The Director of Public Health             Annual Report 2015/16

High Quality


Why are high quality support services important for Healthy Ageing?

Older people in Dudley have told us that enjoying good health and remaining independent, for as long as possible, is very important to them. Many people are able to remain independent through support from their own communities, support networks and by participating in voluntary and community sector activities.


However eventually many older people will have needs that require health and social care services being effective enough to support them. This chapter briefly highlights the services that are needed to support older people and their carers who are experiencing these challenges, and sets out how they can best meet the needs of older people in Dudley to age well and maintain their independence and dignity for as long as possible.


In the introduction we highlighted the main health problems affecting older people in Dudley and further information is available in the information section. There are a wide range of services that support older people with these health problems, and if we are to maximise their quality, there are a number of common features that should influence their design and delivery. Older people and their carers should be engaged in the design and delivery of services on an on-going basis to ensure that they are as conveniently located as possible and are physically, financially and administratively accessible. Clear information should be provided and staff should be helpful and trained to serve older people.


Sadly, frail older people in need of support services can be vulnerable to losing their dignity, and even to abuse.  The Commission for Dignity in Care (2012)(1) concluded that there needs to be a major change in culture and the way that health and social care services think about dignity to drive improvement and set out the action taken nationally and locally to achieve this. ᅠThis involves society having a positive attitude to ageing and services working much more closely with older people, families, carers and advocates to shape care and support to individual needs.

Older people in Dudley when asked about high quality support services identified what was important to them and this is captured in the word cloud below:

Primary care services

Primary care services, provided by GPs and their teams, and also including pharmacies, optometrists and dentists, provide the gateway to the whole range of NHS services, and increasingly to joined-up health and social care services. The role of primary care services includes:

  • Preventing and delaying ill health, particularly by identifying those at high risk of becoming ill, through immunisation, screening and NHS health checks and providing medical treatment to reduce risk and referring to other services that can keep people well.
  • Providing treatment for all medical conditions and onward referral to hospital and specialist health services when necessary.
  • Identifying people with ill health, particularly long term health problems, as early as possible and co-ordinating the care of people with long term conditions.

GPs and their teams also have a key role in planning local health services to meet population need through involvement in Clinical Commissioning Groups (CCG). In Dudley, the CCG have developed and are now implementing an innovative new model of care.



Case Study - All Together Better

Figure 1 Dudley Clinical Commissioning Group Model


Reducing the risk of long term health conditions

The prevalence of long-term conditions is rising as the population in England ages. Around 15 million people in England have a long term condition and people with long term conditions account for half of all GP consultations, and 70% of the health care spend in England(2). More than one in five older people have two or more long term conditions and this proportion rises in areas of high socioeconomic deprivation(3).


NHS Health Checks aim to identify people aged between 40 and 74 who are at high risk of developing a long term condition, so that they can be supported to reduce their risk through both engaging in healthier behaviours and through taking medications such as for high blood pressure and raised cholesterol. People eligible for a health check are invited for the check every five years. In Dudley across the full 5 year cycle, just over half of people eligible for a health check have received a health check and this has been increasing year on year, from 40% in 2013/4 to 45% in 2014/5 to 62% in 2015/6. The number of eligible people who have had a health check also increases with age, from 46% of 60-64 year olds to 63% of 65-69 year olds rising to 87% of 70-74 year olds.


Immunisation is one of the most effective and cost effective ways of preventing ill health. There are specific vaccination programmes that target older people. These protect against seasonal flu, pneumococcal infection and shingles. Flu immunisation rates in people age 65 and over in Dudley have been falling in the last 3 years in line with national trends. There has also been decrease in the percentage of over 64 year olds receiving pneumococcal vaccination in Dudley in 2014/15 compared with the previous year and Dudley now has a significantly lower percentage of over 64 year olds vaccinated than England. Partners in Dudley Council, NHS England (who commission immunisation services), and colleagues in general practice need to work together to recover previous rates. This is particularly important as emergency admission rates for flu and pneumonia among people aged 65 and over are steadily rising in Dudley and intervention is needed to reduce this trend.


Staff who provide personal health and social care to older people can also transmit flu, putting patients already vulnerable at increased risk of ill health. Seasonal flu immunisation is available to NHS staff and to social care staff who provide personal care. Unfortunately, in Dudley rates of flu immunisation in health and social care staff are too low to provide the necessary protection, with uptake at the two main healthcare providers of 26.2% and 36.4% respectively. Urgent action and leadership from within health and social care is needed to increase uptake, particularly in light of recent analysis that indicates the contribution that flu has played in increasing numbers of deaths among frail elderly people(4).


National screening programmes aim to detect signs of specific disease at an early enough stage to prevent it fully from developing. There are four screening programmes that are available to older people. Abdominal Aortic Aneurysm (AAA) screening is targeted at men aged 65. Three quarters of eligible women aged between 53 and 70 received breast screening in Dudley which is similar to the national average. Breast screening rates have been gradually falling since 2011 in line with national trends. Almost 60% of the eligible population of people aged between 60 and 74 in Dudley received bowel cancer screening in 2015. This is significantly higher than the national average. The most recent data on diabetic eye screening uptake among people in Dudley is for 2012/13, 76% of eligible people had received screens which was lower than the England value of 79% however the Dudley trajectory was improving.

Diagnosing and managing long term conditions

Primary care has a central role in diagnosing long term conditions, and GP practices hold registers of their patients who have key long term health conditions including diabetes, a number of cardiovascular diseases, diabetes, respiratory diseases, dementia and mental health problems. Having accurate disease registers enables practices to regularly contact, monitor and review their patients with long term health conditions.


There can be a gap between the number of patients with specific long term health problems a practice would expect to have and the number actually on the register. Often this is because there are people with the condition who have not been identified and diagnosed. There are a number of barriers to people presenting to their GP with symptoms of long term conditions and many of these are more prevalent in more deprived areas. These gaps between expected and actual prevalence exist in Dudley, however when Dudley practices have prioritised finding people with specific long term conditions they have been extremely successful in narrowing this gap. For example there is a high rate of hypertension identification in Dudley.


There are fewer people on dementia disease register in Dudley than expected but, identification is improving. The percentage of people on diabetes (73% of expected cases), heart disease (66% expected cases) and COPD (50% expected cases) disease registers is also lower than expected however detection rates are improving. (These prevalence figures are based on the most current disease models however Public Health England are currently producing new models. These figures will be updated when new models are available.)


Primary care plays an important role in managing and co-ordinating the care of older people with long term conditions including those with more than one multiple long term condition. This is an important part of Dudley’s new model of care. In Dudley, people with dementia whose care has been reviewed in last 12 months increased in Dudley from 70% in 13/14 to 74% in 14/15. 84% of people diagnosed with COPD in Dudley received an annual review, 66% of patients registered with a Dudley GP and on the CHD disease registers received an annual check and 84% of people with diabetes had their annual foot check.


The care management of long term conditions in primary care should also include connecting patients to services and support available in their community that can prevent their condition deteriorating and them losing their independence. Examples of this include ‘social prescribing’ or working with Community Connectors or voluntary sector Linkworkers as is the case in Dudley’s new model of care. The services referred to include some of the support services referred to in other parts of the report, such as housing improvement, transport, financial support, learning opportunities, community groups and community assets that can support them with particular challenges. For example, libraries in Dudley have a dementia collection and Lingo Flamingo is a project in Glasgow that engages vulnerable people in learning a foreign language due to evidence that this can slow down dementia symptoms


Self management

Patients have an important role in managing their own long term conditions and there is evidence that this ‘self-management’ can improve outcomes and reduce demand for healthcare. Self-management is the tasks that individuals perform to live with one or more long term conditions, and having the confidence to deal with medical management, their role, and deal emotionally with their conditions. Supported self-management should be an element of the management of long term conditions, working hand in hand with health services, including for patients with multiple conditions(5).


Dudley has an established self management programme, based on the Stanford University model, in which ‘expert patients’ living with a long term condition (or carers) deliver a structured evidence based programme. This has recently been evaluated and found to be effective in improving quality of life and reducing healthcare usage for those involved in the programme. However, for the benefits of the programme to be fully realised the programme needs to be scaled up and systematically offered to all older people diagnosed with a long term condition.

Secondary care and hospital services

Secondary care provides older people with services that are more specialist than primary care is able to. These may be provided in hospital, the community or at home and can include planned care and urgent care.

Long term conditions account for 64% of all outpatient visits to hospital and 70% of inpatient days at hospital. High rates of emergency admissions for older people can indicate failings in management of care and particularly long term conditions across the whole health and social care system. They often occur when there is an exacerbation of a pre-existing condition and a patient is not able to access support to manage it closer to home. There is evidence that older people who live alone are at an increased likelihood of emergency admission to hospital. This can be partly explained by them tending to have poorer overall health, more difficulties with daily living, more falls, increased social isolation and lack of an emergency carer. There are also some indications that living alone may inhibit access to community based services which might otherwise manage exacerbations and prevent emergency admissions(6).

The main causes of emergency hospital admissions in older people in Dudley are accidental falls, respiratory infections, musculoskeletal conditions, diseases of the urinary system, flu and pneumonia.

We have already highlighted that falls are the largest reason for emergency admissions to hospital in people aged 65 and over in Dudley and that falls and associated ill health are increasing. In Dudley there is currently no system wide approach to falls prevention, starting from encouraging the whole population to improve their bone health from early age through physical activity and healthy eating, to early detection of people at risk of falling - before they fall for the first time, and enabling them access to appropriate interventions in a timely way. A wide range of partners who visit older people in their own home have an important role to play in identifying people at risk of falls, making adaptations and referring on to other services.



As people age, they can become frail as multiple body systems gradually lose their in-built reserves. This increases vulnerability to sudden changes in health triggered by what can seem like small events such as a minor infection, a change in medication or a fall and subsequent unsafe walking. Of people aged over 70 admitted to an acute hospital, 27% have previously diagnosed dementia, 50% have cognitive impairment, 27% have delirium and 24% have possible major depression and 8% have definite major depression(7).  These mental health problems can also increase the impact of frailty on older people.

Nationally there has recently been an increase in the numbers of deaths among the frail elderly and we know from research that frail older people are at greater risk of experiencing harm if admitted to hospital as an emergency, particularly if they are delayed in an emergency department. There is evidence that when an older person presents with frailty, a medical assessment within two hours, followed by specific treatment, supportive care and rehabilitation, is associated with lower risk of death, greater independence and reduced need for long-term care. Research has also found improved outcomes from acute older care assessment units or ‘Frailty Units’, that older people access at the early part of a contact with a hospital. Older people presenting with a frailty crisis can be safely assessed and managed at home as long as care is provided by dedicated, multi-disciplinary community teams which are integrated with primary and secondary care(8). Work is underway to explore how these approaches can be further developed as part of Dudley’s New Model of Care.


Social care

If our health deteriorates with age, we may find we need extra support or care to carry out our daily tasks at home and to help us sustain employment in paid or unpaid work, education, learning, leisure and other social support systems. This is known as social care and it can come from public sources (including benefits and social care services) as well as private sources, including unpaid support from family or other informal carers, and paid-for support from the private or voluntary sector. According to research with older people, few people have actively planned for their need for care or extra help in later life(9). Many people report that they do not want to put provision in place until they absolutely have to, despite recognising that this lack of planning could make an already stressful time more difficult.

Approximately 30% of people use some form of local authority funded social care in their last year of life. The use of social care tends to vary according to the presence of certain long-term conditions, for example people with mental health problems, falls and injury, stroke, diabetes and asthma tended to use more, while those with cancer seem to use relatively less publicly funded social care.

Analysis of reductions in funding to local authorities since 2010 has found that it has led to changes in the provision of publicly funded social care. There are indications that the total number of assessments decreased by 15% between 2009/10 and 2012/13, and the proportion of people who were assessed but not expected to receive any services increased from 17% to 20% per cent over the same period(10). This is leading to some concerns that the quality and quantity of social care available to older people will lead to delays in getting the support they need to stay out of, and be discharged from, hospital.

In Dudley the CCG, Council and other partners from across agencies are working together on the New Model of Care to mitigate the likelihood of these impacts by developing integrated health and social care services for people with long term conditions and for frail older people, which intend to make the best use of collective resources by identifying those at high risk of needing services, managing demand, using generic approaches to care co-ordination and connecting people to the support that is already available in their community.


End of life care

Dying is an inevitable part of life, and how we care for people at the end of their life is a measure of our society’s respect for its sickest and most vulnerable members(11). The UK is recognised internationally as a leader in end of life care. However, despite many examples of outstanding care, for some people, services fall short of what they and their friends and families expect(12).

Patients are considered to be approaching the end of life when their death is expected within the next twelve months. For some, death may already be imminent; others may have become frail through advanced and progressive disease that makes death likely within a few months. Palliative care improves the quality of life of patients with life-threatening illness, and their families and carers, through the prevention or relief of suffering, the recognition that dying is a normal part of living, and the provision of holistic support that manages physical, mental, social and spiritual concerns.

In 2014, 47% of the 470,000 people who died in the UK died in hospitals, while 22% died in their own home, 23% died in a care home and 6% died in a hospice. In Dudley in 2014, 4% of people died in a hospice which is lower than the England (6%) or West Midlands average (6%). However, surveys of terminally ill people consistently find a large majority of people stating that they do not want to die in hospital but would prefer to die at home. Younger people and patients with cancer are more likely to die in their preferred place of death, whilst older people, patients with non-cancer long term conditions (mainly cardiovascular and respiratory disease), people from more deprived areas and people from minority ethnic groups were more likely to die in hospital.

A major challenge is that whereas the course of terminal cancer can take a fairly predictable course, non-cancer conditions such as heart disease or COPD can be characterised by periods of stability and improvement followed by exacerbations and hospital admissions from which the patient often recovers and returns home. It can therefore be difficult to predict when a patient has reached a point that they are unlikely to recover one more time and this makes planning for death at home all the more difficult. It is important to recognise that it is never too early to start thinking about what could make one’s death more comfortable.

Terminally ill patients and bereaved relatives report the importance of good communication and well-coordinated care throughout the day and night, and this can need co-ordination across multiple agencies, so it is essential that patients and their carers can access the right service at any time to avoid unnecessary suffering or avoidable admission to hospital.

As well as support for physical symptoms (mostly pain and nausea), there is often a need for good mental, social and spiritual care. Holistic support for a dying person needs to reflect their social, family and financial circumstances. Regardless of whether they follow a particular religious faith, death can bring questions of our significance, regrets in life, need for closure and future bereavement which chaplaincy teams are highly skilled in listening and responding to. Following death, bereavement in those left behind is natural but can on occasions become crushing without appropriate support.

A recent national audit has revealed variation in the hospital care of dying patients. For example only 4% of patients who died in hospital had documented evidence of an advance care plan before their final hospital admission. In 2015 only 11% of hospitals had 24 hour, seven day a week face-to-face access with a specialist in palliative care, and 37% of hospitals had face-to-face access seven days per week between 9am and 5pm. Many hospitals depended upon telephone contact for specialist advice out-of-hours(13).

People in Dudley aged 65 years and over are less likely to die in their usual place of residence than the England average. Although this rate is declining in line with national and regional trends it remains higher and this indicates a need for partners to understand the need for End of Life Care and develop a clearer understanding of the level of demands and how to meet end of life care needs in the Borough.

Key messages

  • Seasonal flu and pneumococcal infection vaccination in Dudley has declined
  • The prevalence of long-term conditions and multiple long term conditions is rising as the population ages.
  • Inequalities in identification of long term conditions exist, with practices in more deprived areas tending to have a larger gap between the numbers of patients actually on long term conditions disease registers compared to those expected.
  • Successful volunteer led self-management can reduce demand for, and costs of, health care, and include education, psychological strategies, practical support, and disease-specific training.
  • Frail older people are at higher risk of experiencing poorer outcomes if admitted to hospital as an emergency, particularly if they are delayed in an emergency department.
  • Partners in Dudley are at the forefront of national work to implement a New Model of Care which is delivered by a Multi Specialty Community Provider, which will develop integrated health and social care services for people with long term conditions and for frail older people.


  1. Partners from the NHS, Dudley Council, the wider public and voluntary sectors should work together and with older people to deliver a programme to tackle the reduction in screening and immunisation uptake among older people in Dudley.
  2. NHS and social care providers should take extra steps to increase uptake of seasonal flu in staff who provide front line care to older people and this should be reinforced in contracts.
  3. Maximise the impact of the invitation for a NHS Health Check and ensure that older people with risk factors receive measures to reduce their risk both within primary care and through the planned One You Dudley service to support people to change unhealthy behaviours.
  4. Increase early identification of long term physical and mental health conditions and cancer by delivering a programme to raise awareness of signs and symptoms within communities and to identify and overcome barriers to presentation to health services.
  5. Build on the success of healthy living pharmacies and opticians to develop health and care services (including hospitals) as health promoting settings, which make every contact count to prevent, improve the management of long term conditions and are designed as age-friendly and dementia friendly.
  6. Undertake routine surveillance and analysis of emergency admission rates for long term conditions that can most appropriately be managed in the community to inform the further development of services provided through the new model of care.
  7. Develop an integrated falls prevention pathway which includes encouraging the whole population to improve their bone health from early age, promotes physical activity and healthy eating, identifies people at risk of falling as early as possible – before they fall and enabling them access to appropriate services.
  8. Undertake assessment of the current and future needs and assets of the frail elderly in Dudley to ensure that they continue to be reflected in the New Model of Care.
  9. Partners should develop a greater understanding of current and future needs and demands for end of life care in the borough and take steps to meet these needs.
  10. Maximise the effectiveness of telecare across the healthy ageing system.


  1. Confederation, N.H.S., Age, U.K. and Local Government Association, 2012. Delivering Dignity: Securing dignity in care for older people in hospitals and care homes. A report for consultation.
  2. Department of Health (2012) Long term conditons compendium of informaton. Available at: (Accessed: 21 September 2016).
  3. Barnett, K., Mercer, S.W., Norbury, M., Watt, G., Wyke, S. and Guthrie, B., 2012. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet, 380(9836), pp.37-43.
  4. Statistics, O.F.N. (2016) Provisional analysis of death registrations: 2015. Available at: (Accessed: 21 September 2016).
  5. Damiani, G., Basso, D., Acampora, A., Bianchi, C.B., Silvestrini, G., Frisicale, E.M., Sassi, F. and Ricciardi, W., 2015. The impact of level of education on adherence to breast and cervical cancer screening: Evidence from a systematic review and meta-analysis. Preventive Medicine, 81, pp.281-289.
  6. Kharicha, K., Iliffe, S., Harari, D., Swift, C., Gillmann, G. and Stuck, A.E., 2007. Health risk appraisal in older people 1: are older people living alone an ‘at-risk’group?. Br J Gen Pract, 57(537), pp.271-276.
  7. Goldberg et al (2012). The prevalence of mental health problems among older people admitted as an emergency to a general hospital. Age and Ageing 2012:41: 80-86, 2012; and Dignity in the Care of Older People. J Morris. BMJ 2012;314:e533 doi:10.1136/bmj.e533, 2012
  8. England, N.H.S., Safe, compassionate care for frail older people using an integrated care pathway: practical guidance for commissioners, providers and nursing, medical and allied health professional leaders;[cited 2014 Dec 11].
  9. Centre for Ageing Better (2015) Later life in 2015: An analysis of the views and experiences of people aged 50 and over. Available at: (Accessed: 21 September 2016).
  10. Ismail, S., Thorlby, R. and Holder, H., 2014. Focus On: Social Care for Older People Reductions in Adult Social Services for Older People in England. The Health Foundation and Nuffield Trust, London.
  11. Harrison, S., 2014. Leadership Alliance for the Care of Dying People, ONE CHANCE TO GET IT RIGHT: Improving People’s Experience of Care in the Last Few Days and Hours of Life. London: LACDP, 2014, 168pp.(Pbk). Publications Gateway Reference 01509, free of charge. Health and Social Care Chaplaincy, 2(1), pp.146-148.
  12. Department of Health (DH) (2008) End of life care strategy: Promoting high quality care for all adults at the end of life. Available at: (Accessed: 21 September 2016).
  13. Royal College of Physicians (2016) End of life care audit – dying in hospital: National report for England 2016. Available at: (Accessed: 21 September 2016).



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