Skip to main content

It is beyond doubt that the UK’s elderly population is growing and with so too is the prevalence of long term and chronic conditions, which is placing increasing strain on an already overstretched health and care system.

Within the next 20 years the number of people over 80 is predicted to increase by a staggering 69 per cent and patients with severe frailty are known to contact their GPs five times more often. A new approach is called for to anticipate and prevent an influx of activity that would add to pressures already being felt across primary, community, acute and social care.

Step forward Upper Calder Valley Primary Care Network, whose flourishing Ageing Well Service serves as a model for providing proactive, co-ordinated holistic support to older people in a way that has been demonstrated to reduce demand on GP and hospital services, which is now being scaled across all five of the Calderdale PCNs.

Waiting for people to get ill perpetuates inequalities

‘From our perspective as commissioners we realised that we needed to do something different to cope with the increasing needs and demands of our ageing population and the pressures on our workforce, especially in general practice’, explains Emma Bownas, Calderdale’s Deputy Director of Improvement – Primary Care, NHS West Yorkshire Integrated Care Board.

‘Just trying to meet needs once people were ill wasn’t going to solve any problems and would just perpetuate inequalities. People weren’t living as well or as healthily as they could, and our workforce were getting exhausted. So, we started thinking about a population health management approach which involved understanding the cohort of people that would end up needing services if we did nothing.’

Looking for a place to start, the commissioners ‘went where the energy was’ and that led to the Upper Calder Valley, where Faye Batley had recently taken up post as frailty nurse working across three GP practices and had already started thinking about a process of wraparound care for older people that eventually morphed into the Ageing Well Service.

What began as a small initiative launched remarkably, at the height of the pandemic in 2020, is now operating at scale across the five PCNs in Calderdale and has demonstrated some significant outcomes including beneficial impacts on BMI for mild and moderately frail patients and reductions of at least one GP contact and 1.5 hospital contacts per patient per year, the latter yielding a saving of just under £600 per patient per year.

Local difficulties spurred innovation

The need for innovation was prompted by specific local difficulties. Upper Calder Valley PCN is based in a large rural area covering 65 square miles, with the nearest hospital 30 minutes away, the nearest elderly care/frailty unit an hour away and access to community services difficult in some of the more remote areas.

Of the PCN’s 35,000 practice population, just over one in five are over 65, and 10 per cent of these are deemed to be frail, with multiple body systems gradually losing their in-built reserves.

Faye Batley was already receiving referrals from GPs and other members of the primary care team to support older people in their own homes. But, after reviewing their practice data and local knowledge, the PCN members decided to broaden their approach and build a dedicated team that could go beyond responding reactively to referrals by proactively identifying patients with rising risk of frailty and designing personalised interventions.

An newly established ‘task and finish’ group evolved into a full Ageing Well team, pivotal to this clinical leadership and this was included by Dr Nigel Taylor, GP partner at Hebden Bridge Group Practice who shared the vision was instrumental as the PCN Clinical Director, in providing the support and space for the initiative to grow, a frailty nurse (later renamed ‘ageing well nurse’), social prescribing link worker, care co-ordinator, occupational therapist, pharmacist, community matron and adult social care worker. Their stated ambition was to ‘support older people holistically with what matters to them and where possible reduce GP and hospital attendances by supporting them in a proactive and anticipatory way’.

‘People still had to stick to their main jobs and initially there was a bit of resistance because it was something new and different. But now the team are really seeing the benefits and no longer question the model’, says Faye.

Although the Electronic Frailty Index (eFI) provided a snapshot of the PCN population, it wasn’t specific enough for the task, so the team developed their own searches for older people with mild-to-moderate frailty and rising risk, with the support of population health experts in NAPC.

Each member of the team had their own list of older people to contact for review, either by telephone, virtually, or face-to-face. Holistic assessment included completion of the Rockwood frailty score, Patient Activation Measure (PAM), the ONS4 wellbeing scale, the EQ-5D quality of life measure and simple mobility assessments.

Personalised care plans with goal setting, shaped around what mattered to them, were put in place for all patients supported by the team, who were followed up initially at regular intervals but eventually on a flexible basis.

Scrupulous records were kept, and activity monitored at weekly multidisciplinary team meetings involving all team members.

Evaluation showed impressive results

Evaluation of data from 99 mild-to-moderately frail patients supported by the team over two years from 2020 to 2022 yielded the following impressive results:

Improvements in BMI Underweight patients receiving frailty support saw a three-point rise in BMI while overweight patients saw a 0.9-point drop. BMI changes can serve as a proxy for overall health improvements, with underweight and obese patients having up to twice as many GP contacts than those with normal weight;

Reduced GP contacts Before receiving support from the team, patients had an average of 5.5 GP contacts per year, which fell to an average of 4.6 per year afterwards. The real reduction is thought to be significantly greater since Covid had led to an artificially low level of GP demand before the support started;

Reduced hospital costs and contacts Average yearly hospital cost per patient fell by £593 per patient per year, with hospital contact per patient reduced by 1.5 per year following support by the team.

The conclusion is that every £1 spent on frailty support could save as much as £4.20 in terms of reduced primary and secondary care demand before taking account of the benefits to other providers and the patients themselves.

The link between Ageing Well support and reduced NHS contacts is clear to Faye Batley. ‘Obviously patients who are not feeling confident in managing their own health and wellbeing are likely to see their GPs more, access more services and ultimately cost the NHS more’, she says, ‘but if we can upskill the patients and build their confidence and motivation to manage their own health and wellbeing, that is likely to reduce demand.’

In qualitative terms, patients have been hugely grateful for the support they have received.  ‘They have appreciated that we have taken their concerns seriously, followed up on problems they’ve had and not just left them alone to struggle until they became unwell’, explains Faye.

‘It’s amazing how you looked at everything’, said one happy customer. ‘I can’t thank you enough, you dug me out of a hole – everything is great about the service.’

In a recent survey involving 46 patients from all five PCNs in Calderdale, 95 per cent said they were ‘extremely likely’ to recommend the service to friends and family needing a similar service or treatment, and the remaining five per cent were ‘likely’ to recommend.

When asked what they particularly valued about the service, patients referenced a friendly and encouraging approach; feeling listened to and empowered by the team; being able to access resources they didn’t know were available; and having their questions answered and information shared in a way that was easy to understand.

The keys to success

Having a dedicated team leader with protected time to devote to the project was the prime ingredient, closely followed by ringfenced time for the team to focus proactively on the needs of the frail population. Collaborative working between the CCG/ICB primary care team and the PCN, with support from NAPC, helped to enable change and overcome barriers.

At the same time the team built up relationships with the acute trust, mental health, voluntary and social services, working closely alongside them to use all available data and build up a true picture of their patients in what Faye describes as ‘a team without walls’.

Also critical to the Team’s success has been the clinical leadership of Dr Nigel Taylor, a GP partner at the Hebden Bridge Group Practice and Clinical Director of Upper Calder Valley PCN, who has developed and shared the Ageing Well vision and backed his teams in working differently.

A number of important learnings have emerged from the project, including:

  • The need for a proactive first contact with patients, leaving the door open for access at a later date;
  • Recognition that frail people don’t necessarily think of themselves in those terms, leading to the rebadging of Faye Batley’s role as ‘Ageing Well Nurse’ and her team as the Ageing Well Team;
  • The importance of tailoring care to need and being prepared to discharge patients when they and their team worker feel the time is right.

The need to sustain momentum

Initial rollout of the Ageing Well Service in Upper Calder Valley was enabled through non-recurrent funding and the opportunity to make use of some of the additional roles in primary care introduced in 2019.

The challenge is finding a way to sustain that momentum. ‘The aim is for the partners to find the money to continue because they believe this is a way to meet a demand differently’, explains Emma Bownas. ‘We’ve managed to be different with new resources. But where we’d like to get to is being different within our existing resources.

‘One of the things I would love integrated teams to do is stop talking about referring. Because the people we are talking about referring to are actually in our team.

‘Commissioning can help with that. If we are concentrating, say, on waiting lists or response times, the natural thing will be for people to protect their own part of the service. What we need to do is work out what are our preferred outcomes for that locality or that PCN or that neighbourhood team rather than each provider having their own.’

Adds Faye: ‘That’s the advantage of the Ageing Well multidisciplinary team meeting. Instead of referring to different services you can just ask a member of the team to make a quick call to a patient. It’s really about breaking down barriers and getting that streamlined continuity of care for each patient, focusing on what matters to them in meeting their needs.’


The way forward

The Upper Calder Valley PCN is in the process of completing Rockwood frailty scores on all their patients over 65, with a view to building it in to all clinical consultations. And the Ageing Well Team have established special clinics for their older population while continuing to offer home visits.

Due to the success in Upper Calder Valley, the Ageing Well work is being scaled across all five of the Calderdale PCNs to reach a total population of more than 40,000 patients over 65. A full evaluation of the Calderdale Ageing Well Model will be carried out later this year.

At the moment the Ageing Well approach has yet to spread beyond Calderdale, although Faye Batley regularly receives expressions of interest from other areas. What advice would she and Emma Bownas give to any professionals seeking to replicate their success?

‘Don’t be afraid to try something new’, says Faye. ‘Make sure you have a team approach covering more than one practice and be sure to identify unmet need from a population health management perspective. Constantly re-evaluate what you are doing and make sure you are always looking at people proactively to keep them well rather than being pulled into reactive work when they are already ill.’


Emma’s advice is beautifully succinct. ‘Start small, go where the energy is and don’t be afraid to fail.’

Back to News