The old saying ‘prevention is better than cure’ is proving to be true in the Age UK Integrated Care Programme (ICP) which is supporting older people in Dartford, Gravesham and Swanley and Swale areas.

The programme helps older people living with complex health problems, and who have had recent unplanned visits to hospital, to maintain or improve their independence and wellbeing.

Participants identify what they’d like to do to achieve this, and are offered encouragement and practical support by a worker from Age UK. GP practices identify patients who they think might benefit from the programme. Support might include things like help with benefits, sorting out problems with medicines, organising equipment or help in the home, and arranging opportunities to socialise more. Building people’s confidence and giving them time to talk about what they want is the key to success.

The programme draws upon national best practice and brings together voluntary organisations and health and care services to combine medical and non-medical support.

Established in July 2017, the programme set out to support 500 older people, increase their health and wellbeing, improve their experience and quality of care, and make best use of local health and care services.

The results of the programme have been promising. So far more than 400 older people have taken part and results have shown a really significant increase in wellbeing. Eighty-five percent of people reached their personal health and wellbeing goals, and 94 percent were likely or extremely likely to recommend the service to their friends and family. Similar programmes elsewhere have shown reduced demand for health and care services, and information is being collected for a year afterwards to find out whether this has also been the case locally.

Feedback has been very positive. A GP from a local medical group said:

…….it [the Age UK service] has often led to preventing social and other emergencies, which may have led to unnecessary admissions to hospital. The level of care they [Age UK] provide is something we are unable to do. They have the resources to spend quality time with patients and are able to make a detailed assessment of their needs.”

Similarly, the daughter of someone who took part in the programme said

“I also wanted to say thank you for your support and help with Mum. She has moved from being unhappy and lonely to a much happier person since your intervention and suggestion of attending the day centre. She was initially sceptical of what good it would do her, probably a symptom of her frame of mind, but now she actively looks forward to going. She is in a far more positive frame of mind.”

The ICP and other similar projects (sometimes known as care navigators or social prescribers) have recently been extended as part of wider plans to bring GPs, other specialist health services, social care and the voluntary sector more closely together.

Raymond’s story: finding new interests and taking control

The following is an actual example of the kind of support the programme offers.

Raymond is 76 years old with, cancer, diabetes, breathing difficulties and heart problems. He was identified as someone who might benefit from the ICP service through his local GP surgery.

Ray’s wife has health problems too and he has no children. His mobility is poor and he was virtually housebound when first visited by the Age UK worker, Wendy. His mood was low, and he felt his days were wasted sitting in his chair. Ray’s wife can drive but at the moment she cannot use the car to help him get out. She was worried that he may not be able to cope when she goes into hospital shortly.

After chatting to Wendy, Ray mentioned that a few years ago in hospital he saw another patient having a go at marquetry (a traditional craft using wood veneer). Wendy discovered a local group and took him there. He really enjoyed getting out and chatting to new people, all of whom had similar engineering backgrounds. The club made him feel very welcome, providing a box of tools and the offer of one year’s free membership if he came back. He now attends regularly. Wendy helped him to apply for the volunteer transport scheme, who now take him there.

The worker also took Ray to the local day centre, where he took part in an Easter Bonnet parade, and to which he has returned since. She also introduced the day centre’s hot meals service, which the couple will try when Ray’s wife goes in to hospital.

When Wendy returned to see Ray, he was much more positive and felt that he had taken back control of his wellbeing, and was looking ahead. He has spoken about looking into other craft activities in the area, as he enjoys getting out now. He would strongly recommend the service to others.