Integrated care of the frail and elderly

Last updated: 15 October 2012 

The journey

The aim of this programme was to implement an integrated plan for the care of the frail and elderly with the aim of reducing hospital admissions.  Many older people were finding it difficult to access the right services, so part of the aim was to simplify and co-ordinate care for this group of patients.  

The first steps were informal conversations among interested parties.  This led to the formation of a local strategic partnership spanning health and social care specialists.  The programme looked at all areas relevant to patients aged over 65, learning disabled and other vulnerable people.  These included dementia, end-of-life care, balance classes to reduce falls and ‘living well at home.’



The programme is still ongoing, but there is some evidence of fewer hospital admissions in this age group.  Another benefit has been improved relationships between strategic partners and considerable learning in areas such as aligning finances, outcome measurements, assessment processes and the politics of organisational relationships.


Patient setting

In-patient Out-patient Community based   X
Mental health   X Chronic illness   X Cross-systems   X


Clinical area

Staying healthy   X Maternity and newborn Children and young people Acute care
Planned care Mental health    X Long-term conditions    X End of life   X


Information, tools and techniques used

The programme started with informal networking among interested parties and progressed to a more formal local strategic partnership.  Specific change management tools were not used.



Crawley area including Crawley Borough Council; Crawley CCG; West Sussex County Council; Sussex Partnership Foundation Trust and voluntary groups.



The programme is still ongoing.


Contact details and further information

Dr Amit Bhargava, GP Principal, Southgate Medical Group, Crawley:



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