Suffolk & North East Essex Integrated Care System

The best quality of life as we grow older

Achieving this Higher Ambition will mean that:
Everyone in Suffolk and North East Essex is able to live well as they grow older.
As an Integrated Care System we will ensure that:
  • People have a positive experience of ageing
  • As people age, they are as healthy and independent as possible
  • Older people receive high quality care and support
  • People with dementia and their carers have advice, support and care to live well
  • Carers of older people have the support they need to live well
  • Older people are supported with bereavement and loss
What’s the current picture?

Average Health Status Score for Adults aged 65 and over, as measured using the EQ-5D scale.

1 in 5 people are over 65 and this is set to rise to 1 in 3 by 2033.

The number of “oldest old” (over 85) has doubled in the past decade and the percentage of people dying before 65 has remained constant for the past 20 years. Older people can have complex health and care needs, long-term conditions, functional, sensory or cognitive impairment are the highest cost and volume group of services users. Dementia accounts for more expenditure than heart disease and cancer combined. It is important to prevent frailty and deterioration in those already frail.

    Everyone in Suffolk over the age of 65 receives a non means tested Winter Fuel Payment, whether they need it or not. The Surviving Winter Appeal simply asks that if you don’t need it, you donate it, so that it can be given to another older person in the county living in fuel poverty. With 310 excess winter deaths in Suffolk alone, the Surviving Winter Appeal is quite simply a life saver. This last year has seen the partnership further develop with Hopkins Homes offering a £30,000 match fund to get the campaign off the ground. This was to help encourage other businesses to get involved and the fund reached its best ever figure this year of £125,000 heating almost 700 homes. Using Citizens Advice service has not only enabled the rolling out of the grants but it has also enabled benefit and utility reviews, bringing health and wellbeing, living conditions, debt advice and additional money for the older people of Suffolk – not just now but well beyond the winter months

  • The Council of Europe’s report ‘Human Rights of Older Persons and Their Comprehensive Care (2017) made a number of recommendations to protect older people’s rights
  • Prohibit age discrimination
  • Support older people with employment, training and volunteering
  • Promote a positive attitude to ageing
  • Ensure the availability, accessibility and affordability of health care and long-term care for older persons;
  • Integrate health and social care services, and provide centres for older people
  • Organise care around older people’s needs and preferences
  • Adopt a charter of rights for older persons in care settings
  • Support older people in their homes and give carers financial and practical support, counselling and advice
  • Eliminate the abuse of older people
  • Promote active ageing by developing age-friendly and inter-generational environments

    For more information see

This indicator measures “average health status score for adults aged 65 and over, as measured using the EQ-5D scale”. It will provide a greater focus on preventing ill health, preserving independence and promoting well-being in older people – the key to keeping systems functioning and to ensure that the needs of this large group of users are addressed.

Health status is derived from responses to Q.34 on the GP Patients Survey, which asks respondents to describe their health status using the five dimensions of the EuroQuol 5D (EQ-5D) survey instrument: Mobility, Self-care Usual activities, Pain/Discomfort and Anxiety/depression.

This indicator measures “average health status score for adults aged 65 and over, as measured using the EQ-5D scale”. It will provide a greater focus on preventing ill health, preserving independence and promoting well-being in older people – the key to keeping systems functioning and to ensure that the needs of this large group of users are addressed

HOW we plan to make a difference
    1.1People can prepare for later life.
  • We will promote public awareness of advance care planning, power of attorney and register of choices. Decisions and power of attorney should be recorded on shared digital care records to help inform care planning.
  • We will promote improved retirement planning, to prepare for life transition. Retirement can be a vulnerable time, support can help people to think about the practical and emotional impact.
  • 1.2 Older people have support to stay healthy. We will enable this by:
  • Encouraging people to live as healthy a lifestyle as possible, through information and advice, making every contact with health and care services count.
  • Consistent commissioning of health checks for over 75s, in particular for people with dementia. Checks should include medication reviews and advice on prevention of frailty and dementia.
  • Flexible working for older people and their carers.
  • Flexible working patterns can keep people active and connected socially.
  • Ensuring older people and their carers receive all the welfare benefits they are entitled to. It is particularly important to recognise the challenges people who receive benefits but do not have enough income to look after themselves and stay healthy.
  • Providing information on recognising the signs of mild cognitive impairment and possible dementia, including among Black and Minority Ethnic groups, and where to obtain help and advice.
  • 1.3 Older people do not face stigma, discrimination or disadvantage.
  • We will improve public awareness of age-related discrimination and the stigma of ageing. Older people are just people, we should focus on dignity and respect and positive ageing; taking an inclusive approach that includes protected characteristics.
  • Staff working with older people will be trained in stigma and discrimination, and the needs of people with dementia. This should in target supported living and sheltered housing environments, domiciliary care agencies, care homes and public spaces, to ensure all environments are dementia friendly.
  • We will encourage intergenerational approaches. Enabling young people to interact more with older people breaks down barriers and misconceptions.
    2.1 Older people are safe in their homes.
  • We will provide sufficient flexible and adaptable housing for older people, including those with dementia, and care homes providing high quality care.
  • 2.2 Older people’s health is closely monitored to identify risks and prevent frailty, illness or injury. We will enable this by:
  • Encouraging home-based and wearable monitoring equipment such as location trackers for people with dementia or home testing for people taking blood thinners. Predicting events helps to prevent incidents that could lead to a hospital admission, and can enable earlier discharge from hospital. Linking monitoring data to personal health records supports sharing of records and integrating support.
  • For people at risk of falls, providing support such as falls prevention schemes, information, exercise classes and strength & balance training. Such schemes can significantly reduce the likelihood of falls and the need for admission to hospital. A community-based frailty team approach will proactively identify and support patients with a personalised support plan.
  • Targeting people with mild and moderate frailty including people with additional needs such as learning disabilities. Targeted interventions have the potential to prevent deterioration and improve health.
  • Domiciliary care that focuses consistently on enablement and independence. Care packages with sufficient time, quality and capacity to care helps reduce people’s dependency on carers and helps prevent deterioration.
    3.1 Older people will have access to integrated physical and mental health support tailored to their health needs.
  • We will offer people who have the greatest risks and needs targeted physical and mental health support. This will help them in self-care, and to access integrated support - including diabetes, musculoskeletal, heart conditions, dementia and frailty.
  • Allied Health Professionals will work directly with older people in primary care. Advice on falls prevention, environmental adaptations, nutrition, exercise etc. helps prevent deterioration, crisis and hospital admission.
  • Care homes will have support from primary and community services to manage crises, with specialist
  • We will improve access to IAPT for older people with long term conditions, including dementia, and for carers.
  • 3.2 People in their own homes and in care homes can connect with their communities.
  • We will develop peer support schemes. This can include face to face groups, online support, community hubs, drop-ins, and good neighbour schemes.
  • We will promote schemes that engage homes with their local communities. People in care homes in particular can become isolated; greater contact promotes wellbeing.
  • 3.3 Older people have greater choice and control over their care.
  • Application of the NHS Comprehensive Model of Personal Care including people with dementia. The Model enables people to contribute to their care planning and delivery and ensures they and their carers have access to local support from within their own communities.
  • We will increase the number of older people receiving personal budgets, personal health budgets, and direct payments, including those with dementia. Take up of these schemes is low partly due to lack of choice of providers; improved uptake helps people have greater input into their care.
    4.1People with dementia are diagnosed early.
  • We will improve identification of symptoms and diagnosis through access to regular health checks, improved recognition of signs, screening, referral pathways, assessment and access to diagnostics tools. This includes improved diagnosis among Black and Minority Ethnic communities and people with learning disabilities.
  • People with dementia and their carers will have support to navigate the health and care system during and after diagnosis, to access the personalised information and support they need to live well and plan for the future.
  • 4.2People with dementia and their carers have the support they need to achieve their best quality of life.

  • Enhanced community multidisciplinary teams will support people with dementia and their carers in their own homes. These teams will enable people with dementia to stay independent as long as possible, to avoid and manage crises, and help reduce the level of need for residential care.
  • Voluntary and community sector providers will be supported to extend programmes such as Dementia Connect, offering advice and local support following a dementia diagnosis.
  • People will have personalised health and care services, supporting complex needs such as multiple health conditions, mental health and learning disabilities. This includes access to advocacy, Independent Mental Capacity Advocacy and Independent Mental Health Advocacy as appropriate; advance care planning; and high quality end of life care.
  • People with dementia will have a more positive experience of hospital admission and will be discharged without avoidable delays.
    5.1 Carers of older people have their own health and wellbeing needs recognised and supported.
  • We will improve identification of carers, including carer passports. The national GP Patient Survey found 17% of respondents identified as carers.
  • We will improve support to carers to ensure they manage their own health, social and emotional needs, including breaks from caring. An empathetic approach, based on values of equality of access, helps people in their caring role and to stay physically and emotionally healthy.
  • We will support carers to plan for changing needs and for emergencies, to ensure they and their loved one are supported.
    6.1 Older people who experience loss and bereavement have the right support.
  • We will improve access to bereavement care for older people who have lost someone close to them, or where a long-term relationship has ended. Tailored support recognises the additional challenges facing older people, including financial, practical, social, health and wellbeing.
  • Increased healthy life expectancy at 65 – male and female
  • Increased disability-free life expectancy at 65 – male and female
  • Improved health-related quality of life for older people
  • Reduced rates of severe frailty or increasing frailty
  • Fewer excess winter deaths index, people aged 85 and over
  • More older adult social care users and carers who say they have as much social contact as they would like
  • Fewer emergency hospital admissions due to falls in people aged 65 and over
  • More people who care for someone with dementia reporting good quality of life
  • Increased access to strength and balance programmes, and health outcomes
  • More people aged 65+ receiving winter fuel payments
  • Improved Pride in Practice in care for older LGBTQIA+ people
  • Falls prevention schemes delivered in accordance with NICE guidance 161
  • Increased population vaccination coverage: Flu (aged 65+), Shingles (aged 65+), and pneumococcal polysaccharide vaccine
  • Higher rates of diagnosis of people with dementia
  • Increased uptake of post-dementia diagnosis treatment and support services
  • More Comprehensive Geriatric integrated multidisciplinary assessments and care in community settings for people with complex needs
  • Increased uptake of bereavement and loss support services
  • More unpaid carers identified and supported

Last Updated on December 10, 2020

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