Ageing Well is a small but very significant cog in the wider iCAN service machine. The aim is to give more proactive support to those at high risk of health deterioration / hospital admission. It is a collaborative multi-disciplinary approach with Primary Care Networks (PCNs) as the lead organisation, alongside health services, social care and the voluntary sector all working as part of a ‘Ageing Well Team’ within each PCN. It is funded via the Northamptonshire Health Care Partnership. Ageing Well is a true example of Multi-Disciplinary Team (MDT) support.

A PCN is a group of GP surgeries who work together, covering a geographical area. Each PCN has been allowed freedom to develop delivery models and processes to suit the needs of their PCN patient populations, so they all work in a slightly different way.

Ageing Well is a project which aims to bring about the ideological and working practice change necessary to properly join health / social / wellbeing services.

The multi-disciplinary approach emphasises to both patients and professionals that health is more than treating health concerns and also looks at social issues, including housing, social isolation, equipment and access. Meetings take place at the patient’s home, facilitated by a support worker placing the patient and their carers at the centre of the consultation.  Support workers take basic observations e.g blood pressure, respiration, oxygen saturation, temperature, pulse.

This prevents difficult and untimely trips to the GP surgery for the patient/Carer or costly home visits for clinicians. The other is being able to prescribe low level equipment, negating a waiting list of up to twenty weeks in some cases and immediately reducing risk of falls etc. feedback so far tells us this service is valuable and key to building patient resilience.