Hertfordshire and West Essex Integrated Care Strategy

Strategic priority 4: enable our residents to age well and support people living with dementia

We will ensure our residents are supported to age healthily, with access to advice and services that enable them to live well and independently for as long as possible.

Where we are now 
  • The population and proportion of those aged 65 and over is growing in both Hertfordshire, from 17.2% in 2020 to an expected 23.2% in 2043) and Essex (the number of over 65-year-olds is expected to grow by 28% in the next decade, and number of over 85s by 55%).
  • Other data demonstrates social isolation, hospital admissions due to falls and fractures, reablement following hospital discharge as areas for improvement. Whilst there is a range of initiatives to improve clinical outcomes, ageing well is broader than this. Prevention is going to be key to ensure that the population keeps well for as long as possible, as the ageing population will inevitably result in a greater demand for our services.
  • Prior to COVID-19 carers were approximately 10% of the population, this is expected to have grown since the pandemic.
  • Those living with dementia face great personal uncertainty both during its early stages and as their condition progresses. Dementia poses serious challenges for health and care services and has a higher health cost than cancer and heart disease. The condition is sometimes difficult to identify early, and once a diagnosis is given, it can be difficult to find the right support.
  • People with dementia face an increased risk of health or care crisis, sometimes resulting in unplanned admission to hospital, often not the best place for them.
  • Approximately 43% of NHS budget is spent on those aged 65+ years, who account for approximately 12% of the population.
  • It is estimated that between 20% and 30% of hospital admissions in over 85s could be prevented by proactive case finding, frailty assessment, care planning and use of services outside of hospital.
Outcomes we want to achieve

We want people to be able to say:

  • I know how to plan for older years to I can reach them in the best health.
  • I can live independently and take care of my own health and wellbeing, and manage the challenges life may throw at me for as long as I want.
  • I have choice, control and independence over my health and care support needs
  • I feel socially connected and a valued and respected member of my community.
  • I know what support is available and how to access it.
  • I am treated with dignity and respect.
  • I will be asked for my end of life wishes and will be able to die, where practically possible, in my preferred place of care.
What will change

We will:

  • Work in an integrated way to support people to live well for longer, maintain independence and improve early diagnosis and support for those at risk of becoming frail, living with dementia and their families.
  • Support people to increase physical activity and reduce loneliness and cognitive decline through connecting with their local communities by working collaboratively to provide information, advice, and support.
  • Ensure local services, communities and the environment, including outdoor space, transport and buildings, are integrated and are age and dementia friendly.
  • Improve support for people who look after family members, partners or friends because of their illness, frailty, or disability.
  • Develop and support capacity of care homes and discharge arrangements, align specialist services with primary/ community and social care and resolve pathway issues around health and social care to improve flow of patients out of acute settings.
  • Promote and encourage take up of the NHS Heath Check for people aged between 40 and 74 to help prevent the onset of disease (diabetes, heart disease, kidney disease, cancer, stroke and dementia).
  • Improve provision of extra care housing for older people with health and care services embedded so our older residents can maintain their health, wellbeing, and independence into old age.
  • Strengthen multi-disciplinary team approaches where professionals and the voluntary sector work together in an integrated way to provide tailored support that helps people live independently at home for longer.
  • Ensure our information and advice offer is accessible to people affected by dementia throughout the course of their condition, including social and wellbeing opportunities in their local community. 
  • Review and strengthen our support offer to those diagnosed with Mild Cognitive Impairment to reduce the likelihood of, or extend the period between, the development of dementia.
  • Work to review and rollout dementia training for our workforce across health and care services.