Pam Creaven, Services Director, Age UK - presentation from Age UK For Later Life conference, 25th April. For more information: www.ageuk.org.uk/forlaterlife

1. Making integrated care a
reality for older people
Pam Creaven – Age UK, Director of Services

2. Older people and health
• Older people represent 60% of all hospital admissions – older
people are often going into hospital ‘in crisis’
• There are 14m people aged 60yrs or more; it is estimated there will
be over 50% increase of older people in the next 25 years.
• Most older people tell us they want to live independently and
healthily at home for as long as possible, and have choice and
control over the services they need.

3. We know that prevention and early
intervention works.
Some of the key questions:
How do we divert money from acute hospital services to fund
preventative services when the health system has been predominantly
organised to respond to crisis?
How do we transform services for older people that deliver better
outcomes and are cost effective?
How do we ensure that services are person centred, designed around
what a person wants and needs?

4. What are we doing to improve services for older
people?
We are developing an evidence-based model for preventative services and
community-led integrated care pathways that:
• reduce unnecessary hospital admissions over time
• cost less overall than acute services
• improve the wellbeing and quality of life of older people living with long
term conditions
• enables older people to regain control of their lives

5. What unique about Age UK’s
integrated care programme?
• Helping the person – not the condition - person-centred care
integrating across multiple long term conditions as well as ancillary
preventative services that make a huge difference
• A seamless way of connecting health and care services –
creating new care pathways that are clinically endorsed, that work
for older people and ‘bridge the gap’
• Major step change in the approach – putting the local Age UK at
the centre of older people’s health outcomes – requires a ‘whole
system change’
• Targeted approach using the risk stratification of patients and a
sound evidence base to ensure services are focussed where they
can have the greatest impact

6. Whole system change
Joint working & co-ordination across a
vast range of external stakeholders

7. Investing to Save
Age UK is looking to attract social
investment and capitalise on our
local presence and our collective
access to supporters and volunteers
•Finance from public
sector
•Finance from ethical
investors
•Finance from charitable
sector
Creating a sum for
investment in services
•New services for older
people delivered by local
Age UK to reduce hospital
admissions
•Reshaping health and
care services to generate
cashable savings
•Project commissioned
and performance
managed by CCG and Age
UK
A programme of
action
•Commitment to pay by
public sector on
achieving results
compared to an agreed
predicted baseline
•Benchmarked against
baseline of trajectories
•Financial return to
investor, surplus for
public sector and
partners
A commitment to
repay the investor

8. Why Age UK?
• One of the UK’s major charities with a strong and trusted Brand and
many thousands of supporters and volunteers
• The only major charity focused solely on improving later life
• Works with and through a network of local Age UKs that are highly
valued and respected in their communities
• National credibility and extensive local reach is a special
combination
• Ability to bring different organisations, professions and key players
together to help transform the system and better help older people

9. Age UK Cornwall Pathfinder Project
• 100 older patients with two or more long term conditions identified in two
GPs surgeries using historical data, risk prediction & case management
• Patients have the potential of being supported in the community and
want to change their current behaviours and lifestyle
• Two Personal Independence Co-ordinators and team of volunteers
recruited by Age UK Cornwall to provide support to the patients
• The team works towards best practice care management and creates
escalation plans, all agreed by the local health service
• Age UK Cornwall service includes anticipatory planning, self care, peer
support and motivational interviewing
• Focus is on improving patient’s health and wellbeing outcomes and
reducing NHS costs

10. Clinical integration at ground level
‘This has opened up a whole new
opportunity for new ways of working within
the NHS… as a health team we have
benefited from the involvement of the
volunteers…. This has been educational
where I thought patients dependency
would naturally increase… with a little input
we have seen dependency decrease’
Dr Anderson Newquay
‘… This service helps people to
manage their own conditions in their
own home and prevents hospital
admissions…. We are getting new
ideas, learning and developing as
district nurses’
Lucy Clement – District Nurse
Team Leader
Age UK Cornwall Pathfinder Project

11. Cornwall Pathfinder - Initial Findings
• 30% reduction in Acute
Admissions
• Over 16% improvement in
people’s wellbeing
• £4.40 saved for each £1
invested
• Integrated Team working well,
and changing practice outside
the initial 100 patients
Next Steps
• Independent evaluation with
Nuffield Trust
• Build a business case to expand
the service to 1,000-2,500
patients
• Identify funding for the service
• Develop the service operation
for when patient numbers are
increased

12. Questions