Age UK South Gloucestershire Integrated Care Service

Identify & understand

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.


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:

  • Evidence expected increase in service-users’ well-being.
  • Track expected reductions in secondary and community care health service usage.
  • Gather patients’ and stakeholders’ feedback about the service.


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:

  • Unplanned hospital admissions (using ‘SUS’ data, a matched control group approach and cost-analysis to calculate annualised savings).
  • Number of community matron home visits (before and after the intervention).
  • Acute and repeat prescribing (also pre-post).

The following data were also collected and analysed internally:

  • Change in ‘Wheel of Life’ scores (a proxy, pre-post measure of service-users’ well-being).
  • Service-user questionnaires: service satisfaction ratings, qualitative feedback.
  • Mixed methods stakeholder survey.

Case studies.

Review & 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).

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.

  1. People, Place, Purpose: Shaping services around people and communities through the Newquay Pathfinder. The Penwith Pioneer Project Board/Age UK Cornwall & Isles of Scilly, 2013.
  2. Living Well: Pioneer for Cornwall and the Isles of Scilly. A report to The House of Commons Health Select Committee. Tracey Roose, March 2014.
  3. Better Care Fund, NHS England:
  4. Five Year Forward View, NHS England:
  5. More information about Age UK’s Personalised Integrated Care Programme available at:
  6. Integrated Care Services. Age UK (brochure). December 2015.

References downloaded/live as at 25/1/17.

24 May 2017 Draft: Jo Coulson, Evaluation Officer

BNSSG ICB Clinical Effectiveness and Research Team

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