Helping older people maintain their independence

West Suffolk Council and its partners were keen to better understand each service’s pressures, targets and objectives for its older residents.

Design in the public sector

In 2015, West Suffolk Council’s housing service, Suffolk County Council’s Adult Social Services, West Suffolk Clinical Commissioning Group and the area’s largest housing association, Havebury Housing Partnership, worked together as part of the East of England Design in the Public Sector Programme, delivered by Design Council in partnership with the Local Government Association. The team’s challenge focused on tackling an increasingly complicated services issue around supporting older people to maintain their independence.

The Challenge

An ageing population is creating a challenge for service providers across the UK. Preventing unplanned hospital admissions and ambulance call-outs for older people is increasingly a priority as the need for financial efficiency intensifies. Older people living in sheltered housing receive day-to-day support from their housing provider, social services and others, yet this doesn’t appear to have substantially reduced hospital admissions.

Data collected for this multi-organisation project shows that across ten sheltered housing schemes, there are around 11 unplanned hospital admissions a month. With each acute hospital admission costing upwards of £1,000 to the health service alone, halving this rate of unplanned admission would see an immediate annual saving of £66,000 to £100,000 with more savings to come as the approach is rolled out to other providers of sheltered housing accommodation in the area and the secondary benefits to other services are quantified.

West Suffolk Councils, West Suffolk Clinical Commissioning Group (CCG), and Suffolk County Council’s Adults and Communities Service, all recognised the increasing needs arising from the area’s older population and were keen to come together to better understand each service’s pressures, targets and objectives for this group of users.

In one way or another, all the service providers had included the need to address housing, quality of life and improving care services for the older community in their short and long term strategies, and they had already been working together on these. Since 2014, officers from Social Care, Housing and the CCG have been co-located on the third floor of West Suffolk House in Bury St Edmunds, allowing them to consolidate existing partnership relationships and to forge new ways of working.

Engagement and action

As people get older, their housing needs often change. The rising demand for services, coupled with the need to reduce public expenditure provides a need to ensure our services work together. As West Suffolk’s older population is larger than the national average – and on the increase – the council realised that if it failed to identify and plan for the challenges posed, it would face managing crisis scenarios for a number of years to come.

The team’s original challenge was to reconsider the design of services aimed at maintaining older people’s independence. Some older people need support to be able to continue living in their own homes. The organisations’ priority is to prevent older people having to resort to higher cost hospital and residential care solutions.

Admissions to hospital are an increasing source of pressure on health service resources and reducing this is a high priority. It is important to manage inappropriate unplanned hospital admissions by providing alternative interventions and support for the individual experiencing a crisis situation.

It was evident from preliminary discussions and investigations that no in-depth study of sheltered housing residents’ hospital admissions had been undertaken previously. The team therefore agreed to focus on inappropriate unplanned admissions to hospital from sheltered housing.

A local registered provider of affordable housing, Havebury Housing Partnership, agreed to work with the team on the project. Havebury commenced the collection of data on admissions to hospital or ambulance call outs from mid October 2015 for their 10 sheltered housing establishments in West Suffolk, and continue to do so as it provides useful insight into levels of activity and highlights potential areas where additional support/advice could be provided to specific units.


A positive impact of the project to date has been the relationship building between individuals working within different organisations, the shared learning and problem solving. This has helped identify the constraints and potential within partner organisations and, in particular, they have commented that working with Havebury Housing Partnership has been very informative and valuable. Havebury has embraced the challenge of the project and proactively added different dimensions to it.

Information sharing is now taking place regarding alternative support to acute interventions, such as hospital admissions via A&E, or long term residential care. Early analysis indicates that there are potentially approximately a third of unplanned admissions to hospital that are inappropriate and that could have been better supported in other ways. The team foresees a reduction in A&E admissions resulting from falls, reduced social isolation and fewer delayed hospital discharges.

Valuable links have already been made between Havebury and the newly developed Early Intervention Service (a team including therapists, nurses, social workers and carers). The team is able to respond to individuals in a crisis situation, providing the necessary assessment and support and, importantly, avoiding a potential attendance or admission to the acute hospital.

The project team will continue to work with Havebury Housing to increase the data set and its understanding for reasons for admission to hospital, and generally share information on support for individuals in West Suffolk to help keep them healthy and safe in their home environment.

Update: October 2016

Since February 2016, the positive impact of relationship building between individuals working within different organisations as highlighted above originally continues, including that with Havebury Housing Partnership which continues to provide value and insight.

Feedback from Havebury to date is that the reporting procedure and its format allows them to see clearly who are the frequent users and provides the opportunity to consider alternative interventions/services that could potentially avoid crisis situations and so reducing ambulance call outs and hospital admissions. The Independent Living Advisers have found that having the data in one place has meant they are able to use it as a reference point and identify patterns – all highly beneficial when talking to family and medical professionals. This project has also enabled an invaluable link to the Early Intervention Team for Havebury, allowing them good understanding of the service they offer.

West Suffolk and the CCG will continue to review admissions and identify emerging ‘themes’ and patterns in order to assess where admissions may have been avoidable, and identify what other processes could be used. All this will support the continued partnership working, and links to other on-going projects such as Think Big and the Connect Initiatives.

West Suffolk logic model


Julie Salisbury
Housing strategy & development officer
West Suffolk Councils