This chapter should be read in conjunction with the following chapters: Healthy Lifestyles
and Long Term Conditions; Physical Disabilities; Adult Mental Health; Cognitive Impairment
including Dementia; Adult Unpaid Carers; Sensory Loss and Impairment; VAWDASV; Armed
Forces Service Leavers (Veterans)

Recommendations

Cardiff and the Vale of Glamorgan Local Authorities, Cardiff and Vale University Health
Board, and private providers to:

• Recognise the diversity of the “older people” group and provide services to meet the
  needs of such a diverse group, including transport options
  Continue to embed the Cardiff and Vale Rehabilitation Model
• Further develop existing collaborations to provide high quality end of life care
• Integrate care and support services to enable older people to live independently and
  well at home for as long as possible, for example, through the @home programme
• Promote the use of Dewis Cymru to increase awareness of available support services
  Cardiff and the Vale of Glamorgan Local Authorities to:
• Support new building developments to meet the needs of an ageing population, and
  increase the provision of a variety of accommodation options to enable older people
  to make informed choices on where and how they live
• Implement the Housing Adaptations Strategic Framework; and ensure existing
  properties are appropriate, safe, and support older people’s independence
• Apply urban design standards and accessibility criteria when redesigning existing
  infrastructure, for example, increasing the time for people to cross the road at a
  light-controlled pedestrian crossing (113)
  Cardiff and Vale University Health Board and Primary Care to:
• Promote the Royal College of General Practitioners ‘Tackling loneliness. A
  community action plan for Wales’ amongst health care providers and partners to
  raise awareness of loneliness, and advise how lonely patients can be identified and
  supported (113)

Overview
In this Population Needs Assessment, older people are defined as people aged 65 and above
(although it is accepted that in other contexts the age threshold may vary). For the purposes
of this needs assessment, where possible we will also divide this population group into
those aged 65-84, and those aged 85 plus. Older people are not a homogenous population group, and will have different needs and wants. Age is
a risk factor for many conditions such as dementia,
cataracts and falls, which will influence individual
people’s care and support needs.

The needs of people
with dementia are discussed in chapter 14.
Figure 8.1 and Table 8.1 show the wide variation in the numbers and percentages of people aged between 65 and 84 and aged 85 plus across primary care clusters in Cardiff and Vale. Western Vale has the highest percentage of people aged 65-84 (23%), however, Cardiff North has the highest number of those aged 65-84 (16,003).

In contrast, Cardiff
South East has the lowest percentage of people aged 65-84 plus (5.5%), but City and Cardiff
South has the lowest numbers of 65-84 year olds (2,475). Looking at the population aged 85
plus, Eastern Vale has the highest proportion of people aged 85 plus (3.4%), but Cardiff
North has the highest population (2,859 people). Across Cardiff and Vale of Glamorgan
there are an estimated 81,645 people aged 65 plus, as at mid-2020 (114).

Across Wales, the number of people reporting 2 or more longstanding illnesses has
remained at 21% in 2016/17 and 2019/20; similarly those reporting to be limited by the
longstanding illness is similar at 33% in 2016/17 and 35% in 2019/20 (115) (see also chapter
9: Healthy Lifestyles and Long Term Conditions). As more people live to an older age, more
people are likely to have two or more long term illnesses.

Engagement

Two focus groups were conducted: one for people aged 65-84 (4 participants) and one for
people aged 85 and older (3 participants). Forty-five percent (n=293) of the 647 respondents
of the public survey who provided their age were 65 or older: 172 were aged 65-74, 91 were
75-84, and 30 were 85 and older. Sixty-eight respondents of the provider’s survey provided
services for older people aged 65 and older. This is not representative of the population of
Cardiff and the Vale of Glamorgan, but does provide additional depth of insight and lived
experience.

What has changed since 2017?

Pre-COVID-19
Nationally, the following has changed since the 2017 Population Needs Assessment:

• Welsh Government published ‘Age Friendly Wales: Our Strategy for an Ageing
  Society’ in October 2021, setting out the vision for Wales to be a place that supports
  people of all ages to live well and age well and where older people are celebrated
  (116).
• In 2020 Welsh Government published ‘Connected Communities: a strategy for
  tackling loneliness and social isolation and building stronger social connections’
  (117). Whilst this issue does not solely impact older people, it is recognised that it
  does impact their lives, and this strategy followed the 2017 inquiry by the National Assembly for Wales’ Health and Social Care Committee into loneliness and social
  isolation which had a particular focus on older people (118).
• The rights of older people are enshrined in the Social Services and Well-being
  (Wales) Act 2014, which states that services should be prioritised in relation to older
  people with complex needs and long term conditions, including dementia (119). The
  Older People’s Commissioner for Wales’ strategy 2019-2022 (120) sets out their
  vision of celebrating an ageing society, supporting vulnerable older people and
  empowering people to understand their rights and access the support and services
  they need.

Regionally, the following changes have taken place:

• The impact of integrating health and social care services has been demonstrated
  through the Independent Living Service (ILS) provided by Cardiff Council and
  Wellbeing Service at Vale of Glamorgan Council Contact 1 Vale (C1V). This has
  focused on a prevention model since 2017. The aim of ILS is to reduce the need for
  social care, support people to stay living independently in their own homes and
  improve their well-being. The provision of a hospital based discharge support service
  has enabled collaborative working to help patients get home with the services they
  need in place, and improved partnership working with a range of sectors.
• ILS are a key partner in the South West Cardiff primary care cluster MDT (multidisciplinary team) model, which began in 2019. GP practices in the cluster meet every other week to discuss individual patients’ needs, as many of their needs can be met outside of healthcare. Partners around the MDT table include ILS, and third sector service providers, who can support people with issues such as social isolation, adaptations needed in their home and financial support. The MDT partners can signpost them to services or activities which will meet their needs. Many older people have been supported through the MDT model, and it is planned to roll out this model in other clusters.
• The Well-being Service in the Vale of Glamorgan offers a range of support to older people to meet their needs. Cardiff Well-being Support Service was set up in response to the pandemic and the needs around isolation, anxiety about going out and need for general support. Health and Well-being Mentors provide 1 to 1 support for a wide range of needs, and Community Inclusion Officers organise a range of community activities.
• Cardiff and Vale UHB, with Cardiff and Vale Local Authorities and other partners, have implemented the “@home” locality-based integrated care model within the Cardiff and Vale Regional Partnership Board, which aligns with the UHB long term strategy ‘Shaping Our Future Wellbeing’, which has a focus on community based care. This is a collaborative, person centred model, focused on prevention, early intervention and keeping people well.
• Both Cardiff and the Vale of Glamorgan local authorities are in the process of applying for Age Friendly status with the World Health Organisation, which is supported by both Public Service Boards. This is in line with the United Nation’s Principles for Older Persons rights.
• The 2019 Annual Director of Public Health for Cardiff and Vale report focussed on healthy ageing, and included three themes of: feeling a sense of meaning and purpose; having good social connections; and living in places that enable people to remain safe, active and independent (113).

COVID-19

Physical health and access to health care
COVID-19 has had a significant impact upon older people, including ill-health, mental and physical well-being, and mortality perspectives. The mobility and circulatory conditions of older people have deteriorated in lockdown and de-conditioning has occurred, potentially leading to increased risk of falls (121). Research has shown that age increases the risk of dying from COVID-19 due to deterioration of immune systems and being more likely to have long term conditions (122).

Focus groups with people aged 65+ and 85+ highlighted the following issues arising from COVID-19:
• Feeling that COVID has taken priority for healthcare services
• Difficulties accessing health services: “Impossible to see any health service, doctors or dentist”

Respondents to the professional and providers survey who provide services for older people identified an increased need in domiciliary support and packages of care, and increased dependency amongst service users due to lack of timely preventative services.

Mental health and well-being
There are increased risks of health anxiety, panic, and depression for older people, particularly those in institutions (123). COVID-19 has had adverse effects on the well-being of older people in care homes, for example, constraints on social contact due to suspension of indoor visiting (124). An Office for National Statistics survey across Britain during April/May 2020 found over 50% of the over 60s were worried about their well-being; of these 70% were worried about the future, 54.1% were stressed/anxious and 43.3% felt bored
(125).
Loneliness and isolation have increased for many older people, and feelings of anxiety and fear have emerged due to the pandemic and lockdowns. People who were previously self sufficient found themselves in need of support and their resilience and dealing with day to day issues decreased (126). Many older people have struggled with getting support when leaving hospital, sometimes leading to longer hospital stays.

“…if you have anything that’s not COVID it felt not important – just ignored and got worse but can’t do anything about it” – older person, focus group

Focus groups with people aged 65+ and 85+ highlighted feelings of helplessness: “scared
and lost many friends” and loneliness due to isolation: “not seeing family is the worst” and
“afraid to go out” due to COVID-19.
Professional leads and respondents to the professional and provider survey corroborated
these findings, identifying:

• Deterioration of mental and social well-being
• Increase in social isolation and loneliness
• Loss of confidence in going out and accessing activities and services
• Change of behaviour, staying in more, being less active
• The loss of social role, for example, through bereavement, retirement, or an inability
  to undertake a hobby or activity anymore had been identified as concern prior to
  COVID-19. With increased isolation due to pandemic restrictions, this is likely to be
  exacerbated
• Restrictions in accessing face to face services, for example toe nail cutting, exercise
  classes and social activities such as daycentres and lunch clubs
• Financial insecurity
• Help with practical activities such as shopping, as people were unable to leave their
  homes
• Increased need for input from health and mental health teams to ensure service
  users remain safe and well; bereavement support
  

Digital Exclusion

The Welsh Government Future Trends report 2021 identifies a reduction in internet non-users between 2012 and 2020, from 18.2% to 9.8% across Wales. Amongst those aged 50- 64, 6% in 2021 were digitally excluded, compared to 33% aged 75+. However, this is a considerable improvement compared to 2017/18, when 13% of those aged 50-64 and 60% of those aged 75+ experienced digital exclusion (127).
However, the digital divide has become significant during the pandemic, with more services moving to online only (128). Digital exclusion has been an issue for many older people in accessing vital support services, not just because of a lack of equipment but a lack of confidence or a fear of using online services (126).

These findings were also identified by professional leads, leading to exclusion for those who cannot work in roles that require digital connections, social isolation, and problems accessing services which switched to being a virtual only service. However, there has been
an increase in the number of older people who are using digital technology, particularly
during the COVID-19 pandemic. Digital inclusion projects have supported people to get
online and be taught how to use the technology to keep in contact with people, and access
the internet. This can help address social isolation and loneliness.

Impact on Service provision

Respondents to the professional and provider survey who provided services for older people
identified the following changes in their service provision, due to COVID-19 or restrictions:

• Reduction in face-to-face services and home visits, and use of telephone or online platforms
• Reduction or pausing of some services
• A respondent working in nursing and residential care home stated: “We have had to protect all residents at all times from the public including their own families”
• Respondents identified the following impacts on staff working in services for older people
  included:
• Anxiety, stress, isolation, with causes of stress identified as due to working additional hours, increased work load, and fewer resources, alongside feeling fearful due to the passing of service users, lacking face to face peer support, and a lack of access to other services that service providers would normally rely on. Other challenges included dispelling misinformation, fear of COVID-19, feeling undervalued, uncomfortable wearing personal protective equipment (PPE) and cancelled annual leave
• Staff shortages have been identified, and compounded with issues such as staff sickness, and self-isolation requirements of Test, Trace, Protect
  

Positive impacts of COVID-19

There have been some positive impacts observed due to the pandemic however. Services have had to adapt and in some cases this has resulted in more people being able to access them, and services have implemented flexible and agile ways of working. New connections have been made, and many people volunteered within their communities to support older people in particular with shopping, collecting prescriptions, or befriending via telephone.

Services integrated well and worked alongside each other, and new working patterns meant some flexibility for the workforce. COVID-19 has encouraged the development of digital solutions to link together. Health and social care staff have used technology to link people with their families, for example, tablets in care homes and hospital wards, so that families and loved ones can talk. A report from the British Geriatrics Society (2020) highlights some innovations and collaborations to help protect and improve the care of older people during the pandemic (129), examples include:

• Anticipatory care intervention for those who are high risk
• Multidisciplinary team response to urgent care needs
• Hospital at home collaboration to keep people at home
• Multiagency approach for rapid guidance and support to care homes
• Advanced care planning to identify individual needs
• Older people who were cared for on a children’s ward experienced improved wellbeing due, in part, to the presence of children’s nurses and play specialists and the creative, bright, and joyful ward design
• Integrated discharge planning
• Proactive rehabilitation with targeted physiotherapy prior to discharge
• Delivery of telephone and digital appointments

What are the care and support needs?

Individual
Resilience in older people
Third sector organisations articulated during the
COVID-19 pandemic that there were increasingly divisive messages emerging from media which exacerbate intergenerational tensions, for example, talk of making sacrifices during the pandemic to “protect” older people. Third sector organisations identified the risk that older people, whose contribution to society is well documented, will increasingly be seen as a drain on resources and that their personal stories will be lost in the negative messages being disseminated. These negative attitudes and thinking can have an impact upon older peoples’ mental health and well-being and should be tackled.

The importance of creating a society where people of all ages are equally valued is highlighted in the Royal Society for Public Health report, “That Age Old Question” (130). The report highlights that people with negative attitudes to ageing live on average 7.5 years less than those with more positive attitudes to ageing. Recent studies show they are also more
likely to develop dementia. The Older People’s Commissioner for Wales is leading the way in
the UK through recognising this issue as detrimental to health and to society more widely,
and her team has launched a campaign, “Taking Action Against Ageism” to encourage more
people to recognise and challenge ageism. Age UK document the racism as well as ageism
experienced by the Windrush generation, and others (131).

Diverse needs
Cardiff and Vale has a diverse population, with people from many different cultures and backgrounds, which is a great asset in our communities, but also means that needs can differ across the population. Services need to be able to adapt and respond to this diversity, as well as to the fact that the coming generations of older people will have different needs and offer different assets to the community, for example more will be familiar with digital technology as we move into the future.

It is expected that significantly more older people from minority ethnic backgrounds will need to access social care services in the future (124), due to families not being able to offer the support they perhaps once did. Access to culturally sensitive and appropriate health and social care provision is a priority in the Race Equality Action Plan being developed by Welsh Government.

Long term health needs
Many older people live in good health, 56.7% of older people in Cardiff and the Vale were living in good health in 2017/18 – 2018/19 (56.1% in Cardiff, 58% in the Vale) (132). Most (71.6%) of older people responding to the PNA survey rated their well-being as ‘good’ or ‘very good’ prior to the COVID-19 pandemic. This dropped to 52.8% in the last year due to the impact of COVID-19, but this was still the highest level amongst the groups surveyed.

Only 47.7% of older people in Cardiff and 50.2% in the Vale of Glamorgan live free from limiting long term illness (132).

Language and communication
There is no local data available on the Welsh language profile of older people living in Cardiff and the Vale of Glamorgan. The Strategy for an Ageing Society – Age Friendly Wales (116) specifies the importance of ensuring people can use Welsh language services in a way that suits them, and this is central to creating an age friendly Wales.

In Cardiff and the Vale of Glamorgan, Arabic, Polish, Bengali and Chinese are the four most common languages spoken after English and Welsh. Healthcare service providers have a responsibility to provide interpreters during consultations to ensure care provided is appropriate and culturally sensitive. Translation services are required for all interactions such as pharmacy and housing. Language was an issue raised by the focus groups participants, and in the survey around one in six (15.9%) older people felt the care and support received has not been in the language or communication format of their choice.

Community

Frailty and falls
The Healthy Ageing Programme in Wales (116) aims to increase activity among older people, reducing frailty and physical decline, and support people to live independently as they get older. Demand for services based on levels of frailty are predicted to increase due to the increased numbers of older people in the future, and previous modelling predicted an increase in demand of up to 31% in Cardiff and the Vale of Glamorgan between 2015 and 2025

Physical ability was by far the biggest issue preventing older people who responded to
the PNA survey from being in control over their daily lives (62.9%). Frailty can be a cause of falls, and falls are a key public health concern for older people. Telecare Cardiff undertook some analysis of clients who fell during 2020-21 and found that 84% of those who fell were repeat fallers, i.e. they had fallen more than once. Strength and balance loss was stated as the reason for most of these falls, followed by long term health conditions. Telecare are taking a proactive preventative approach to reducing falls among
clients (133), and Cardiff and Vale UHB has developed a falls prevention service which launched in 2018 aimed at reducing people’s risk of having a first fall. Dementia rates are also predicted to rise which will impact upon service provision. For more information about the needs of people with dementia please see chapter 14, and for the needs of unpaid carers see chapter 15.

End of life care
High quality palliative care can improve the quality of life of a person with a life limiting illness, and support their loved ones. Welsh Government’s 2017 Palliative and End of Life Care Delivery Plan has been extended until March 2022 (134). Palliative and End of life Care have been given new all Wales programme status and this work has commenced. The national framework for the delivery of bereavement care was published in October 2021, to support people in the period prior to, or following the death of a significant person in their lives (135).

Due to an aging population, an additional 135,000 annual deaths are projected by 2040 in England and Wales, compared to 2014. This is associated with a higher complexity of care with more than one serious illness contributing to palliative care needs. Studies have estimated that approximately 75% of people who die would have benefitted from palliative care (136). Patterns of place of death have changed, with increasing proportion of deaths at home and in care homes, and a reduction in hospital deaths, between 2004-2014 in England and Wales (137). Marie Curie report that an increased number of deaths took place at home in 2020, compared to the 5 years prior, in part due to COVID-19 restrictions and changes in
care and funding provision. Prior to the pandemic, although half of deaths took place in hospital, only 7% of people in the UK stated a preference to die in hospital (138). These changing patterns will impact the demand for, and expectations of, palliative and end of life care provision and delivery in all settings.

Advance Care Plans facilitate conversations between a person nearing the end of life, their family, and health and social care professionals, around the person’s wishes and what matters to them, including care preferences, treatments, and their preferred place to die. Such discussions enable improved choice, control, and quality of end of life care for the person, and lessens the bereavement burden for their loved ones. Advance Care Plans are embedded into the Cardiff and Vale UHB ‘Shaping Our Future Wellbeing Strategy 2015- 2025’ (139).

A review of Specialist Palliative Care Services in Wales published in 2021 identified that COVID-19 has brought end of life care into focus. Against a backdrop of the vision described by the Welsh Government long term plan “A Healthier Wales”, which aims for services provided at, or close to, home in a seamless manner, the following priorities have been identified:

• Equitable provision of and equitable access to palliative and end of life care
• Build on the principles of value based health care, including patient reported outcome measures, and patient reported experience measures
• Learning from COVID-19, including co-production of care delivery; speed of clinical intervention, innovation, and policy; and placing palliative and end of life care centrally in future pandemic planning
  

Currently, Cardiff and Vale UHB has a mixed provision of specialist provision between statutory and third sector services. There is a statutory inpatient specialist palliative care service with 24/7 consultant advice, and community nurse specialist support service to inpatient hospital sites at weekends during core hours. Most inpatient palliative care is provided in hospitals (140), although inpatient hospice care is provided by the Cardiff and Vale Marie Curie Hospice. Marie Curie in the Vale of Glamorgan, and City Hospice in Cardiff provide specialist palliative care input in the community including care homes. Marie Curie provides the Hospice at Home service across Cardiff and the Vale, which works alongside district nurses, GPs and families/carers providing core end of life care in the community supporting people to remain at home where that is appropriate (141).

Wider determinants of health

Deprivation
Life expectancy is known to be associated with socio-economic status: in 2017, there was a life expectancy gap of 8.6 years for males and 6.6 years for females, between the most and least disadvantaged areas in Cardiff and the Vale of Glamorgan (113) (see also Chapter 4: demography). An analysis of life expectancy in Wales prior to COVID-19 found wide and increasing life expectancy gaps between the richest and poorest fifths in Wales. For females, respiratory disease, cancers and circulatory diseases were most influential, and for males, circulatory disease, cancers, and respiratory conditions contributed the most to the life expectancy gaps (142).

The Older People’s Commissioner for Wales’ report in 2019 identified that the healthy life expectancy gap was 18 years in Wales, between the most and least deprived areas (143). The report identifies that older people tend to have lower incomes than people aged under

Approximately one-third of people aged 60-74 in Wales receive an income of under £200 a week (£10,400 per year). Women are more likely to be poorer than men (143). Pensioners in the poorest fifth of the UK population are more likely to have one or no close friends, compared to pensioners in the richest fifth, in research conducted in 2014/15 and 2017/18 (144). Financial barriers were prominent in focus group discussions, regarding access to care and support services, as well as leisure and community activities.

Professionals supporting older people reported that cost of activities can be a barrier for older people. Financial barriers should be addressed when services are being provided.

Housing
Cardiff and Vale’s ageing population has particular implications for the amount, type and location of accommodation which is specific to their needs. The majority of older people on the Housing Waiting List in both Cardiff and the Vale need one bedroom properties (29) (145). Poor or unsuitable housing can impact disproportionately on older peoples’ physical and mental health, independence and well-being (145). An assessment of older person’s housing accommodation undertaken for the Regional Partnership Board in 2018 (146) estimated a need for an additional 3,051 units of older persons’ accommodation by 2035 in Cardiff, which should be a mix of housing, housing with care, and nursing care. In the Vale, the report forecast the need for an additional 1,297 units by 2035.

The Vale of Glamorgan Housing Strategy notes the anticipated demographic changes and increasing trends of the proportion of people with long term limiting illnesses. The need for housing to enable people to remain independent is emphasised, for example, through provision of high quality, affordable and suitable housing. Alongside this, enablement services, Telecare and Extra Care housing are considered (147). The Cardiff Housing Strategy, similarly, identifies mechanisms by which to promote people’s independence, for example, through availability of specialist housing for older people (such as sheltered
housing and extra care provision). For example, council sheltered housing schemes will include communal spaces, dementia-friendly features, offer charging and storage facilities for scooters, and be accessible and culturally inclusive. The Strategy highlights the Independent Living Services as a preventative support service to help maintain independence (148). A separate Older Person’s Housing Strategy was published in Cardiff in 2019, which aims to improve existing houses, maintain independence, meet the needs of
the most vulnerable, and tackle social isolation (145).

Older people responding to the PNA survey were more than twice as likely to report that their home was too big, compared to any of the other groups surveyed. Many older people require adaptations to their home to enable them to remain living independently (52% reported the need for adaptations in the PNA survey).

The draft Housing Adaptations Strategic Framework developed by Welsh Government provides stakeholders involved in the delivery of aids and adaptations, service users and others with a framework which facilitates a more strategic and integrated approach to delivering adaptations services at a local level. The framework should become operational from April 2022. The framework includes the requirement to establish a common understanding of the population need and demand for adaptations and identify inequalities and links to RPBs and the population needs assessments (149).

Both Cardiff and the Vale of Glamorgan will be developing new residential units for older people in the coming years. In order for these to best benefit the health and well-being of the future residents, older people should be considered in the design of these developments. For example, enabling people to travel by reliable and regular public transport, as well as walking or cycling is vital for older people to stay active and improve their health (150). Well maintained paths, adequate lighting, locating residential units close
to existing services, and ensuring safe spaces for cycle storage all encourage walking and cycling. Charging points for electric mobility aids must be available and accessible at locations decided upon in tandem with those who use them.

Domiciliary care
Cardiff and Vale Regional Partnership Board (RPB) aims to deliver services as close to home as possible, through the “@home” integrated care model. This includes the development of cluster-based multi-agency teams. These will provide a rapid response to a crisis, prevent avoidable hospital admissions, and facilitate discharge home where hospital admission was needed. “Home first” is a key theme across all three RPB programmes of Starting Well, Living Well, and Ageing Well (151). The RPB vision is of people living the best lives they can in their homes and communities, and is supported by the Regional Outcomes Framework.

Domiciliary (home-based) care can be provided by local authorities, independent or private providers, and the third sector (152). A Welsh Government White Paper in 2021 identified that more adults are receiving care and support services at home, which had increased demand beyond available domiciliary care provision prior to COVID-19. Delayed transfers of care from hospital were often due to waiting for domiciliary care packages (153).

Analysis of trends in Wales between 2006/07 to 2018/19 identified that although the over 65 population increased in number, the number of residential care services did not. Possible explanations include a preference for domiciliary care, as well as extra care housing, informal care from family and friends, and older people living healthier lives (152). The Wales-wide report states that the impact of COVID-19 on attitudes towards care homes is still unknown (for example, due to excess mortality reported in care homes (154)) but may influence the demand for domiciliary care services in future. Future demand may also be shaped by the relative prevalence of conditions affecting older adults, for example, provision of domiciliary care may be more complex for people who have severe dementia. Domiciliary care was observed to be particularly vulnerable during COVID-19 (153) (152).

Research from Cardiff University in December 2021 investigating the impact of COVID-19 on domiciliary care workers in Wales found that 28% had sought mental health care, and identified emotional and well-being risks to domiciliary care workers such as increased workload, isolation, and lack of recognition of value. Risks of exposure to COVID-19 were also identified, such as through staff shortages, the personal nature of care provided to clients, uncertainty in client COVID-19 status, and impracticalities of using PPE (such as the client’s fear; difficulties communicating; glasses steaming up during bathing of clients) (155).
The Social Care Recovery Framework published by Welsh Government prioritises enabling older people and disabled people to be active members of their local communities, and to remain active and independent in their own homes.

The Framework recognises that long COVID is likely to impact domiciliary care services through recruitment, retention, and management of sickness amongst staff. The Framework aims to increase the capacity and reach of domiciliary care through a variety of means, including through the commitment to
the Foundational Economy (156)

Unmet need

Professional leads identified the need to better understand what older people want from services, and giving greater consideration to how best to support people with cognitive impairment. Also a need to increase the support around addressing frailty. Focus group participants identified the following gaps:

• Better access to healthcare to meet needs: “struggle to get an appointment, even in an emergency”
• Better public transport systems
• Improved accommodation: “Better sheltered housing”
• Enhanced support: “Better support for people to live independently”;
• “More support groups to meet with other people”
• Respondents to the professional and provider survey identified the following unmet needs:
• Access to day care services, domiciliary care, and lifting service
• Long waiting lists for support services including mental health, physiotherapy, hospital services, and care at home; delayed care was identified as increasing people’s needs
• Socialisation opportunities
• Gaps in knowledge and understanding include:
• In depth knowledge and understanding of what older people want from services
• Consideration of how best to work with people with significant cognitive impairment
• A common understanding of the population need and demand for adaptations and identify inequalities within and between regions.
• A clear understanding of language needs for older people in Cardiff and Vale
• Benchmarking and the “social model of care”
• Where the gaps in service provision are
• Where to focus prevention work to have the biggest impact on reducing hospital admissions

What are the range and level of services needed?

Prevention and assets
To address the issues facing people as they age, prevention is crucial as it can keep people
healthier for longer, living independently, reduce the need for social care and demand for
other services. These key elements around prevention have been identified by professionals
and older people:

• Legal framework around mental capacity, Power of Attorney and Advanced Decision
  making
• Financial management and support
• Falls prevention services
• Mental health and resilience
• Digital inclusion
• Integrated health and social care services across sectors
• Addressing loneliness and social isolation
• Maintenance of social roles in families and communities, to give life a meaning

Assets to support well-being

Focus groups, discussions with professionals supporting older people and survey results highlighted sources of support and wellbeing for older people in Cardiff and the Vale.

Family and friends were valued: “I rely on family for many things”. Community-based settings support independence and wellbeing. 42.2% of survey respondents who are older people reported to attend a setting within their community.

Examples of local assets include drop-in centres (“support workers at drop-ins”); over 60s clubs in community venues such as mosques, libraries/ hubs, clubs such as drama, books, cooking or gardening. Third sector organisations such as Age Connects, Age Cymru, Red Cross provided support, and the Alzheimer’s society Dementia Friends programme was also helpful. Healthcare services were supportive and care home staff “are superb, they take the time to care”. Extra care housing facilitate independence
amongst people with care needs.

Dewis Cymru provides a list of local and national organisations that can provide help and support for residents across Wales, including Cardiff and the Vale, for a range of topics including well-being, safety, managing money, being at home, and looking after someone (157).

Community Services

Rehabilitation and reablement
Rehabilitation describes the concept of providing personalised support to an individual to enable them to live as active and full a life as possible. This includes reablement, which describes the process of regaining skills and confidence. Rehabilitation can prevent a need arising or escalating, promote self-management, help recovery after an event such as a hospital admission, and span physical and mental health (158).
The five-tiered, evidence-based Cardiff and Vale Rehabilitation model, introduced in 2020, is shown in Figure 16.4. There are four “rehabilitation rules” that span all five tiers, indicated in blue double-headed arrows in the figure. The design principles (in red) are taken from the Cardiff and Vale UHB strategy ‘Shaping our Future Wellbeing’. Rehabilitation aims to reduce health inequalities, promote independence, pre-empt and avoid crises, and enable people to enjoy a meaningful life at home where possible (158).

Transport
Transport was identified in the 2017 PNA as a way of improving people’s independence and well-being (159). The Centre for Ageing Better published a report on barriers and enablers to active travel amongst people aged 50 to 70, with key themes around physical ability, confidence, proximity to amenities, maintained footpaths and cycle paths, social norms, and motivation (150). The Welsh Government Strategy for an Ageing Society incorporates public and community transport that is accessible to all older people, as a priority. Transport is viewed as critical to enable older people to realise their independence, participation, reduce isolation and loneliness, and access services. Barriers to access included poor co-ordination between transport systems, availability of public toilets, and seating. Free bus travel for
those aged over 60 is continued in the new Wales transport strategy.

Three key areas include development of demand responsive transport, improving bus services, and
supporting people to plan their journeys door to door (116). Health services need to be accessible for older people, including by public transport. Age-friendly spaces are discussed in the 2019 Director of Public Health for Cardiff and Vale’s annual report (113).

In Cardiff and the Vale, there are a number of third sector community transport providers, including Age Connects, Voluntary Emergency Service Transport, Hospital Transport Service, alongside others (160).

Partnership Approach

Future thinking
The demographic shift will be a significant future challenge, and the demand for social care in particular is going to be rising. There are issues with recruitment in social care currently which need to be addressed, and there is a need to ensure services are sustainably funded.

Societal changes such as employers enabling flexible retirement opportunities may impact the services demanded and utilised. Social care needs to be sustainably funded for the long term.

Person-centred services
Services need to be joined up. Prevention should be prioritised, in order to support older people to live and age well (116). Social prescribing (161) and provision of a wide range of support services can enable older people to have their needs met such as addressing isolation and potentially reduce their need for health and social care. The Royal College of General Practitioners has developed community action plans to tackle loneliness for each of the four UK nations. In Wales, the plan aligns with the Well-being for Future Generations Act, encourages partnership working between Primary Care and other services, and calls for everyone to take action to tackle loneliness (162)

Services need to be flexible enough to meet needs of the individual and their choices. There has been a positive shift towards supporting people to stay in their own homes, and to have rights to say what they want and need. More people are choosing not to live in residential care accommodation, but staying at home and receiving support there, which comes from a variety of sources including third sector. There is often still a need for nursing care at a point in people’s lives however. A range of service providers needed to work jointly – health, local authority and third sector to provide the right care at the right time.

What is likely to happen in the future

In Cardiff and the Vale of Glamorgan the number of people aged 65 to 84 years is expected to increase from around 70,000 people to around 93,000 people between 2019 and 2039. This will mean a rise from 14% of the total population in 2019 to 16.2% in 2039. Figure 8.2 illustrates the rate of growth expected in this age group between 2019 and 2039. It should be noted that predictions become less accurate the further forward into the future they project.

The number of people who are aged 85 and over is expected to rise even more sharply, with numbers expected to double in the next 20 years. This will mean a rise from 2.4% of the total population in 2019 to 4.2% in 2039. Figure 8.3 illustrates this change.

Health and social care will need to adapt and focus not only on the ongoing impact of the pandemic, but the need to continue to build an integrated system which delivers the best quality services for the population. Welsh Government will concentrate efforts on the “whole system” putting citizens at the centre and surrounding them with resilient local communities alongside primary and community care (25). Health services need to be agile and responsive and social care services caring, effective and linked seamlessly with local communities and health services, to provide support for those in their own homes.
Future demand for formal care for people is not simply linked to the fact that the population is ageing. However, the projected growth in the numbers of older people with complex care needs (including severe dementia) is highly likely to result in increased pressure on health and care services (163), for example, the number of older adults living with severe dementia is predicted to double by 2040 in Wales.

Recommendations

Cardiff and the Vale of Glamorgan Local Authorities, Cardiff and Vale University Health
Board, and private providers to:

• Recognise the diversity of the “older people” group and provide services to meet the
  needs of such a diverse group, including transport options
• Continue to embed the Cardiff and Vale Rehabilitation Model
• Further develop existing collaborations to provide high quality end of life care
• Integrate care and support services to enable older people to live independently and
  well at home for as long as possible, for example, through the @home programme
• Promote the use of Dewis Cymru to increase awareness of available support services
  Cardiff and the Vale of Glamorgan Local Authorities to:
• Support new building developments to meet the needs of an ageing population, and increase the provision of a variety of accommodation options to enable older people to make informed choices on where and how they live
• Implement the Housing Adaptations Strategic Framework; and ensure existing properties are appropriate, safe, and support older people’s independence
• Apply urban design standards and accessibility criteria when redesigning existing infrastructure, for example, increasing the time for people to cross the road at a light-controlled pedestrian crossing (113)

• Cardiff and Vale University Health Board and Primary Care to: Promote the Royal College of General Practitioners ‘Tackling loneliness. A community action plan for Wales’ amongst health care providers and partners to raise awareness of loneliness, and advise how lonely patients can be identified and
  supported (113)