Dr Ian P Donald Consultant in Old Age medicine Gloucestershire Hospitals NHSFT

* Getting your GP to visit? * Most consultants do not do domiciliary visits * OT’s do carry out assessment visits, but very time-consuming, so fewer * Home Improvement Agency often unknown * Where to refer for impartial advice?

* Impact on disability * Impact on quality of life and mental health * Whether discharge home is possible Geriatricians have generally failed to make the connection between health, social care and housing disrepair

* Average length of stay around 7 days for over 80’s in DGH * Around 15 days for Community Hospitals, but often far away from their home * Hospital staff rely on community staff to pick up the issues eg fallers

* Is self-evident (shown again in recent Gloucester survey), yet strong confounders: * Smoking * Education * Diet and obesity * Wealth * Employment * Mental health Absence of randomised controlled trials Only 2% of Gloucester residents thought their housing had adverse effect on their health

* Those over 85 spend 90% of their lives indoors * LTC’s increase vulnerability to damp and cold * Loneliness and social isolation

52% = 3,300 households

 37% live in non-decent homes  ¾ of these are in private housing  14% are in homes in serious disrepair  ½ of all homes in serious disrepair are inhabited by old people

* 80 years lady, lives alone * Early Alzheimer’s disease * Lives in this townhouse for 40 years * No savings, and cautious with money * recurrent chest infections (no admissions) * All windows and doors rotting * Uses storage heaters * No family

* Home environment assessment by trained therapist observing the patient reduces falls frequency by 40% * Untrained assessment more equivocal benefit (eg home safety checks) * No evidence for reduced fractures * Most benefit for high risk fallers eg frequent fallers, poor vision etc

* Probably the most consistent impact and benefit from housing improvements * Improved quality of life for all in receipt?

* How to measure things that have not happened * Multiple competing factors in frail older people * You may “prevent” the fractured hip, but a stroke occurs * Hospital admissions already very brief, so savings mainly in social care

* Investment in improved housing conditions can be cost-effective * Savings are clearer in younger disabled * Majority of older people awaiting an adaptation are not in receipt of homecare * For some, the adaptation may not be the critical determinant of staying at home * Best value where homecare no longer required * Health is less stable – so further deterioration may soon occur * Can save health expenditure in the future

* 40,000 more deaths in UK during winter * UK does not have hard winters * Much larger variation than in Scandinavia * UK homes have poor thermal efficiency * Those over 85 spend 90% of their time at home

* One turned heating off * Another wandered outside at night and fell

Years difference

* Usually reach the easiest to reach * Can result in increasing inequality * Exercise promotion * Healthy eating * Health checks * Breast feeding * Should we target better? * Can we find all the high risk households?

* Case example – how to manipulate the system?

* Major change in health * Dementia * NOT change in social support * NOT housing conditions * 70% couldn’t imagine anything that make them move * 10% only if there was a major catastrophe I’ll have to have my back to the wall, kicking and screaming before I go I have many friends, and can’t imagine them all going Even if it falls on top of me, I’m not leaving. It would need to be a bloody big earthquake!

* Only 6% living in non-decent homes are dis-satisfied with home * Only 12% would consider interest- free loan

* Falls and fracture prevention through participation in exercise and balance classes, combined with trained home assessments for hazards * Targeted “Warm and Well” at >75’s * OT’s on rotation hospital to community, and Community Nurses, being regularly informed and updated