Older Adults aged 65 and over

Are you aged 65 and over and living in Royal Borough of Kensington & Chelsea and Queen’s Park and Paddington area of Westminster?

Are you caring for, or acting as an advocate for, someone aged 65 and over in the area?

Access to health care, social care and voluntary services in your area is changing.

Your local NHS is introducing a new service.

The change is coming in response to calls from local people for improved consistency and coordination of care for people aged 65 and over.

What’s changing?

Your local NHS is working with local health, social care and voluntary organisations and introducing a new service to support the health and wellbeing of people aged 65 and over in this area.

The new service is a commitment from all health and social care agencies to collaborate with patients and carers to avoid hospital stays and help older adults to remain independent and living in their own homes for as long as possible. 

It is putting patients, service users and carers at the centre of the decision-making process about the care or support that is needed and is bringing patients together as equal partners with their GPs and other health and social care professionals.

Why is the new service needed?

The new service is responding to calls from local people for more consistency of care and greater, more efficient coordination in the provision of care for people aged 65 and over in our communities.

Your local NHS is acknowledging that proactive and personalised care planning involves more than looking after a person’s physical health needs. It must also take into account that person’s emotional and mental needs as well as working together with them in partnership for the best possible remedies.

For more details please look at the benefits of the service.

How is the new service working?

Our new service is giving older adults regular, planned access to their GP teams and any other health and social care professionals and service relevant to planning their care.

It is enabling health and social care teams to coordinate their responses to changes in patient health and to proactively plan each patient’s care in anticipation of any potential changes.

What is proactive and personalised care and why do I need it?

GP teams and patients are collaborating to agree personalised and proactive care plans for older adults aged 65 and over to manage any changes that person’s health or social needs. The new service means that the provision of care for older adults is focusing on:

  • Self care – exploring all the options available to patients from other organisations that fits with their care plan to maintain their health and well being 
  • Awareness ­– Regular assessing of the patient’s current physical, emotional and environmental needs by a coordinated team of health and social care professionals
  • Monitoring – At point of care anticipating and actively preparing for any changes in an older adult’s needs, actively supporting them to avoid hospital stays as well as implementing strategies for a better recovery


How can I access the new service?

You can access the service via your participating GP practice. As of 1 April 2016, 25 GP practices have signed up to offer this pioneering service.

Your local NHS is investing in new staff and over 40 new employees recruited to GP practices to support GPs in collaborating with their older adults to benefit from partnership care planning.

For more detail we have some frequently asked questions specifically for patients.

Where can I access the new service?

Patients aged 65 and older are accessing the new service through their local GP surgeries.In addition to this, your local NHS has invested in 2 new Integrated Care Centres, where older adults are accessing a range of care services under one roof.

The Integrated Care Centres are near Ladbroke Grove and close to Chelsea Town Hall.


My GP is referring me to an Integrated Care Centre. What will happen there?

Your local NHS is bringing together a range of health and social professionals involved in patient care under one roof and in one place at Integrated Care Centres. Depending on your needs you may see a range of people during your visit to an Integrated Care Centre.

The Integrated Care Centre health and social care professionals may include the following as just an example:

  • GPs
  • Case managers
  • Social care staff
  • Occupational health staff
  • Pharmacists
  • Podiatrists
  • Dementia nurses
  • Cardiologists
  • Respiratory doctors
  • Voluntary organisation staff