Age UK’s Personalised Integrated Care Programme is helping older people regain their independence

Meet 77 year old Robert.

Living in Thornton Heath, he was never apart from his wife of 45 years who he was caring for as she had cancer.

However, that was all about to change.

After becoming unwell, Robert was admitted to hospital with breathing difficulties where he remained for almost a year, during which time his wife sadly passed away.

When he was eventually discharged from hospital and returned home, he found himself alone for the first time in nearly 50 years, and became fearful about what would happen.

Nervous about using the stairs, he became confined to the top floor of his home, with only an electric heater to keep him warm through the winter as he had no central heating.

“I used to walk to the top of the stairs, look down, and think ‘No, I can’t do it.’”


He also lost weight and began suffering panic attacks for which he needed regular medication.

But things began to change for Robert when his local GP practice, the Brigstock Road Medical Practice, referred him to Age UK’s Personalised Integrated Care Programme.

Health, social care and the voluntary sector coming together

Robert met Age UK Croydon’s personal independence co-ordinator Sylvarani. Sylvarani worked with Robert to draw out his goals, his main one being to live more independently in his own home.

Together, they worked to create a care plan which brought together services from across the health service, the council and the voluntary sector, with the aim of enabling Robert to achieve his independence again.

With the help of these partners, Sylvarani made representations to Robert’s letting agent and successfully managed to get heating installed in his home.

She also helped him apply for financial support and worked with him to set small, achievable targets to develop independence in his own home, such as walking up and down the stairs once a week.

What’s more, pharmacists also came to Robert’s house showing him how to take all his medicines and in what order.

Sylvarani met regularly with Robert’s GP and others from across health and social care in a multidisciplinary ‘huddle’ to monitor his progress and review his care plan, focussing on all aspects of his health.

The difference

This integrated support is making a real difference to Robert’s life.

He can now go up and down the stairs a few times a day, and his increased mobility has allowed him to cook his own meals, which has helped him gain weight.

He’s even well enough to start driving again and doesn’t require an ambulance to take him to hospital.

His confidence has really been boosted.

We know people’s care is better when organisations work closely to provide health and social care, physical and mental health.”

Dr Dev Malhotra, GP at the Brigstock Road Medical Practice 

However, this isn’t just happening in Croydon. Age UK’s Personalised Integrated Care Programme is making a difference to older people’s lives and wellbeing across the country.

Launched in Cornwall in 2012, it has now expanded to fourteen sites in total, with many other health commissioners asking Age UK and other voluntary sector organisations to undertake similar work

And we know the need for personalised integrated care like this is growing all the time, with life expectancy and the number of people with multiple long term conditions on the increase.

With this in mind, we hope our Personalised Integrated Care Programme will continue expanding, providing care and support to enable older people like Robert live more independent and fulfilling lives.

Read more about our Personalised Integrated Care Programme

The Age UK Personalised Integrated Care Programme has been funded jointly with local commissioners, Age UK, The Big Lottery Fund and the Roger De Haan Charitable Trust.

Author: Age UK

Age UK is dedicated to helping everyone make the most of later life. In the UK we help more than 7 million older people each year by providing advice, combating loneliness and enabling independence. Locally, we work as part of a network of independent charities which includes Age UK, Age Cymru, Age NI and Age Scotland and over 150 local Age UK partners in England and Wales.

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