Getting the whole health and care system working together for older people

Proactive and coordinated health and social care services supporting older people in their homes and in hospital.

What we have achieved so far:

  • worked with NW London geriatricians to agree a set of clinical standards for older people’s care across NW London
  • developed integrated plans to join-up health and social care
  • launched a new training programme with London Ambulance Service and community rapid response teams which has seen 100 extra people a month cared for at home, rather than going to A&E
  • piloted a frailty service at Ealing, Northwick Park and Hillingdon hospitals to get frail patients to the right service quickly on arrival at A&E

We will continue to:

  • provide coordinated health and social care to keep older people well and able to stay at home whenever possible
  • have senior doctors and multi-disciplinary teams assess an older person’s health if it worsens and they need more care, to see if the right support and treatment can be provided at home if possible
  • fully coordinate treatment if an older person does need to visit or stay in hospital, so they get well and back home as quickly as possible.

It is better for people because:

  • older people are supported to stay at home wherever possible, saving them, their families and carers the worry and stress of unnecessary visits to hospital
  • a special team will be on hand if older people do visit hospital, sorting out the care and support they need to get healthy and home as quickly as possible.

It is better for the health and care system because:

  • health and social care expertise and resources will be used more efficiently
  • with more older people being cared for at home or in their community, hospitals will run more smoothly, including scheduled operations and emergency care
  • there is more capacity to care for other sick patients and for scheduled operations
  • millions of pounds can be reinvested in other health and care services.

Key facts:

  • around 13,000 over-65s had to stay overnight in hospital in NW London last year because they didn’t have the right support available either at home or in the local community.

Expected outcomes:

  • up to 3,300 fewer overnight stays in hospital for older people every year
  • senior clinician input as standard
  • consistent hours and level of service across NW London.