Hertfordshire and West Essex Joint Forward Plan 2023 - 2028

ICS Priority 4: Enable our residents to age well and support people living with dementia

ICB Strategic Priority: 

  • Increase the numbers of citizens taking steps to improve their wellbeing
  • Increase healthy life expectancy, and reduce inequality

ICB Clinical Priority:    

  • Reduce attendance and admissions for falls, people with frailty and people in last year of life
  • Development of more proactive, preventative care models for management of long-term conditions and frailty

ICB Challenge:    

  • Growing numbers of frail and older people, and people with multiple conditions
  • The population and proportion of those aged 65 and over is growing in both Herts, (from 17.2% in 2020 to an expected 23.2% in 2043) and Essex (the number of over 65-year-olds is expected to grow by 28% in the next decade, and number of over 85s by 55%).
  • It is estimated that between 20% and 30% of hospital admissions in over 85s could be prevented by proactive case finding, frailty assessment, care planning and use of services outside of hospital

Expected outcomes:    
We will ensure our residents are supported to age healthily, with access to advice and services that enable them to live well and independently for as long as possible.

Governance Groups:    
ICS Frailty Board

What our residents say:
Stevenage Borough Council’s Independent Living & Flexi-care Health & Wellbeing Survey (Stevenage), March 2022.  This is an annual survey to gain an understanding of how residents in independent living and flexi-care housing schemes view themselves physically and mentally.

260 residents living with frailty across 3 independent living and 2 flexi-care housing schemes responded – a 28% return rate. The age group of residents is primarily 55+. The survey found that:

  • Approximately two thirds of respondents are living with health issues, with dementia, diabetes, COPD, cancer and depression being the most prevalent. 
  • 13% are smokers with only 1% wanting support to quit 
  • most were not concerned about their levels of alcohol consumption 
  • approx. one third consider themselves overweight, but of those, only 15% saying they would like support to do something about it. 
  • over 50% of women are doing very little physical activity, and approximately 33% of men.
  • 23% of men reported feeling lonely, or anxious/stressed all or most of the time

Healthwatch Essex 2017 – Dementia Voices focus group research – five focus groups of people living with dementia. Research found that:

  • There are still high levels of stigma/ignorance around dementia, which impacts on how people feel about themselves and how they live well in communities
  • A good diagnosis experience sets the scene for living better with dementia, with clear info and support from the start
  • The care and support from families/carers is appreciated, need arrangements in place when things get difficult
  • People with dementia want to remain independent for as long as possible and to be included in conversations / decisions that concern them
  • Peer friendship and support is highly regarded
  • Not everyone feels comfortable using technology but lots of people with dementia use mobile phones/kindles in their everyday lives.  This is likely to be more common. 

Recommendations (summarised):

  1. People with dementia should have the same rights, considerations and protections as other disabled people
  2. Services should make every effort to empower people living with dementia to have their views heard.
  3. Information required at diagnosis, with other touchpoints thereafter
  4. Peer support facilitated flexibly around home/work/interest
  5. Access to digital technology not to be assumed
  6. Carers to have targeted emotional and physical support

When asked what three things should be in place to support people living with dementia, participants said:
1) Support for carers, 2) friendship and peer support, 3) dementia awareness and combatting stigma

“Don’t forget most of us depend on our carers – the carer is the main person to look after us – to keep us all going.”  
“Your carer needs more information about what can happen to you.” “I think it would be a lot easier if people were made more aware of dementia”

The Essex Carers all age strategy, 2022 – 2026, produced by Essex County Council, reviewed feedback from 90 carers in Essex on its carers strategy.  Carers expressed support for the commitments in the strategy – saying that:

  1. It is hard to find and access information and support/navigate system
  2. They faced a lack of support currently and no assessment, or a poor assessment process
  3. They needed more support when their caring role ended – help with loss of identity and support networks.
  4. Breaks and respite care are important and a flexible choice of breaks is needed
  5. More identification of young carers and greater support for young carers is needed 
  6. Listening to carers’ views and engaging with them is important. Carers are central to decision making

“A more joined up approach is required, often carers are left alone to find information out for themselves and struggle when their lives are challenging enough”.

Year 1 priority actions

1.    Prevention - strength and balance classes, self-referral to falls prevention / falls response services

2.    Clinical, focused on:

  • Coverage of community based services with 2 hr response times – falls response etc
  • Target work of integrated neighbourhood teams using PHM approaches 

3.    ICP action areas focused on:

  • Raising awareness / public messaging
  • Improve (through co-production) dementia information and advice offer
  • Improve staff training
  • Develop further the use of assistive technologies

For further details about key deliverables across the next five years, please refer to pages 42 - 46 of the PDF.

Hertfordshire and West Essex Joint Forward Plan 2023 - 2028

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