Co-morbidities and older people

Our work aims to support the delivery of a more integrated approach to the management of patients with multiple physical, mental and social needs, focussing on wellness rather than illness.

Currently, 80% of healthcare spend goes on caring for people with chronic diseases. There is widespread agreement that the growing prevalence of chronic diseases, an ageing population, and the financial challenges faced by the NHS, demands a different way of organising and delivering healthcare.

The challenge

Traditionally, patient care has been organised by disease, with initiatives to integrate care across whole patient pathways predominantly focused on coordinating care for single diseases. However, living with multiple long-term conditions is commonplace: 50% of 65 year olds have more than one long-term condition, rising to 75% of 75 year olds. Focussing on coordinating care for single diseases often creates silos, which leaves the patient to navigate their own care across multiple pathways.

Multiple co-morbidity is associated with poorer quality of life, more hospital admissions and higher mortality. It also has a strong social gradient with more disadvantaged individuals and communities having poorer outcomes. We aim to balance the dissemination of locally led work with programmes that reach across the partnership, supporting broader delivery of integrated care at pace and scale.

Progress to date

To date, our work has focussed on four main work streams. The detail and successes of these work streams are outlined below.

Defining what matters most to older people and those living with frailty

Resources outside of the partnership also support the work we do. The website and blog, LittleThingsTLC aims to improve person centred care by providing a forum for blogs and discussion about how it is often the little things that make the biggest difference to patients.

Whole system improvement

  • Barking & Dagenham, Havering and Redbridge – An audit of 500 consecutive patients aged 75 and over attending Queen’s Hospital was completed in 2013 to provide understanding of current patient journeys, experiences and health seeking behaviours. Three project groups were formed with a shared aim of reducing unnecessary A&E attendances in people aged 75 and over. Watch our animation Better for Beryl
  • West Hertfordshire – An audit of 36 patients in A&E and 14 patients within the Rapid Response Service was carried out in May/ June 2014. Patients were interviewed whilst under the care of A&E or Rapid Response and then followed up approximately one month later. This provided an understanding of patient journeys and experiences and has enabled the organisations in that area to develop a joint plan around priorities for older people. This is being taken forward by the West Herts Partnership for Older People which will help to inform and test a framework of whole-system measurement in partnership with the Care Quality Commission.

Targeted interventions

  • PROSPER (Essex) – This is a two year project funded by a Health Foundation grant. Interventions include the implementation of Quality Improvement methodology, NHS Safety Thermometer and Manchester Patient Safety Framework (MaPSaF). Visit the Health Foundation website to find out more.
  • Improving end of life care (pan-London)
  • Barnet care homes – we are working with a Darzi fellow in Barnet to implement and test the Significant Seven tool. This tool aims to help care home staff identify and manage early signs of infection, thus reducing admissions to hospital.
  • Dementia training in care homes – we are working with the Health Innovation Network (South London AHSN) and the London Dementia Strategic Clinical Network to deliver training to approximately 80 care homes. This training includes dementia awareness training, the DeAR GP tool and research awareness.

Shared learning

  • Frailty bulletin – We worked with North East London NHS Foundation Trust (NELFT) to launch a frailty bulletin, collating policy, research, resourced and local news. This is now hosted by NELFT and Care City. Subscribe to the bulletin.
  • Joint webinars with Kaiser Permanente, USA
  • Dementia webinars – we worked with the Health Innovation Network, The London Dementia Strategic Clinical Network and the National Skills Academy to produce a series of podcasts and tweet chats for Dementia Awareness Week 2015. Over 1400 people registered. This was featured on the Academy of Fabulous Stuff.
  • We co-hosted ‘Lessons from Europe Seminar: exploring new system models for active and healthy ageing’ with the NHS Confederation in September 2015. View the presentations.
  • We co-hosted the first Digital Legacy Conference in May 2015: Exploring death, digital legacy and bereavement in today’s increasingly digitised World. Find out more about this conference.

Programme leadership

Jenny Mooney, Head of Programmes at UCLPartners