Report : Making our health and care systems fit for an ageing population

Our fragmented health and care system is not meeting the needs of older people, who are most likely to suffer problems with co-ordination of care and delays in transitions between services. This report sets out a framework and tools to help local service leaders improve the care they provide for older people across nine key components.

About the report

Within each component of care, the report sets out the goal the system should aim for, presents key evidence about works, gives examples of local innovations, and some pointers to major reviews and relevant guidance. It argues that if the health and care systems can get services right for our older population – those with the highest complexity, activity, spend, variability, and use of multiple services – they should be easier to get it right for other service users. The twin challenges of demography and funding demand no less.

Whole-system changes are needed to deliver the right care at the right time, and in the right place, to meet older people’s care preferences and goals. The nine main components of care covered by the report are as follows.

    Healthy, active ageing and supporting independence
    Living well with simple or stable long-term conditions
    Living well with complex co-morbidities, dementia and frailty
    Rapid support close to home in times of crisis
    Good acute hospital care when needed
    Good discharge planning and post-discharge support
    Good rehabilitation and re-ablement after acute illness or injury
    High-quality nursing and residential care for those who need it
    Choice, control and support towards the end of life

The final section of the report discusses how to make integrated care happen. Key issues across all components include the use of comprehensive geriatric assessment at the right time, and the effective provision of co-ordinated primary, community and social care services closer to home.

Policy implications

There is no one model for successfully providing integrated care for older people; the right approach will vary according to the local context. But it is clear that transforming services for older people requires a fundamental shift towards care that is co-ordinated around the full range of an individual’s needs (rather than care based around single diseases), and care that truly prioritises prevention and support for maintaining independent living for as long as possible. Achieving this will require much more integrated working to ensure that the right mix of services is available in the right place at the right time. Incremental, marginal change is not sufficient; change is needed at scale and at pace. This requires teams in physical and mental health, social care, public health and the wider public, private and voluntary sectors to work together much more effectively to deliver person-centred care.