Globally, isolation and loneliness are a significant and growing problem in the older population (Fakoya et al, 2020) and have become an increasing challenge in the UK. A report by Age UK in 2016 showed that the number of chronically lonely older people had reached over 1.2 million, with over half a million not speaking or seeing anyone for up to 5 days (Age UK, 2016). Their report 2 years later estimated that the number of people over 50 years old experiencing loneliness would reach two million by 2026 (Age UK, 2018).
There is a difference between isolation and loneliness. Isolation has been defined as separation from social or familial contact, community involvement, or access to services (Public Health England, 2015; Age UK, 2015a); while loneliness can be understood as an individual's personal, subjective sense of lacking these things (Age UK, 2015a). It is therefore possible to be isolated without being lonely, and to be lonely without being isolated. Social isolation has been identified as a risk factor for all cause morbidity and mortality (Laugesen et al, 2018). Loneliness can lead to various physical disorders like diabetes, autoimmune disorders like rheumatoid arthritis and lupus, cardiovascular diseases like coronary heart disease, hypertension, obesity, physiological aging, cancer, hearing problems and poor health (Mushtaq et al, 2014). It also has an impact on mental health and overall wellbeing, causing people to feel empty, alone and unwanted (Mushtaq et al 2014).
Loneliness has been linked to increased contact with primary care services by the elderly (Dreyer et al, 2018), but health professionals struggle to address mental health and loneliness due to lack of time (Kellezi et al, 2019). Some healthcare commissioners and providers are implementing initiatives such as social prescribing (see Box 1) to reduce the economic burden of loneliness (Kellezi et al, 2019). This involves supporting patients to join third-sector groups such as charities or social enterprises and has been shown to be an effective way to address loneliness and improve health (Hemingway and Jack, 2013; Kellezi et al, 2019). However, a lack of clarity on social prescribing between staff and patients fosters poor levels of uptake and engagement (Stickley and Hui, 2012; Pescheny et al, 2018). To ensure schemes to target loneliness in older people are effective, they should involve older people at every stage, including planning, development, delivery and assessment (Age UK, 2015b).
Box 1.Social prescribingSocial prescribing is a means of enabling GPs, nurses, and other primary care professionals to refer people to a range of local, non-clinical services.As people's health is determined by a range of social, economic and environmental factors, social prescribing aims to address people's needs in a holistic way and support them to take greater control of their own health.Social prescribing schemes can involve a variety of activities which are usually provided by voluntary and community sector organisations. Examples include volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice and sports. They are often focussed on improving mental health and physical well-being.Adapted from The King's Fund (2017)
This London practice has 1500 registered patients aged over 70 years, of which 100 are unable to leave their homes. Our aim was to run a regular coffee morning in the practice to reduce isolation and loneliness in some of these patients.
Method
We wanted to check the feasibility of running a regular coffee morning for isolated patients in the GP practice and to find out the impact it had on the attendees. After attending the coffee mornings, we anticipated that patients would:
- Have a local, accessible and safe space to socialise and share experiences with others
- Be given assistance with transportation to the coffee morning should they need it
- Be aware of the services that different health professionals in the practice provide
- Understand how they can be healthier and improve their general wellbeing
- Be aware of relevant services and support that are available to them in the community
- Connect to each other, health professionals, charities and services.
To prepare for the coffee mornings we sought the views of professionals and patients, made practical arrangements, and devised a method of evaluation.
Gaining the views of professionals and patients
The views of professionals working in the practice were pursued through designated meetings with the practice business partner, GP partners, nurses and administrative staff. All were encouraged to offer their ideas and practical advice.
A focus group was held with 12 patients. It comprised of 10 women and 2 men aged between 80 and 95 years of age. Two were housebound. Transport was arranged to collect them.
The group was facilitated by LJ, supported by the patient liaison lead, two GPs (one was lead for adult safeguarding), the facilities lead, and the wellbeing hub navigator. The patients determined that a coffee morning at the practice would feel safe as they are familiar with the staff. Many ideas for content were provided by the participants (Box 2). It was agreed that 8 weeks would be enough time to see how the coffee mornings would work, and they were willing to pay a small contribution should they continue.
Box 2.Patients' ideas for inclusion in a coffee morning
- Thai chi
- Pilates
- Falls prevention
- Networking
- Mindfulness
- Chair dancing
- Trips out to art galleries
- Walks
- Computer introduction and skills
- Board games and bingo
- Puzzles
- Memory exercises
- Poetry
- Memory sharing
- Age UK
- Animal charities
- Story telling
- Visits from local children
- Christmas carols
- Bereavement support
Practical arrangements
The practical arrangements included booking an appropriate room and providing refreshments identifying and inviting suitable patients, arranging transport, organising staff and speakers, and structuring sessions.
Booking an appropriate room and providing refreshments
A room was identified that would safely house 25 patients and was booked for a Thursday morning from 11am to 1pm for 8 weeks. A local café offered to provide cakes free of charge.
Identification of suitable patients
The full practice team were presented with the plan and taught which patients were eligible and how to refer them. For the pilot, eligibility comprised being a registered patient aged 80 years and above, living in Putney, having a basic understanding of English language, not requiring one-to-one care, no diagnosis of severe mental illness, and unlikely to be disruptive or cause distress. The practice team identified individual patients who were socially isolated, through their relationships with patients and their families, as well as existing registers of housebound and vulnerable patients.
Arranging transport
Transport was arranged for housebound patients to get to the coffee mornings by the patient liaison lead and the facilities lead. An 8-seated van, driver and chaperone were provided by a local existing service.
Organising staff and speakers
It was planned that clinical hours would be blocked, and administrative time allocated to accommodate staff required to attend the coffee mornings. Speakers, charities, and exercise specialists were invited.
Structuring sessions
The 8-week programme was designed using the themes of health and wellbeing, education, exercise, and charities and services. It was structured as follows:
- 11-11:30 arrivals/welcomes/refreshments
- 11:30-12:30 a practical session, visitor or speaker
- 12:30 wind down and chat
- 13:00 finish
Funding
The costs of the pilot were covered by the project grant. The grant was provided by The Charlie Waller Memorial Trust.
Evaluation method
A questionnaire was completed by patients at the end of the pilot. It was uncomplicated and focused on obtaining information to decipher the feasibility and practicality of the coffee mornings and whether the objectives set were achieved.
Box 3.Befriending services
- Age UK has a network of local groups across the country that have befrienders who visit someone who lives alone: https://www.ageuk.org.uk/services/befriending-services/
- Re-engage bring older people together into social groups at a time in their lives when their social circles are diminishing: https://www.reengage.org.uk/about-us/
- Independent Age provide friendship services through phone calls, visits, and telephone discussion groups: https://www.independentage.org/about-us/how-we-help
- Royal Voluntary Service help older people stay active and connected to their local community by running social clubs and activities, exercise classes and hobby groups, and lunch clubs and community cafés: https://www.royalvoluntaryservice.org.uk/our-services#_ga=2.192169386.1606834909.1594734473-2074521645.1594734473
- The Silver Line offer telephone friendship where they match volunteers with older people based on their interests, facilitated group calls, and help to connect people with local services in their area: https://www.thesilverline.org.uk/what-we-do/
Results
There were 25 places in the coffee morning. In total 30 patients had experience of attendance. Five dropped out and their places were taken by others. Reasons for dropping out included feeling overwhelmed by the amount of people, it not being their thing, and too many females.
Views of patient attendees
All 25 patients who continued to the end completed the questionnaire. In total, 21 were female. The questionnaire covered safety and comfort, transport, socialisation, health and wellbeing, awareness of healthcare roles, and access to services in the community.
Safety and comfort
Fifteen of the attendees thought the space was comfortable and safe. The remaining attendees stated it was too small, crowded, noisy and warm. Some patients with deafness found the sound from lots of people in a small room to be difficult and could often not hear what a speaker was saying.
Transport
All patients stated they were offered transport to the coffee morning. Nineteen did not need to use it as they had lifts from relatives or caught public transport. Four patients that used it acknowledged it was convenient and had no issues, but two said sometimes it was later than expected.
Socialisation
Twenty-one of the 25 patients felt it was easy to talk to each other at the coffee mornings and felt an increased sense of community and connection. Some of them met up with each other on other occasions.
Health and wellbeing
Twenty patients stated that they learnt how to be healthier and work on their wellbeing, citing useful sessions as thai chi, pilates, mindfulness and falls prevention. Several patients then signed up for some of these activities.
Awareness of healthcare roles in the practice
Twelve patients asserted that they learnt about the services offered and the roles of health professionals within the practice, saying they found this both interesting and helpful.
Awareness of relevant services and support available in the community
Twenty patients stated they were made aware of services and support within the community (the speaker from Age UK gave the patients a list of resources and contact details so they could go on to access these services if needs be).
Some comments from participants included:
‘I think it is doing me good, I am not so lonely.’
‘It has given me a sense of worth.’
‘I have made new friends.’
In addition, we received letters and verbal feedback from carers and family members of those attending the group stating that they had noticed an improvement in morale and wellbeing.
Practical problems
The room we booked was too small as we had not considered how much space the various mobility aids would take up. Removing some of the furniture made it more comfortable and safer, but it still felt cramped. It was also very noisy. Transport was sometimes delayed when patients were not ready when the bus arrived.
More patients were referred to the coffee mornings than there were spaces. Due to work pressures, practice staff were not always able to attend the coffee mornings or stay for very long.
Practical successes
A small local café delivered a freshly made cake weekly and came in to meet and chat with patients. Patients started to bake cakes and bring them to share. These donations helped keep down costs. Following the pilot, the patient volunteer group agreed to coordinate and run the coffee mornings with support from reception, service delivery and facilities managers.
Costs
The recurring financial cost to the practice was providing transport (£25 per hour) for housebound patients and some of the speakers required a fee (at an average cost of £50).
Discussion
To ensure the comfort of attendees a larger room (which is available) could be booked, or the number of attendees could be reduced. Having a smaller number of attendees may encourage those who felt overwhelmed by the large number of people. As only one in five males in the UK reach the age of 90 years compared to one in three females (Office for National Statistics, 2019), it is to be expected that the coffee mornings will have a higher female presence. To prevent delays, the transport service could work out their route before picking up patients and give patients a more specific time of pick up. Given that practice staff found it difficult to attend the coffee mornings and more than half of the patient attendees reported that they were still unfamiliar with their roles, it may be beneficial to have one coffee morning during the programme designated for this purpose. Staff rotas could be prepared to accommodate this. Having one whole session on the role of practice staff may make it clearer for patients rather than short hurried snippets at each session. A system needs to be in place to deal with the higher number of patients referred to the coffee morning than spaces available. One way to deal with this would be to create a programme of a fixed number of weeks for patients to attend. Patients would then be recorded on a waiting list and be offered a place on the next programme. Other advantages to having a short programme include:
- Patients requiring transport may be willing to pay as there would be a definitive cost
- A fixed programme which rolls over negates the need for new organisation and planning
- Speakers become familiar and confident with their presentations
- The focus would be to enable patients to connect and engage with community services
- Eligibility could be broadened.
Despite the fact that social isolation is being experienced by more people during the current coronavirus pandemic situation, it would not be possible to set up a coffee morning in this way at the moment. Thought could be given to how a virtual coffee morning might work.
Conclusion
This pilot has shown that it is feasible to hold a coffee morning for isolated patients in general practice. The practical difficulties have been highlighted and can easily be overcome. Patients reported they felt part of a community, knew how be healthier, and how to access support and services. To increase the number of people benefitting, consideration could be given to the coffee morning being open to participants for a finite number of sessions, with the focus being on joining some of the outside activities presented.
KEY POINTS:
- Social isolation and loneliness have been identified as a risk factor for all cause morbidity and mortality
- Loneliness has been linked to increased contact with primary care services by the elderly but health professionals struggle to address mental health and loneliness due to lack of time
- Older people should be involved in schemes to target loneliness to ensure they are effective
CPD reflective practice:
- How are isolation and loneliness in the elderly currently addressed at your place of work?
- What services are available for social prescribing locally?
- How could the staff at your place of work improve engagement with these services?