The Newcastle-under-Lyme over 75s project has taken a dynamic approach that has allowed it to identity and respond flexibly to local needs, making best use of local services, resources and innovations. The project has taken a fully person-centred approach, putting the needs and personal preferences of individual older people at the forefront, and building a flexible network of care and support around them, led and coordinated by the Elderly Care Facilitator.

The project can celebrate numerous achievements, including:

  • Great engagement with older people. Over the two-year period of the project, 90% of people who were aged over 85 years, housebound or had dementia accepted a home visit assessment and 75% of the people aged 75-84 years returned the screening questionnaire.
  • Older people have been at the forefront of the project and there has been excellent inter-agency collaboration around them, both between different GP practices and between health, care, voluntary, public and community services
  • An unprecedented ‘needs assessment’ for almost the whole population aged over 85 years in this locality and for a substantial proportion of the population aged 75-84 years.
  • Substantial impact for individuals. For example: 36% of older people were not claiming all the benefits they were entitled to (attendance allowance new claims as a result of the project had an estimated annual value >£275,000) and 24% of older people had newly identified mobility problems.
  • Carried out with very minimal investment and its success is almost entirely due to the vision of the lead GP, the skill and enthusiasm of the Elderly Care Facilitators, and the widespread willingness of the primary care teams involved to ‘get organised and get on with it’.

The project also highlights several opportunities for further service review and development:

  • Data from the assessments was collected in a very systematic way and this coded data has been entered into the electronic primary care record. This offers significant potential to follow up and analyse the longer-term outcomes for the cohort of older people involved and thus to assess the longer-term impact of the project.
  • The project has provided very interesting learning about this approach to screening and proactive intervention in this population. In particular, it was found that the Tilburg Questionnaire might not be the most appropriate tool to identify people to be offered the home visit assessment.
  • The project identified the enormous value of the newly developed role of ‘Elderly Care Facilitator’ and provides evidence for the significant potential to further develop and embed this role across primary care teams on a much larger scale.

To read the full project report click here