Review and Act
Key findings after the service had been running for 18m were:
- 43% reduction in non-elective admissions in the ‘ICS cohort,’ versus 25% reduction in a ‘matched cohort.’ (Individuals were matched on age, gender, LTC, geographical area & recent unplanned admissions history). This equated to an 18% greater fall in admissions for the people referred, and an annualised saving of £531 pp/yr.
- 12% reduction in acute prescribing (3m pre-intervention compared to up to 12m post-intervention, based on annualised and consolidated data).
- 25% reduction in community healthcare staff home visits (6m pre- to 6m post-intervention).
- 27% increase in patients’ self-reported well-being.
- A mixture of stakeholders gave an average score of 3.86/5 for different levels of the service. The top rating (4.15/5) was for successful integrated care working. The value of integrating Age UKSG staff into MDTs to provide personalised patient care, and strong praise for the dedication and enthusiasm of staff, also came through strongly from qualitative data.
- Patients themselves gave an average score of 9/10 for different levels of the service. The top three scores were: helpfulness and friendliness of Age UK staff, getting sufficient updates from them, and appreciation of participating.
Age UKSG presented their findings to stakeholders in January 2016 and produced a final project report, which was well received. Learning was also disseminated to Age UK’s head office, who run a national Personalised Integrated Care Programme (PICP) 5,6.
Age UKSG were successful in obtaining further funding to scale up the service, from both SGCCG and via adoption into Age UK’S PICP programme. Stakeholders reported anecdotally that they had learnt from both the evaluation process and findings themselves. Evaluation methods have since been reviewed and improved e.g. validated measures are being piloted. And evaluation is being streamlined with Age UK’s national outcomes and performance monitoring framework and their national independent evaluators. Age UKSG also now have an Evaluation and Service Development Officer post. Learning will continue to feed into service development and improvement plans, both locally and nationally, as well as future commissioning cycles.
1People, Place, Purpose: Shaping services around people and communities through the Newquay Pathfinder. The Penwith Pioneer Project Board/Age UK Cornwall & Isles of Scilly, 2013. https://www.cornwall.gov.uk/media/6162062/Newquay-pathfinder-Evaluation-proof3.pdf
2Living Well: Pioneer for Cornwall and the Isles of Scilly. A report to The House of Commons Health Select Committee. Tracey Roose, March 2014. https://www.cioslep.com/assets/file/Strategic%20Economic%20Plan/Pioneer%20Health%20Select%20Committee%20Report.pdf
3Better Care Fund, NHS England: https://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/
4Five Year Forward View, NHS England: https://www.england.nhs.uk/ourwork/futurenhs/
5More information about Age UK’s Personalised Integrated Care Programme available at:
6Integrated Care Services. Age UK (brochure). December 2015. http://www.ageuk.org.uk/Documents/Post-conf%20with%20BIG%20logo%20-%20Age%20UK%20Integrated%20Care%20Programme%20Booklet%20v.2.pdf?epslanguage=en-GB?dtrk=true
References downloaded/live as at 25/1/17.
24 May 2017 Draft: Jo Coulson, Evaluation Officer
BNSSG ICB Clinical Effectiveness and Research Team