Delivering sustainable solutions for Adult Social Care

Throughout the UK, increasing demographic pressures are leading to higher demand for both acute and community care services. This increase is resulting in a need to reduce pressures on the acute and shift the delivery of care in the community, to manage future demand through preventative techniques and to ensure that people can be cared for closer to home.

Integrated care is now a key focus for Health and Social Care throughout the UK. The undertaking of this is often hindered by isolated working practices. When in fact there is a need to collaborate between pathways of ‘acute’, ‘primary’ and ‘social’ care.

Peopletoo were compliantly procured through Bloom and NEPRO to address this and implement innovative changes to health and social care integration projects for our customer.

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Peopletoo worked with a local authority, health board, the third sector and other partners on innovative health and social care integration projects. Including the Older Persons Integrated Care Pathway and the Care Closer to Home Plan. The primary objectives of these projects included:

•    To keep people living safely and independently in their own homes. 
•    To reduce non-elective hospital admissions and A&E attendances.
•    To avoid unnecessary admission into institutionalised care.
•    To develop effective anticipatory care planning.
•    To develop a continuum of multi-agency provision, deploying the right resources at the right time.
•    To develop capacity for effective early prevention.
•    To develop outcome focused service provision within a community setting as an alternative to primary care.


Through Bloom and NEPRO, Peopletoo were compliantly procured to design and support the delivery of an integrated pathway for the older people that reside in the area. The Pathway is a move away from a ‘demand’ to an ‘intelligence’ based model.

A locally developed risk stratification tool was used in GP practices to identify individuals with a risk score of 3-7% who, if they were to endure a crisis, would be forced over the ‘tipping point’ into the category of high needs service users requiring long-term care and support (top 1-3%).

By proactively engaging this group and providing low- or no-cost support costly and frequent use of more expensive services can be prevented.

This differs from the majority of risk stratification tools used elsewhere, which identify and proactively manage the care needs of those individuals with high needs.

Care Facilitators are based in GP practices and visit eligible patients to create a ‘Stay Well Plan’ (SWP). SWP’s are created with individuals and their families utilising motivational techniques to create positive behavioural change.


These projects built upon significant work undertaken by both the health board and the Local Authority, supported by Peopletoo and resulted in savings in excess of £12m per annum.

These projects have contributed towards improving performance across the system. Reducing the DToC rates by 63% and the rate of older people supported in care homes by 21%.

•    A significant reduction in attendances at A&E (22 out of 100 attendances prevented) and in emergency admissions (15 out of 100 attendances prevented).
•    A significant reduction in Frailty (CRT) episodes (10 out of 100 episodes prevented).
•    Fewer people that participated in the Older Persons Integrated Care Pathway programme received Social Care packages and for those that did access, a reduction in the length of package.

“Peopletoo were proud to have  collaborated with various stakeholders to implement these innovative solutions that are delivering tangible benefits across health care systems”

Kirsty Jordan
Services Director, Peopletoo