Elizabeth Mair, Dr Moon Halder, Dr Niamh McNamara, Dr Mhairi Bowe, Dr Blerina
Kellezi, Dr Juliet Wakefield, Dr Iain Wilson & Dr Clifford Stevenson NOTTINGHAM TRENT UNIVERSITY Sept 2018
AGE FRIENDLY NOTTINGHAMSHIRE PILOT EVALUATION – SUMMARY
DOCUMENT
1
EXECUTIVE SUMMARY
1 There is overwhelming evidence of the negative impact of loneliness on the health and
wellbeing of the population. The elderly are especially vulnerable and, while there have
been extensive policy-based initiatives to tackle loneliness throughout the UK, these are
rarely informed by a theoretical framework or systematic research evidence.
2 Academic research illustrates the importance of social relationships (and group activities
in particular) to the health and wellbeing of communities and their residents. Studies of
the use of support groups show substantial and sustained benefits to people’s health. On
this principle, varieties of models of ‘Social Prescribing’ have been developed to
capitalise on these benefits and improve the social connectivity and health of vulnerable
populations.
3 Likewise, volunteering has been found to be an effective form of social activity in
enhancing the wellbeing of particularly engaged community members. In part, this is
due to the impact on volunteers’ sense of personal self-efficacy and self-esteem and in
part because of the social relationships and group activities involved. However, this
evidence is rarely included in the development of Social Prescribing initiatives.
4 Age Friendly Nottinghamshire is a unique approach to Social Prescribing which
combines a resident-centred Social Prescribing model with a programme of community
activation and volunteering. Neighbourhood coordinators work organically within
communities to identify individuals’ social needs, support volunteers to develop local
initiatives, and scaffold or deliver local groups and activities. The goal is to deliver a
more integrated, active and healthy community, thereby reducing the burden on health
and social care resources.
5 Our evaluation has systematically charted the impact of these activities on those
involved by:
2
5.1 Mapping the activities of AFN neighbourhood coordinators across the target
communities of Beeston and Ladybrook
5.2 Conducting a community-wide survey assessing the levels of loneliness,
engagement in AFN activities, levels of volunteering and levels of health and
wellbeing
5.3 Surveying AFN beneficiaries at an initial timepoint, followed up 4 months later,
giving us an assessment of the impact of AFN on individuals’ health, wellbeing
and service use over this time
5.4 Interviewing beneficiaries of AFN activities, including both volunteers and
recipients of support
5.5 From this work we are able to give a clear and comprehensive assessment of the
effectiveness of the AFN approach, its impact upon these target communities.
6 Our mapping exercise indicates a range of groups and activities supported by AFN
across both areas which serve to reach a wide variety of residents. These activities were
organically developed and resident-led rather than programmatic or universal in
delivery. The maximum number of service users at any one time was estimated at 258,
with an additional maximum of 62 long-term volunteers and 77 ‘Movers and Shakers’
supported to set up and lead group activities. Neighbourhood coordinators supported 32
groups across the two areas and liaised with 364 businesses and organisations.
7 Our community survey indicates a strong relationship between social isolation,
loneliness and poor health in both target areas, which match patterns across the UK. The
beneficial effects of social support are more pronounced in Beeston than Ladybrook,
suggesting an inequality in community cohesion between the two areas and a greater
need for intervention in Ladybrook. Across both areas there were low levels of
participation in AFN initiatives and very low levels of awareness of AFN in Ladybrook.
3
8 Our interviews with beneficiaries indicate the profound effects that loneliness has on
residents, especially those who are older or have complex health needs as well as the
remarkable impact that AFN has had upon their lives. Those who took up a volunteering
role reported both increased social integration and a sense of contributing to the
community, both of which they experienced as positive.
9 Our longitudinal survey of beneficiaries of AFN showed that for all who participated in
the survey at the initial timepoint, there was already strong associations between their
participations in AFN, their sense of community integration and their wellbeing. (The
follow-up occurred within a shorter period than we would expect to see evidence of
health improvement). Yet still, we see some evidence of improvements in our main
measure of health.
10 Our cost analysis shows that, after only three months, participants evidenced some
reduction in their usage of health and social care services. With some caution, we can
suggest that there is likely to be an overall return on investment from the programme, in
the region of £1.26 per £1 spent. In addition, the increased level of volunteering and
uptake of community activities within each area was estimated as being as much as
£198k.
11 Overall, the outcomes of AFN in these two pilot areas compare favourably to many
other similar initiatives elsewhere and point to the enormous potential of volunteer-
based community development to improve health and wellbeing through reducing
loneliness.
4
Contents 1. Introduction ............................................................................................................................ 5
2. Background ............................................................................................................................ 6
3. The Age Friendly Nottinghamshire Pilot ............................................................................... 7
4. The NTU Evaluation .............................................................................................................. 8
5. Service Mapping Study .......................................................................................................... 9
6. Community Survey Analysis ............................................................................................... 11
Community Life Survey Analysis ........................................................................................ 11
Beeston and Ladybrook Community Survey Analysis ........................................................ 11
Volunteering analysis ........................................................................................................... 11
7. Longitudinal Survey Analysis.............................................................................................. 13
8. Interview study..................................................................................................................... 14
Residents’ analysis ............................................................................................................... 14
Volunteers’ Analysis ............................................................................................................ 14
9. Costings Analysis................................................................................................................. 16
10. Discussion and Conclusion ................................................................................................ 17
5
1. Introduction
• Increased awareness of the importance of social factors in health, alongside economic
pressures to deliver care with the help of the third sector, has led to intense interest in
‘Social Prescribing’ as a way of providing sustainable care within community
settings.
• Age Friendly Nottinghamshire (AFN) is a community-based Social Prescribing
approach to tackling loneliness which employs community activation techniques to
address the needs of isolated adults by linking them to groups and activities.
• NTU have been commissioned to evaluate this initiative. The team custom designed a
large-scale multi-method evaluation approach and the current report details their
framework and the evidence they have collated.
• On this basis, this report outlines the extent to which AFN is achieving its goals and
sheds light on the processes through which it works.
6
2. Background
• The UK population is ageing and older adults are especially vulnerable to loneliness due
to a range of personal and social factors which can undermine their ability to connect with
others. Loneliness has a variety of impacts upon people’s mental and physical health with
effects on health and mortality comparable to those of smoking and obesity.
• Government policies targeting loneliness have recognised the extent of this challenge and
have identified the need to provide inclusive communities for older adults, identify the
community supports that would address their specific needs, and to assist and enable
older adults to self-manage their own challenges in order to remain socially integrated.
However, these policies have rarely been based on sound theoretical principles or
systematic reviews of research evidence.
• Social Prescribing is one form of intervention which aims to tackle loneliness by linking
participants into social networks within their local communities. A body of evidence has
emerged attesting to the positive impacts of Social Prescribing initiatives upon the health,
wellbeing and health service usage of participants, though this provides less detail on the
reasons why social relations have these positive effects.
• Volunteering is another form of loneliness intervention which has been found to have
particularly pronounced effects on participants who are able and willing to actively
participate in local activities. This has been found to have a positive impact upon health
and wellbeing by improving the self-efficacy and self-esteem of participants as well as by
enhancing their social networks and sense of community belonging.
7
3. The Age Friendly Nottinghamshire Pilot
• Nottinghamshire County Council have developed a model of care through which
community capacity is developed and social action encouraged. The Age Friendly
Nottinghamshire Pilot does this by drawing on the strengths of both Social
Prescribing and volunteering approaches to tackling loneliness.
• The AFN pilot runs in two strategically selected areas. Beeston is a university town of
21,000 residents on the outskirts of Nottingham in which 20.1% of households consist
of single pensioners living alone. Ladybrook is an ex-mining town in Mansfield of
around 4,300 residents in which 14.3% of households consist of single pensioners
living alone. Both areas are considered to have a high risk of loneliness at
neighbourhood level for individuals aged 65 and above.
• The aims of the AFN initiative include using local knowledge to engage and empower
local communities to meet the needs of their isolated residents.
• The expected outcomes of the initiative are to reduce loneliness and its associated
healthcare costs in the target areas as well as to increase connectedness between
residents, local community organisations and agencies in the area.
8
4. The NTU Evaluation
• NTU conducted a large-scale multi-method evaluation of the AFN programme to provide
academic-grade evidence of the efficacy of the programme. Their work is modelled on
the most comprehensive and esteemed Social Prescribing evaluations available to date.
• Their work comprises four interlinked studies which each capture a facet of the AFN
initiative and allow an overall assessment of its impact.
• A longitudinal mapping exercise captured interview data from the Neighbourhood
Coordinators at three time-points over a 9-month period. Neighbourhood Coordinators
reported the scale and scope of their activities as well as the number of beneficiaries
within the communities.
• A community level survey was developed on the basis of an analysis of the Cabinet
Office’s Community Life Survey, which illustrates a nation-wide relationship between
community identity, support, loneliness and wellbeing. NTU’s custom-made survey
explored these factors and in addition investigated the impact of social inclusion and
volunteering activity on the health and wellbeing of residents.
• A longitudinal survey examined the experiences of 64 AFN beneficiaries at an initial
timepoint, then 22 of these at a second timepoint 4.4 months afterwards. Analysis of the
changes in their health and service usage at each timepoint provided data for our cost
analysis of the programme.
• An interview study allowed us to explore the experiences of beneficiaries of the AFN
initiative. We interviewed those participating in AFN activities as well as those who had
adopted a volunteering role and analysed how they reported the impacts upon their
wellbeing.
9
5. Service Mapping Study
• We talked to the AFN Neighbourhood Coordinators at three timepoints over the
course of the intervention to ask about their activities. Timepoints were three months
apart and coordinators were asked to report on activities which had been undertaken
in the interim.
• NCs reported that up to 258 individuals were engaged with AFN activities at any one
point and that one-off events had been attended by 1579 participants. Of these
beneficiaries, 208 of the long-term engaged participants, and 205 of the one-off
participants, were local residents.
• Neighbourhood Coordinators signposted 316 individuals to groups and activities over
the course of the evaluation. These beneficiaries reported being motivated primarily
by social isolation, but also by a lack of local activities and the desire to develop a
sense of local community.
• Neighbourhood Coordinators worked with a maximum of 62 volunteers at any one
timepoint and engaged with a total of 172 one-off volunteers. These reported being
motivated by a sense of community, wanting to develop a sense of purpose, and
wishing to gain experience for future employment. They also signposted 87 of these
volunteers to other groups and activities.
• Neighbourhood Coordinators also identified individuals who were willing and able to
set up new groups and lead activities. There were a maximum of 77 of these ‘movers
and shakers’ at any one time and they were motivated primarily by a sense of
community and a desire to improve their own wellbeing. 85 of these were signposted
to other groups or activities.
• In total, 32 groups and activities were estimated to have been either created or
supported by the Neighbourhood Coordinators in Beeston and in Ladybrook across
10
the three time points of data collection. NCs provided support through developing
ideas with groups, assisting members to attend and providing administrative support.
• Neighbourhood Coordinators had ongoing engagement with 364 businesses and
organisations at any one time over the course of the programme with an additional
198 one-off contacts with other organisations. 110 businesses were signposted to
community groups and activities, with 71 accepting the referral.
• In addition, Neighbourhood Coordinators worked with additional organisations and
initiatives across the Ladybrook and Beeston areas, including libraries, museums, and
educational services, places of worship, volunteering organisations, arts organisations,
health organisations, and council services.
• While this data relies on self-report estimates provided by Neighbourhood
Coordinators, and is vulnerable to duplication between Coordinators and across
timepoints, it does reflect a very high level of activity undertaken by the AFN staff.
11
6. Community Survey Analysis
Community Life Survey Analysis
• Our analysis of the Cabinet Office’s Community Life Survey shows strong
relationships between community identity, social support, loneliness and wellbeing
across England. This forms the basis for the rationale for our study and suggests that
insofar as these same factors impact upon loneliness in Beeston and Ladybrook they
are likely to be relevant in other settings across the nation.
Beeston and Ladybrook Community Survey Analysis
• Our community level survey elicited a substantial response across the target areas
with 619 survey responses (452 from Beeston and 167 from Ladybrook)
• Awareness of AFN varied widely between the two areas with 55% of Beeston
respondents being aware of the initiative, but only 5% of respondents in Ladybrook.
• However, awareness of the specific activities which have been directly or indirectly
supported by AFN was high across both areas with 50% of Beeston participants and
44% of Ladybrook participants being aware of at least one AFN supported activity
• Across both areas, participation in these activities was low, with only 4.3% of
Ladybrook participants and 2% of Beeston respondents having attended an activity.
• Analyses of survey responses showed strong relationships between the variables
measured, with community identification associated with better health and wellbeing
and loneliness associated with poorer health and wellbeing in both areas.
• Our advanced analyses replicated the Community Life Survey findings, showing how
community identity has positive effects on health and wellbeing by reducing
loneliness. This provides strong evidence for the generality of these patterns and for
the relevance of the current findings for the wider UK.
12
• However, our analyses also showed asymmetries between the areas with social
support predicting lower loneliness and better health in Beeston, but not Ladybrook.
This is thought to reflect the differences in levels of ‘social capital’ in the two areas,
whereby a more cohesive and proactive community in Beeston benefits the health of
its members more directly than the less cohesive Ladybrook community. This
suggests that community identity is likely to be very important for the wellbeing of
Ladybrook residents, but that much more remains to be done to support and improve
the social relations between residents in this area.
Volunteering analysis
• Our analysis of the levels of volunteering in Ladybrook and Beeston again show low
levels of participation in AFN activities among our sample. However, a good number
of respondents (16%) do volunteer for a wide variety of reasons, most often to enact
their values and for social motivations. Volunteering for career reasons was least
associated with levels of engagement or activity.
• Our analysis of the effects of volunteering shows that overall participating in
volunteering is associated with stronger social relationships, feelings of community
identification and feelings of being able to collectively cope with adversity. Positive
experiences of volunteering are also associated with improved health and wellbeing.
• Our advanced analyses show how volunteering behaviour improves health. In the first
instance volunteering behaviour increases a sense of identity with the community
which in turn predicts better health. Secondly, volunteering also increases the level of
social support in the community which both improves wellbeing directly and also
through the increase in a sense of collective coping or ‘efficacy’ among community
members.
• Overall, this work indicates that volunteering has a pronounced effect on individual
and collective wellbeing within these communities.
13
7. Longitudinal Survey Analysis
• In order to assess the impact of participation in AFN activities, we conducted a
longitudinal survey of beneficiaries. A small sample of 64 participants completed our
survey at an initial timepoint and 22 re-completed this between 4-6 months later.
• Participants were predominantly between 60 and 70 years of age and typically
attended a group or activity once a week.
• At baseline, the 64 participants’ survey data showed similar patterns to those found in
the community survey, with their health and wellbeing related to their community
identity, social support and loneliness. In addition, those who reported volunteering
for AFN showed a higher level of self-reported wellbeing.
• We examined the change in these variables over the period between the first and
second timepoints. Though we would not expect an intervention of this type to have
substantial effects in such a short timeframe we did find improvements in the main
measure of wellbeing, the EQ5D. On all dimensions of this measure, some
participants improved, with no participants evidencing a decline. While the data from
this very small sample needs to be treated with caution, we interpret this as the first
‘green shoots’ of the impact of the intervention.
14
8. Interview study
Residents’ analysis
• With regard to the experience of isolation, the qualitative analysis demonstrates that
isolation was recognised as being experienced by both participants and others in their
communities. This is reflective of isolation being considered as a primary reason why
Neighbourhood Coordinators felt residents engaged with the service in the Service
Mapping Study. Ageing was considered to be significant in the experience of
isolation, both in the sense of ageing bringing associated health issues, but also that
there was a feeling of becoming ‘too old’. This feeling created a barrier to
involvement which was considered to be challenging to address, and it was suggested
by interviewees that keeping active and involved in the community may counter this
feeling.
• The recognition of the importance of connections, accompanied by the comparison
between the isolation experienced before interviewees’ involvement in groups and the
social connection experienced after involvement, highlighted that engagement with
groups and activities promoted a sense of belonging. Attending groups allowed the
opportunity to form and subsequently develop connections, with residents
acknowledging the reciprocal support experienced.
• As reflected in the Service Mapping Study, listening to the needs of groups and
communities was raised as important for the success of the development and
continuation of groups. The success of a group was considered to be related to the
group addressing a community need and gaining the support and interest of others. A
barrier to the development of groups was that it required support, and yet there was
the perception that only the most active within communities would be willing to lead
15
group development. It was raised that for groups to be sustainable, there is a need to
encourage others to provide input.
Volunteer’s Analysis
• The analysis demonstrates that volunteering was regarded by participants to be rewarding,
both on a personal level, in that participants valued and enjoyed their time spent
volunteering, and on a motivational level, with participants expressing the desire to make
a difference through volunteering for the benefit of the community.
• Groups were recognised as important for providing the opportunity for older people to
connect with others. Through their voluntary work, participants emphasised their sense
of connection to the community and the need to work together for the community.
• As raised within the Service Mapping Study, participants felt it is important to network,
develop their skills as volunteers, and to access funding, in order to address barriers to the
sustainability of the groups. It was highlighted that AFN facilitated access to such
resources.
16
9. Costings Analysis
• In order to calculate the economic impact of AFN we conducted an analysis of the impact
of the programme on the beneficiaries who completed our longitudinal survey (64 at time
1 and 22 at time 2) and multiplied the results by the total number of beneficiaries
involved in the initiative (258).
• The change in health and social care usage among the sample over the period between the
timepoints was small but evidenced an overall trend towards reduction. The reduced
usage equates to a saving of £146 per person, which if scaled up to 258 beneficiaries over
the course of the programme could indicate a saving of £102,871.6. (This figure must be
viewed with caution as it reflects a substantial change in costs among just one of the 22
time 2 participants).
• The change in the EQ5D measure of wellbeing allowed us to calculate the change in
‘Quality Adjusted Life Years’ over the course of the 3-6 month period of the survey.
Using the n=258 beneficiary estimates, there is a gain of 11.15 QALYs annually in the
second year of the intervention (12 months) across the beneficiaries. The overall benefits
of the programme from the QALYs in monetary terms are estimated at £204,291.
• The overall cost of the AFN programme was £243,000, so the savings associated with
improved health and reduced care costs suggest an overall saving of £62,929 or a return
of £1.26 per £1 spent. This compares favourably with comparable Social Prescribing
interventions assessed over a similar timeframe. In addition, the economic benefit of
volunteering as a direct result of the programme could be as high as £198,603.
17
10. Discussion and Conclusion
• Our multimethod evaluation of the AFN pilot intervention allows us to consider the
various forms of impact that the programme has had and to ascertain an overview of its
efficacy.
• In terms of the design of the programme, there is much evidence supporting the
community inclusion-based approach to tackling loneliness as well as on the emphasis on
volunteering and community activation.
• There is also a wide array of evidence attesting to the fundamentally important service
that AFN provides to older isolated individuals and the transformative impact it has upon
their lives. This is backed up by quantitative evidence as to the improvements in
participants’ health and in particular the marked benefits of volunteering on wellbeing.
• While any assessment of costs needs to be carefully caveated in terms of the limits of the
data collected and the analyses conducted, we do see the green shoots of success in terms
of health as well as health care and social care usage. Given the short timeframe of the
intervention, this is an impressive result.
• A more substantial and significant estimate is the financial benefits of volunteering which
stand in addition to the health costings.
• In terms of recommendations, we suggest that AFN could do more to develop a clearer
focus and rationale for its activities. This would help distinguish it from other initiatives,
evidence its accomplishments and successes and establish familiarity among target
communities.
• A clearer rationale for how and why AFN works would also allow a differentiated
approach to communities such as Beeston and Ladybrook which clearly have different
needs and responses to outside initiatives.
18
• A stronger emphasis on the volunteering aspect of AFN and its implications for
sustainable community development would also help showcase its financial viability.