Calderdale Clinical Commissioning Group (CCG) has coughed up £1m out of its non-recurrent budget in order to fund an as-yet ill defined project to end loneliness in Calderdale.

This £1m NHS money complements the Council’s existing neighbourhood schemes, which cost £0.25m a year.

The Council and Calderdale CCG say that loneliness causes people to:

• visit their GP more often
• use more medication
• fall more often
• become more reliant on care services
• die earlier than other people
• have a greater risk of high blood pressure, developing a disability and clinical dementia than other people
• experience mental illness and even commit suicide in older age

But there is no solid evidence about whether reducing loneliness will improve people’s health or increase their life expectancy.

A public health specialist told Plain Speaker that despite this, the Calderdale scheme isn’t necessarily problematic as long as it’s thoroughly evaluated in ways that contribute to building up such evidence.

According to a Calderdale Council press release, Calderdale Council’s Director of Public health, Paul Butcher, said,

“We are still in the early stages of planning the programme but we have already researched schemes which have worked well in other areas. This could include befriending lonely older people providing them with regular contact with a friendly face; activity clubs where people can meet to prepare and share meals for those who struggle to cook and mobile solutions to help dementia sufferers get around.”

Some evidence that loneliness harms people’s health

Studies like the 2010 Meta Analytic Review of Social Relationships and Mortality Risk,  carried out by Holt Lunstad and others, have found that lonely people with poor social relationships are more likely to die earlier than other people.

However, the public health specialist whom Plain Speaker contacted said that the difficulty is to see whether it is really the loneliness that causes earlier deaths, or something else that goes along with the loneliness – what is called a “confounding relationship”.

Cost effectiveness of NHS spending

Reducing loneliness is worth doing as an end in itself, even if it doesn’t improve health outcomes – but if you’re spending NHS money the question has to be, what is the opportunity cost of this? In other words, what evidence-based NHS services are you forgoing, that you know would improve people’s health and increase their life expectancy?

In England and Wales, NHS treatments are subject to the National Institute for Health and Care Excellence guidelines. These are evidence-based assessments of what treatments offer the best value for money, in promoting good health and preventing ill health.

At present there don’t seem to be any NICE guidelines that assess the cost effectiveness of interventions to reduce or end loneliness – there isn’t yet enough evidence to create guidelines.

Calderdale End Loneliness evaluation study not yet in place

The End Loneliness scheme is a 2-3 year experiment and a university will be involved in researching its effectiveness.  Plain Speaker asked Paul Butcher:

• which university Calderdale Council/Calderdale CCG has engaged to evaluate the end loneliness scheme,
• what specific health outcomes the study will assess
• how many people will be included in the study
• whether there is a control group study of people who are not involved in the End Loneliness scheme; and if so how many people will be included in the control study and how they will be selected
• how many years the study will monitor people’s health outcomes
• whether Calderdale CCG has any idea of the cost effectiveness of the End Loneliness scheme, in terms of improving specific health outcomes
• if so, how the cost effectiveness compares to more traditionally evidence-based interventions to achieve the same health outcomes

Paul Butcher replied that he is in discussions with academics at the moment about a potential evaluation. The contract to do this work has not been awarded, so he can’t give specific answers to the questions at this stage. But Calderdale has been awarded money to pay for the contract and the steering group is due to meet soon to determine the evaluation.

Paul Butcher added,

“As for traditional public health interventions, evidence is varied, some contested and is not subject to traditional randomised control trial approaches. I would argue that a lot of NHS activity lacks randomised control trial evidence and that the reality of improved health is that probably only 20 percent of health improvement comes from the NHS eg the smoking ban is far more effective in reducing coronary heart disease than most clinical interventions at a population level.”

Evidence of the effectiveness of the smoking ban is strong. The main study in England that looked at how the smokefree legislation reduced emergency hospital admissions for heart attacks in the year following the law found that around 1200 fewer admissions were observed in England.

However, many would disagree with Paul Butcher’s statement that public health interventions have a poor evidence base. For smoking cessation, for example, there are dozens of randomised controlled trials showing the best way for people to stop smoking and well conducted longitudinal studies that illustrate how many years of lives can be saved by stopping. There is also good evidence around things like alcohol brief interventions and treatment for alcohol dependence. These are all things that NHS and local government funding is meant to be spent on.

Robbing Peter to pay Paul – or robbing the NHS to pay for social care

The £1m Calderdale NHS expenditure could be seen as robbing Peter to pay Paul – more specifically: robbing the NHS to make up for Coalition government spending cuts to the local authority’s budget.

In 2013, as part of its Efficiency Review of Services, Calderdale Council cut the following Health and Social Care services or outsourced them to cheaper private companies:

• Home Support for people with Dementia
• Support for Adults with mental health needs
• Day services for Older People & Adults with a learning disability
• Business Support for Health and Social care
• Homecare in Extra care schemes

According to Holly Holden, one of the authors of a recent Nuffield Trust study, Focus On: social care for older people,

“Our analysis paints a picture of increased rationing of social care in response to deep cuts from central Government, despite the growing numbers of older people in the population. It is highly likely that this is having a negative effect on older people’s health and wellbeing and that of their carers, but without adequate data to assess this impact, the NHS and Government are flying blind.”

The report’s key findings include:

• Between 2009/10 and 2012/13 spending on social care for older people fell by 15 per cent in real terms from £10.6 billion to £9.8 billion;
• Almost a quarter of a million fewer older people received publicly funded community services in financial years 2012/13 compared to 2009/10, a 26 per cent drop;
• Home and day care spending by councils fell by 23 per cent (or £538 million) over the same period;
• The number of older people receiving home-delivered meals has more than halved since 2009/10;
• Transfers of money from the NHS to adult social care have more than doubled since 2009/10. Without these, service cuts in social care could have been even more drastic.

These are all services which helped housebound and frail people to stay in touch with others and have some kind of social life.

Calderdale and Huddersfield Strategic Review reconfiguration likely to worsen patients’ loneliness

Increased efficiency and reliance on telehealth and telecare are central to the Strategic Review, aka Right Care Right Time Right Place proposals for a controversial reconfiguration of NHS and social care services in Calderdale and Huddersfield.

These changes are likely to increase the loneliness of people with long term illnesses, through undermining face to face, long term relationships between GP and patient. The importance of this relationship in recognising and trying to help alleviate loneliness is explored here in A Better NHS blog, written by a GP.

How will remote monitoring of symptoms via interactive digital technology and remote patient- doctor consultations via phone or skype do anything but make the loneliness of often housebound chronically ill patients even worse?

In a recent Phoenix Radio interview, the Calderdale CCG vice chair Dr Stephen Cleasby said that increased efficiency was key to the Strategic Review. And the Strategic Outline Case says that the main way to cut costs is to reduce the bill for staff wages. Fewer staff will mean less face-to-face care for patients.

Does Calderdale CCG’s left hand know what its right hand is doing?