Better Care Plans To Help Elderly And Reduce Hospital Visits

The Better Care Fund, also known as the Integration Transformation Fund (ITF), will help join up local health and care services to improve care and reduce A&E admissions.

The plans, which will also provide more dignity for older people and reduce the length of stay in hospital, are funded by the government’s £5.3 billion Better Care Fund. It was originally set at £3.8 billion but has increased significantly following additional local investment.

It will bring GPs, community nurses, and care workers together so they can provide better care closer to home. This will keep people independent and healthy for longer and prevent unnecessary stays in hospital and give families more confidence in how their loved ones are looked after.

NHS England estimates that, based on local plans, the Fund will be supporting at least 18,000 individuals in roles providing care out in the community. This will be a range of social workers, occupational therapists, care navigators, doctors and nurses, deployed based on local needs and delivering care outside of hospital.

The plans will improve people’s experience of health and care services by providing:

  • 7 day care services so people get care at the weekends and are not left waiting in hospital
  • a named professional who joins up different services around people’s individual needs
  • better sharing of information so people only have to tell their story once
  • joint assessments so services work together from the start and provide a care plan that works for the user

These plans show how local services aim to achieve:

  • 163,000 fewer stays in A&E, resulting in a 3.07% reduction in admissions and savings of £253m
  • £532m savings for health and care services
  • 101,000 fewer unnecessary days spent in hospital by reducing delayed transfers of care
  • 12,000 more older people still at home 3 months after being discharged from hospital
  • 2,000 more people prevented from being admitted into a care home and supported to live independently

Developed together by councils and local NHS organisations, the plans are the centrepiece of the coalition government’s commitment to joining up the health and care system. They will help to put the service user first and make this vision for joined up care a reality across the country for the first time. It is a key part of the government’s response to the call for further integration of health and social care set out in NHS England’s ‘Five Year Forward View’ and supported by the Local Government Association.


Health Secretary Jeremy Hunt said:

For years, successive governments and NHS leaders have talked about joining up our health and care services so people get better care at the right time and in the right place. The time for talk is over – our plans will make this vision a reality for patients and help deliver a sustainable future for the NHS.
Too many families experience being passed from pillar to post, between the NHS and their council, endlessly repeating their stories along the way. By breaking down barriers within the system, these plans will allow staff to work together to prevent people from becoming ill in the first place, meaning our hospitals can focus on treating the patients who really need to be there.

Secretary of State for Communities and Local Government, Eric Pickles said:

People are happier and healthier when they have family and friends nearby. So investing in care services that are tailored to individual needs make sense. It means people can stay at home for longer, which is better for everyone involved.
They can also be helped back to health in high quality community care centres or leave hospital more quickly when they do have to be admitted. This will not only improve services and reduce waste, it will give elderly people the dignity and independence they deserve in later life.

Care and Support Minister Norman Lamb said:

Too often care is uncoordinated, leaving many people needlessly going back to A&E again and again. By getting local health and care teams working together to focus on prevention, not just the treatments we need, we can stop families and the NHS from having to pay the price for these unnecessary crises.
Fourteen pioneering areas have already delivered fantastic improvements for their patients and these plans show just how driven local areas are to make this the reality everywhere. The prize is enormous — better care for people and better value for money for our health and care services.

Progress so far

Local areas have led the way in developing plans so that they are tailored to meet the specific needs of their local communities and are being delivered in partnership with NHS England and the Local Government Association. The money to make these plans a reality will be available from next April, although some areas are already delivering these changes for their local population.

For example in Leeds – one of our Integration Pioneers – community matrons and social workers assess patients at the same time so that the user only has to tell their story once and then gets a joint plan built around their needs. In the case of Patricia, 78, her Type 1 diabetes and multiple sclerosis led to 3 hospital admissions over 12 months – two of which were to A&E. This left her lacking the confidence to go out when she was at home. They carried out a joint assessment and, with her involvement, came up with a joint plan to rebuild her confidence by helping her get to community social clubs. Since then she’s had no hospital admissions and has needed far fewer GP appointments but more importantly has the confidence to travel by herself to shops and markets and to see friends.

In Bexley, the Queen Mary’s Hospital runs a community rehabilitation unit to help people recuperate after an accident or illness. Its staff is made up of physiotherapists, occupational therapists, social workers and a geriatrician, who all work together to help patients regain their mobility and be able to live at home with the support they need, rather than be readmitted to hospital. One woman, Mrs T, spent 5 weeks in the unit, which enabled her to live out her last few months surrounded by friends and family at home, rather than being admitted to a care home.

In Croydon, Mrs J was admitted first to an intensive care unit and then a specialist rehabilitation centre following a stroke. Before being discharged from the centre, a team assessed her needs to understand what support she’d need at home. At first, she was given intense home support, consisting of 3 visits a day and community occupational therapists worked alongside these visits to provide the equipment she needed to help her regain her independence. After 6 weeks, her husband felt able to take over his wife’s care, meaning she could carry on living independently at home, with support on the end of a phone as required.














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