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Northamptonshire co-produced a model of care that provides holistic care planning for frail people. This was in response to a growing demographic of people living with frailty and long-term conditions who reported healthcare service dissatisfaction (for example, fragmented care planning, having to repeat their story, multiple referrals and having to navigate a complex system on their own).
The Northamptonshire offer is built around primary care network footprints (with populations of around 70,000). The central idea is that ‘Home First’ should always be the priority.
Local integrated teams (also known as Age Well teams) deliver responsive interventions, such as extended GP reviews, clinical-supported decision-making, peer support groups, befriending and remote monitoring. Individuals are assigned a named person who provides continuity of care. On average, these teams receive and manage approximately 400 new referrals per month.
Age Well teams are built with staff from cross-sector organisations, such as healthcare, social care, voluntary, community and social enterprise sector and local authorities. Teams typically consist of a GP frailty lead, project lead, and members from community health trusts, adult social care, Age UK, Northants carers and the Alzheimer’s Society. Co-production has enabled effective partnership working, improving the integration of services and ensuring the Age Well programmes are sustainable.
Key learnings
- Co-producing a vision was helpful in developing a comprehensive understanding of people’s health and social care challenges.
- A collaborative, system-wide approach by voluntary organisations, community groups and the integrated care board provided a joined-up overview of what is possible and positive for people in their local communities.
- Investment in local resources gave people more time to design and deliver change.
- The presence of senior clinicians at patient groups (for example, heart failure patient groups) reduced both anxiety and need for GP appointments. It also provided high-level education and medical advice to support self-management.
- Alongside healthcare specialists, the voluntary sector played a critical role in directly supporting individuals and creating links to other resource (for example, by providing education about lifestyle factors that are the root cause of many chronic conditions).
Impact
In the 18 months up to March 2023, the programme reported to have seen:
- 9% reduction in hospital attendances for over 65s
- 20% reduction in falls-related acute attendance due to improved rapid response unit
- 25% reduction in 5 or more unplanned hospital admissions for over 65s
Additional benefits include:
- improved retention of GPs who report enjoying their jobs again and would likely have stepped back or retired without the programme
- increasing specialist knowledge and learning across a pool of frailty GPs
- reducing the stigma among those seeking help for mental health, including dementia
- strengthened working between Age Well leads and urgent care partners, including following up on care concerns from the ambulance service and joint working with frailty same-day emergency care services
There has also been strong endorsement from people and their families:
“… (the multidisciplinary team [MDT]) was refreshing and helpful … My mum could be at home so she was comfortable in her own space. It was relaxed. The people felt professional yet warm and we were together as a family and could have a discussion together”. Daughter of a woman who was supported at a GP-led MDT
“My mum would have ended up in a care home if it wasn’t for her extended GP review”. Daughter of person who had a GP-led review
“I feel confident to go out in my garden on my own” and “I feel like I am learning new things each week, and I can understand why I need to do the exercises to keep me healthy”. Attendees at a strength and balance class
“Dad is usually a quiet man, but he is really enjoying the group and talking about you by name at home”. Attendee at a memory hub meeting
“An appointment was made with the Aging Well team and I feel like someone is listening! I was visited at home by the lovely lady who arranged equipment to support me while I wait for a hip replacement. She organised a call with the doctor to discuss my pain and has referred me for physiotherapy as she seems to think it might help. She seemed knowledgeable and has restored my faith. My husband is pleased as this has also helped to relieve him”. Person referred to the service
Publication reference: PRN01756_ii