Rescheduled, delayed, cancelled: the knock on impact of the pandemic on routine health care

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Recently published figures show that waiting times for some non-urgent care across the UK have risen dramatically with the pandemic squeezing the already stretched resources of the NHS. Figures from Public Health Scotland, published in June 2021 found that when comparing to pre-pandemic levels, the waiting list size is 30.3% higher than the 12-month average prior to the onset of the pandemic (Mar 19 – Feb 20), while in England figures published in August 2021 showed NHS waiting lists in England reached a “record” 5.45 million people.

In addition to strains on acute NHS care services on the frontline, there are warnings about the additional public health impacts of delays to preventative healthcare measures like screening and routine medical care as well as concerns about a surge in demand when people who have delayed seeking non-urgent diagnosis and treatment return to hospitals.

At the outbreak of the pandemic many hospitals took the decision to delay or stop entirely routine pre-planned surgeries and preventative screening and diagnostics. Some even suspended treatment for more urgent care like cancer treatment on a short-term basis. While many of these services have resumed since the beginning of the pandemic, albeit with a backlog of patients now to be seen, significant strain on the NHS as we come into the winter months because of coronavirus is still anticipated.

In many areas this has led to a backlog of care, both for those patients already in the system awaiting routine surgeries, as well as those who are yet to be diagnosed but would have been through preventative screening programmes run by the NHS.

Delays in healthcare and routine screening

Even before the coronavirus pandemic took hold, many NHS hospital trusts were under criticism because of the significant length of waiting times for people who required routine operations. Doctors across the UK are now warning that these delays could be increased further unless the NHS receives additional support to increase capacity across all areas of care not just urgent care in the coming months.

It has been suggested that delays in diagnosis and routine treatments could lead to an increased number of hospitalisations further down the line, requiring higher levels of care, longer lengths of stay, and increased hospital readmissions.

And despite the recent announcement of a new arrangement for health and care funding, commentators are quick to stress that the £1.4bn the new funding programme is expected to generate may not be enough to suitable address all of the concerns across health and social care, which they highlight has been chronically underfunded for a significant number of years, even before the pandemic exposed the frailty of parts of the system.

A reluctance to visit hospitals and use primary care services

Research from the Health Foundation found that there had been a significant reduction in the number of GP consultations since the start of the pandemic which has led to concerns about the care of non-covid patients, patients with long term health conditions and also the potential for delayed diagnosis. Primary care consultations also reduced and have remained low consistently since the beginning of lockdown.

Figures have also shown a reduction in the number of referrals, medical tests, new prescriptions and immunisations. While some of these reductions are the result of advice to delay routine referrals to free up capacity for hospitals to deal with the potentially large number of cases of Covid-19, routine referrals have still not recovered to pre-lockdown levels.

These figures, and other contributions from commentators and researchers suggest that government messages to ‘protect the NHS’ may have had the unintended consequence of discouraging people from seeking urgent medical care when it was required for fear of using services unnecessarily or for fear of contracting the virus when attending hospital or primary care settings.

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A potential future crisis for the NHS

Commentators are now warning that the treatment backlog which has been caused by the coronavirus pandemic, in addition to diagnostic delays and screening programmes, may lead to a future crisis of care or significant delays in care for people waiting to receive more routine treatment.

Delays in care have not only been reported in cases of physical health. There have also been significant delays in referrals for those seeking treatment for a mental health condition, an area of the NHS which was already facing significant delays in referral and transfer of care even before the pandemic. Research suggests that incidence of mental illness during the coronavirus pandemic increased. However, the numbers of people accessing services and being referred for treatment have not increased proportionate to this. People with mental health conditions may have been unable to access appropriate support through primary care pathways, which could potentially impact on their long-term health and care.

Finally, concerns have been raised about the wider social determinants of health such as employment and poverty. Public Health England (PHE) published a monitoring tool which looks at the wider impacts of the Covid-19 pandemic on population health, and it is likely that the knock-on impact of the virus could have far reaching consequences for public health in the future as the health implications of lockdown, lack of social interaction and rising unemployment could be significant. 

Where next?

While the NHS delivered some elective treatment during the course of the pandemic, the pressure of caring for large numbers of patients, many of whom were seriously unwell with COVID-19 has led to longer delays for the growing number of patients on waiting lists. Figures also show that access to elective treatment fell further in the most deprived areas of England during 2020. Tackling the backlog, and working towards the “levelling up” agenda to reduce health inequalities, both of which have been significantly exacerbated by the pandemic will be a key component of the work in health and social care over the coming months and years.


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Food for thought: how the UK food strategy is trying to revolutionise the way we think about and access food

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Research has shown that healthy food choices are three times more expensive than unhealthy ones, food bank use is at it highest ever level and the NHS is anticipating significant struggles in long term treatment of people with conditions linked to obesity and unhealthy lifestyles, like cancer, diabetes and heart disease.

A forecast published in a report by the Food Foundation showed that if we continue at our current rate and type of food consumption 22% of children born in 2020 will be overweight or obese by age 5, rising to 46% by the time they reach age 21.

But the impact doesn’t stop there. The food system – agriculture, food production, distribution and retail combined – releases more greenhouse gases than any other sector apart from energy. In the UK, the food system accounts for a fifth of domestic emissions – but that figure rises to around 30% if we factor in the emissions produced by all the food we import.

The food we eat – and the way we produce it – is doing damage to both the environment and our health and the government is now trying to take steps to mitigate the damage, and improve our health and wellbeing in the process through the roll out of a national food strategy.

Fixing a broken system

Figures from the Trussell Trust show that between April 2020 and March 2021, a record 2.5 million emergency food parcels were given to people in crisis. The increasing use of foodbanks shows just how deeply entwined inequality, food and health are, and how important it is for a robust and equitable food strategy to be rolled out.

The Broken Plate 2021 report from the Food foundation provides an overview of the food system in the UK, looking across four main themes:

  • making healthier options more appealing;
  • making healthier options more affordable;
  • making healthier and more sustainable options more available; and
  • addressing inequalities in food so that everyone can have the chance to live longer, healthier lives.

In July 2021 the UK government published a review into how the food system in the UK works and the interventions that could be brought in to prevent the harms from what we eat and the way we eat. The plan sets out recommendations and a strategy for the future which focuses on food being equitable, accessible, healthier, and sustainable.

The recommendations cover a number of key themes:

  • escape the “junk food cycle”, including introducing a Salt and Sugar Reformulation Tax;
  • reduce diet-related inequality, including extending eligibility for free school meals;
  • make the best use of our land – including guaranteeing agricultural payments to help farmers transition to more sustainable land use; and
  • create a long term shift in food culture, including the development of a robust system of data collection and reporting to help monitor long term progress.

Inequality exacerbated by unequal access to food

One of the most pressing issues around food is its availability and its ability to exacerbate existing inequalities, particularly among disadvantaged groups. We have already seen that food bank use is high (disproportionately so among lower income groups) and that eating healthier food is more expensive than unhealthy food.

The shelf life of more unhealthy and highly processed food is also often longer, so it is easier to store, and food can be spread out and eaten across multiple days more easily. Processed foods, which are often higher in sugar, salt and trans fats (unhealthy fats) also often require less cooking (both in terms of heat energy required to cook them and knowledge of how to prepare them) which for people with reduced access to kitchens, experience of fuel poverty or limited knowledge of preparing food can be more convenient. Research consistently shows that people who fall into these groups are significantly more likely to come from lower socioeconomic backgrounds and have experience of poverty.

Steps are being taken to try and improve access to healthier food for people living on lower incomes, including free school meals and (with a bit of persuasion from Marcus Rashford) a wider roll out to also offer meals during school holidays. The government also runs a voucher system for new parents to help them get access to fresh food like fruit and vegetables.

More recently there has also been discussion about the roll out of “food on prescription” services, both for those people on lower incomes and for those people who are at risk of medical complications or disease as a result of being overweight or obese.

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Sustainable as well as healthy

As has been made clear in the reports, food systems don’t just impact on us as individuals, they also have a significant impact on the environment. The changing climate is at the forefront of everyone’s mind, including multiple extreme weather events, the publication of an IPCC report on climate change, and the run up to COP26, due to be held in Glasgow. So the way we grow and process our food, and how this negatively impacts our environment is coming under greater scrutiny.

Currently, many practices are having a negative and detrimental impact on our environment across a number of areas including carbon emissions, water pollution, reduction in soil health, loss of biodiversity, land use/deforestation.

And commentators are now emphasising that our food system as well as being healthy and accessible should also be sustainable, with programmes developed to reduce food waste, support community-based agriculture schemes, help farmers to transition to more sustainable ways to farm and use land and stimulate demand for in season, sustainably grown, locally sourced food.

Final Thoughts

Food, and our relationship with it is becoming increasingly important, not only for our own personal health and wellbeing, but also for the health of communities more generally, and the health of our planet.

Sustainable, healthy and equitable food systems help to promote healthier choices and reduce our impact on the planet. And food can also play its part in helping to relieve other pressures on society, like food poverty, inequality and the rising use of food banks. Food on prescription services can help support people to make better choices and reduce the risk of diseases like cancer, heart disease, stroke and obesity.

In short, food is not just vital for life, but also for living well.


Follow us on Twitter to see which topic areas are interesting our research team.

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How have health librarians been responding to the Covid-19 pandemic?

The impact of the coronavirus pandemic over the past 18 months has highlighted the vital role of information and knowledge services in supporting health and social care, public health, and medicine.

Last month’s Annual CILIPS Conference included a presentation about #HealthLibrariansAddValue – a joint advocacy campaign between CILIPS and NHS Education for Scotland (NES) which aims to showcase the skills of health librarians and demonstrate the crucial role of health libraries.

Library and knowledge services in the health sector have faced increased pressures and a multitude of challenges throughout the pandemic as they have continued to develop and deliver vital services and resources to colleagues under unprecedented restrictions and changed working practices. With the demand for trustworthy and reliable health information higher than ever, it is clear that well-resourced, coordinated and accessible knowledge services are essential.

Supporting the frontline

Throughout the pandemic, the work of health librarians has been vital in supporting frontline workers including doctors, nurses, pharmacists, and social workers. Hospital library services have been directly involved in medical decision-making, providing evidence and resources to support patient care and the training of medical staff. As the information needs of the medical workforce have changed through the course of the pandemic, health libraries have had to be fast and flexible to provide time sensitive and urgent information to those on the frontline.

A project undertaken by the NHS Borders Library Service saw the creation of a new outreach service for local GPs, which involved the delivery of targeted current awareness bulletins, resource lists, and Covid-19 research updates, all of which directly informed the provision of primary patient care and helped to keep GPs up to date on emerging knowledge about the coronavirus.

Health Education England’s (HEE) Library and Knowledge team adapted their services to meet changing workplace needs, ensuring 24/7 access to digital knowledge resources, gathering evidence on how to keep staff safe while working, and developing training programmes to support virtual working practices for healthcare staff.

Supporting decision-making across sectors

Health librarians have played a major role in informing the UK’s pandemic response at a national level, aiding public health decision-making and facilitating partnership working across sectors.

Librarians from Public Health Scotland’s (PHS) knowledge services have worked closely with PHS colleagues to coordinate Scotland’s response to the pandemic. Their work included the creation of daily Covid-19 updates for PHS’ guidance teams, distributing the latest and most relevant research on key topics, and adapting these updates in line with PHS’ changing priorities (for example as their focus shifted from virus transmission to vaccine efficacy). Librarians at PHS have also been involved in creating evidence summaries to support specific Covid-19 research projects, such as an investigation into the relationship between Covid-19 and vitamin D. The evidence gathered by knowledge services helped PHS to formulate their response on the issue and make national recommendations relating to vitamin D intake.

On 12 July 2021, PHS launched their Covid-19 research repository, which is managed and maintained by the library team and collects, preserves, and provides access to Scottish Covid-19 research. This project aims to support policymakers, researchers, and the public by bringing together Scotland’s Covid-19 research in one place and making it easily accessible for all who need it. It is also aimed at reducing duplication of effort, which health librarians had recognised as a concern during the pandemic.

Similarly, Public Health England (PHE)’s library aimed to tackle the duplication of effort across England by creating their ‘Finding the evidence: Coronavirus’ page which gathers emerging key research and evidence related to Covid-19 and makes it accessible in one place. Many resources on the site are freely available and include a wide range of resources including training materials, and search and fact checking guidance.

Health libraries have also been informing decision-making across the social care and third sectors, with NES librarians facilitating digital access to research and evidence via the Knowledge Network and Social Services Knowledge Scotland (SSKS), and providing training and webinars to help users make the most of such services. NES librarians have been involved in partnership working with organisations such as the Care Inspectorate, SCVO, and Alliance.

Keeping the public informed

A key challenge for health librarians during the pandemic has been in dealing with the information overload and spread of harmful misinformation around Covid-19.

Library and information professionals have had a key role to play in providing trustworthy information to patients and the public, helping people to make informed choices about their health and wellbeing. As previously mentioned, librarians have helped agencies like PHS to deliver clear, meaningful, and authoritative guidance to the public, as well as making up-to-date and reliable Covid-19 research centralised and widely accessible to the public.

The World Health Organization (WHO) emphasises the importance of health literacy in enabling  populations to “play an active role in improving their own health, engage successfully with community action for health, and push governments to meet their responsibilities in addressing health and health equity”. Health librarians have been at the forefront of efforts to promote and improve health literacy during the pandemic.

NES’ knowledge services have been delivering training and webinars to health and social care staff on how to improve people’s health literacy, and health librarians working with HEE have created targeted Covid-19 resources for specific groups such as older people and children and young people.

Final thoughts

Clearly, the work of health librarians has been crucial to the UK’s pandemic response and recovery so far, and advocacy campaigns like #HealthLibrariansAddValue are central to highlighting this important work and demonstrating its impact.

Looking forward, it is clear that innovative and high-quality knowledge services will be essential in a post-pandemic world as they continue to aid recovery, promote health literacy and support the health and social care workforce. As set out in HEE’s Knowledge for Healthcare framework, investment is required at a national and local level to build expertise and support the digital knowledge infrastructure which will be required.


Further reading: more on health from The Knowledge Exchange blog

Keeping our finger on the pulse: recent additions to our collection across health

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The health and care landscape has been changed in unprecedented ways over the past year. The coronavirus pandemic has not only highlighted strains within the system and required a response to a public health emergency unlike anything else that has been seen for decades, it has also provided an opportunity to push innovation in areas like digital infrastructure and partnership working, and encouraged decision makers to look at public health as an essential part of policy making in all areas.

The Knowledge Exchange database is full of reports, articles and documents which offer insight into these themes, published by organisations from across the heath and social care landscape. In this blog post, we’re highlighting some recent additions to our collection and some of the big themes being discussed within the sector.

Covid-19, “building back better” and a “health in all policies” approach

In March 2021 think tank IPPR published their report State of health and care: the NHS Long Term Plan after Covid-19. The recommendations form a £12 billion blueprint to ‘build back better’ in health and care and the report calls for an adaptation of the NHS Long Term Plan published in 2019 focusing on cancer, mental health, cardiovascular disease and multimorbidity. The authors believe the Long Term Plan needs to change to ‘build back better’ health and care post-pandemic, in relation to: ensuring a sustainable workforce; resourcing the NHS to deliver transformation; empowering integration; upgrading the digital NHS; funding and reforming social care; and levelling up the nation’s health.

Another report, from the Local Government Association (LGA), published in September 2020, provides specific guidance to local authority councillors on ways to improve the approach to population health and use of public health resources in dealing with the pandemic, highlighting the Health in All Policies (HiAP) approach to addressing health inequalities and improving wellbeing. There are a number of other resources which look at public health approaches to tackling other areas of policy such as youth violence and urban regeneration.

Build back fairer: the Covid-19 Marmot Review: the pandemic, socioeconomic and health inequalities in England, published by the Health Foundation and the Institute of Health Equity examines inequalities in coronavirus mortality, looks at the effects that the pandemic, and the societal response, have had on social and economic inequalities, the effects on mental and physical health, and the likely effects on health inequalities in the future. The report assesses the inequalities in the risk of COVID-19 and mortality and explores the impact of containment on inequalities in the social determinants of health, in terms of: early life; education; children and young people; employment and working conditions; a healthy standard of living; healthy and sustainable places and communities; and healthy behaviours.

Mental health

Mental health services have been under significant pressure in the UK for a number of years now, with children’s services (CAMHS) particularly stretched as the number of specialist practitioners is limited. The coronavirus pandemic has, according to many specialists, exacerbated existing pressures and placed even more demand on services. In April 2021 the All-Party Parliamentary Group on a Fit and Healthy Childhood published a report: The COVID generation: a mental health pandemic in the making – the impact on the mental health of children and young people during and after the COVID-19 pandemic  which explores a range of themes in relation to the impact of the pandemic on the mental health of children and young people. The report presents evidence from a range of sources on the potential implications of the pandemic on young people’s mental health and discusses the impact of school closures on children’s future health and well-being.

The Children’s Commissioner for England recently published a report  which looks at the progress made in improving children’s mental health services in England, and  the impact of the pandemic on the mental health of children. The report also examines the provision and accessibility of children’s mental health services in 2019/20, finding that access is still not adequate and not improving as quickly as expected.          

The other pandemic: the impact of Covid-19 on Britain’s mental health  explores how the mental health of people in the UK has been affected by the pandemic, drawing on a survey of over 4000 people. It describes the different experiences of groups across society and the highlights the disproportionate mental health impact on people who are exposed to higher levels of social deprivation, as well as on women, younger people and those who live alone.

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Structural reform

In August 2020 the Health Devolution Commission launched its final report, Building back health and prosperity. Among other themes, such as taking a “health in all policies approach”, the report found that devolving accountability and power to a more local level creates the potential to understand communities and places better, and to meet their needs.

One of the main focuses of the health and social care white paper published in February 2021 is around developing an integrated health and social care system and taking a ‘population health’ preventative approach to healthcare, while a report from the NHS confederation recommends a reformation of the framework for elective care and increased healthcare funding.

Digital transformation

Even before the pandemic, The King’s Fund was publishing widely on digital transformation. But their recent report Understanding factors that enabled digital service change in general practice during the Covid-19 pandemic  looks specifically at the impact of the pandemic on accelerating the transformation of the delivery of some services by GPs to focus more on digital delivery and whether this change can (or should) be sustained once the pandemic is over. It explores the challenges around trust, staff and patient digital literacy and the evaluation of digital tools in practice. Parliamentary Office of Science and Technology (POST) published their own review of AI and healthcare , providing an overview of AI in the healthcare system and its potential impacts on the cost and quality of healthcare, and on the workforce.

Final thoughts

The landscape of health and care is changing. The Covid-19 pandemic has placed unprecedented demands on a system which was already facing significant challenges. While in some instances this has led to innovation and accelerated the pace of change, it has also exposed some of the significant weaknesses of the system.

This blog highlights some of the big topics the sector is currently grappling with, but there is more available for TKE members on our database. Members can also sign up to receive our health Topic Update, which will provide fortnightly email updates of items recently added to the collection in health, easily allowing you to stay up to date.

If your organisation is not a member of the Knowledge Exchange and you would like more information, please contact us.


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Better housing for older people means better lives for all

“Sheltered Housing – MVRDV” by KJBO is licensed under CC BY-ND 2.0

Housing is at the heart of a good quality of life. This is especially true as we get older, when health and wellbeing, independence and end-of-life care can all be greatly enhanced by decent housing.

Four recent reports have underlined the importance of good housing for older people, and the wider benefits for society.

Housing with care: progress and problems

The Commission on the Role of Housing in the Future of Care and Support  (CRHFCS) was established last October by the Social Care Institute for Excellence (SCIE). The new commission aims to produce a blueprint to enable greater choice and availability of housing and support for people aged 65 and older who may find it difficult to live independently at home, or who choose to live somewhere which provides more support options. The Commission will focus on five key areas: care homes; retirement communities; retirement housing; supported living; and the Shared Lives schemes.

The first report of the CRHFCS highlights progress made since the Commission on Residential Care 2014 (CORC) reported its findings in 2014. There have been some positive developments concerning the take-up of more new technologies in care settings, such as telehealth, telecare and smart home devices to help people maintain their independence.

Progress has also been made on age- and dementia-friendly housing design. And the report commends the Housing our Ageing Population Panel for Innovation (HAPPI) reports for raising awareness of housing specifically designed for older people.

However, little progress has been made on CORC’s recommended expansion of the market to give greater choice of housing with access to care. Options remain limited, especially for those struggling to pay for accommodation.

The CRHFCS sets out some initial policy proposals. These include planning reforms to make it easier to build retirement community housing, and improved information and advice to support informed decision-making for older people seeking housing with care and support facilities.

The Commission’s final report will appear in the summer, when it will make recommendations about the future shape of housing that facilitates care and support.

Needed: a clear vision about housing for older people

The findings from the CRHFCS report are echoed in another report, published in April by the Cambridge Centre for Housing and Planning Research. The Cambridge report identifies numerous constraints to supply, investment and demand in the market for specialised housing for older people. 

One of the study’s key findings  is that retirement community development is unviable in many areas outside of London and the South East of England.

“Coupled with the fact that the majority of house moves made by older people are relatively local, this constraint to supply reduces housing options for those living elsewhere in the country, particularly home owners who do not qualify for assistance with housing costs. Unless the viability of retirement community development can be improved and the supply of mid-range retirement properties be raised, these households will have very little choice around moving in later life.”

Among the recommendations in the Cambridge report are calls for national government to provide a clear vision about housing for people as they age:

“For example, greater clarity is required around the joint priorities of ‘downsizing’ and ‘ageing in place’, and how these priorities can be best implemented at the local level.”

The report also recommends that local authorities should give priority to housing for older people, through the creation of clear strategic and local plans and guidelines for developers:

“Collaboration between local authority planning, social care, health and housing teams could allow for better planning around retirement housing. For example, retirement housing may make savings possible within health and social care budgets.”

The Cambridge report encourages housing providers to diversify the retirement housing offer, and to gain a better understanding of preferences of different older people:

“Rather than drawing on stereotypes of old age, providers face the challenge of recognising older people as a complex and heterogeneous group of consumers with diverse aspirations.”

Closing the generational divide

According to a report by the Intergenerational Foundation (IF), England now has two housing nations: the first is older, well-housed, often well-off, with space to work and self-isolate; the second nation is younger living in cramped flats or shared homes with little or no access to outside space.

The IF says that the pandemic has exacerbated housing inequalities between the young and the old, and observes that “…while younger generations have lost their jobs, their homes and even their mental health during COVID-19, older generations have stockpiled space.”

The report also highlights a rise in the number of second homes as a consequence of the pandemic.  There are now 5.5 million second homes in England – a 50% increase between 2011 and 2020 – most of them owned by older people.

Space inequality has also increased. Owner-occupied homes have a third more space on average than privately rented homes, and almost double the space as social housing.

Like the previously mentioned reports, the IF calls for market failures on retirement housing to be addressed. It recommends reform of stamp duty to encourage downsizing, and reforms to the planning system both to give a greater voice to the homeless and badly housed and to encourage developers to build more retirement homes.

Making a house a home: impacts of poor-quality housing

While some older people enjoy the benefits of good housing,  there are substantial numbers of people aged 50 and older living in poor-quality accommodation.

A report by the Centre for Ageing Better (CfAB) has found that living in cold, damp housing, or homes in a state of disrepair can increase the risk of illness and accidents. Poor housing also has wider impacts: first-year NHS treatment costs for over-55s living in the poorest quality housing are estimated at £513m.

But there are barriers preventing older people from making the improvements that would help them live healthier, more independent lives. These include a lack of finance and uncertainty about where to find trustworthy information about home improvements.

The CfAB report calls for a  wider range of financing options, including government grants and loans, to help older people adapt their homes. It also recommends clear signposting and advice to support informed decisions about home improvements, as well as initiatives to raise awareness about the impact of poor quality homes on health and wellbeing.

Final thoughts

The number of people aged 65 and over is set to rise from 12 million to more than 20 million by 2030. While poor quality housing presents risks for older people, age-appropriate housing can keep them healthy, help them to live independently and reduce the need for social care.

These reports highlight important issues that must be addressed not only to support older people, but to advance the radical changes needed to fix Britain’s broken housing market. Better housing for older people is better for us all.


The reports highlighted in this blog post have recently been added to The Knowledge Exchange (TKE) database. Subscribers to TKE information service have direct access to all of the abstracts on our database, with most also providing the full text of journal articles and reports. To find out more about our services, please visit our website: https://www.theknowledgeexchange.co.uk/

Further reading: more on housing for older people on The Knowledge Exchange blog

A nudge in the right direction? Using behavioural insights in health

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Behavioural insight is a term which has been increasingly heard across a range of policy areas worldwide in the past decade. Essentially it involves using a combination of psychology, economics and studies of behaviour and decision making to better understand how people react to specific interventions, and evaluating and learning lessons from the way people react to help decision makers to develop better, more effective policies.

Its application has been widespread in the USA and Europe. In the UK, first under the Conservative-Liberal Democrat coalition and then more recently under the Conservative administrations in the UK, the approach has gained increasing traction, with the establishment of a UK government “behavioural insights team”.

The Behavioural Insights Team, also known as The Nudge Unit, is now a social purpose company. It is partly owned by the Cabinet Office, employees and Nesta

The coronavirus crisis has posed a big challenge for those who need to be seen to be creating policies that protect and support the public. It has also been challenging for those trying to predict how people will respond, whether they will comply and how we can “nudge” the public to make what the government sees as “better” choices.

As well as informing steps to ease lockdown and the recovery from coronavirus, behavioural insights is being more widely applied to understand how people make choices in relation to their health, and how these can be applied to preventative health measures and health based inequalities.

Nudging as part of policymaking

Nudging as a technique has been used widely across a number of different policy areas, including criminal justice and education. Its application in relation to public health has been wide ranging and has had significant implications for health policy of previous governments.

Key policy areas in public health for the UK behavioural insight team include:

  • antimicrobial resistance
  • vaccination
  • obesity
  • mental health

Using behavioural insights across all of these areas, the idea is to develop an understanding of how people think about these topic areas as issues and how their behaviour is influenced by their own thoughts, patterns of behaviour and environmental factors like ease of access to services.

Techniques like direct incentives (such as vouchers in return for healthy behaviour), measures that restrict choice (like restricting takeaways from schools), and outright bans (such as the restriction on smoking in public places) are all interventions designed in one way or another to “nudge” us towards certain behaviours.

Steps like text message reminders for appointments, offering salads or fruit instead of fries as a side, or opt out organ donation are further examples of how behavioural science techniques are being applied to encourage people to make healthier choices and reduce the strain on health services.

Many of the steps being taken are designed not only to save time and money for the public and organisations delivering services, but also to help encourage early intervention and preventative action, a key focus of public health strategies in the UK.

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A crucial role to play in understanding vaccine rollout

Vaccination decisions can be a complicated and emotive process, but with the rollout of the coronavirus vaccine understanding the routes to uptake and how people make decisions on vaccination are more important than ever.

Behavioural scientists have been at the forefront of the vaccinations programme, looking to create a better and more thorough understanding of how to manage the rollout and develop an understanding of how people see the benefits and challenges of vaccination, both collective and individual.

The ‘Increasing Vaccination Model’ they say is a helpful framework for categorising the barriers to vaccination and possible behavioural interventions. The evidence indicates that closing the ‘intention–behaviour gap’ in vaccination behaviour by improving ease of access (and thus removing practical barriers to vaccination) is the most effective type of intervention. In contrast, focusing on motivation or educational interventions appears to be less helpful.

However, behavioural scientists have noted that in relation to the coronavirus vaccine even more barriers exist, with one survey reporting that 16 per cent of UK adults would ‘probably’ or ‘definitely’ avoid a COVID-19 vaccine. There is a suggestion that compressed development timelines, misinformation and media reporting could all undermine confidence and therefore uptake. Behavioural scientists are working hard to understand what steps could be taken to understand vaccine hesitancy and improve uptake across all communities in the UK and internationally.

Final thoughts

Behavioural insights, data analytics and “nudge” techniques have been part of policy making for the best part of ten years. They aim to help policymakers understand people’s reactions to policies and use this insight to help more effective policy in the future.

The coronavirus pandemic has presented a new and challenging opportunity for behavioural insights and has required them to apply their knowledge and understanding of how policy is applied and received like never before, with vaccine rollout being just one key area, along with other lockdown measures which require mass compliance in order to be effective.

How behavioural insights will continue to inform the recovery and public health strategies more widely remains to be seen, but it does appear that for the meantime at least, the “nudging” will continue.


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Virtual reality: a game changer for mental health treatment?

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Multi-agency partnerships and the transformation of domestic abuse support

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Domestic abuse has been rising up the political agenda in the past few years. 2019 saw the appointment of the UK’s first Domestic Abuse Commissioner, and last month, the updated Domestic Abuse Bill was introduced to the UK Parliament (expecting to see Royal Assent in April 2021). But domestic abuse is still a widespread and endemic problem across the UK, with figures suggesting incidents across all areas of the country and across multiple demographic groups.

Often people who experience domestic abuse are difficult to identify and can struggle to engage directly with domestic violence support services. However, there is a growing recognition that knowledge sharing, and partnership working between statutory services, like housing or health teams, is vital to identifying and supporting victims and survivors in a timely and effective way.

Increasingly, the criminal justice system, health sector, social housing providers, charities, and local government have been attempting to work together to ensure that they are all able to respond effectively and provide the necessary support to domestic abuse victims and survivors.

The impact of lockdown

The most recent Crime Survey for England and Wales released by the Office for National Statistics (ONS) showed that an estimated 2.3 million adults aged 16 to 74 years experienced domestic abuse in the last year (1.6 million women and 757,000 men). Research published by the London School of Economics (LSE) after the first lockdown found that in London domestic abuse calls to the police increased by 11.4% on average, compared with the same weeks in 2019. The increase was, in a large part, due to an increase in calls from third parties not directly witnessing the incident, including neighbours or family members.

Similarly a report from Women’s Aid found that those delivering services needed to grapple not only with increased demand for support, but also with the challenge of delivering effective support in a different way as many services were only able to be accessed virtually.

Coordinated community responses transforming support for survivors

Organisations are becoming increasingly aware of the roles they can play in supporting people who experience domestic abuse and in the early identification of people at risk. Research also suggests that if someone is experiencing abuse, there is a high likelihood that they will also be experiencing other “needs”, which may cause them to come into contact with multiple services at once. Co-ordinating the response between services encourages organisations to share information to ensure consistency of care and experience; it can also help identify any gaps in support and allow for appropriate signposting and places the onus on the organisations, rather than on the person experiencing abuse.

Coordinated community response (CCR) approaches encompass the broadest possible response to domestic abuse; CCR addresses prevention, early intervention, dealing with crisis, risk fluctuation, and long-term recovery and safety, working with a wide range of services, pathways, agencies, and systems.

The fundamental premise of the CCR is that no single agency or individual can see the complete picture of the life of a family or individual within that family, but all may have insights and can provide interventions that are crucial to their safety and wellbeing. The CCR enables a whole system response to the whole person. It shifts responsibility for safety away from individual survivors to the community and services existing to support them.

The CCR is made up of 12 components: survivor voice; intersectionality; shared objective; structure and governance; strategy and leadership; specialist services; representation; resources; co-ordination; training; data; policies and processes. Taking a CCR approach provides communities with method for coordinating a response to domestic abuse. It places survivors at the heart of decision making and is an approach many frontline services can and do take when designing and implementing support services for people who have experienced domestic abuse.

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A pilot roll out for wrap around housing support

The Whole Housing Approach (WHA) to domestic abuse was first conceptualised in 2018 by the Domestic Abuse Housing Alliance (DAHA) in collaboration with the National Housing and Domestic Abuse Policy and Practice Group This approach aims: “to improve the housing options and outcomes for people experiencing domestic abuse so that they can achieve stable housing, live safely and overcome their experiences of abuse.”

The approach enhances how people who have experienced domestic abuse have control over their own lives, considers what they want to achieve and change, and offers interventions based on this. The key principles of the WHA are outlined as: safety; inclusivity; empowerment; accountability; and prevention, with 12 additional key components which make up the practical application of WHA programmes.

The initial WHA pilot project was delivered in three areas from October 2018 to the end of March 2020. Six specialist domestic abuse organisations, as well as a civil society organisation, have been working with 10 local authority areas, including in London, Stockton and Cambridgeshire to establish comprehensive and consistent housing practices and deliver a WHA.

A whole housing approach toolkit has been published which contains more information on the pilots, evaluations and analysis of the programme. The toolkit includes a dedicated section for each of the twelve components of the WHA. Each section can be read as a standalone toolkit that outlines key initiatives to help survivors achieve safety and stable housing. It offers practical guidance and resources to local areas to deliver a consistent WHA to domestic abuse.

Image Via DAHA

Final thoughts

While the landscape of domestic violence support is varied and is delivered in different ways by different agencies, there is a growing understanding of the practical steps which should be taken to ensure that partnership working and effective coordinated responses between services are offered to survivors of domestic abuse. It is clear that there is an appetite among those who work within frontline services to improve the availability of support. The ultimate aim of a coordinated response and a wraparound service to survivors of domestic abuse is achievable if current best practice and effective pilot schemes can be built upon, with additional funding and wider roll outs.


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Devolving health and social care in England: an opportunity to transform how we approach health and care?

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In recent years, the Department of Health and Social Care (DHSC) has increasingly encouraged the transfer of powers over health and social care in England away from central government and towards city regions. These bodies, DHSC argues, are uniquely placed to understand the challenges faced by their local populations, the capacities and expertise of their local NHS and to develop plans for the future. This should enable them to approach health at a local level, promoting increased delivery of care in the community, and a greater integration between health and care services.

Putting local places at the centre of “Build back better”

In August 2020 the Health Devolution Commission launched its final report, Building back health and prosperity. Among other themes, like taking a “health in all policies approach”, the report found that devolving accountability and power to a more local level creates the potential to understand communities and places better, and to meet their needs.

The NHS Long Term Plan has also outlined a new direction for the NHS based on the principle of collaboration rather than competition, and the introduction of new structures such as Integrated Care Systems, Integrated Care Providers and Primary Care Networks. These partnerships bring health and social care commissioners together to plan and deliver integrated and person-centred care.

In the context of “building back better”, awareness of how our external experiences and contexts impact our health and wellbeing (for example the impact of poverty, deprivation, housing, and unemployment) is increasingly important.

Beyond the immediate recovery from the pandemic, health devolution could be one way of opening up the possibility of integrating not just disparate services within the NHS – or even NHS and social care services in a locality – but bringing together in a combined strategy and structure all of the services, systems and partners in a community that have an impact upon the health of a local population, and the care services to better meet their health needs.

“It doesn’t have to be a battle”- partnerships and balance are the key to effective devolution

The move away from centralised processes and organisations towards more local ones can sometimes be portrayed as a rejection or an attempt to “break free” from central government. However, practitioners have been increasingly stressing that devolution does not mean complete independence, and that while improved local decision making will improve outcomes for local people, that does not mean that the need for some centralised decision making is completely removed.

On the contrary, some decisions should and will be taken at a national level, but the ability to distribute power, decision making and accountability to a local level will have significant positive impacts for improving “citizen voice”, transparency and co-production in decision making.

This is where the Health Devolution Commission argues that balance, communication, and partnership between the local and national infrastructure needs to be aligned so that devolution can be successful and sustainable. Integrated planning and management of long-term health care strategies is important, as is the ability to bring citizens and local decision makers into discussions about national health policy.

The Voluntary, Community and Social Enterprise (VCSE) sector, including patient voice and carers organisations, also plays an important role in linking together services and communities. As well as partnering to deliver services, these organisations also often offer vital bridges between statutory systems and those communities which can often be excluded from engagement with services or who can find it harder to access them. The commission also emphasised the importance of bringing these bodies into the conversation on devolution going forwards as they will be invaluable partners in the process.

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DevoManc providing the blueprint?

In 2016, as part of a pilot, control of the health and social care budget for Greater Manchester was transferred to a partnership team in the area comprising local authorities, clinical commissioning groups, NHS foundation trusts and NHS England.

The combined authority identified that the health of its population was one of the key obstacles to its economic growth. By relating the concept of regional economic prosperity with health, they began to see health in a completely different way – as part of a wider plan and an investment for growth, not a burden.

“It’s better to have decisions made locally, because local people understand what local problems are and what Greater Manchester needs. We need to work together.”

Lord Peter Smith, Chair of Greater Manchester Health and Care Board

The Greater Manchester Health and Social Care Partnership are working in partnership with other sectors including education and housing to support everything from good eating habits and exercise to education and everyone’s ability to earn a decent living. The partnership is taking action to give children the start they need, support independence in old age, tackle illness earlier on and even prevent it altogether by improving the lifestyles of local people.

Other areas of England are also currently undertaking their own health devolution journeys, including London, West Yorkshire and Harrogate, as well as some other combined authority areas. However, one of the big challenges is that currently, while we can learn from the experiences of those already on their devolution journey, there is no common, consistent or comprehensive understanding of what good heath devolution looks like, full evaluations of the benefits it brings or overarching strategies on how it should be developed.

This is something that will need to be addressed if health devolution is to be successfully rolled out across England.

Final thoughts

Devolution of health to a more local level provides an opportunity to tackle the big public health challenges of our time at source, and to create a better, more joined up community health ecosystem. It also provides the chance to share and collaborate, learning from best practice and delivering improved health and social care services at a regional and national level.

It has been suggested that the coronavirus pandemic, while traumatic in more ways than one for the NHS and its staff, may provide the re-setting point needed to implement some of the changes proposed in relation to greater health devolution. Proponents of this view argue that improved funding to support effective and high quality care, improved integration between health and social care, and greater positioning of health and assessment of the impact of decisions on health across all policy areas, should be among the top priorities as the country looks to recover from the pandemic.

As the Health Devolution Commission underlines:

The pandemic has shown we cannot go back to the way things were. We need a ‘new normal’ and we believe that comprehensive health devolution is the only viable solution to the challenges the country now faces.”


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“The infrastructure of everyday life” – has the time come for the foundational economy?

The last few years has seen growing interest in what has been termed the ‘foundational economy’ and its potential value for achieving economic security and social sustainability. Accounting for around 44% of UK employment, it has been argued that supporting this section of the economy could ultimately improve productivity. And the current pandemic has placed even more emphasis on the importance of the foundational economy – the part of the economy that cannot be shut down.

What is the foundational economy?

The foundational economy provides universal basic services built from the activities which provide the essential goods and services for everyday life, regardless of the social status of consumers. Primarily delivered locally, these goods and services encompass infrastructures, utilities, food, retailing and distribution, education, health and welfare. Because of this, it is thought to have considerable potential to regenerate the areas where the local economy is relatively weak – perhaps the perfect solution for the levelling up agenda?

The initial manifesto for the foundational economy from researchers at the University of Manchester resulted from dissatisfaction with generic industrial and regional policy focused on promoting competition and markets; with success measured in terms of job creation and GDP growth. According to the manifesto, the foundational economy is “the mundane production of everyday necessities” which is taken for granted by all members of the population. As such, it is often also referred to as the ‘sheltered’ or ‘invisible’ economy.

Scale and value

In providing the infrastructure for everyday life, the foundational economy is also very large. It has been noted that in all European countries, it directly employs around 40% of the workforce. In the UK, around 44% of the workforce is employed in foundational activities. In Germany, it is 41% and Italy it is 37%. The value of foundational output and volume and diversity of foundational employment is therefore much larger than in high-tech and tradeable services, with which policymakers are determinedly focused on.

Other measures of value have also been highlighted, such as household expenditure. The initial manifesto notes the importance of weekly spend on the foundational economy with nearly 30% of all household expenditure going on foundational activities.

Despite providing vital services, and employing a significant portion of the UK population, the foundational economy is marked by low-tech, low-wage, part time and often precarious employment and is potentially at risk from automation, despite the significant ‘human’ element to many of the different job roles which make up this part of the economy. Within society a lot of foundational jobs are still considered by many (often who don’t work in the sector) to be “jobs you move on from” where in reality, for many people, particularly women and migrant workers, this isn’t the case.

But where would we be without these roles providing for all citizens’ basic needs? Job creation and GDP growth may suggest a successful economy but this, it is argued, does not show the wellbeing of all society or sustainability. In the face of current, and indeed future, crises, it seems perceptions may be starting to change as more and more people become concerned with health and wellbeing and the environment. Indeed, it has long been argued that necessity is only recognised in times of crises.

Has Covid-19 shone a vital light on the foundational economy?

While many sectors were shut down due to the coronavirus pandemic, the foundational economy remained open as it was considered systemically important for meeting basic needs. The pandemic has highlighted that this part of the economy is needed at all times, including at times of crisis.

Healthcare staff have become frontline heroes and food delivery drivers are recognised as key workers. But this enhanced status has also highlighted the poor pay and conditions of many key workers delivering these essential goods and services and the inherent inequality that exists in society.

Just like other crises, from natural disasters to large scale economic shocks, these bear most heavily on the poor and vulnerable. The pandemic has shown that these inequalities must be addressed so that basic everyday services are more equally available.

The pandemic has also shown that economies are about more than market economies. It has been argued that there needs to be a move towards meeting a population’s basic needs rather than on individual consumption.

Way forward

Advocates of the foundational economy argue that public policy should focus on securing the supply of basic goods and services for all citizens in a socially responsible way.

The 2020 manifesto for the foundational economy from The Foundational Economy Collective argues for the renewal of the foundational economy with a ten-point programme, including proposals related to:

  • better health and care
  • housing and energy
  • food supply
  • social licensing
  • tax reform
  • disintermediation of investment from pension funds and insurance companies
  • shorter supply chains in foundational commodities
  • citizen engagement
  • better technical and administrative capacity at all levels of government
  • international constructive responsibility

It has been widely agreed that a return to business-as-usual approach following the pandemic is not the way forward and that there needs to be a shift in economic policies in order to achieve a more socially and economically just society. Perhaps if such policy change is achieved, a more balanced economy that provides a good quality of life for all can eventually be realised.


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Healthy ageing: how health inequality can be tackled at the local level

Image: Peter Kindersley via Centre for Ageing Better

Older people make up a significant portion of our population, and projections show the proportion of people over the age of 60 within the global population is set to rise even further over the coming years. ONS data shows by 2066 there will be a further 8.6 million projected UK residents aged 65 years and over, taking the total number in this group to 20.4 million and making up 26% of the total population.

Supporting people to age well, and age healthily is something which both local and national policymakers will have to take account of in order to not only ensure good quality of life for their ageing populations but also ensure that services are not overwhelmed.

Studies show the higher levels of deprivation people face in their earlier years, the more likely they are to enter older age in poor health and die younger compared with people who experience lower levels of deprivation. This highlights the need to tackle inequality across the life course, with the preventative action having a positive knock on impact on health inequalities in later life.

Some of the main drivers of inequalities include: social exclusion and isolation; access to and awareness of health and other community services; financial difficulties including fuel poverty and housing issues; insecure or low paid employment, with reduced opportunity to save or enrol in a formal pension to prepare for retirement; a lack of transport and distance from services; low levels of physical activity; and mobility or existing poor health, often characterised by long term chronic health issues.

These inequalities often combine and overlap to create even more challenging situations as people move into older life. More recent research has shown that the Covid-19 pandemic has only exacerbated these inequalities further.

Tackling inequalities at the local level

Alongside the national discussions around ageing, local demographic change has received comparatively less attention, despite place-based policies and concepts like “ageing well in place” being used in public health conversations for a number of years.

Research from the Resolution Foundation explores the intersection between demography and place, and its implications for politics and policy while further research is looking increasingly at local level case studies to highlight pockets of best practice which could help to inform the national approach.

A review from Public Health England looked at the specific experiences of older people in coastal and rural areas and the specific challenges they face in comparison to people living urban areas, exploring local level interventions and interventions which adopt a place- based approach, responding to the specific needs of people living in the area.

Other research in this area stresses that councils have a clear leadership role in supporting an ageing society and that they are uniquely placed to create strategies which reflect the needs of their populations. Through local engagement of older people systematically and regularly, and through co-production and co-design in the production of local policies and services, councils are in a position to underpin a more positive outlook on ageing, ensuring that older people are regarded as full citizens, rather than objects of charity or pity.

Approaches to poverty reduction in Greater Manchester

In Greater Manchester, healthy ageing and age inequalities have been made mayoral priorities and the Greater Manchester Combined Authority set up the Greater Manchester Ageing Hub to respond to what policymakers there see as the opportunities and challenges of an ageing population.

In 2018 the city published an “Age Friendly Strategy” to promote increased social inclusion within the city by trying to tackle the barriers to inclusion created by poverty and inequality, including creating age friendly places which allow older people to participate within their local communities, and promoting healthy ageing through strategies like GM Active Ageing, a partnership with Sport England.

Image: Peter Kindersley via Centre for Ageing Better

Creating a consensus on healthy ageing

The Centre for Ageing Better and Public Health England established 5 principles for healthy ageing which they are urging government and other policy actors to adopt to support future healthy ageing the five principles are:

  1. Prevention
  2. Opportunities
  3. Good homes and neighbourhoods
  4. Narrowing inequalities
  5. Tackling ageism

These principles can be used as building blocks to help organisations create strategies and policies which accurately reflect the core needs of people as they age. One thing which continues to be a challenge, however, is integrating intersectionality into both research and strategies or frameworks on ageing.

Not treating “older people” as one homogenous group, but taking account of the individual experiences of specific groups and how this may impact on their experience of inequalities: this is something researchers are making efforts to resolve in their work, and while there are limited studies which look specifically at BAME or LGBT groups, in the future taking account of intersectionality in ageing and inequalities will become more commonplace.

The future of ageing

We are living longer than ever before. Taking steps to reduce inequalities and support healthy ageing will ensure that those extra years are fulfilling, both for the individual and for society.

Helping people to continue to contribute to society, to really live into old age, embrace and enjoy it and not just exist in old age should be a priority for everyone, Reducing inequalities to support people to age well will be a major contributor to ensuring this happens.


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A home for life? Developing lifetime neighbourhoods to support ageing well in place

“Same storm, different boats”: addressing covid-19 inequalities and the ‘long term challenge’

Inclusive streets: from low expectations to big dreams

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