The Director of Public Health             Annual Report 2015/16

Age friendly environments

Why is the environment important for healthy ageing?

There are ways that the environment can be designed and planned to support healthy ageing. The World Health Organisation healthy cities programme includes a number of age friendly towns and cities that are working to provide environments in which older people are celebrated, welcomed and have their practical on-going needs met. There are also a growing number of dementia friendly communities where people are trained as ‘dementia friends’ to support people to live in their own communities for longer.

As people age, being able to get to shops, health services and affordable activities is an increasing priority, so transport becomes a key issue. If people who have driven a car all their life can no longer do so, navigating public transport can be a barrier to them going out, increasing their social isolation. This can be exacerbated if personal mobility is also compromised. The risk of falling increases as a person ages so feeling safe and secure in your own home becomes as important as feeling safe outside. Warm homes are essential for good health and affordable warmth is a problem for older people on limited budgets. Access to green space, whether that is gardens or parks, or just somewhere safe to walk and sit outside can have a positive impact on a person’s health and wellbeing.

 

The things that are good for healthy ageing are also the things that make life more pleasant for all age groups in the population. This section will focus on three key themes about environments that support healthy ageing:

  1. Housing
  2. Transport
  3. The built environment

1.  HOUSING

Why is housing important for healthy ageing?

Older people are particularly vulnerable to the health effects of poor and unsuitable housing, which can include excess winter deaths and hospitalisation due to exacerbations of circulatory and respiratory diseases, falls, mental health problems and social isolation. We have already set out how important it is for older people to be connected to their community in the previous chapter. Sadly, all too often unsuitable housing means that older people need to move out of their homes as their health and care needs increase, disconnecting them from their community and the social support that could be provided by friends and neighbours. Lifetime housing that is designed to be suitable for people throughout their lives can enable people to live in the same home as they age. Designing such housing in communities that bring the generations together, with focal points and that retain historic landmarks that can be familiar to people with dementia are key features of age friendly housing design.

Approximately 7.4 million homes in the UK fail to meet the government’s decent homes standard and up to 1 in 5 pensioner’s homes fall below these standards. Vulnerable people, a high proportion of whom are older people, occupy 1.1 million non-decent private homes(1). People aged 75 and over who have been living in the same home for a long time are most at risk of living in a home falling below decent standards(2).  Only 5% of homes have the four key features of accessibility - level access, flush threshold, sufficiently wide doors and circulation space for a wheelchair and a WC at entrance level(1).  Research by the Building Research Establishment has estimated that the health consequences of poor housing costs the NHS in excess of £600 million per year(2,3).

One of the main housing issues affecting older people is fuel poverty. This is where people cannot afford to keep their home warm. Older people are particularly vulnerable to fuel poverty because they are less likely to be in paid work, reducing their income and often increasing the time they tend to spend in the home; and because they are more likely to have long term health problems that can be exacerbated by cold, damp homes such as respiratory diseases and circulatory diseases(4). People are classed as being in fuel poverty if they have required fuel costs that are above average and if they were to spend that amount they would be left with a residual income below the official poverty line(5).

In 2013/2014, 1.6 million people (14% of the population) above state pension age lived in relative poverty, receiving less than 60% of the UK average income. Nine hundred thousand pensioners live in severe poverty, receiving less than 50% of the UK average income(1). Black and minority ethnic groups are at a greater risk of poverty in later life, with 27% of Asian and British Asian pensioners classed as living in poverty(1).

In 2013, a total of 2.3 million households nationally were in fuel poverty and of these, 542,000 households were made up of people aged 60 and over(1,5). It is estimated that cold homes cost the NHS £1.4 billion per year and contribute to an average 25,000 excess winter deaths(1,4). During the winter of 2012/2013, nationally there were an excess 31,000 winter deaths, the majority being in older people and largely attributed to cold and badly insulated housing(6).  Cold weather is known to increase the risk of heart attacks, strokes, respiratory illnesses, infectious diseases (e.g. flu) and injuries from increased falls(4). Evidence suggests that in an average winter, most of the health problems associated with cold weather and cold homes occur at relatively moderate outdoor temperatures ranging between 4-8 ͦ C(4).

What is the situation in Dudley?

The Dudley Housing Market Intelligence report (2013)(7) surveyed residents on the suitability of housing in Dudley. It found that the overwhelming majority (91%) of respondents of all ages believed their accommodation was adequate for their needs. More than a quarter (26.7% or 34,161) of Dudley households of all ages included a person with a disability and the majority (66%) of disabled households included people over the age of 60. It is positive that the majority (87%) of households including a person with a support need felt they were getting enough care and support. One in ten properties had been adapted to provide more suitable accommodation.

 

The report also included a specific section on the housing needs and preferences of older people. It found that older people planning a move within the borough would prefer to move to owner occupied properties (43.3%), closely followed by Dudley Council rented properties (42.9%). Older people’s preferred type of housing would be a bungalow (41.5%) and they would prefer 2 bedrooms (47.4%). The analysis found that there is a requirement of 3,257 units of sheltered housing and 665 extra care units for existing older households and those who may move into the borough to be near family.

 

Over two-thirds (83,645) of the existing housing stock in the borough require one or more steps to access. This could have a major impact as the population ages and becomes less mobile.

 

In the West Midlands in 2013, 320,000 households (all ages) were in fuel poverty and in Dudley borough, there were estimated to be 16,600 households (all ages) in fuel poverty(5).

Case Study One

Dudley Winter Warmth Service

Dudley’s Winter Warmth Support Service helps to keep people warm and healthy in their own homes. It targets older people to deliver two broad aims: to reduce the number of excess winter deaths, and to reduce the number of households in fuel poverty. See Mr and Mrs Harper’s experience of the service in the video clip here.

People can access the service directly or via referral from a range of frontline staff. The service supports those who have been recently discharged from hospital to reduce the number of re-admissions due to returning to a cold home

Connections to other themes:

Social Connectedness - staff from the service refer into befriending schemes to reduce isolation for those unable to get out in poor weather.

 

Healthy Behaviours - staff refer into a variety of lifestyle services

 

High Quality Services - the service delivers 700 visits per year

 

Case Study Two

Dudley’s ‘Living well, Feeling safe’

partnership scheme

Dudley’s ‘Living well, Feeling safe’ is a partnership scheme, offering older people living across Dudley borough, practical safety, security and wellbeing advice in their own home.

By working together the partnership offers older people a complete safety and security advice and support service, including services such as personal alarms, sheltered and supported housing options, advice on preventing falls, home improvement help and adaptations, handyperson service and fire safety advice.

For more information watch the video on ‘Living well Feeling safe’ scheme (right).

 

Dudley’s Living Well Feeling Safe partnership has launched a brand new on-line tool to help people understand the kinds of equipment and support is available to people who are struggling to live independently at home.

The tool offers individuals the opportunity to carry out an online self assessment about their individual living circumstances at home. Living well feeling safe - online will then provide individuals with a personalised report about the support and the aids that are available to them and where they can purchase suitable equipment.

The online tool offers advice and support with daily chores such as problems with getting in and out of the bath, climbing stairs, washing, dressing and cooking and much more.

What more needs to be done?

Reforms in the energy market over the last 5 years have made it easier for consumers to check their existing energy deal and switch their energy tariff and supplier. Households can save several hundred pounds per year by switching their energy supplier and it is estimated that continued reform will lower household energy bills by 5-9% on average between 2016–2030(8).

Between 2010 and 2015 the Department of Energy and Climate Change developed a policy paper on household energy and launched a number of new initiatives with the aim of combating fuel poverty, helping households to increase energy efficiency and reduce fuel bills(8).

Although existing schemes have made some impact on the burden of poor housing and fuel poverty among the elderly, Age UK have criticised the schemes for not producing adequate and timely results and not targeting some particularly vulnerable groups e.g. people living in static mobile homes which are difficult to heat and not always eligible for the above schemes(1).

Energy bills can be reduced and the health impacts of cold and inaccessible housing lessened by making homes more energy efficient, safer and with better access. This can be done through adapting existing housing stock, building high quality new homes or enabling older people to live in the most appropriate housing type for their needs. Age UK advise that all new homes need to be built to the lifetime standards to improve accessibility and make future modification easier and cheaper(1).

It needs to be easier and cheaper for older people to obtain the adaptations and equipment they need to live healthy and independent lives, reducing subsequent demand on NHS and social care services. Improving the suitability of older people’s houses by making minor adaptations could result in a 26% reduction in falls related injuries(1).

Older people also need greater housing choices. More retirement housing in both the private and social sector with affordable social provision is required to meet older people’s needs and expectations. Older people need the choice to help modify their existing homes or be offered a greater range of specialist retirement housing with flexible care and support(1).

2.  TRANSPORT

Why is this important for healthy ageing?

Research has identified a number of barriers that older people face when undertaking journeys, both on foot and by public transport. These include physically inaccessible transport vehicles, the pedestrian environment, safety concerns, and attitudes of transport staff and other road user’s awareness.

The importance of being able to “get out and about” is seen by older people as being critical to wellbeing: maintaining connections with families; friends and neighbours; keeping in touch with normal life; and retaining independence. The provision of a wide variety of local amenities and services (post offices, newsagents, stores, pharmacies, GP practices) are associated with increased walking in older people, with all of the health benefits that provides. The role of transport in connecting older people to support is crucial in maintaining wellbeing and social connectedness. Community transport programmes enable people with mobility problems to access activities and services in their locality. Discounted travel e.g. bus passes and rail passes, enable people to access activities further afield.

The Department for Transport requires all local authorities to undertake accessibility planning, which involves mapping the extent to which different groups in their population have access to a range of key services such as supermarkets, health care and employment sites.  Plotting areas that are poorly served by buses and trains with respect to journey time or cost to a number of ‘key services’  may not accurately represent the real-life situations faced by older people when moving around their local area. This can only be established by listening to older people themselves.

What is the situation in Dudley?

Dudley is very well served by bus routes, which makes travelling within the borough quite easy. Older people in the middle and north of the borough have good access to bus services but the south and south east of the borough have high densities of older people but poorer services. These are the more affluent areas of Dudley and older people here are more likely to have cars and continue to drive into later life. However, these people could suffer from social isolation if health problems and older age prevent them from driving.

Let’s get Dudley Active. Dudley physical activity (PA) and sport strategy 2014-2019 (9) recognises the interaction between people and place impacts on health and wellbeing across the life course and has recommendations for older people. One of these is to produce an Active Travel Strategy. This will incorporate new national guidance and will reflect emerging West Midlands Combined Authority (WMCA) priorities, which have the potential to have an impact on transport and older people. The draft strategy is complete and will be consulted on during 2016, and engagement will take place with older people. The strategy’s core principles are captured in the model below, and aim to address the key barriers and issues for older people identified above.

 

As well as enabling older people to connect to support and services and be more physically active, a good public transport system can have a positive impact on air quality by reducing reliance on private car usage. Older people are less likely to benefit from the connectedness that car ownership provides and so potentially more likely to be negatively impacted by poor air quality which can exacerbate long term health conditions such as heart disease and respiratory disease. However, encouraging modal shift from private vehicle use to either walking, cycling, using public transport or a combination of all three will not only help to address air quality concerns but also improve personal fitness and provide the overall psychological wellbeing that regular exercise affords. To embed the use of healthier alternative transport modes into normal everyday life is a priority for the Dudley Air Quality Action plan.

What more needs to be done?

Transport is like so many things not the domain of one team, section or organisation: it is connected to housing, planning, health, air quality, emergency services, industry and employment; all of which are enormously important to communities. However for many older people the way they transport themselves and the reasons why, can be missed in the bigger picture and their specific connections can be lost. We must strive to enable safe pleasurable journeys from doorstep to destination and see these journeys through the eyes of older people. This will require contributions and involvement from a host of council departments, stakeholders and partners and will be difficult in times of financial constraints, but the benefits to older people and the borough as a whole will be huge and long lasting.

3.  THE BUILT ENVIRONMENT

Why is this important for healthy ageing?

The environment in which older people live, work or volunteer, use support services and spend their leisure time can have an important impact on their health and wellbeing and can benefit the rest of the population as well. The built environment can enable people to connect with each other by providing communal spaces that bring people together. It can also make healthy behaviours easier by providing pleasant and safe places for people to walk, grow their own food and by providing a mix of food outlets that provide healthy food.

The built environment can also be designed to make it more accessible and welcoming to older people, for example town centres can include positive images of older people, provide suitable seating for people to take breaks and ensure bus routes pass parts of the town centre that older people want to visit. This can be achieved by always ensuring that older people are considered and involved in the design of the built environment.

Living in areas that promote physical activity and provide access to healthy foods is associated with a reduced incidence of type 2 diabetes (10). Older adults are the least physically active group in the population with less than 30% of 65-74 year-olds and less than 15% of adults aged 75 and over, reported doing any exercise that lasted more than ten minutes in the previous four weeks. Neighbourhoods with safe walking environments and access to physical activity had lower rates of decline in walking activity than other less favourable neighbourhoods as people age(11).

Highly walkable neighbourhoods with low density of fast food outlets are associated with healthy weight, increased levels of physical activity, and reduced blood pressure in middle-aged and older adults(12). Physical activity also appears to reduce the risk of mental disorders in older people, including depression and dementia. Neighbourhoods with more motorised travel appear to be associated with a rise in physical disability reducing mobility(13). Streets with higher volumes of faster moving vehicles are also associated with lower levels of social interaction between neighbours(14).

The perceptions of older people living in poverty, on street safety and crime (but not necessarily true crime rates), are also associated with development of physical disability affecting mobility(15). Other neighbourhood problems such as excessive noise, inadequate lighting, and heavy traffic are also associated with functional loss among older people(16). A well designed built environment can enable older adults to enjoy physical and social activity. Access to green spaces has been shown to have a positive impact on mental health and wellbeing.

Buildings can be designed to be dementia friendly by ensuring, for example, that there are clear signs and good lighting, suitable flooring, there is plenty of seating that is recognisable as seating and that the entrance and exit are clear and there are recognisable landmarks to aid navigation. The International Dementia Design Network has developed a checklist for dementia friendly design.

What is the situation in Dudley?

Dudley’s Supplementary Planning Document (SPD) provides supporting information and guidance for planners, developers and investors on how our environment and the planning decisions we make impact on the health and wellbeing of the population.  It is a material consideration in determining planning applications and should be used to inform future plans, strategies and development briefs and in making policy decisions.

 

The SPD states that,

 

“As we progress into later life, our daily requirements will change and it is imperative that communities are developed to incorporate services and opportunities which older people may need and desire.”

 

:: Follow this link to view Dudley's SPD document

What more needs to be done?

The World Health Organisation has developed a programme of Age-friendly Environments and Cities(17). The programme involved consultation with older people, carers and service providers on the advantages and barriers they experienced in city living, leading to the development of a guide and checklists that can be used by local government and planners to make towns and cities more appropriate for older people. These cover outdoor spaces and buildings, transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, and community support and health services. The WHO Global Network of Age-friendly Cities was established in 2009 to link participating towns and cities encourage evaluation of age-friendly initiatives and provide support. This check list can be used to help inform planning decisions in Dudley and also the design of housing and transport developments to be delivered through the combined authority

A copy of the checklist is available here:  http://www.who.int/ageing/publications/Age_friendly_cities_checklist.pdf

 

Key messages

  • Older people are more likely to live in homes that do not meet the government’s decent home standards
  • Whole life housing can enable older people to stay in their homes for longer and maintain their connections with their friends and neighbours to support their health and wellbeing
  • Cold damp homes caused by fuel poverty exacerbate heart disease and respiratory disease and inadequate housing negatively affects mental health and contribute to increased rates of ill health and death in the winter months
  • Being able to access shops, services and family and friends provides important health and social benefits to older people
  • Affordable and accessible transport helps older people move around and stay connected socially
  • There is good evidence about how towns can be designed to be age friendly and to enable older people to be healthy. When implemented these measures benefit the whole population, not just older people.

Recommendations

  1. Health and social care services should include identification of older people living in fuel poverty housing need which makes them vulnerable to ill health and placing demands on health and social care services in assessments
  2. Opportunities should be explored to integrate housing measures into care pathways for older people, particularly falls, circulatory disease and respiratory diseases
  3. Housing developments delivered through the West Midlands Combined Authority should reflect the needs of older people now and in the future
  4. Housing providers should explore how they can consider the assets and health and wellbeing of potential residents in housing allocation
  5. Opportunities should be sought to actively involve older people in the design of new transport developments through combined authority
  6. Service commissioners and providers should consider how they can use information from the community asset mapping taking place in Dudley to connect older people with mobility problems, with local people who can help them access social support and services
  7. Partners and contractors should be encouraged to use the WHO age friendly check list to inform decisions about the design of the built environment and the International Dementia Design Network checklist for the design of buildings

References

  1. Age, U.K. and House, T., 2010. Agenda for Later Life. 2013.
  2. Age, U.K., 2014. Housing in later life. Age UK, London.
  3. Nicol, S., Roys, M. and Garrett, H. (2011) The cost of poor housing to the NHS. Available at: https://www.bre.co.uk/filelibrary/pdf/87741-Cost-of-Poor-Housing-Briefing-Paper-v3.pdf (Accessed: 20 September 2016).
  4. Public Health England (PHE) (2015) The Cold Weather Plan for England. Protecting health and reducing harm from cold weather. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/543964/CWP_2015.pdf (Accessed: 20 September 2016).
  5. Department of Energy and Climate Change (DECC) (2013) Energy Trends. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/262972/et_sep_13.pdf (Accessed: 20 September 2016).
  6. Age, U.K., 2014. Care in Crisis 2014. Age UK, London.
  7. The Dudley Housing market Intelligence report (2013) (Unpublished)
  8. Department of Energy and Climate Change (DECC) (2015) Annual Fuel Poverty Statistics, 2015. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/468011/Fuel_Poverty_Report_2015.pdf (Accessed: 20 September 2016).
  9. Dudley MBC (2015) Let’s get Dudley active. Available at: https://lets-get.com/wp-content/uploads/2016/04/Lets_Get_Strategy_May_OP.pdf (Accessed: 20 September 2016).
  10. Auchincloss, A.H., Roux, A.V.D., Mujahid, M.S., Shen, M., Bertoni, A.G. and Carnethon, M.R., 2009. Neighborhood resources for physical activity and healthy foods and incidence of type 2 diabetes mellitus: the Multi-Ethnic study of Atherosclerosis. Archives of internal medicine, 169(18), pp.1698-1704.
  11. Li, F., Fisher, J. and Brownson, R.C., 2005. A multilevel analysis of change in neighborhood walking activity in older adults. J Aging Phys Act, 13(2), pp.145-159.
  12. Li, F., Harmer, P., Cardinal, B.J. and Vongjaturapat, N., 2009. Built environment and changes in blood pressure in middle aged and older adults. Preventive medicine, 48(3), pp.237-241.
  13. Clarke, P., Ailshire, J.A. and Lantz, P., 2009. Urban built environments and trajectories of mobility disability: findings from a national sample of community-dwelling American adults (1986–2001). Social science & medicine, 69(6), pp.964-970.
  14. Appleyard, D., Gerson, M.S. and Lintell, M., 1981. Livable streets, protected neighborhoods. University of California Press.
  15. Clark, C.R., Kawachi, I., Ryan, L., Ertel, K., Fay, M.E. and Berkman, L.F., 2009. Perceived neighborhood safety and incident mobility disability among elders: the hazards of poverty. BMC Public Health, 9(1), p.1.
  16. Balfour, J.L. and Kaplan, G.A., 2002. Neighborhood environment and loss of physical function in older adults: evidence from the Alameda County Study. American Journal of Epidemiology, 155(6), pp.507-515.
  17. World Health Organization, 2007. Global age-friendly cities: A guide. World Health Organization.

 

 

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