus. It represents a massive, heterogeneous mel�ng pot of condi�ons, symptoms, disabili�es and human consequences

(at the individual and societal level).

I oHen used to reflect on the Census ques�on about feelings of wellness and wonder if everyone felt as ‘off it’ as I did

(meaning that I was just a wimp for feeling so overwhelmed) or whether I was, in some way, put together a bit differently. I’ve

resolved that one now. In a sense, this could be an isola�ng thing, but on the other hand, I have a sense of valida�on now and

solidarity with other ‘not-100%-well’ people. I know now (‘it’s official’) that I haven’t been a lazy lightweight all my adult life –

this ma&ers a lot more than it should to me (I think it’s more about my own perceived s�gma around fa�gue, which is,

perhaps, culturally biased); but at least I am figh�ng with that no�on less now and can be a bit kinder to myself.

The concepts of biographical disrup�on and pre&y much the en�re contents of Bury’s paper resonate strongly with me and

this is a huge comfort because I can recognise my own struggles in others. I feel unwell quite oHen, but s�ll look pre&y normal

(certainly not ghastly enough to be feeling so wrecked) and this makes me feel like a fraud. The ups and downs are unpredict-

able and disrup�ve. I feel guilty if I’m not produc�ve and guilty if I overdo it and then crash – i.e. fail to pace myself well. Pac-

ing is very hard to nail.

In this second part of her reflec�ons on chronic illness and social isola�on, Public Health Registrar and

GP Sophie Egerton takes a personal look at her own experiences. From challenges of the health system,

a@tudes of fellow medical professionals and her own insecuri�es, to the comfort and strength found in

friends and loved ones; Sophie provides an insighFul perspec�ve on the highs and lows of living with a

chronic condi�on.

“I know now that I haven’t been a lazy lightweight all my

adult life – this maHers a lot more than it should to me”

16

The advice I’ve been given makes perfect logical sense; “if you’ve got the energy to do something, then do 75% of what you

think you can….to keep some [energy] in reserve”. I entreat everyone to try this, because even if we could objec�vely measure

the energy expenditure of a given ac�vity, it defies human nature and the laws of momentum to call it a day prematurely

when we are feeling ok and enjoying a sense of achievement. Anyway, how on earth does one ¾ empty the bins? Social pacing

means knowing when to hibernate, but withdrawal from contacts carries a risk of eventually being leH out of the loop, so this

is another aspect which must be managed with some discipline. This can be difficult for people who tend to prefer

spontaneity.

What started as an acute health crisis eventually resolved into a chronic illness state, compounded by a great degree of

uncertainty. A con�nued lack of any therapeu�c consensus and on some points, complete polarisa�on of expert opinion re:

safe management, have done nothing to facilitate the prescribed Kubler Ross process! Having said that, I’m slowly learning to

accept my new normal (which is, ironically, anything but ‘normal’ as it fluctuates unpredictably) – perhaps be&er to call it a

new reality. It’s a mindfulness trick really.

As for pacing, in reality it just boils down to a very challenging process of trial and error. The idea is simple – to try to fla&en

out the energy ups and downs and adapt to living somewhere in the middle so that I can achieve a more predictable,

sustainable level of func�oning (produc�vity) and feel more ‘useful’. This is where social isola�on can be a useful technique, if

only as a thought experiment. I actually need to acknowledge my differentness and disengage with my default ideology –

which has always inclined me to calibrate my ‘normal’ according to professional norms and the behaviours of colleagues and

peers - people who are hopefully ‘well’. So I must consciously deviate from what I have tended to measure myself against and

derive a new model of what ‘ought to be’ normal for me. The word ‘ought’ is, of course, loaded with judgement and designed

to make us feel obligated – so it’s also about challenging one’s inner discourse, trea�ng the ‘self’ more benignly and making

peace with inevitable change.

I wish I could say that I’d finally tapped into some hitherto-concealed reserve of inner strength or sheer marvelousness but,

notwithstanding the stuff about reciprocity, for me it really has been about people. A cherished friend told me about intui�ve

empaths recently. Being one myself, I’m fortunate to have a few of them around me in my life and they seem to have appar-

ently inexhaus�ble reserves of compassion. But I suppose that emo�onal support is the thing I’m most likely able to

reciprocate. Being a mum has kept me from dipping below Maslow’s base camp and I think I’ve earned my Kubler Ross stripes

aHer a fair few loop-backs.

So what has been the constant lifeline for me is the polar opposite of social isola�on. Love, kindness, friendship, and empathy

have been key rehabilitators for me. (This goes very much for clinical interac�ons too – the smallest act of compassion can

offset a whole lot of badness). When a person who loves you has the willingness to gently mo�vate and empower, it becomes

much harder to fail. These ‘goods’ of love and solidarity are located mid-hierarchy if we take Maslow literally (which is proba-

bly not as intended), but if we can learn to accept help with the caveat of less than perfect reciprocity, these precious

resources are most certainly available at base camp too.

That’s if we have the luxury of friends and loved ones. Many people suffer from appalling social isola�on and are not as fortu-

nate as I have been. I saw it when I was a GP and hospital doctor and even during my s�nt as a telemedic. The number of

�mes I thought to myself, “If I could just get this person a network” was too many to count. This is not a problem which is easy

to ‘fix’- the government can’t force it and social care is stretched beyond belief. But if every single one of us realised that we

can make a difference, however small, in somebody else’s life, it would be a start. Think about it.”

A6er two near misses, with bilateral spontaneous caro�d artery ruptures, Sophie is

living with the long term effects of a disorder affec�ng all body systems, including the

autonomic nervous system, the a6er effects of mild trauma�c brain injury and the

con�nued, unpredictable risk of a catastrophic event. The less drama�c symptoms

have been there since early adulthood and although they have worsened, there has

been some comfort in being able, finally, to ra�onalise them.

[email protected]

17

THE SILVER LINE

It’s true to say that if

you make something simple enough for everyone

to use, then they will.

Esther Rantzen’s vision to create a “ChildLine for

older people” is a simple concept – the first, free 24

hour helpline, available every day and night of the

year, where you can ask about services in your

area, talk in confidence, get some friendly advice

or quite simply have a chat. And for people who

would appreciate a regular call from the same

person every week there are now more than 1500

volunteer Silver Line Friends who share the belief

that a simple connec�on with another human

being can be life-changing. As one caller told his

Silver Line friend “when I get off the phone, I feel

like I belong to the human race”.

What sort of calls does The Silver Line re-

ceive?

Our specially trained helpline staff offer in-

forma�on, friendship and advice, and link

callers to local groups and services. As well

as offering regular befriending calls, we work

in partnership with Ac�on on Elder Abuse

and the CQC to protect and support those

who are suffering abuse and neglect. The

main reasons for calls are…

•Loneliness 37%

•Health 16%

•Lifestyle / Social 19%

•General Info 7%

•Abuse 5% (current 3% - historic 2%)

•Advice 5%

•Volunteering 1%

•Other (various) 10%

Silverline sta#s#cs...

Daily call volumes are averaging 1000 a day

There are 1200 older people receiving regu-

lar weekly calls from their volunteer Silver

Line Friends, plus 1100 keeping in touch calls

taking place each week

40% of our callers are male and the remain-

ing 60 % are female

There are 1500 volunteer ‘Silver Line

Friends’ trained

34% callers are aged between 60-69, 23%

between 70-79, 18% between 80-89, 5% are

over 90 but this age group are twice as likely

to call than any other group as a % of the

90+ UK popula�on

67% of callers contact the helpline because

they are lonely or isolated, 88% live alone

and 54% say they have no one else at all to

speak to, 68% of calls are aHer 6pm or at

“The hardest thing is ea�ng alone and

the flat, dead nights … there is noth-

ing worse than trying to eat a meal on

your own in my opinion. It seems to

bring it home to you.” Dorothy, 85

How it all started

Dame Esther Rantzen wrote an ar�cle for a na�onal

newspaper about the loneliness she experienced hav-

ing being widowed and living alone for the first �me in

her life, at the age of 72. She received a huge number

of le&ers from people who shared similar intense feel-

ings of isola�on but were reluctant to talk about it to

family or friends because of the s�gma associated

with admiLng to being lonely. Having established

ChildLine in 1986, Esther recognised the transforma-

�ve effect a telephone call can make to people who

feel vulnerable and depressed. She researched what

was available for older people and found there was a

gap – no helpline offering informa�on, friendship and

advice which was available at any �me of the day or

night when older people might need to use it.

18

Esther Rantzen says:

“When you walk into our helpline base you hear the sound of laughter. There’s no

‘call-handling �me’ we love the conversa�ons and the memories we share. For

the majority of our callers have nobody to talk to, at all, apart from us.

I spoke to Bill on Christmas Day. He told me:

“This is the first Christmas Day for years when I have spoken to anyone. It can

be a week I go without talking to anyone. It can be several weeks that I go

without having a proper conversa�on.”

So what have we learned over the past year? Firstly, how profound the need is,

and how crucially important it is to break through the prison of silence that

loneliness creates. Secondly, how proud the older genera�on are, and how

determined ‘not to become burden’, as our callers tell us.

“when I get off the phone, I feel like I belong to the human

race”

What challenges does a service such as The Silver

Line face?

The Silver Line has been opera�ng as a na�onal service

for 18 months and has received more than 400,000

calls. So the simple idea is having a transforma�onal

effect on the lives of thousands of older people and a

huge, previously unmet need has been revealed. There

is no other helpline, available 24/7, free and

confiden�al, and offering informa�on, friendship and

advice, linking older people to local groups and

services, and suppor�ng those who are suffering abuse

and neglect. But funding is our greatest challenge as

more people use The Silver Line, our costs increase.

From recrui�ng, training and suppor�ng volunteers

who befriend older people and make weekly friendship

calls, to staffing the helpline 24/7, 365 days a year is a

hugely expensive opera�on. Recording our calls for

safeguarding through a virtual call centre means that

the charity pays for all the calls made by our volunteer

Silver Line Friends to older people, and older people

who call the helpline use our call-free number. So apart

from answering every call with a quality response, and

ensuring every older person who requests a Silver Line

Friend is matched to a trained volunteer, making sure

we are sustainable as we approach our second birthday

and into the future, is a key challenge for the

organisa�on.

What can the health professionals and policy

makers do to help?

Health professionals play a cri�cal role. OHen they have

awareness of and access to people who are among the

most vulnerable and isolated. As a free 24/7 helpline

we are appealing to many people and our focus needs

to remain on reaching hard-to-reach groups who may

not necessarily know about us. Health professionals are

usually perceived by an older person as trusted source

of knowledge and referrals from a trusted source are

known to be more effec�ve than blanket media

coverage. Health professionals are able to iden�fy

people who perhaps currently use services

inappropriately (i.e mul�ple GP appointments due to

loneliness) or equally they may iden�fy people who are

not accessing services when they should be. There is a

real opportunity for partnership opportuni�es with

GPs, CCGs and Health and Wellbeing boards – we can

provide dedicated support to older people with

tangible and measurable outcomes. We can provide

support to the most lonely and isolated pa�ents and

reduce the burden on the health service. We have rich

data on our callers and are in a posi�on to be able to

publish our findings through independent evalua�on

which can influence policy and shape services and

decisions rela�ng to older people in future. Policy

makers need to ensure that they engage with us

proac�vely and we are keen to develop these

rela�onships at all levels.

19

SO, LONELINESS IS A PUBLIC HEALTH ISSUE? … WHATEVER!

By Ian Walker. Phase 2 Public Health Registrar

So if you have got this far in our issue of PH1 (well done!) you are either a) an insomniac for which this edi�on has

surprisingly not cured you; b) interested in this topic and have some mo�va�on to explore this issue c) a du�ful person who

will read anything you are told to (!) or e) a scep�c that does not believe this has much to do with public health.

Whichever category you fall into (or another not listed) we have tried to encourage you to see that loneliness and social

isola�on are indeed public health issues and that 21st

century public health specialists should be engaged. However, if like

me, you have lingering ques�ons and issues with this whole issue then my random thoughts below may scratch where you

are itching…

• Now we have a ubiquitous label ‘loneliness’ which covers a mul�tude of social and inter-personal ills, are we not in

danger of medicalising this social issue as we have done for child birth and bereavement. For all we know there could be

a drug company, at this very moment, rebranding an anxioly�c as a cure for loneliness!

• As we have explained in this issue of PH1, it is hard enough defining loneliness, let alone quan�fying it. Admi&edly

researchers have done an admirable job at this but can robust science really equate the effects of an existen�al feeling

of isola�on with the profound health risks of smoking cigare&es.

• Does no-one else see the poten�ally posi�ve aspects of loneliness on our health? Infec�ous disease risk is greatly

lowered for a start, as would be stress-related poor health from inter-personal conflict.

• If over 90% of people are not lonely, surely this is a good news story. Despite the increasingly individualis�c culture,

mobility through work and careers, transforma�on of models of family life and the (evil?) internet, we are not geLng

propor�onately more lonely. Older people today report the same propor�on of loneliness in the UK that they have since

the 1940’s. Despite the challenges to social cohesion, modern Britain may be riding the storm.

• If loneliness is more predominant in older age groups, does this not reflect the existen�al/spiritual distress of being

nearer death. The foreboding approach of the end of our lives is likely to lead to symptoms of detachment and separa-

�on from others that may be manifest in the survey results regarding loneliness. Is the real issue perhaps a spiritual

one, as we consider shuffling off this mortal coil?

• There is large varia�on interna�onally in reported levels of loneliness. As reported by Walker and Maltby (1997) the

prevalence of loneliness amongst older people in Europe ranges from:

under 5% in Denmark

around 5% to 9% in Britain, the Netherlands and Germany

to over 20% in Portugal and 35% in Greece

Now this could represent an issue of interpreta�on and language, but it must be worthwhile considering what factors

may influence these differences before coming to any firm conclusions in the UK.

As with most issues we wrestle with as public health specialists, the ques�ons and answers to loneliness are not simple. We

should not pretend that they are. In order to address the issue maturely, we must accept the doubts and concerns that are

obvious to many of our non-specialist colleagues who will need persuading as we seek to exert influence in this policy area.

Reference. Walker, A. and Maltby, T. (1997) Ageing Europe. Buckingham: Open University Press.

20

SO WHAT CAN WE DO AS PUBLIC HEALTH SPECIALIST REGISTRARS?

Here are a few sugges#ons…….

CHECK THE FACTS: Familiarise ourselves with the evidence. That which we have refer-

enced in this edi#on of PH1 and from the many other sources we come across. As public

health experts we need to cast a cri#cal eye and be convinced of the evidence behind the

headlines to sa#sfy ourselves that it all stacks up.

LOCAL MAPPING: Find out what is going on in your area on this issue. Ask around your

departments, check your local JSNA and discuss it with your supervisor and DPH. The Cam-

paign To End Loneliness is keen to hear about what is happening in Local Authori#es around

the country and par#cularly about new ini#a#ves and projects.

ADVOCATE: If you are convinced about the relevance and importance of this issue in your

local area, you can champion the cause. You will find a lot of resources and support on the

CTEL website . www.campaigntoendloneliness.org

RESEARCH: If this issue has really grabbed you, why not get involved in researching this

topic and adding to the embryonic evidence base. This is a quickly growing and poli#cally

resonant area of research which is a>rac#ng funding, par#cularly in rela#on to health.

VOLUNTEER: You could do something personally to address loneliness e.g.

Make contact with a neighbour who may be lonely.

Be aware, no#ce friends/acquaintances/ work colleagues who may seem on the

fringes.

Volunteer at a local befriending/visi#ng service.

We hope you have enjoyed reading this edi#on of PH1...

The Yorkshire and Humber Registrar Editorial Team

21

ph1 april 2015 - y&h edition

Documents