Age Well

Age Well supports our older and frail population and aims to:

“support the development of integrated, neighbourhood-based networks that keep people as healthy and independent as possible in their home, and for those admitted to hospital enables safe and timely discharge”

The Age Well workstream focuses on keeping older people and their carers as healthy and independent as possible in their home and the community through:

  • Joining and connecting neighbourhood services and teams to ensure access to the right support is as easy and as fast as it can be
  • Proactive health and care, reducing the need to reach crisis by responding to deterioration early
  • Focusing on social determinants (social, economic, and environmental factors) which impact health and wellbeing
  • Providing a holistic offer of support working collaboratively with the person and their carer
  • Ensuring support is accessible, appropriate, and acceptable for the person, received in the home and/or in their neighbourhood.

You can see what the Age Well workstream are currently working on under ‘Age Well in action’ below.

The Age Well workstream currently includes:

  • Systemwide prevention and management of falls in the borough
  • Meeting the needs of people and their carers affected by dementia
  • Supporting our carers in Southwark to care

To support this work we have:

  • Mobilised leadership and workstream delivery groups made up of clinical and operational leaders who are responsible for the delivery of identified priorities and projects
  • Partnered with Public Health, King’s College Hospital NHS Partnership Trust and our expert workforce to ensure understanding and awareness of population health management, and that ideas and interventions are based on up-to-date evidence, information, datasets, and real patient experiences
  • Developed relationships and networks with the voluntary and community sector and people who have lived experience to design interventions in partnership, for example setting up a new Carers Partnership Forum to involve carers to work hand in hand with a Carers Delivery Group made up of clinical and operational managers to deliver shared outcomes.

The Age Well Leadership Team are:

  • Brenda Donnelly, PCN Clinical Director, South Southwark
  • Pauline O’Hare, Director of Adult Social Care, Southwark Council
  • Kate Gregory, Chief of Therapies, Rehabilitation and Allied Clinical Services, KCH
  • Sophie Wellings, Director, Link Age Southwark.