Introduction

Adult social care covers a wide range of activities to help people who are older or living with disability or physical or mental illness to live independently and stay well and safe. An individual's need for social care and support, and the extent to which these needs are met or unmet, are complex concepts and challenging to measure. They are influenced by a variety of factors including available supply, a person’s environment, their ability to source support for themselves, underlying health and disability status, and their expectations. As people live longer and with more complex conditions, more people are likely to need adult social care to support them to live the lives they want.

The Care Act 2014 requires local authorities to prevent, delay or reduce people’s need for care and support. The focus is on being proactive and deploying early interventions to reduce dependency, rather than just providing intensive services at the point of crisis.

This Joint Strategic Needs Assessment (JSNA) summarises the factors that influence social care need and demand, with a focus on prevention and reducing inequalities, in order to support the vision of the Nottinghamshire Integrated Care Strategy, the Nottinghamshire Plan, and the Local Account to enable every person to enjoy their best possible health and wellbeing. enjoy their best possible health and wellbeing.

Factors Associated with Risk or Greater Need for Adult Social Care

 The factors that affect the likelihood of developing preventable health conditions and a need for social support are often linked to wider social and community issues, rather than traditional medical needs. These form the building blocks of health such as education and skills, good quality housing, a stable income, and strong transport links.

Research shows that across England adults aged 65 and over from the most deprived areas are twice as likely to need help with activities of daily living as adults living in the least deprived areas. Moreover, those with unmet needs were also higher in more deprived areas.[1] This is because some of the building blocks of health in deprived areas are more likely to be weak or missing and there is a strong link between deprivation and unhealthy behaviours such as tobacco use, physical inactivity, and poor nutrition.[2] To create a society where everybody can thrive, we need all of the right building blocks in place.

Loneliness and social isolation are also risk factors which are preventable and addressing them can reduce the need for health and care services in the future. In Nottinghamshire, research suggests 23% of adults report feeling lonely always, often or some of the time which is similar to the England average of 22% but there is likely to be significant variation across districts (2022).[3]

Older People

Population ageing is and will remain the main driver of the projected numbers needing social care. Projections in Nottinghamshire show an increasingly ageing population, for both males and females, and a higher proportion of people aged 65+ will be 85+ which is increasing over time.

There are many ways in which ill health can be prevented in old age. For example, research shows that modifiable risk factors for dementia include smoking, obesity and low social contact.[4] Falls, an area of major concern because of the links with morbidity and mortality, can be prevented by removing home hazards and addressing deterioration in muscle strength.

Disabled People and Long-Term Conditions

People may need social care support because they have a disability. Disabled people are disproportionately affected by poverty, exclusion from education and employment, social marginalisation, and barriers to accessing healthcare, which contribute to poorer health status and outcomes.[5]  In Nottinghamshire there is an increasing number of adults under 65 with disabilities. This is driven in particular by more people with learning disabilities being diagnosed and supported, and many are now living longer than they once did.

Research indicates certain long-term conditions are more likely to lead to disability, such as stroke and heart disease. This suggests that interventions to prevent and importantly slow down disability progression and/or improve recovery could significantly reduce social care needs and costs.[6]

People with multimorbidity (two or more long-term conditions) experience a range of challenges including higher rates of disability, poorer mental health, and reduced quality of life.[7] In Nottinghamshire there are significant inequalities related to sex and deprivation such that on average, women in the most deprived areas have their first long-term condition 15 years before their peers in the least deprived areas. This ‘health gap’ is 8 years for men.

Frailty

As the population ages, the number of people living with frailty has been increasing. Frailty is strongly associated with experiencing a poor quality of life, inactivity, social isolation, loneliness, mental health challenges, and a range of adverse health outcomes, such as falls, and increased use of health and social care services. It is concerning that most older people with mild or moderate frailty are not known to services, which prevents help at an earlier stage when recovery may be possible and crises might be prevented.

Listening to the Voices of Local Communities

Studies show that closer working with and listening to people with lived experience of care and support can lead to better-informed decision-making, improved experience for people with care and support needs, and increased trust in support provided. Recent consultations and engagement activities in Nottinghamshire are very valuable in helping to understand the views and priorities of people who draw on care and support across the social care and health system. These are not restricted to views on prevention but highlight the areas of support that are important to people and those they would find most valuable. This shows the areas of opportunity where people are likely to be most receptive to intervention which could reduce, delay or minimise the need for social care support in the future, and reflect some of the recommendations identified by the data and literature review for the JSNA.

Evidence for Prevention Approaches and Interventions

The evidence of different prevention approaches can be summarised as:[8]

• Advice and guidance: evidence from health is promising but there’s no evidence from the social care sector.
• Physical activity promotion: there’s strong evidence of the impact of promoting exercise and movement, and the role of social care in this work should be further explored.
• Social prescribing: the evidence for social prescribing is uncertain, however, the number of these schemes is likely to increase which will give a better evidence base for assessing their effectiveness.
• Reablement: there’s evidence to support that reablement improves health-related quality of life and improved service outcomes. Research is ongoing to consider the cost-effectiveness of the approach.
• Asset-based and strength-based approaches: the complexity of this approach makes forming conclusions from the different types of evidence difficult, but there seems to be potential in developing this approach and a growing literature base to draw on.

Evidence Gaps

• Projections of healthy life expectancy are scarce and at present are not able to explicitly include changes in diseases, lifestyle factors or socio-economic status which might influence future trends.
• There is a need to develop our understanding of inequalities within the adult social care system by exploring disparities in access, outcomes and experiences of different groups.
• It is important to improve our understanding of shared risk factors, the effectiveness of prevention and how diseases progress (especially frailty).
• There is also a need to go beyond a focus on single conditions and start to understand how conditions interact with one another (multimorbidity) and how this might translate to different care needs.

Themes for consideration

This JSNA profile pack identifies themes for developing approaches to prevention within Adult Social Care and key partner organisations along with examples of the types of interventions that may be considered as part of the Adult Social Care Prevention Strategy which is in now in the early stages of development. There is already a lot of work taking place in the local social care and health system that promotes the themes identified below. This is about building prevention approaches and input collectively in the right places, where we can do more and where we can test and learn.

These themes are grouped under the headings of ‘Prevent’, ‘Reduce’ and ‘Delay’ in line with the duties set out in The Care Act 2014 to prevent, reduce and delay the need for care and support. 

[1] NHS Digital (2023) Health Survey for England, 2021 part 2 (Accessed May 2024). Available at: https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2021-part-2/social-care

[2] Institute of Health Equity (2010) The Marmot Review, Fair Society Healthy Lives

[3] Sports England (2022) Active Lives (Accessed May 2024). Available at: https://www.sportengland.org/research-and-data/data/active-lives/active-lives-data-tables#november-2021-22-32461

[4] Livingston G, et al (2020) Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet. 2020 Aug 8;396(10248):413-446

[5] Banks LM, Kuper H, Polack S. Poverty and disability in low-and middle-income countries: A systematic review. PLOS ONE. 2017;12(12)

[6] Andrew Kingston, Raphael Wittenberg, Bo Hu, Carol Jagger, Projections of dependency and associated social care expenditure for the older population in England to 2038: effect of varying disability progression, Age and Ageing, Volume 51, Issue 7, July 2022

[7] Kingston A, Robinson L, Booth H, Knapp M, Jagger C; MODEM project. Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Age Ageing 2018; 47: 374–380

[8] Skills for Care (2019) Prevention in social care: where are we now?

Jennie Kennington                                                                 
Senior Executive Officer, Adult Social Care & Health              jennie.kennington@nottscc.gov.uk                                            

Katy Ball
Service Director, Strategic Commissioning and Integration
Katy.Ball@nottscc.gov.uk