Access to services

Access to services is influenced by both structural service characteristics (the structure, organisation and delivery of services; service characteristics such as location and opening times) and the characteristics of the population being served (demographic characteristics, for example being an asylum seeker, being homeless, having a learning difficulty, or living in a rural area; cultural characteristics, for example if the person does not speak English as their first language or lives in a Gypsy or Traveller community; behavioural characteristics, for example illicit drug use or commercial sex work, that people may want to actively conceal; attitudinal characteristics, for example being suspicious of the services offered or being unaware of the health benefits that might be gained; lifestyle characteristics, for example being a carer). People who do not routinely access standard health and social care services in particular are at increased risk of poor health, which can accumulate through life and lead to increased demand on services and increased health and social care costs. The most vulnerable groups are often the ones least able to access services. These are also the groups most likely to be suffering from social isolation and loneliness.

Rural deprivation

Rural areas tend to be associated with higher well-being inequality, and the gap in personal well-being could be more pronounced between employed and unemployed people in rural areas.

Geographical access to key services forms part of the Welsh Index of Multiple Deprivation 2019 (WIMD 2019), which is the official measure of deprivation in Wales. This domain of the WIMD considers the average travelling time to access a range of services considered necessary for day-to-day living. These include:

• pharmacy & GP surgery
• post office
• primary school
• food shop
• public library
• leisure centre

As of 2019, the domain now includes a new digital indicator (percentage of unavailability of broadband at 30Mb/s).

13 lower super output areas (LSOAs) in Conwy County Borough and 14 LSOAs in Denbighshire feature in the 10% most deprived in Wales for access to services.^[1] These data tell us primarily about travel times to physically access services and indicate a significant population who are likely to suffer poor physical access to services or to be significantly reliant on private transport.  Information from the census also shows a substantial minority of households who do not have access to a private car or van. That more LSOAs in Conwy County Borough and Denbighshire in 2019 feature in the 10% deprived in Wales for access to services than five years ago, is probably likely to the additional indicator measuring broadband. Traditionally rural areas are expected to suffer from poor broadband service and 3G/4G/5G reception compared to the more urban areas, but it is worth noting that these internet not-spots are not confined to the more remote and inaccessible areas (see ‘Growth of new technology‘ for more information).

The Legatum Institute Foundation published its updated UK Prosperity Index in 2021, to map levels of prosperity and how this compares with the last ten years.^[2] This index will likely inform UK-wide and national policy interventions. The index draws together 256 indicators into around 50 themes. The key weaknesses to prosperity in our area tended to focus on our economy and living conditions (for example, access to amenities and services and digital infrastructure). Conwy County Borough was ranked as 319th in terms of overall prosperity when compared to 379 other UK local authority areas (and ranked as 339th in 2011 and 328th in 2020). Denbighshire ranked 329th in terms of overall prosperity when compared to 379 other UK local authority areas (and ranked as 333rd in 2011 and 325th in 2020). Both counties were listed in the bottom 20 for Living Conditions.^[3]

In its recent briefing (April 2020), the Centre for Rural Economy and Rural Enterprise UK, Newcastle University, highlighted the resilience of many rural areas – that have historically coped with severe challenge, such a Foot and Mouth Disease, but also stressed that rural areas were less likely to be eligible for Covid-19 recovery support and more likely to have limited access to other services to support community and individual well-being. ‘Rural women entrepreneurs’ were highlighted as a group particularly challenged by the pandemic; as they tended to operate a micro (or bigger)-business alongside childcare and home-schooling, and older people were seen as critical to volunteering efforts in rural areas.^[4]

Loneliness

There are different types of loneliness; emotional loneliness and social loneliness. Emotional loneliness is the feeling of losing the companionship of one specific person; very often a partner, sibling or best friend. Social loneliness derives from a lack of broader social network or group of friends. Loneliness can be a feeling which comes and goes, and individuals can suffer from loneliness at specific times of the year, for example at Christmas. Loneliness can be chronic where a person can feel alone most of the time. Feeling lonely is subjective; if a person feels lonely then they are lonely.

Loneliness can affect anyone – regardless of the individual’s age. However, as we age, the risk factors that can lead to feelings of loneliness increase and converge. These factors include:^[5]

The North Wales Population Needs Assessment recognises that loneliness and isolation can impact all age groups. The National Survey for Wales found that for the period April 2019 to March 2020, younger people were more likely to be lonely compared to older people. 9% of over 65s reported being lonely compared with 19% of those aged 16-44 and 15% of those aged 45 to 64. It should be noted however that older people may be less likely to report feelings of loneliness. However, there was an overall decrease in loneliness in 2019 – 2020 with 15% of respondents feeling lonely which was a decrease from 2016-2017 when 17% of people reported feeling lonely.

Factors impacting upon loneliness includes factors such as:

• Overall health and wellbeing: individuals who consider themselves to be in ‘bad health’ are more likely to report feelings of loneliness compared to those in ‘good health’. The National Survey found that 35% in bad health and 24% in fair health were lonely compared with 11% of those in good or very good health.
• For those with a mental illness 44% reported feeling lonely compared to 11% without an illness.
• Socioeconomic factors also contribute to feelings of isolation and loneliness; it can also have disproportionate impact on those with protected characteristics.^[6]

Social isolation and loneliness have been identified as risk factors for poor health (especially poor mental health) and lower well-being, including morbidity and mortality, depression and cognitive decline. Research identified in the North Wales Population Assessment suggests that:

• loneliness has an impact on death rates equal to smoking 15 cigarettes per day.
• loneliness increases the risk of high blood pressure
• individuals are also at risk of physical deterioration
• loneliness places individuals at more risk of cognitive decline
• one study concluded that lonely individuals were 64% more likely to develop clinical dementia
• lonely individuals are more likely to suffer from depression
• loneliness and lack of social networks are predictors of suicide in older age groups

Older people who are socially isolated are also more vulnerable to the complicating effects of unforeseen events such as falls. Because older people who are isolated have smaller networks of relatives, neighbours and friends, they have less unpaid or informal support to fall back on to help meet their social care or other needs; and they may not access the appropriate formal health and social care services, which in turn could have harmful longer-term consequences.^[7]

The North Wales Population Assessment identifies the importance of preventing or mitigating loneliness to enable older people to remain as independent as possible. In terms of the impact of loneliness on public services, lonely individuals are more likely to:

• visit their GP, use more medication, at more risk of falls and an increase in the risk factors of being in need of long-term care
• gain early access to residential or nursing care
• use accident and emergency services independently of chronic illness
• according to the WRVS, lonely individuals are less likely to use preventative services (specifically health services).

Social isolation is also a problem for both children and adults who are carers. The time commitment given to the cared for often means that the social and emotional needs of carer are set aside. Figures show that the number of carers in the community is increasing and therefore the number of socially isolated people in our communities will increase as well.

Isolation within the rural community is a particular issue for those who are older, younger or on lower incomes, and can contribute to other health and well-being problems.^[8] Isolation for older people is, of course, not limited to rural communities with almost one in five households in Conwy County Borough and one in six households in Denbighshire occupied by a single pensioner. A significant number of these lone pensioners do not have local family support, due to having moved to the area to retire or having children who have moved out of the area.

The National Survey for Wales measured loneliness for the first time in 2016-17.^[9] Whilst it is not possible to drill down to local authority level, these findings are available for Wales as a whole. These results challenge some of the conclusions of earlier research, which found that older people are more likely to be lonely than young people; however, loneliness is often due to of impact of a number of factors on a person’s life.

The National Survey analysis found the following results for their respondents:

• 17% of people were classed as lonely and 54% experienced some feelings of loneliness.
• Younger people were more likely to be lonely than older people: 20% of 16-24 year olds were lonely, compared with 10% of those aged 75 or over.
• Poor general health, limiting long-term illness, low mental well-being and low subjective well-being were associated with being lonely. The impact of having a limiting long-term illness on loneliness was stronger for younger people.
• 37% of people who were in material deprivation were lonely.
• People who felt safe after dark, who felt a strong sense of community and/or were satisfied with their area, were less lonely.
• 20% of people experienced loneliness related to the absence of close personal relationships, and 34% of people were lonely due to a lack of wider social contacts.

[1] Stats Wales https://statswales.gov.wales/Catalogue/Community-Safety-and-Social-Inclusion/Welsh-Index-of-Multiple-Deprivation/WIMD-2019/localauthorityanalysis Accessed 10 August 2021.

[2] The Legatum Institute Foundation. (2021) The United Kingdom Prosperity Index. file:///C:/Users/emm90623/Downloads/UK-Prosperity-Index-2021-web.pdf Accessed 2 August 2021.

[3] According to the Institute, living conditions reflects the extent to which a reasonable quality of life is extended to the whole population. This includes being free from poverty through access to sufficient resources, access to adequate housing, safety at work and in the lived environment, and the ability to connect and engage in core activities in society.

[4] Covid-19 and rural economies, Briefing note prepared by staff of the Centre for Rural Economy1 and Rural Enterprise UK2, Newcastle University, April, 2020. Jeremy Phillipson, Matthew Gorton, Roger Turner, Mark Shucksmith, Katie Aitken-McDermott, Francisco Areal, Paul Cowie, Carmen Hubbard, Sara Maioli, Ruth McAreavey, Diogo Souza Monteiro, Robert Newbery, Luca Panzone, Frances Rowe and Sally Shortall https://www.ncl.ac.uk/media/wwwnclacuk/centreforruraleconomy/files/researchreports/CRE-briefing-Covid19-and-rural-economies.pdf

[5] Campaign to end loneliness, 2016

[6] The population needs assessment is currently being refreshed.

[7] Health and well-being consequences of social isolation in old age, National Institute for Health Research 2014

[8] Rural Futures (Rural Poverty in Wales: Early insights from the Rural Futures programme, funded by the National Lottery Community Fund.

[9] National Survey for Wales, 2016-17