Working together to help people age well

A team of clinicians, representatives from hospitals, local VCSE sector groups, care homes and community providers are overseeing a programme of work for the BSW Partnership to help local older people receive the best care.

BSW Partnership’s Ageing Well workstream is pulling together a number of projects all designed to ensure people receive the care they want, as close to home as possible and avoid the risks for older people associated with long stays in hospital.

Dr Robin Fackrell, a Consultant Physician and Parkinson’s Disease Specialist and Associate Medical Director for Ageing Well & Frailty at the BSW Partnership said the broad programme of work was designed to help people live their best lives as they get older.

“People are living longer and therefore have an increased likelihood of becoming frailer. The population in BSW is 4.5 years older than the national average, so we are facing a silver tsunami of ageing and frailty.

“As a health and care system, we need to focus on keeping older people healthy. We also need to think about how we can do things differently by providing individualised care closer to older people’s homes, rather than bringing them to hospital which can be a detrimental environment for them.”

Work under way as part of the Ageing Well programme includes several projects, pilot projects and new initiatives all designed to give older people more choices about their own health and care.

One initiative has seen a single standardised form introduced across health and care services in BSW which allows people approaching the end of their lives to set out what they want to happen to them in an emergency health situation.

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form is a patient held document, completed following discussion between a patient and a healthcare professional.

Using one form across all health and care settings in BSW will mean patient’s wishes are much more likely to be met.

Another pilot project running across five sites in BSW is focussing on the importance of making decisions about healthcare and treatment with patients in a shared way.

Shared decision making ensures patients are supported to make decisions that are right for them.  It is a collaborative process through which a clinician supports a patient to reach a decision about their treatment. The conversation brings together a clinician’s expertise, such as treatment options, evidence, risks and benefits with patient preferences, personal circumstances, goals, values and beliefs.

The Ageing Well team at BSW Partnership would like to hear about your experiences of ageing. Please send any comments and thoughts about your own experiences to

Making choices for end-of-life care

Although it is a difficult thing to think about, what happens to all of us in terms of health and care at the end of our lives is important and the Ageing Well programme in BSW is all about making sure those experiences are as good as they can be.

Dr Robin Fackrell shares one patient’s journey to show how things should be.

“We were seeing a woman with heart failure, kidney disease and diabetes who was very frail. These are difficult diseases to manage together. When we found out the patient was having difficulty getting out of bed and was deteriorating, one route would have been to have her admitted to hospital, and another would be to take the necessary steps to treat her at home. It was clear to us that she wanted to be in her own home.

Through a pilot project – the Swindon community frailty virtual ward which is now called Enhanced Health @Home – and an urgent assessment, the patient was set up at home with monitoring equipment. She was monitored by the community nursing team and regular calls between the community matron and geriatricians at the Great Western Hospital in Swindon.

The patient did eventually get worse, so we brought in help from a local hospice – Prospect House  – and district nurses to make sure the patient had access to the right medication and support.

Sadly, the patient passed away, but she did so in her own bed, with her daughter, feeling well supported and in her home environment. This was far preferable to spending a long period of time in hospital.”