Joint Forward Plan Appendix 10

Appendix 10: Detailed Live Well Domain Plans – Age Well

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1.1 Age Well – Supporting people and their carers to live safely and independently as they grow older

1.1.1 Ageing Well Programme

Why is this important for people in Suffolk and North East Essex?

People in England are living longer than ever before, and as result, the number of older people in England is growing significantly and is projected to increase further over the next 20 years. While an indication of improved health and wellbeing, this creates challenges, as increasing age is associated with an increased prevalence in long term conditions and higher health and social care needs.

Frailty is more common with increasing age, with 10% of those aged over 65 living with frailty. Older people can have complex health and care needs, long-term conditions, functional, sensory, or cognitive impairment are the highest cost and volume group of service users.

Dementia accounts for more expenditure than heart disease and cancer combined. It is important to prevent frailty and deterioration in those already frail.

The Ageing Well programme within the NHS LTP is a blueprint for attenuating rising health service demand. It promotes healthier ageing and begins to address inequalities through PHM. Evidence suggests fragmented, reactive, and poorly coordinated care for frailty produces poor functional outcomes, dependency and increases services’ demand and costs.

The WHO Integrated Care for Older People (ICOPE) model is a model which supports health and social care workers in community settings to detect and manage declines in intrinsic capacity and to comprehensively address the health and social care needs of older adults. The measurement of intrinsic capacity and decline of that capacity within a model is closely aligned to the cumulative deficit model of frailty, and thus the principles of the iCOPE model to:

• improve musculoskeletal function, mobility, and vitality
• prevent severe cognitive impairment and promote psychological well-being
• prevent falls
• maintain sensory capacity
• manage age-associated conditions such as urinary incontinence
• support carers

What do we know about people’s local experiences?

The number people living in SNEE aged 85+ is set to increase by 49% in the next ten years (compared with 33% for England).

As of February 2023, ESNEFT is developing a comprehensive, joined up strategy for frailty. This strategy treats frailty as a chronic health condition that requires appropriate interventions both medical and social. We will embed this in all parts of the health and social care system working with our partners and particularly the neighbourhood teams.

Frailty and its consequences are major drivers for the pressures in all parts of the system and pro-active management should help to reduce this pressure. The North East Essex Alliance is developing a template based on the Rockwood frailty score, particularly for use in primary care but also on wards and within community services.

How we plan to make a difference:

• to enable the ageing population to live a healthier life for longer in the persons preferred place of residence
• people with frailty are supported at home and unnecessary hospital admissions are avoided
• to have an active ageing population

To enable the ageing population to live a healthier life for longer in the persons preferred place of residence

People can prepare for later life

Promote public awareness of advance care planning, power of attorney and register of choices. Decisions and power of attorney should be recorded on shared digital care records to help inform care planning.

Anticipate the health, care and wellbeing needs of the population by identifying people at an earlier stage and providing a multi-disciplinary approach to their needs to avoid unnecessary hospital admission.

People are empowered to take control of their own well-being and have the tools and techniques to proactively manage their own care.

Support advance care planning and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) conversations at an earlier stage.

To increase the number of residents accessing Integrated Urgent Community Response Services to be treated and remain safely at home.

To increase the number of residents accessing older people’s mental health services in the community.

Complete resident surveys to assess satisfaction in care home and community settings.

To have a more healthy and active population at age 65 plus.

Older people have support to stay healthy

Encouraging people to live as healthy a lifestyle as possible, through information and advice, making every contact with health and care services count.

People have direct access to local health and social care services with support from the VCSE sector.

For all people in SNEE to have access to a responsive, multidisciplinary service when they become unwell, or have an acute deterioration in their function or wellbeing.

Consistent commissioning of health checks for over 75s, in particular for people with dementia. Checks should include medication reviews and advice on prevention of frailty and dementia.

Flexible working for older people and their carers. Flexible working patterns can keep people active and connected socially, ensuring older people and their carers receive all the welfare benefits they are entitled to. It is particularly important to recognise the challenges people who receive benefits but do not have enough income to look after themselves and stay healthy.

Providing widely available information on recognising the signs of Frailty, mild cognitive impairment, and possible dementia, including among ethnic minority groups, and where to obtain help and advice

Older people do not face stigma, discrimination, or disadvantage.

We will improve public awareness of age-related discrimination and the stigma of ageing. Older people are just people, we should focus on dignity and respect and positive ageing; taking an inclusive approach that includes protected characteristics.

Staff working with older people will be trained in stigma and discrimination, and the needs of people with dementia. This should in target supported living and sheltered housing environments, domiciliary care agencies, care homes and public spaces, to ensure all environments are dementia friendly.

We will encourage intergenerational approaches. Enabling young people to interact more with older people breaks down barriers and misconceptions.

People with frailty are supported at home and unnecessary hospital admissions are avoided

Older people are safe in their homes

Reduce the number of people falling and subsequently attending and being admitted to hospital.

Increased clinical frailty scoring for the population aged 65 plus and utilise appropriate community pathways of care.

Decrease the predicted trajectory of attendances at hospital for people aged 65 plus.

Investing in Raizer Chair falls lifting equipment, particularly within care homes and community response teams, to reduce the impact of falls and provide links into community services that can support people to remain independent.

Increased investment into digital tools such as Pendant Alarms, falls sensors and wearable monitoring devices that enable people to safely remain at home and raise the alarm when assistance is needed.

Older people’s health is closely monitored to identify risks and prevent frailty, illness, or injury

Encouraging home-based and wearable monitoring equipment such as location trackers for people with dementia or home testing for people taking blood thinners. Predicting events helps to prevent incidents that could lead to a hospital admission and can enable earlier discharge from hospital. Linking monitoring data to personal health records supports sharing of records and integrating support.

For people at risk of falls, providing support such as falls prevention schemes, technology such as sensor equipment and pendant alarms, information, exercise classes and strength and balance training. Such schemes can significantly reduce the likelihood of falls and the need for admission to hospital. A community-based frailty team approach will proactively identify and support people with a personalised support plan.

Targeting people with mild and moderate frailty including people with additional needs such as learning disabilities. Targeted interventions have the potential to prevent deterioration and improve health. Domiciliary care that focuses consistently on enablement and independence. Care packages with sufficient time, quality, and capacity to care helps reduce people’s dependency on carers and helps prevent deterioration.

Older people will have access to integrated physical and mental health support tailored to their health needs

We will offer people who have the greatest risks and needs targeted physical and mental health support. This will help them in self-care, and to access integrated support – including diabetes, musculoskeletal, heart conditions, dementia, and frailty. Joined up services will also enable the persons story to be told once and avoid repeating the same story to multiple professionals.

AHPs will work directly with older people in primary care. Advice on falls prevention, environmental adaptations, nutrition, exercise etc. helps prevent deterioration, crisis, and hospital admission Care homes will have support from primary and community services to manage crises, with specialist input.

We will improve access to NHS Talking Therapies for older people with long term conditions, including dementia, and for carers.

People in their own homes and in care homes can connect with their communities

We will develop peer support schemes. This can include face to face groups, online support, community hubs, drop-ins, and good neighbour schemes.

We will promote schemes that engage homes with their local communities. People in care homes in particular can become isolated; greater contact promotes wellbeing.

Older people have greater choice and control over their care Application of the NHS Comprehensive Model of Personalised Care including people with dementia. The Model enables people to contribute to their care planning and delivery and ensures they and their carers have access to local support from within their own communities.

We will increase the number of older people receiving personal budgets, personal health budgets, and direct payments, including those with dementia. Take up of these schemes is low partly due to lack of choice of providers; improved uptake helps people have greater input into their care.

To have an active ageing population

An active ageing population can reduce the impact of mental and physical health conditions resulting in a healthier and longer life

To improve the amount of referrals into the Strength and Balance programme and boost delivery to more residents, including care homes.

Improve the number of people engaged with Alliance commissioned activity-based community groups, in partnership with our voluntary community sector.

To increase physical activity in care homes with programmes to boost residents’ movement.

To work in collaboration with Public Health organisations to support the delivery of activity to our community.

We will know we are making a difference because we will see:

• an increase in disability-free life expectancy at the age of 65 by 2028
• reduced rates of severe frailty or increasing frailty by 2028
• fewer emergency hospital admissions due to falls in people aged 65 and over by 2028
• higher rates of people with joined-up mental and physical health services for the older population by 2028
• more carers identified and supported by 2028

Case Study: Strength and Balance Programme

Mr J is an 80-year-old gentleman residing in a care home in Colchester. He has Insulin dependent diabetes mellitus (IDDM), hypertension and vascular dementia. He moved to the care home in 2020 as he was having lots of falls at home and could not cope living independently. He relied heavily on his walker frame and was falling over at least once a week.

He completed all 12 sessions of his strength and balance course which was hosted at his care home. By the end of the programme, he had stopped having falls altogether and has not had a fall since.

Mr J continues to complete his Otago exercises with encouragement from the activities coordinator at the care home. He has his own booklet that he ticks off as he completes the exercises each day.

Mr J is feeling stronger and appears more confident. He is now completing short walks without his walker and is helping out at activity time at the care home by picking up the bowls equipment.

Case Study: Raizer Chair Pilot

SNEE ICB has implemented falls lifting chairs and a post falls decision support tool in 20 of their care homes. In the past, these care homes defaulted to calling 111 or 999 following a fall, resulting in long lines, and unnecessary ambulance callouts and hospital admissions. By providing these care homes with the necessary tools, the care homes have been able to reduce ambulance callouts and improve outcomes for the residents.

Felgains have supported this pilot scheme by providing the HelpFall post falls decision support tool – to help the care staff safely assess and lift fallen residents – and the Raizer 2 Lifting Chair – to help care staff lift fallen residents up from the floor quickly and safely.

Across the 3-month pilot period, SNEE has seen an 84% reduction in ambulance callouts to care homes, an 80% reduction in ED attendances from care homes using HelpFall, and the percentage of ‘no abnormality conveyances’ has decreased from 27% down to 0%.

These statistics show the very positive impact that this project is having, both in terms of cost and time savings for the ambulance service and E.Ds.’ SNEE ICB is now looking at how we can widen this project out to include more homes in the area.

1.1.2 Dementia

Why is this important for people in Suffolk and North East Essex?

Dementia describes a set of symptoms that include loss of concentration, memory problems, mood, and behaviour changes, as well as challenges with communicating and reasoning. These symptoms can occur when the brain is damaged by certain diseases such as Vascular or Alzheimer’s.

Dementia is a progressive condition and affects the quality of life of those living with dementia as well as their family and friends. It is a complex condition that can cause physical, neuropsychological, emotional, and financial stress.

Evidence shows that 40% of dementias are preventable through action across an individual’s life course. Research undertaken (Lancet Commission) identifies a call for nine ambitious recommendations to be undertaken by policymakers and individuals in their areas. Alongside are those caring for a loved one living with dementia and there is a need to ensure people are diagnosed and have the best support available to live well with dementia and in the community.

Public Health England suggests that 60% of people with dementia are more likely to be lonely. Approximately 60% of people with dementia go out of their houses less than once a week and in sparsely populated rural areas, it is harder for older people living alone to find the opportunity to mix with others.

Important factors for people are a timely diagnosis, support for those with dementia and the family/carers to live well in the community.

What do we know about people’s local experiences?

In SNEE, latest census showed 257,300 people aged 65 or over in the locality – almost 1 in 4 and more than 72,000 live alone. In 20 years’, time this will have moved to 1 in 3 along with the number of people aged 85 or over almost doubling in the same time period. These longer lives are a success story, but as people live longer, many more people will develop dementia and will need support.

Predicted prevalence of people aged over 65 with dementia in the community increases monthly in line with the ageing population. In September 2022, the locality prevalence was predicted at 15,681 of which 9,456 people in SNEE have a recorded diagnosis. This equates to a diagnosis rate of 60.3%. It is also important to recognise those with young onset dementia (under 65) of which there are 284 recorded diagnosis, slightly lower than the national average.

1 in 5 people aged 65 and over in SNEE are estimated to have a limiting long-term illness that limits day-to-day activities.

Key local findings are:

• services can be fragmented and hard to navigate with reliance on the carer who themselves seek support
• the time from referral to diagnosis and accessing further support for those experiencing dementia and the family / carer can be lengthy and has been further impacted by the pandemic
• current avenues of support do not always help the person, carers, and families to withstand the emotional pressures they face
• dementia cannot be seen and continues to carry a stigma with the need for greater community awareness
• family carers are not aware of the range of alternative options in the community to residential care
• existing pathways push people toward residential care because the right support can’t always be found in the community
• identified requirement to derive a greater knowledge and skillset across the workforce to improve the levels of dementia care with consideration for advanced care planning
• understanding the importance of what “dementia” means and its impact on marginalised communities, including ethnic minorities, LGTBQ+ prisons and homelessness
• young-onset dementia has a growing prevalence and tends to come with additional complexities without the appropriate services available to support

How we plan to make a difference

In May 2022, the Government announced a new 10-year plan to tackle dementia and boost the £375m funding already committed for research to better understand neurodegenerative diseases. The plan aims to reduce the 40% of dementia considered to be potentially preventable, including exploration of new technology, science, and medicine to help reduce the numbers and severity of dementia. It also aims to help reduce the NHS backlog because of Covid-19 to ensure more timely dementia diagnosis.

As part of this there was an ask for local dementia strategies to be coproduced considering national and local plans. A revised Southend, Essex and Thurrock (SET) 2022-26 Dementia Strategy will be published in early 2023 and Suffolk in conjunction with Waveney, have commenced scoping and engagement to deliver a country wide strategy later this year (2023-2028). This will embed a long-term commitment to enable better links between health and social care systems, utilise community assets and ensure that the person living
with dementia and their carers/families are at the centre of everything.

There are a range of programmes of work underway across SNEE, inclusive of plans for the future which will evolve as the strategies are published.

We will focus on the following:

• achievement of the national 66.7% dementia diagnosis rate by October 2024 and an increase in dementia annual care plan reviews completed year on year until 2028
• the reduction of memory assessment backlogs and delivery of a timely dementia diagnosis in line with national standards by March 2025
• in line with transforming models of care within communities, individuals will be able to obtain a dementia diagnosis within primary and community care settings (where appropriate) by 2026
• delivery of a seamless, integrated package of services linked to frailty services to respond proactively to those with dementia or suspected dementia and their carers in their own homes and community settings by 2027
• an ongoing awareness and information programme across the next 5 years focused on both health and social care professionals as well as wider community services with a focus on those hard to reach and from marginalised communities. This could include delivery of the Virtual Dementia Tour, the Dementia Infolink and general dementia awareness education across the system
• continue working with system partners to derive dementia friendly communities, expanding community assets to support those living with dementia inclusive of family and carers via the relevant system governance including the SNEE Alliance’s and Essex and Suffolk Health and Wellbeing Boards

We will know we are making a difference because we will see:

• delivery of the SNEE ICB diagnosis rate of at least 66.7% by October 2024
• every individual diagnosed with dementia, including their carer or family offered and able to access support within communities to support later life modifiable risk factors by 2025
• vidence of dementia assessments/diagnosis taking place outside of specialist services and within community environments by 2026
• delivery of the diagnosis pathway that presents an average duration of referral to diagnosis for dementia within six weeks by 2027
• year on year increase of annual care plan reviews being completed for those diagnosed with dementia up until 2028

Quote: “The prevalence of dementia is ever increasing and those who live with such diseases are still people. They have their own unique personality and character and are frequently capable of so much more than we can imagine. With the appropriate facilities to obtain a timely diagnosis and the right awareness and support, it is possible for people living with dementia to remain and live in communities happily and with a good sense of purpose and value. In SNEE we are committed to working in partnership with all agencies including those with dementia and their family/carers to improve and build networks and relationships across communities to enable better access to care and support that is compassionate, grounded, and available in every facet of day-to-day life.”

Sue Hughes (Co-Chair of the Suffolk Dementia Action Partnership and Chair of the Suffolk, North East Essex, and Waveney Dementia Forum)

Case Study: Anne’s Story

Anne has had a longstanding history of depression and anxiety due to a number of significant bereavements, since 2016 Anne has had underlying depression and anxiety with regular GP visits saying that she “did not feel good” and prescribed anti-depressants. Anne was given a CPN via the GP who she saw for monthly sessions to discuss her depression, and also paid for private counselling.

By 2018 Anne’s memory loss began to become more prominent when her daughter received a distressed phone call when she had had a complete memory lapse. She could not remember where her daughter lived or how to get there by car. Her daughter took her to an open surgery as she was so concerned about her, the GP was very dismissive of her symptoms putting this down to the long history of depression and anxiety. The GP implied that as her mother came across as articulate and looked immaculate, which because of this her daughter felt that her decline in memory loss was not taken as seriously as it should be, a GP COG was undertaken and the results were seen as ok so was not taken any further, despite the concerns of the daughter.

At the end of 2019 Anne’s daughter paid for a private psychiatrist as felt they were not getting anywhere with the practice as they had seen 2-3 different GPs and a CPN who all appeared dismissive of the daughters concerns that there was something more going on.

The psychiatrist concluded that Anne’s memory loss was more than just anxiety and depression, they wrote to the GP with the recommendation that Anne attend a memory clinic.

Anne did not understand why she needed an assessment, and her partner didn’t really want to have further assessment as he didn’t want to think about the fact, she may have dementia. It was finally agreed by the GP to make a referral to the memory assessment team.

Anne attended a memory assessment clinic in 2020, followed by CT and MRI scans and a psychology assessment. In November 2020 this resulted in a diagnosis of Alzheimer’s Disease, which was given over the phone due to the pandemic. Her daughter was left to have difficult conversations with her mother about giving up driving as she was increasingly concerned that her mother’s ability and safety had further deteriorated over the diagnosis period.

Anne’s daughter felt that a carers concerns about the health of their loved ones should be taken seriously at the early stages as they know that person more than anyone else, despite continuing to flag with professionals she felt that her opinions was dismissed. Having a diagnosis has helped Anne’s daughter understand why she has behaved the way she has over the years, to understand the diagnosis and help find coping mechanisms to support Anne and prepare for the future. Anne has little understanding of her own diagnosis and frequently forgets that she has dementia, which has led to challenging conversations regarding her mother’s ability and safety.

1.1.3 Carers

Why is this important for people in Suffolk and North East Essex?

The term carer in this section, refers to those people of all ages with caring responsibilities (anyone who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support.

It is likely that every one of us will have caring responsibilities at some time in our lives. Juggling caring with education, work and other family commitments means that your own health, relationships, and finances can be adversely affected, and your own personal needs can often go unmet.

In recent years across SNEE, we have engaged with adult carers, young carers, parent carers and those caring for individuals with specific conditions. We have spoken to VCSE groups, practitioners, and carers’ champions about many aspects of the caring role and engaged with health and social care organisations to fully understand the need across SNEE.

What is the current picture?

• Estimated by Carers UK in 2022 (Carers week research report), the number of unpaid carers nationally has gone up from 6.5 million in 2011 to 10.6 million in 2022. This means that 1:5 adults in the UK are currently providing care
• The largest age band of carers is 55 – 64 years (Survey of Adult Carers, 2021-22)
• The average age of ‘sandwich carers’ (those caring for more than one person) was 40 – 54 (Carers UK)
• There has been an increase in carers reporting that their health has been impacted by their caring role. In 2021-22, there was an increase in the proportion of carers reporting general feelings of stress and feeling depressed, year on year from 2016/2017 – 2021/2022 (Survey of Adult Carers, 2021-22). 1:7 employees are carers. 1:6 give up work or reduce their hours to care (Carers UK)

The Census 2021 shows that the provision of unpaid care has changed overtime in England:

• decreases in the proportions who provided 19 hours or less of unpaid care a week in England (from 7.2% in 2011 to 4.4% in 2021)
• increases in the proportions who provided between 20 and 49 hours of unpaid care a week in England (from 1.5% in 2011 to 1.8% in 2021)

The proportions of people who provided 50 or more hours of unpaid care a week remained similar in England (2.7% in 2011, 2.7% in
2021).

Key findings for SNEE ICS from the July 2021 GP Practice Survey are shown below. In SNEE ICS, 27,683 questionnaires were sent out, and 12,676 were returned completed. This represents a response rate of 46%.

• 19% of carers were providing 50+ hours of care a week
• 51% of carers were over the age of 55
• 63% of carers reported a long-term health condition, disability or illness compared to 53% of non-carers
• 17% of carers said they had felt isolated from others in last 12 months
• 14% of carers reported a long-term mental health condition compared to 10% of non-carers

The NHS LTP recognises that carers make a vital contribution to the NHS and strives to improve the recognition of carers, and the support they receive. In Suffolk, projections suggest that the number of people aged 65 and over who provide unpaid care will increase between 2019 – 2035, from 25,300 to 33,700 (an increase of 33%)

Based on data trends from the Survey of Adult Carers in England (S.A.C.E.) 2021-22, it is anticipated that carers’ health will continue to be impacted, with increasing social isolation, feelings of stress and depression, and many feeling they do not have enough control over their own daily life.

What do we know about people’s local experiences?

In August 2018 there were nearly 8,400 individuals in Suffolk in receipt of carer’s allowance, of whom 3 out of 4 were female. This represents 11.4% of the unpaid carers identified in the 2011 census. It is predicted that there will be an increase of 33% in people who are 65 and over who provide unpaid care from 2019 to 2035.

The state of Suffolk report 2019 found that the population growth since 2011 has been exclusively in the older age groups and is expected to continue. Currently 1:5 people living in Suffolk are aged 65 or over.

This is forecast to increase to 1:3 for Suffolk (nationally it is likely to be 1:4).

Through recent consultation, we heard that adjusting to the role of carer and finding that you have less time for yourself is seen as a big challenge, however carers also stated that the role of a carer can also be rewarding.

Carers in Essex recently reported (2021) being tired, feeling isolated and guilty, and having poor emotional wellbeing. It was also noted that carers often feel that others don’t understand the responsibilities and pressures they face. Many carers would welcome more support from our clinicians, an improvement in social care assessments and reviews, and employers recognising their rights as carers.

How we plan to make a difference

As an ICB, we will ensure that:

• carers are identified at the earliest opportunity
• carers can easily access information, advice and support when needed
• young and young adult carers’ health, education/life skills, choices and opportunities are not adversely affected by their caring role, and they are supported through transition in readiness for their adult caring responsibilities
• we have systems and services in place that work for and support carers, which are developed and influenced by our local carers
• carers can enjoy improved health and well-being across SNEE

Carers are identified at the earliest opportunity

Supporting individuals to be able to tell their story once.

Working with our clinicians to improve professional knowledge, skills, and confidence to enable them to recognise those in a caring role.

Supporting individuals to recognise that they are in a caring role and where to find help.

Ensuring partnership working with local carer organisations.

Carers can easily access information, advice and support when needed

Ensuring information and advice is made accessible at multiple points of contact.

Making information clear, concise, and accessible to all.

Enhancing accessible digital information and advice.

Empowering statutory, voluntary and community organisations locally to identify carers and provide appropriate information, advice, and support.

Assisting employers to support carers in the workforce and those who want to return to work.

Young and young adult carers are not adversely affected

Young and young adult carers’ health, education/life skills, choices and opportunities are not adversely affected by their caring role, and that they are supported through transition in readiness for their adult caring responsibilities.

A family first approach to support young carers, ensuring all the needs of the family are met.

Ensuring that young carers who are not in school have access to the same opportunities as other children / young people.

To better understand what support is needed to facilitate a tailored and targeted transition into an adult caring role.

Developing more safe places for young carers to access someone to talk to.

We have systems and services in place

We have systems and services in place that work for and support carers, which are developed and influenced by our local carers.

Developing the core offer that young and adult carers should have available across SNEE, improving the way that organisations work together.

Listening to carers as expert care partners and acting based on what we hear.

Actively involving people with caring responsibilities in care planning, shared decision making and reviewing services.

Enabling carers to have their support needs assessed and to receive an integrated package of support to maintain and/or improve their physical and mental health.

Ensuring timely information and advice is provided to carers following admission to hospital and prior to discharge.

Supporting the development and recording of contingency plans in the event of an emergency.

Carers can enjoy improved health and well-being across SNEE

Ensuring people with caring responsibilities are not only seen as carers, but also as family members and friends.

Developing systems that encourage healthcare professionals to recognise and identify carers, and ask ‘who is looking after you?’

Developing support when providing care at the end of a caring role with end-of-life care and bereavement support.

We will know we are making a difference because we will see

• an increase in the number of carers identified on GP systems from the 2023 level of 3.4% across SNEE, to 5% by 2028
• more carers identified on GP systems, year on year
• an increase in the number of carers registered with a contingency plan, year on year
• an increase in the number of GP Surgeries attaining Carers Quality Markers developed by NHSE or equivalent, year on year
• increased referral and signposting of Carers across all healthcare settings
• carers telling us that they feel recognised informed and supported via established surveys and provider feedback
• improved signposting to carers assessments with tailored support packages and ongoing review as required

Quote: “It is encouraging to see that the JFP recognises the importance of family carers and has aligned its ambitions with the Suffolk All Age Carers Strategy and the Essex Carers Strategy. This will ensure that family carers are given due consideration within the context of the ICB’s priorities”

Kirsten Alderson – Chief Executive Suffolk Family Carers

Case Study: Jane’s Story

Jane was referred to Suffolk Family Carers by her GP for additional support. Jane provides care for her mother who has escalating needs resulting in her increased anxiety, feelings of isolation and uncertainty of support available.

A Suffolk Family Carer Advisor utilised Health Coaching Approach to assist Jane in identifying her own needs and wishes and provide clarity on level of support required with her caring role. A plan forward has been developed and the Carer feels empowered and supported.

Case Study: Shona and Brandon

Shona and Brandon care for each other. Shona, 51, supports her son Brandon with his learning and mental health difficulties. Brandon, 24, provides Shona with practical support to help her manage the symptoms of her kidney disease.

Shona said “Having someone there just to talk to if I need to have advice or somebody just to listen has helped me immensely as time progressed. I now feel supported which has really changed my caring role for the better. Being registered with Carers First in North East Essex has given me a sense of no longer being alone.”

Brandon said “Caring for mum can be quite difficult, it’s a big responsibility, especially as my mum doesn’t have anyone else coming in to support her, but she is worth it! Having the opportunity to go to different groups and events is a nice distraction.”