The Integrated Care Service (ICS) was set up as a South Gloucestershire Clinical Commissioning Group (SGCCG) ‘Test-and-learn’ GP surgery referral scheme for older people living with long-term health conditions (LTCs), and a history of unplanned hospital admissions. Such patients tended to go to their GP for non-medical issues such as loneliness, other psycho-social challenges and practical needs. The model evolved from emerging evidence from Age UK Cornwall’s ‘Pathfinder’ work1, 2, and against a backdrop of drivers such as The Better Care Fund3 and the Five Year Forward View4.
Age UKSG staff (ICS practitioners) joined surgery-based multi-disciplinary team meetings as equal partners, taking referrals from both GPs and Community care staff. They conducted ‘guided conversations’ in service-users’ homes to explore their current challenges, goals and ambitions. Practitioners then went on to tailor their support to empower individuals to improve their self-care, make lifestyle behaviour changes, increase their social support, or access appropriate community services or sources of practical support. ageuk.org.uk/southgloucestershire
Local stakeholders were identified as: SGCCG, the steering group, Age UKSG staff, service-users and primary and community care staff. The evaluation aimed to investigate whether the service was meeting its objectives and how well it worked from different stakeholders’ perspectives. It was also designed to inform commissioners’ decision-making.
A mixed-methods evaluation approach was taken to:
To conduct the evaluation, Age UKSG drew on both internal resource and the services of an external consultant, who conducted analyses on the following pre-existing health service usage data:
The following data were also collected and analysed internally:
Key findings after the service had been running for 18m were:
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 CCG Clinical Effectiveness and Research Team