THE HIGHLAND COUNCIL HOUSING & SOCIAL WORK COMMITTEE, 19 SEPTEMBER Report by Director of Social Work

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1 THE HIGHLAND COUNCIL HOUSING & SOCIAL WORK COMMITTEE, 19 SEPTEMBER 2007 Agenda Item Report No Report by Director of Social Work THE DEMOGRAPHIC CONTEXT OF THE DEVELOPING STRATEGY FOR OLDER PEOPLE IN THE HIGHLANDS 1. SUMMARY This report provides a summary of the demographic projections being used to inform the development of the joint Community Care Plan for Highland. The first step in this process is to consider how to align services to meet the care needs of older people. Over time the development of a strategy for older people in the Highlands can be developed which would consider the broader needs of older people and the contribution they make to our communities. 2. THE DEMOGRAPHIC CONTEXT FOR A STRATEGY FOR OLDER PEOPLE IN THE HIGHLANDS 2.1 The context for the development of a strategy falls into four broad areas: What proportion of the Highland population will consist of older and very old people in the coming decades? How healthy will these people be? What levels of working age population will we be able to employ to provide care? What changes do we expect to see in the population of informal carers? 2.2 To ensure a good understanding of the above, an extensive piece of work was undertaken by Catherine Hesset on behalf of the Council and NHS Highland. The summary of her findings on demographics and related forecast expenditure has been incorporated with other information to give the outline of the demographic position and some of the implications set out in this report. 3. DEMOGRAPHICS 3.1 In considering the following projections, it is important to remember from the outset that population projections are based solely on past trends and do not take account of any policy initiatives which may influence the demographic profile of Highland in the future.

2 3.2 Data has been linked between the NHS and the Council but in considering the geographical variations within Highland, the data has been grouped into Highland Council Management Areas. 3.3 As shown in Figure 1, the population aged 65+ in the Highland Council area is projected to rise by 13% between 2005 and 2010 and by 62% between 2005 and Figure 1 Increase in population 65+ by Management Area 25,000 20,000 Population ,000 10, ,000 0 North Mid & West East Management Area 3.4 Figure 2 shows that this increase is most pronounced in the population 85+ where there is projected to be an increase of 28% by 2010 and an increase of 118% by The biggest proportional increase in population aged 85+ is in the North where the projected increase is 27% by 2010 and 129% by 2024.

3 Figure 2 Increase in population 85+ by Management Area 4,000 3,500 3,000 Population 85+ 2,500 2,000 1, , North Mid & West East Management Area Figure 3 People 65+ with a limiting long term illness and living alone by Management Area 5,000 4,500 4,000 LLTI/living alone aged 65+ 3,500 3,000 2,500 2,000 1, , North Mid & West East Management Area

4 Figure 4 People 85+ with a limiting long term illness and living alone by Management Area 1,200 1,000 LLTI/living alone aged North Mid & West East Management Area 3.6 Figures 3 and 4 show that these trends are reflected in those people who are over 65 and 85 who are living alone with a limiting long term illness. This measure has been used as a proxy to give an indication of the vulnerability of older people, the clear suggestion being that not only will the proportions of older and very old people in the Highlands be increasing, but so will the proportion of those people with more complicated health and social care needs. 3.7 Whilst there is expected to be a significant increase in people living longer with different types of Long Term Conditions such as diabetes; stroke and heart disease, there are also expected to be increases in the number of people who are living with dementia. This is a particularly important factor given that these people may well also suffer from one or more long term conditions, but the greatest compromise to their ability to self care is likely to lie in their dementia. It can be assumed that roughly 20% of the total populations over sixty five modelled above, will be living with dementia.

5 Highland Carers Care Hours 2001 Census Figures 50+ per week 4, to 49 hours per week 2,080 0 to 19 hours per week 12, Analysis suggests that the Highland Council area will not see the decline in informal carers predicted in other council areas, however this aspect should not be omitted from planning for future care needs. In the Highlands there is expected to be an increase in the number of carers and the volume of care provided by informal carers. The table above indicates the current number of carers in the Highlands. The Local Authority and the NHS have a number of stipulated responsibilities to support these carers, and there are accordingly two issues that need to be planned for: What increase will we require to achieve in Carer Support to meet the expected demographic rise in informal carers?; or What provision will we need to make to provide care if the increase in informal care does not meet projections? 4. EXPENDITURE 4.1 With the growth in the older and vulnerable older population, expenditure requirements can be expected to rise in a number of areas, specifically: Expenditure on home care would require to rise by: 18% from 2005 to 2010, from 8.1m to 9.6m 88% from 2005 to 2024, from 8.1m to 15.3m. Expenditure on care homes would require to rise by: 12% from 2005 to 2010, from 26.7m to 30.0m 61% from 2005 to 2024, from 26.7m to 42.9m. Expenditure on all GP budgets for people aged 65+ are would require to rise by: 14% from 2005 to 2010, from 122.9m to 140.2m 69% from 2005 to 2024, from 122.9m to 207.7m. Expenditure requirements are on the basis of carrying on providing care at current levels with a growing elderly population. No account has been taken of inflation or actual budget provision in this analysis and all figures are at levels.

6 5. THE IMPLICATIONS OF DEMOGRAPHY ON SERVICE PROVISION 5.1 On the basis of the above projections work has been initiated to define further the shared resource available to provide services for older people. The Partnership between the Council and NHS Highland is clearly aware that the achievement of best service provision, and the continued attainment of national targets such as delayed discharge, will require a shift in resource use from a dependency on residential care to an expanded use of care at home to support. This will require closer alignment of resource use and the management of service through an enhanced partnership between health and social care managers and practitioners. 5.2 This factor is exacerbated by the demographic impact not only of the ageing population, but also of the decline of 8% in the Highland working age population, that is those who would be looking after the increasing frail, older population. 5.3 As was referred to the above figures; the number of people requiring care and the cost of providing it is set to grow over the next 17 years and beyond. The NHS Highland/Highland Council Partnership simply cannot afford to continue to provide care in the ways that it has, and is of the view that joint service change and modernisation is required to provide care that is not only affordable; but also more effective. 5.4 The exercise that has to be undertaken is referred to as Shifting the Balance of Care ; from institutional and residential provision; to community based provision to enable more people to remain as close to home as possible, for longer. 6. SHIFTING THE BALANCE OF CARE 6.1 The charts below illustrate that the Partners have three choices when considering the implications of the demographics as they effect the cost of emergency admissions to hospital; residential care and home care costs: 1. Continue to provide care as we do at present As shown in Figure 6, this is unlikely to be an option because of affordability. It would simply result in a continued rise in the cost of providing care, this being particularly pronounced in the case of the cost of emergency hospital admissions. It is also unlikely to be satisfactory for older people as most prefer to be cared for community settings for as long as possible.

7 Figure 1 Projected Increase In Cost of Emergency Admissions; Residential & Home Care 140, , , ,000 Emergency Admissions '000 Care Homes '000 Home Care ' ,000 90,000 80,000 '000 70,000 60,000 50,000 40,000 30,000 20,000 10, / / / / / / / / / /2015 Year2015/ / / / / / / / / Manage the Demographic Trend Figure 8 models resource shifts that would be required to hold residential and home care client numbers at current levels To do this we will need to make changes in: Service cost; i.e. obtain services more cheaply to provide more service at the same cost. Service Activity; use less service to provide the same level of care Service Modernisation; i.e. change the way that we provide services to improve efficiency and effectiveness. Figure 7

8 Residential and Home Care Places 8,000 7,000 6,000 Residential Care Increase in Home Care to beat demography Home Care Increase in Self Care to beat demography 5,000 Clients 4,000 3,000 2,000 1, MANAGE THE DEMOGRAPHIC TREND WITHIN AFFORDABLE LIMITS AND IMPROVE EFFECTIVENESS 7.1 This would require the same activities to be undertaken as indicated in beating the trend; but would require to yield greater efficiencies and effectiveness to beat the trend and then meet further need, all within the current cost envelope. This would allow investment in other service, eg. if we are able to provide the same levels of residential care, but at a reduced cost, then the savings can be reinvested in care delivered at home. 7.2 The need to increase self care also requires specific mention. It is with this group in particular that issues around anticipatory care and support of informal carers will require to be further addressed. This area will require new ways of joint working to ensure that early support is offered to assist patients and carers to understand and manage their own illnesses for longer with limited support; but with the clear commitment that when the challenge becomes too great, the support is there to keep patients in their communities for as long as possible. This will require a further revisiting of the economics of care given that the Partnership may have to accept that residential care may be more cost effective than care based in the community 8 PRACTICAL APPLICATION OF THE MODEL 8.1 The model described in Figures 6 & 7 is able to give an impression of where the resources need to shift to manage the demographic changes; and even to give a broad impression of the magnitude of resource that needs to shift. In Figure 2, the yellow and green areas show the level of increase that will be required in self care and in home care if the demographic trends are to be

9 beaten and the level of commitment to residential and home care kept at the same levels; implying a rise in self care What it does not describe is: The degree by which the Partners wish to shift the demographic and expenditure projections How this would be achieved 8.2 The practical application of this model requires more detailed work to outline the level of change required, and then the initiatives which will contribute towards this. 8.3 Joint work is in progress to consider how best to meet the care needs of older people which take into account the demographic change, Government targets and to consider different scenarios for shifting the balance of care. This will be reported to Members this financial year. 9. CONCLUSIONS 9.1 The analysis of demographic trends, leading to the development of a model for describing the Shift in the Balance of Care required summarises a number of complex and challenging issues which requires more work within the Partnership. The establishment of targets for the level of shift that we want to see from residential to community based care brings with it the need to prioritise resource on those in greatest need and to ensure that such provision is achieved flexibly and with frequent review. The future provision of care will require a more dynamic approach than is currently the case, with care packages flexing, i.e. increasing and decreasing to meet heightened then reduced need. 10. Recommendations 10.1 Members are asked to note the implications of the demographic change projected for the Highlands Members are asked to agree that this work should feed into the development of a Joint Strategy for Older People being developed with the NHS. Signature Designation Director of Social Work Date 10 September 2007 Background Papers Author/Reference Simon Steer

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