Enabling older people to live the life they choose in Birmingham

Understanding the scale of the challenge

As a system, we recognise the need to improve older people’s experience of health and social care in Birmingham and ensure their long-term health and happiness.

In the past, instead of working together, we have responded as individual organisations to the problems faced by older people using our services and the challenges faced by staff. This has resulted in a series of ‘sticking plasters’ rather than a single, unified, whole-system plan that we all agree to.

As a result, we completed a diagnostic across the whole system in Autumn 2017, alongside Newton. It highlighted several opportunities to improve care for older people by focusing on:

• People admitted to hospital who could be better looked after elsewhere

• People in elderly care and longer stay wards who are medically fit but delayed, waiting to leave hospital

• People who would benefit from a different pathway out of hospital, one better suited to their needs

• Achieving greater independence following a stay in a short-term bed

• Improving enablement services for people who need them

The resulting Early Intervention workstream will address these opportunities. It has been initiated by the Birmingham and Solihull Sustainability and Transformation Partnership and is being jointly delivered by health and social care organisations. Our workstream is just one part of the Birmingham Older People’s Programme which wants the right care, at the right time, in the right place for all older people in the city.

Early Intervention Vision

The vision of the Early Intervention workstream is underpinned by a recognition that sometimes older people will need treatment and support for a short period of time, but that this should be designed to promote faster recovery from physical and mental issues associated with ageing, illness or injury.

Our aim is to prevent hospital admission when it is not necessary, support appropriate discharge from hospital and maximise people’s ability to lead independent lives outside the system. We will try to prevent premature admission into long-term residential care, minimise delays and avoid taking decisions about long-term care in a hospital setting.

We want to ensure people remain in their homes whenever possible. In most cases, older people are more comfortable in their own homes and recover and regain their independence more quickly if good quality therapeutic support can be provided.

People will have to tell their story only once and will have a single coordinated plan tailored to their needs and desired outcomes. They will know who to talk to for help during this time and who will be supporting them if they need ongoing support.

Improvement Managers

Eight members of staff from across health and social care, both clinical and non-clinical, have been recruited onto the Early Intervention workstream as full-time Improvement Managers (IMs). They will work alongside frontline teams to achieve our vision on the ground.

Over the past few weeks, the IMs have completed a training academy to understand more about each other’s organisations and the difficulties each of them face, as well as more about the Early Intervention workstream and how we can work together to implement the changes needed.

Next steps

Over the next year, the Early Intervention team will be working with hundreds of frontline staff across all organisations involved in the programme and the Newton team. Frontline teams will design, test and implement new ways of working that transform how we care for older people in Birmingham and ultimately achieve our vision.

Abigail Bychmore

Early Intervention - Improvement Manager

Seconded from Birmingham and Solihull Mental Health Foundation Trust


  • Acute
  • Acute > Medicine
  • Acute > Medicine > Preventing delayed discharge
  • Social Care
  • Social Care > Integrating health and social care
  • Commissioning and Procurement
  • Commissioning and Procurement > Fabulous Stuff
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