Welcome to November’s blog. Last month, my attention centred around performance so this month, I want to change tack and take a closer look at the services we’re developing specifically for older people.

A Growing Focus on Later Life

Our mission across the Norfolk and Waveney Integrated Care System (ICS) is to help our population live longer, healthier, and happier lives. With an aging population – where 1 in 4 residents are over 65, and 1 in 30 are over 85 – we must adapt and transform the care we provide to support people to age well.

While life expectancy here is generally good (80 for men and 84 for women), we see variation in healthy life expectancy, particularly across socioeconomic groups. For example, healthy life expectancy can range from 70.5 years in the least deprived areas to 52.3 years in the most deprived.

As part of our Joint Forward Plan (JFP), we set a clear ambition in May 2023 to transform care for older adults. This was built upon extensive consultation with experts, including public health colleagues, local communities, and the Voluntary, Community, and Social Enterprise (VCSE) sector, helping us craft a framework to support people to plan for three distinct phases – preparing for later life, active ageing, and frailty, working across nine priority areas:

1. Enabling independence and promoting wellbeing

2. Population-based proactive care

3. Integrated urgent community response, reablement, rehabilitation, and intermediate care

4. Frailty and Dementia-Attuned Acute Care

5. System-wide awareness and understanding of frailty

6. Reimagining outpatient and ambulatory care

7. Enhanced health and care in care homes

8. Coordinated and compassionate end-of-life care

9. Support for families and informal carers

We now have a whole programme of work in support of this, with e four primary workstreams, each led by named operational and clinical leaders. Below are some updates on these focus areas:

1. Frailty-Attuned Acute Care

Our first priority is standardising frailty care. We’re currently piloting the Rockwood Clinical Frailty Score at Queen Elizabeth Hospital (QEH) and aim to implement this system-wide if successful. By creating a common frailty definition and assessment tool, we can better identify, coordinate, and target care to support residents with frailty. The goal is that any resident flagged as frail receives tailored, coordinated care. For instance, we want a person with frailty to have a single comprehensive assessment rather than being referred to and attending multiple different specialty appointments for their planned care. For urgent needs, we’re exploring ways to provide care through an Urgent Community Response visit or an admission to the virtual wards, ensuring that hospital admissions are minimised wherever possible.

2. Prevention

We’re working with public health to establish a proactive, population-based approach to healthy aging. This includes reviewing current services, understanding gaps, and making evidence-based recommendations for future preventive efforts. We’re also launching a winter campaign aligned with our Age-Friendly City initiative to address social isolation, transportation, housing, and employment for older adults.

3. Dementia

Our system-wide dementia programme includes a new charter setting expectations for providers, and we’re pleased that six statutory providers have already signed up. The programme also includes awareness training for primary care and care home staff, as well as data enhancements to improve dementia care. We recently held a roundtable to discuss real-life cases and are targeting identified gaps in dementia services.

4. Care Homes and Housing with Care

We aim to support care homes to keep residents safe and well at home. We want to prevent inappropriate 999 calls and ambulance conveyance to hospitals, focusing on alternative, in-place support whenever possible. We now have dedicated quality improvement nurses to support our care homes and a Champions Network Group, has also started emphasising nutrition and hydration as essential aspects of resident care.

Preparing for Winter

As we approach winter, our focus on UEC and frailty services becomes even more critical. We recently opened a Frailty Same Day Emergency Care unit at QEH, complementing the existing services at NNUH and we are putting in significant extra support from December, to make in-home care the easiest and best option for care home residents.

Additionally, our efforts around ReSPECT and advance care planning will support proactive management for end-of-life patients, minimising unnecessary admissions and keeping patients comfortable and well supported in their preferred place of care, wherever possible.

If you’d like to learn more about our initiatives or get involved, please reach out to our Ageing well and palliative care Clinical Programmes Senior Manager James Allen james.allen26@nhs.net. Together, we can ensure Norfolk and Waveney’s older population receives the compassionate, proactive care they deserve.

Best wishes, Frankie