Improving care outside of hospital
One of the central tenets of the NHS Long Term Plan (2019) is to move healthcare delivery from hospitals into the community. For the elderly, this means a significant focus on strengthening primary and community health services to enable people to live independently at home for longer and avoid unnecessary hospital admissions. To achieve this, the plan introduced several new service models, which are delivered locally through Integrated Care Systems (ICSs).
Integrated care systems and primary care networks
By April 2021, Integrated Care Systems (ICSs) were rolled out across England, bringing together various health and care organizations to improve population health and deliver coordinated services. Within these systems, Primary Care Networks (PCNs), groups of local GP practices covering 30-50,000 people, are at the forefront of delivering care to older people. These networks work with community health teams, social care, and the voluntary sector to provide proactive, targeted support to those with moderate frailty.
Key initiatives under the 'Ageing Well' priority
The "Ageing Well" priority within the NHS Long Term Plan introduces specific new service models and enhancements to existing care pathways. These initiatives address a range of needs, from proactive support to crisis intervention.
Enhanced Health in Care Homes (EHCH)
The EHCH model was designed to offer proactive and personalized care to residents, moving away from reactive approaches. Key features of this model include:
- Each care home is linked to a PCN.
- Residents receive support from a named clinical lead and a multidisciplinary team.
- Timely access to emergency out-of-hours support is guaranteed.
- Care homes are supported to share relevant information securely with the NHS via platforms like NHSmail.
Urgent Community Response
Crisis situations, such as a fall or sudden illness, can often lead to an unnecessary hospital admission for an older person. To counter this, the NHS plan significantly increased the capacity and responsiveness of community services. These rapid response teams, comprised of GPs, district nurses, and other professionals, aim to provide urgent support within two hours of referral in a crisis. The plan also pledges to offer access to recovery, rehabilitation, and reablement support within two days of referral.
Proactive care for frailty
Beyond crisis management, the plan emphasizes proactive, personalized care for those identified as having moderate frailty. By routinely using the electronic Frailty Index, GPs can identify those most at risk of deterioration and offer targeted, multi-disciplinary support. This can include physiotherapy, balance training, and connections to community resources to build resilience and maintain independence.
Improved dementia care
The Long Term Plan identifies dementia as an improvement priority, aiming to improve care for people with dementia and delirium in both hospital and home settings. This involves strengthening joined-up, coordinated care between different services and improving access to timely diagnoses and evidence-based post-diagnostic support. The plan also committed to a national rollout of the Alzheimer's Society's Dementia Connect service, a single point of access for support.
Personal health budgets
The plan expands the use of personal health budgets, giving individuals greater choice and control over their care. This involves discussions with healthcare professionals to agree on goals and plan how to best use the budget for tailored support. It connects people to NHS and community support services, empowering them to manage their conditions and live independently.
How the NHS Long Term Plan for the elderly compares to previous approaches
| Feature | Before the Long Term Plan | With the Long Term Plan |
|---|---|---|
| Care Model | Often reactive and fragmented, relying heavily on hospital-based services for crises. | Proactive, personalized, and integrated, with a strong focus on community and home-based support. |
| Frailty Management | Inconsistent approach, often reacting to crises rather than identifying risk early. | Uses tools like the electronic Frailty Index for early identification and targeted, multi-disciplinary interventions. |
| Urgent Care | Lengthy waits for community services, leading to preventable hospital admissions. | Introduction of two-hour urgent community response and two-day reablement access targets. |
| Care Home Support | Unequal access to NHS services for care home residents despite complex needs. | Guarantees support through the Enhanced Health in Care Homes (EHCH) model, linking homes to PCNs. |
| Patient Involvement | Less emphasis on patient-led decision-making and support planning. | Expansion of personalized care and personal health budgets to give patients more choice and control. |
| Use of Technology | Historically an 'analogue' service with limited digital integration. | Leverages technology like the NHS App for appointments and records, and remote monitoring for home care. |
Conclusion: A fundamental shift in elderly care
The NHS Long Term Plan for the elderly represents a fundamental shift in philosophy, moving from a reactive "sickness service" to a proactive "prevention service". By prioritizing out-of-hospital care, personalization, and the use of technology, the plan aims to create a more joined-up and responsive system. The implementation of models like Enhanced Health in Care Homes and Urgent Community Response teams seeks to prevent crises and support independence. However, the plan's success ultimately depends on effective local delivery and sufficient investment in the community workforce and social care. Ongoing monitoring and public engagement will be crucial to ensure these ambitious goals translate into meaningful improvements for older people across the country.
How to learn more about the NHS Long Term Plan
For an in-depth look at the overall plan, including its priorities beyond elderly care, visit the official NHS website. The summary provides a comprehensive overview of the commitments outlined in the plan: The NHS Long Term Plan
What is the NHS Long Term Plan for the elderly? (FAQs)
What is the main goal of the NHS Long Term Plan for the elderly? The main goal is to help people "age well" by shifting healthcare from hospitals into the community, providing more proactive and personalized care, and reducing preventable hospital admissions.
How does the plan improve care for people in care homes? The plan introduced the Enhanced Health in Care Homes (EHCH) model, which links care homes to Primary Care Networks to provide proactive, integrated support from a multidisciplinary team.
What is an Urgent Community Response team? Urgent Community Response teams are rapid-response services that aim to provide older people with urgent community health support within two hours of referral during a crisis, helping to prevent hospital admissions.
How does the NHS Long Term Plan address dementia? The plan prioritizes improving dementia and delirium care by strengthening integrated working and providing better access to timely diagnoses and post-diagnostic support through a more coordinated approach.
What is Personalized Care in the context of the plan? Personalized Care gives individuals more control over their own health, using personalized care plans and budgets to support them in managing long-term physical and mental health conditions based on what matters most to them.
What role does technology play for the elderly in the plan? Technology is used to enable digital-first access to services, with the NHS App allowing for online appointments and records. It also promotes virtual healthcare models and remote monitoring to support people at home.
How are health inequalities for older people addressed? The plan includes a systematic approach to reducing health inequalities by requiring local areas to set specific, measurable goals and targeting higher funding shares to areas with greater need.
Does the plan cover social care? The 2019 plan acknowledged the need for social care reform, but mainly focused on the NHS's role. Future plans, such as the 10 Year Health Plan of 2025, have continued to highlight the importance of social care reform.
