Our ageing population

Our ageing population – integrating their care today


Helen Pyecroft, Head of Strategy at Attain, talks about the work our team have been engaged in to help support our ageing population…


The Kings Fund highlighted recently ‘when the NHS was founded in 1948, 48 per cent of the population died before the age of 65.’ That figure has now fallen to 14 per cent. By 2030, one in five people in England will be over 65.

Service users, clinicians and social care professionals and those at the front-line in the voluntary sector are consistently illustrating the real-life impact of these figures with personal and affecting stories that drive home to commissioners and providers that action is imperative.

Attain has been working alongside a CCG in London for 15 months now to support them to design, build and implement a new model of care for their over 65s population. An extensive (and challenging) co-design process including multiple organisations across health, social care and the voluntary sector and hundreds of service users from across the community, has yielded a new model of care built on the principles of:

  • Integration and holistic care – the model is designed to consider and care for the whole person; not just their medical needs, but with partnership across primary care, community, mental health, secondary care and the voluntary sector
  • Personalised and co-ordinated care – service users will benefit from coherent and tailored support with the model including risk stratification, care co-ordinators and care  planning
  • Shared values and culture – colleagues work together to look after people in their care irrespective of organisational form
  • Prevention – the model has a significant emphasis on prevention and self-care, recognising that many of those over the age of 65 are healthy and active.

The transformation of primary care and the opening of two Integrated Care Community Hubs are at the heart of the model. The Hubs represent ‘one-stop-shops’ for service users where they can see their own GP alongside allied, mental health and social and secondary care colleagues for a care planning appointment. Service users can coordinate other health appointments with the wider services provided in the building and enjoy a Salsa class or afternoon tea, provided by the voluntary sector. We are delighted that the first of these hubs opened on the 21st September 2015 and patients are being seen there today.

By starting with the ambition to get the right people in the right room to look after vulnerable over 65s, service users, commissioners and providers are starting to see the benefits of coordinated and integrated care. The model and the hubs have balanced the need to provide high quality, local and personalised care with supporting front-line clinicians and social workers with additional resources and driving out efficiencies in the wider system.

Although ultimately important to the delivery of sustainable health and social care economies, if the Programme had waited for organisational structures, capitated budgets, shared data platforms and complex contractual vehicles to be in place to enable this, we would have risked never taking the first step of facilitating these care professionals coming together today.

The Programme’s motto was ‘Ready, Fire, Aim’ – a concept driven, unrelentingly, by the GP Clinical Lead. He and the wider CCG leadership are fully committed to delivering the model of care today, rather than waiting for complex organisational structures and a ‘perfect’ environment for delivery tomorrow. Well, the model of care has been rolled out, the Hub has opened and the feedback from service users and clinicians alike is very positive. Now, we look forward to watching the service evolve and the organisational and contractual mechanisms falling in behind the clinicians and front-line teams to support them to do what they want to do – care for the vulnerable people in their communities.


Helen Pyecroft, Whole Systems Integrated Care Programme Director

Get in touch with Helen.