Ageing Well

Ageing Well – supporting older adults to maintain their independence through a new offer, promoting; stronger communities, self-care, and integrated care teams.

The population of West Cheshire is ageing, people are living longer, and although this is something to celebrate it also places additional pressure on health, social care and housing.

Over the past five years an 18% rise the number of people over the age of 85 has resulted in a 40% increase in the number of unplanned hospital admissions, and a 30% rise in unplanned hospital bed days. Using current demographic forecasts it is estimated that to maintain existing service standards would require an additional £19.1 million.

We want people to live active, healthy and safe lives within their communities, providing genuine choice and support where needed. Integrated community teams will help older residents to live independent lives at home, with hospital admissions only taking place when absolutely necessary.

Our approach in the short term focuses on scaling-up and extending existing good practice, developing more sustainable provision through a new funding and contracting model, through which payment will be driven by outcomes rather than activity over the medium to longer term.

Altogether Better approach

New approach Old approach

Valuing older adults and a stronger role for  communities supporting people to help themselves  where possible.


An over-reliance on public services to respond to the  needs of older adults following a crisis, encouraging a  culture of dependency.



A single point of access and common assessment for  health and social care for better access to the right services,  treating people in a holistic way. Sharing of information.



Multiple front doors and varying assessment processes leading to a fragmentation and duplication.


A better approach to self-care, maximising the potential of  personalisation, shifting power and responsibility to  citizens.



A fragmented approach to self-care.


Integrated locality teams aligned to GP surgeries – bringing together health, social care, the voluntary and  community sector, and other professionals. Joint case work.



Fragmented approaches often lead to an escalation in  need and demand on costly acute services.


Better early local interventions – such as reablement,  telecare, rapid assessment interface and discharge (RAID),  Hospital at Home, end of life care, and extra care housing.



Interventions often not taken to full scale and  commissioned on an organisational basis.


A new funding and contractual model which  provides the right incentives to have a model of care  which shifts activity and resources from inappropriate  acute setting towards community-based care.



A funding and contractual model which places greater  focus on activity rather than outcomes and does not  encourage the generation of efficiencies across the  system, risk sharing or integrated care.



Reduced demand for more costly services that gives people greater control and personal choice over services. It also reduces confusion and duplication.

This approach will reduce the number of unplanned hospital admissions and re-admissions, while also reducing the demand for long-term care placements. We estimate a reduction of costs of £26.1 million over the next five years.

Business Case


Permanent link to this article: