Making our health and care systems fit for an ageing population

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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.

See more on this report

Improving care for an ageing population: what works?

By 2030, one in five people in England will be aged over 65. That we are living longer is a cause for celebration, but it presents major challenges to our health and care system.

This slideset summarises our report. It highlights nine components of care (and an integrated system to support these components) that need to be improved to provide person-centred, relevant care for older people. The slideset sets out the current situation and provides practical guidance on actions that will make a difference.

Related events


Mary Oparaocha

Groups of team managers in health and social care/ student.,
Skills for care Organisation
Comment date
08 October 2018

I strongly agreed with Oliver's comment on our aging population and their health, especially the older adults in our communities who are very frail with higher conditions should give basic treatment and respect, at least to remember when they were young, and put them at the centre of care for the rest of their life, and minimize judgmental approach for the benefit of our society, by placing them in care system to avoid embarrassment to our youths.

Dr Prasanna N…

Consultant Old Age Psychiatrist,
Northumbria healthcare trust
Comment date
28 March 2014
1. We need to start actively collaborating with tech engineers and innovators in assistive technology, for example a smart (Chip & Pin) card to carry basic problem records / medication lists, remote incontinence alarms, object finders, smart bins to detect accidental disposal of personal belongings in hospital
2. We need to use a common system to succinctly describe multimorbidity such as SBARD, which includes a section on anticipated risks and their safeguards
3. We need more awareness of delirium, dementia and depression associated with hospitalised elders and avoid inappropriate use of the Liverpool Care Pathway (and other similar processes) to deprive them of fluid in order to hasten death (as happened in Mid staffs and other hospitals)

Mitzi Blennerhassett

medical writer/author,
Trustee, Rarer Cancers Foundation
Comment date
06 March 2014
I do so agree with your comments, Anthony Harvey. A great report, but the 'patient held record' has dangled like an unobtainable carrot for too long. Now we are even expected to share our medical information ( so that the NHS may benefit and some would even benefit financially. Patients have come of age. We no longer want things done TO us, we want to be part of the discussion and knowledge is power. At the very least, we should have access to all the information about us.
I always ask for copies of correspondence involving my care, and time and again I have found errors in my medical record - from stating I had 2 children, when I was a mother of 4, to an error in my place of birth.
A great GP once told me he always asks his patients to write their own referral letters, which he sends with his own, as patients often supply far more useful information for consultants when they have the chance to write about the symptoms and history in their own time at home. So that's what I do. Every little helps - towards patient autonomy - and towards improving both the patient experience and the standard of healthcare.
Patient-centred care has to mean there is genuine patient partnership - and that has to start with respect for the person.

Anthony Harvey

a Patient of the NHS,
Comment date
06 March 2014
I congratulate you on this report & recognising integrated care for older people.
Having been involved professionally with the NHS & IT for many years, over that period the focus has been on clinical IT systems to help the various clinical & nursing professionals to do their job & also the need to report for management & for national audits.
There has been no real focus on who we serve, the patient, who is often thought of as secondary to IT with a bolt on "peek" at their record via a portal.
This leads to fragmented information, even within hospital organisations as various systems only pass on pockets of information & never the full picture.
There is also an expectation to keep a patient record view & the language the way clinical professionals work & expect patient to immediately understand.
What if in theory you gave the patient all of the data, all of the information so that they could use IT systems of their choice to display it together with other health information that they collect themselves. To also be able to pass on the pockets of information that their GP or specialist hospital needs, their information for their long term conditions so they manage it how they want to.
By focusing on the patient, IT systems would then start to be joined up, integrated care system.
It is not to say let the patient be responsible to keep all their data, but more & more patients are starting to want to keep their data & share it with whom they need to share it with together with their fitness apps, their dental record too.
Yes one day the patient will be holding the screen with the health professional looking keenly over their shoulder.
It might be too far fetched for most professionals, but if you are one of them, take a step back & think of all the benefits this will deliver changing the focus of healthcare IT.
& for those tempted to focus on the negative aspects, look at the younger generation & see what they currently do with technology.

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