In Northamptonshire, the population is ageing and the number of people aged 65 and above is expected to be 1 in 5 by the year 2019, including another 5,000 people aged over 85.

This change in the local demographic will bring additional pressure onto the health service but NHS Nene Clinical Commissioning Group is already working with partners in health and social care to ensure frail elderly patients receive their care in the most appropriate setting, and help reduce the number of avoidable hospital admissions among this vulnerable group.

The Community Elderly Care Service (CECS), launched in December 2010, is already making a difference, and between 01 April 2011 and 31 March 2012, the service ensured 1830 frail older people received community based care and avoided having to be admitted to hospital.

CECS was developed, with input from all relevant stakeholders including patients, GPs, and representatives from all sections of health and social care, to ensure older people receive their care either in the comfort of their own home or in a community bed. The service has an annual budget of £3.7m which is managed by Nene.

Under the CECS scheme, patients have access to a dedicated community team including nurses, pharmacists, intermediate care, social care staff and consultants who specialise in working with the elderly.

Achievements of the CECS scheme in its first full year (1 April 2011 – 31 March 2012) include:

• Prevention of 1830 emergency admissions a year for frail, elderly patients across the county
• Prevention of 4285 excess bed days a year for frail, elderly patients
• Prevention of 306 emergency admissions a year for patients with class 2 cellulitis eligible for home and antibiotic therapy
• Prevention of 312 readmissions from Specialist Care Centre beds

Dr Bharath Lakkappa, the lead clinician for the CECS scheme, said: “The aim is to look after older people either in the comfort of their own home or in a community bed, which is not only a more appropriate setting for them in many cases, but also reduces pressure and emergency admissions at both Northampton and Kettering general hospitals.

“CECS was developed and commissioned by Nene Commissioning with agreement from all members of the Northamptonshire Integrated Care Partnership (NICP), which is made up of representatives of all parts of the local health service including hospitals, GPs, community health services and local authorities. The NICP identified that there was an issue with an increasing number of elderly patients who require healthcare but not necessarily hospital care.

“Since the service was launched, as well as preventing admissions and readmissions to hospital, the service has improved integration between different parts of health and social care services, improved speed of access to quality care for frail elderly patients, and a daily pharmacist review for those in the specialist care centre beds.”

GPs were involved in the development of CECS pathways, and there were a series of engagement events that took place including clinical roadshows.

Patient feedback and involvement was also key to the development of the CECS business case. A consultant document was developed to capture input from the public and Nene’s patient and public council was engaged in designing the pathways.