Ageing Well

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People in England can now expect to live for far longer than ever before, but these extra years of life are not always spent in good health, with many people developing conditions that reduce their independence and quality of life (see NHS Ageing Well webpage). Ageing is a cross-cutting issue with multiple economic, public service and societal impacts, for example, on pensions, social care, housing and well-being.

World Health Organisation (WHO) defines healthy ageing as “the process of developing and maintaining the functional ability that enables wellbeing in older age”. Functional ability combines the intrinsic capacity of an individual, the environment they live in, and how they interact with that environment. Healthy ageing is therefore influenced by multiple factors throughout the life course (described in the OHID report: State of Healthy Ageing in Yorkshire and the Humber 2023).

The NHS 10 Year Health Plan for England sets out some changes required to support the population to age well. The plan articulates that extending independence as we age requires a targeted and personalised approach, enabled by digital health records, population health management and shared health management tools. Promoting the prevention, early identification and self-care agendas enables people to look after their health and well-being, prevent, delay, and minimise the severity and impact of Frailty, and maximise outcomes.

The World Health Organisation (WHO) have developed an Age Friendly framework and guide which addresses societal barriers to the health and wellbeing of older people. These are reflected in eight domains, including, for example, social participation, buildings, and transport.

Our Kirklees population continues to grow with a shift in the age structure towards older ages. By 2050, one in four people will be aged over 65 compared to one in five in 2019. An almost 30% increase.

The Health and Care sector is faced with challenges in supporting an ageing population as the likelihood of losing functional ability and living with complex health conditions increases as we age with many people developing conditions that reduce their independence and quality of life.

This also impacts on the wider system as supporting people who are not ageing well is substantial and will increase, creating significant economic pressure.

As an Age-Friendly Community we need to ensure that our health, social and physical infrastructure and services meet people’s expressed needs to enable them to age well.

1. About the issue

UK’s Ageing Population:

1.1     The population has continued to age. Across England, more than one in six people (18.4%) were aged 65 years and over on Census Day in 2021. This is a higher percentage than ever before (see ONS Census 2021 analysis webpage).

1.2     As the UK’s population continues to grow there has been a shift in the age structure towards older ages meaning we have an ageing population. Like many other countries, the UK’s age structure is shifting towards older ages. By 2050, it is projected that one in four people in the UK will be aged 65 years and over, an increase from approximately one in five in 2019. This is the result of the combination of declining fertility rates and people living longer (see ONS population overview report). While living longer may be a cause for celebration, the ageing population has implications on several policy areas (see ONS population analysis report).

1.3     Ageing is a cross-cutting issue with multiple economic, public service and societal impacts, for example, on pensions, social care, housing and well-being.

1.4     At age 65 years, both men and women can expect to spend around half of their remaining life expectancy in good health. However, the likelihood of being disabled and/or experiencing multiple chronic and complex health conditions among those aged 65 years and over increases with age. As life expectancy increases, so does the amount of time spent in poor health (Figure 1).

Figure 1 : Life expectancy and the proportion of life spent in good health at age 65 years, by sex, 2018-20

Source: Fingertips, Department of Health and Social Care

 

1.5     Healthcare requirements increase with age, with healthcare costs increasing steeply from around age 65 years (Figure 2). As an indicator of hospital activity, NHS Finished Consultant Episodes (FCEs) were higher in 2023/24 (over 21 million) compared with any of the previous 10 years. The proportion of older patients is also increasing – in 2023/24, patients aged 65 plus represented 44.5% of FCEs, equating to more than a million more FCEs for this age group (Figure 3, NHS England Hospital Admitted Patient Care Activity statistics).

Figure 2 : NHS general and acute care age-cost curve, 2013/14, England

Source: Technical Guide to Allocation Formulae and Pace of Change for 2019/20 to 2023/24 revenue allocations, NHS England

 

Figure 3 : Trends in number of NHS Finished Consultant Episodes by age group, between 2017/18 and 2023/24, England

Source: NHS England, Hospital admitted patient care activity

 

• Social care requirements also increase with age. According to the 2017 GP patient survey, one in five men and women aged between 75 and 84 years have at least some problems washing or dressing. This rises to 34% of men and 42% of women at ages 85 years and over.
• According to an Age UK report (Falls Prevention Exercise – following the evidence):
• Falls and fractures in people aged 65 and over account for over 4 million hospital bed days each year in England alone.
• The healthcare cost associated with fragility fractures is estimated at £2 billion a year.
• Injurious falls, including 70,000 hip fractures annually, are the leading cause of accident-related mortality in older people.
• After a fall, an older person has a 50 per cent probability of having their mobility seriously impaired and a 10 per cent probability of dying within a year.
• Falls destroy confidence, increase isolation and reduce independence, with around 1 in 10 older people who fall becoming afraid to leave their homes in case they fall again.
• A tailored exercise programme can reduce falls by as much as 54 per cent

2. Contributing factors

2.1     A report by the Office for Health Improvement and Disparities (OHID, ‘State of Healthy Ageing in Yorkshire and the Humber 2023’) uses the World Health Organisation’s definition of healthy ageing as ‘the process of developing and maintaining the functional ability that enables wellbeing in older age’. In this context, functional ability refers to people’s ability to: 1) meet their basic needs to ensure an adequate standard of living; 2) learn, grow and make decisions; 3) be mobile; 4) build and maintain relationships; and 5) contribute to society. The intrinsic capacity of an individual can be maintained into older age through supportive environments and access to appropriate healthcare.

2.2     The OHID report also explains how individual factors such as age, gender, ethnicity, sexual orientation, disability and deprivation interact with one another to influence our vulnerability to poor health. This will be discussed further in the ‘Who is most affected’ section below.

3. The Kirklees Picture

3.1     The Kirklees population increased by around 10,800 between the last two censuses (held in 2011 and 2021, ONS comparison of Census 2021 and 2011). During this time, there has also been a shift in the age structure towards older ages (Figure 4).

Figure 4 : Population change (%) by age group in Kirklees, 2011 to 2021

Source: Office for National Statistics Census 2021 and Census 2011

 

3.2     In Kirklees, between 2011 and 2021, there was an increase of 19.7% in people aged 65 years and over, a decrease of 1.0% in people aged 15 to 64 years, and an increase of 1.1% in children aged under 15 years. This compares to increases for England of 20.1% (people aged 65 years and over), 3.6% (people aged 15-64 years) and 5.0% (children under 15 years).

3.3     The latest available population projections from the Office for National Statistics at Local Authority level were released in June 2025, using 2022-based population estimates. In line with national projections, these figures predict an increase in the older population, from 17.9% of the Kirklees population being aged 65 and over in 2022 to 22.2% in 2047 (Figure 5). These projections equate to around 26,700 more older people (aged 65+) and 11,400 fewer younger people (aged 0-15) in 2047, compared with 2022.

Figure 5 : Kirklees population projections, 2022 baseSource: Office for National Statistics, Population projections for local authorities

3.4     The 2021 census showed that more than half (56%) of those in Kirklees aged 65 plus self-reported to be in good health, an improvement compared with 47% in 2011 (Figure 6). The 2021 figure is similar to the value for England (58%) and Yorkshire and the Humber (56%).Figure 6 : Proportion of Kirklees population aged 65 plus in good health, 2011 and 2021Source: Office for National Statistics Census 2021 and Census 2011

3.5   However, older people in more deprived areas of Kirklees are less likely to report good health compared with those in the least deprived areas: 39.5% of those aged 65 plus in the most deprived decile, compared with 69.7% in the least deprived decile (Figure 7).Figure 7 : Proportion of older population in Kirklees reporting good health, by deprivation decileSource: Office for National Statistics Census 2021

3.6     The 2021 CLiK survey highlighted the following findings for people aged 65 plus (compared with people aged 16-64):

• Adverse indicators: Higher rates of poor physical health, requirement for regular prescription medications, need for help to continue to live in their own home, disability, sensory impairment, and increased likelihood of a range of health conditions (including cardiovascular disease, respiratory disease, pain, and diabetes).
• Positive indicators: Lower rates of poor mental health, higher life satisfaction scores, higher levels of emotional wellbeing.

3.7     Falls

• In Kirklees, falls are a significant concern, especially among older adults. Approximately one-third of people over the age of 65 experience at least one fall per year, this rate increases to about half for those over 80 (NICE Clinical Guideline CG161: Falls in older people: assessing risk and prevention)
• Hospital Admissions:
  • In 2022/23, Kirklees had the second highest rate of hospital admissions for falls for people aged 65 and over. This is significantly higher than regional or national average (Figure 8)
  • People aged under 65s account for around 24% of hospital admissions for falls and 82% of the population. Whereas those aged 65+ account for 76% of hospital admissions for falls and 18% of the population (Figure 9)
  • Cause of the fall: For those aged 65+, the highest proportion of hospital admissions for falls (43%) were repeat falls not from accident, followed by unspecified fall (23%.) For under 65s, the highest proportion were slip/trip/stumble (21%) (Figure 10)
  • Length of Stay: People aged 65+ were twice as likely to stay in hospital for 10+ days, compared with under 65s. People under 65 were almost twice as likely to stay in hospital less than a day, compared with those aged 65+ (Figure 11)
• Data – CLiK Survey, 2021:
• Overall, 16% of survey respondents had fallen and hurt themselves in the last 12 months. This rises to 28% for people aged 75+.
• People with a disability are much more likely to fall than those without. 29% of those with a disability have fallen, compared with 9% of those without a disability.
• People living in the most deprived areas are more likely to fall than those in the least deprived areas. 18% for the most deprived quintile vs 15% for the least deprived quintile.

Figure 8 : Hospital Admissions for Falls, Aged 65 and Over (2022/23)Source: Fingertips, Department of Health and Social Care

Figure 9 : Hospital Admissions for falls by age, Kirklees, Complete Episodes, 2017-21Source: Hospital Episode Statistics, NHS England

Figure 10 : Hospital Admissions: Cause of FallsSource: Hospital Episode Statistics, NHS England

Figure 11 : Hospital Admissions for Falls: Length of StaySource: Hospital Episode Statistics, NHS England

3.8     Care Homes

• Although the overall rate of permanent admissions of people aged 65 plus to residential and nursing care homes is significantly higher across our region compared with the national figure, Kirklees is one of only two local authorities in the region with a significantly lower rate (400 per 100,000 in Kirklees, compared with 498 for England overall and 550 for Yorkshire and the Humber) (Figure 12).

Figure 12 : Permanent admissions to residential and nursing care homes per 100,000 aged 65+, 2020/21Source: Fingertips, Department of Health and Social Care

3.9     Spend

• In 2021/22, Kirklees spent £59.5m on long and short term care for the elderly. More than half of this money (54%) was spent on physical support (£32m); the proportion spent on mental health support in Kirklees (11.7%) was the highest in the region (Figure 13).

Figure 13 : Gross Current Expenditure on long and short term care combined, for clients aged 65 and over, by primary support reason, 2021-22Source: Adult Social Care Activity and Finance Report, England, 2021-22 – NDRS (digital.nhs.uk)

4. Who is most affected (demographic variance)?

4.1     According to the 2021 census, around 16,000 people aged 65 plus live in areas defined as amongst the most deprived 20% in England. People living in more deprived areas are generally more likely to have worse health outcomes, including lower life expectancy and lower healthy life expectancy.

4.2     The OHID report ‘State of Healthy Ageing in Yorkshire and the Humber 2023’ highlights many demographic differences for older people in Kirklees and the wider region. Ethnic minorities face challenges due to an accumulation of disadvantages built up over the life course. The disadvantages span across a large number of areas in life. People from black, Asian and ethnic minority groups aged 50-70 are more likely to live in deprived neighbourhoods, be in low paid jobs and/or with less access to other sources of income, such as pension savings and assets and are less likely to own their home than their white counterparts. Some ethnic minority groups are more likely to experience language barriers than their younger counterparts. Other barriers in accessing services are due to structural issues such as cultural inappropriateness, long standing mistrust of authorities, and experiences of racism, discrimination and stigma. Figure 14 shows that Kirklees has the second highest proportion of people of non-white ethnicity (aged 50-64 and aged 65+) in the region, behind Bradford.

Figure 14 : Proportion of older people in Yorkshire and Humber from ethnic minorities (excluding white minorities) by age groups 65+ and 50-64, 2019Source: Population denominators by broad ethnic group and for White British, local authorities in England and Wales: 2011 to 2019 – Office for National Statistics

4.3     Area level deprivation is significantly associated with health outcomes and a major factor in health inequalities. Those living in the most deprived areas are more likely to have worst health outcomes, creating a cumulative impact throughout life course. Up to a quarter of older people in Yorkshire and Humber are living in income deprivation with Kirklees being in the worse 95% decile (Figure 15).

Figure 15 : Older people in poverty: Income deprivation affecting older people index (IDAOPI) 2019 %Source: Fingertips, Department of Health and Social Care

4.4     According to the 2021 CLiK survey, people aged 65+ of Asian ethnicity were twice as likely to report being in poor physical health, compared with people aged 65+ of White ethnicity. Rates of poor physical health were much higher for older people living in the most deprived areas compared with those in the least deprived areas (comparing most and least deprived quintiles). Conversely, amongst people aged 65+, higher rates of poor mental health were found in those of White ethnicity (compared with those of Asian ethnicity) and those in the least deprived areas (compared with the most deprived areas, at quintile level).

5. Where are people most affected (geographical variance)?

5.1     Figures 16a-c show the distribution of older people in Kirklees, and Table 1 lists the population aged 65 plus by electoral ward. Mirfield has the highest number of people aged 65 plus (4,781), representing almost a quarter of the population in this ward.

Figure 16a : Distribution of population aged 65+, Census 2021Figure 16b : Distribution of population aged 75+, Census 2021Figure 16c : Distribution of population aged 85+, Census 2021Source: Office for National Statistics Census 2021

Table 1 : Population aged 65+ by ward, from 2021 Census

• The areas with the highest numbers and proportions of older people tend to be in the least deprived areas in Kirklees. This has a positive impact on their health outcomes compared those living in poverty and deprivation who experience multiple risk factors across the life course such as exposure to smoking, air pollution and access to green space, compared to those living in the least deprived areas (see Chief Medical Officer’s Annual Report 2023: Health in an Ageing Society). However, many of these areas are often beautiful and welcoming, but underserved in health care, with less accessible transport links and insufficient infrastructure designed for older adults, including housing. People who have moved to these new areas in later life often do not have the social support networks.
• As highlighted in Sections 1.7 and 3.7, older people are at increased risk of injurious falls, leading to higher rates of hospital admissions for hip fractures. Figure 17 shows the variation in hip fracture admission rates by electoral ward across Kirklees, with Crosland Moor and Netherton having the highest value (standardised admissions ratio: 136.0) and Dewsbury West having the lowest value (59.4).

Figure 17 : Emergency hospital admissions for hip fractures in persons 65 years and over, standardised admissions ratio, at electoral ward levelSource: Office for Health Improvement and Disparities, Local Inequalities Explorer Tool 2023

6. Local views

6.1     The World Health Organisation (WHO) have developed an Age Friendly framework and guide which addresses societal barriers to the health and wellbeing of older people. These are reflected in eight domains, including, for example, social participation, buildings, and transport. The baseline for how Age Friendly an area, must be established with the continuous involvement of older people themselves.

6.2     In 2023, Kirklees joined the national network of Age Friendly places and are working through a five-year associated programme to establish baseline, action plan and measure performance.

6.3     In Kirklees there are very many groups that meet regularly and are welcoming to older people. Visibility and awareness of these groups varies, however they represent a good infrastructure upon which to engage older people in Kirklees and between 2023 and 2024, over 500 people have been engaged with professionals in a community led outcome based accountability (CLOBA), process to establish what matters most to older people Kirklees, what might need to change, who can drive that change and what any performance measures might look like.

6.4     So far, this work has established seven clear priority areas and an Older People’s Research and recommendations group, drawn from the older people’s groups, is now established to continue the CLOBA work. The work draws together relevant insight from Healthwatch and local Place Planning activity.

6.5     Priorities Highlighted by Older People in Kirklees: Community Led Outcome Based Accountability 2023-2024:

• “We have places to gather”
• “Printed information and face to face communication is what I need, especially around health and what’s on.”
• “I am respected and not infantilised”
• “Intergenerational please”
• “I am able to get a bus”
• “I can get adaptations for my home”
• “I want to shop face to face”

7. What is being done / what can be done

7.1     We need to drive the changes that are needed to respond to this shifting age demographic.

7.2     The World Health Organisation (WHO) have developed an Age Friendly framework and guide which addresses societal barriers to the health and wellbeing of older people. These are reflected in eight domains (Figure 18), including:

• Outdoor environments
• Transport and mobility
• Housing
• Social participation
• Social inclusion and non-discrimination
• Civic engagement and employment
• Communication and information
• Community and health services.

Figure 18 : Eight domains of age-friendly environmentsSource: World Health Organisation

7.3     The NHS Long Term Plan sets out some changes required to support the population to age well. The plan articulates that extending independence as we age requires a targeted and personalised approach, enabled by digital health records, population health management and shared health management tools. Promoting the prevention, early identification and self-care agendas enables people to look after their health and well-being, prevent, delay, and minimise the severity and impact of Frailty, and maximise outcomes.

7.4     The Kirklees Health and Care Plan is based on the life course approach. This includes the development of the Ageing Well Programme. The future vision being that our ageing population will be enabled to self-care to optimise their health and wellbeing, identify their own needs, and be supported to live as safely and independently, for as long as possible, through an integrated proactive approach across the health and social care system. This will be achieved through the delivery of 7 workstreams that have been developed based on national guidance and recommendations.

8. Asset-based approach

8.1     Older people in Kirklees say they wish to be respected for what they can do, what they know and what they are capable of. They do not wish to be infantilised or viewed only through a lens of frailty and safety.  Public spending on support services is reduced and for most forms of public services and support, demand exceeds available resources.

8.2     There has never been a more compelling time or reason to consider older people in the role of contributors and leaders in their community as a major health and social care asset.

8.3     Currently two areas for focus identified by older people are “places to gather” and “accessible communications”. Older people explain that information exchange by word of mouth, including radio, and print media as it relates to health, health literacy and What’s On guides, is missing.  All opportunities must be taken to communicate with older people in a way that is accessible to them, alongside the growing prevalence of online based information exchange.

8.4     Older people tell us that the importance of accessible public spaces for them cannot be overestimated. This might be places associated with businesses, community, faith, health and or publicly owned spaces. A research partnership with Manchester University will continue to gain insight into best use of space as determined by older people themselves with a view to enabling the use of space, giving people reason and opportunity to get together, organise and share food, travel arrangements, friendship and information.

9. What commissioners and service planners could consider

• Creating age friendly communities: Through Age Friendly Communities Kirklees place is performing Community led outcome-based accountability in the community with older people. Older people will continue to be involved in identifying opportunities to drive work that responds to insight gathering and enables good outcomes.

Key considerations being;

• WHO outlines eight key domains of wider factors that affect older people’s health outcomes. Developments in any of these areas must rely on an approach that involves older people in coproducing how they can contribute to and benefit from associated activity. The inclusive community’s framework is a helpful involvement tool.
• Older people must not automatically be assumed to be frail or dependant. Conflation of vulnerability and age can lead to people being discriminated against and infantilised. Where possible, older people should be supported to become leaders and contributors with regards their own lives and in the delivery of available services and support. E.g; expert patient programme models of care, leaders of neighbourhood activity, active participants in coproduced critical health literacy.
• In wider regeneration activity, older people can be considered as an important contributor to our place’s economic success. All efforts to design places and spaces that are accessible to older people must be taken. Again, inclusive communities’ framework is a useful involvement tool.
• Preventative activity, both targeted and community level, should deliberately include and involve older people.
• The move to a Kirklees ICB offers opportunities to look at Kirklees solutions and equitable access to services for older people. Key points include:
• The south of the district has an older population
• Huddersfield is in the middle of the district with regards size of population and is roughly speaking the most accessible point for most people, older people tell us that public transport, in particular buses, are important with regards ability to travel.
• Older people wish to remain Independent. Older people rely on communication methods that are in addition to that which is online. Developments such as older people’s community radio, networks of older people’s groups and frontline workforce and collaboration with existing print media are important communication channels to promote uptake such as home adaptations and assistive technology which enables Independence. Ensure voluntary services/groups are accessible and the information is available.
• Opportunities to maximise multiple positive outcomes for older people across exercise, health, being social should be prioritised. Older people tell us they most wish to be social and evidence suggest that this is a key determinate of ageing well. Developments such as Integrated neighbourhood teams can seek to promote social outcomes as they develop. Ie; taking opportunities for people to be social as they access health offer and vice versa. Enable people and communities to be more connected, develop meaningful relationships and reduce loneliness.
• Trust – Age UK and the NHS are still trusted names for older people and can be utilised with regards reaching older people. Important communications, especially related to health, health literacy and poverty ameliorating initiatives, e.g. pension tax credits, should consider relevant collaborations and partnerships with these organisations.
• Identify key assets within communities.
• Places to gather and key existing assets. Older people are being actively engaged in understanding in more detail how physical assets are best used on behalf of the community.
• Access to adaptations to enable people to stay independent in their own homes, including technology, assistive technology and physical adaptations.
• Radio, existing print media and groups where older people are already meeting. These assets represent huge potential to close an accessible communications gap for older people who might either struggle with using online communications or importantly, chose not to live their lives in that way.
• Prevention – Embed and mobilise the NHS England Proactive Care Framework to support people to age well. This includes outcome focused care planning through the development of personalised care and support plans to enable the ageing population to live as independently as possible, achieving the outcomes that matter most to them.
• Review and embed the recommendations in Yorkshire and Humber State of Ageing Report
• Skilled workforce: Frailty-framework.pdf (skillsforhealth.org.uk)
  Skills required;
  • Community development
  • Asset based ways of working
  • Capacity building
  • Coaching
• Review and consider the RightSizing Campaign
• Frailty identification and support – population-level frailty identificationand stratification can help plan for future health and social care demand whilst also targeting ways to help people age well (see NHS England work on supporting people with frailty). Early identification of frailty can slow its progression and delay loss of independence (Chief Medical Officer’s annual report 2023: health in an ageing society).
• Focus on falls prevention: local system wide workshop to enable national recommendations to be embedded within Kirklees with a collaborative approach i.e. Strength and Balance.

10. References and additional resources

Age UK, Falls Prevention Exercise – following the evidence

Centre for Ageing Better: Age Friendly framework

Chief Medical Officer’s Annual Report 2023: Health in an Ageing Society

Kirklees Health and Care Plan

Kirklees Inclusive Communities Framework

NHS, Fit for the Future: 10 Year Health Plan for England

NHS England: Ageing well

NHS England: A population health management approach to ageing

NHS England, Hospital Admitted Patient Care Activity statistics

NHS England: Proactive Care Framework

NHS RightCare: Frailty Toolkit

NICE Clinical Guideline CG161: Falls in older people: assessing risk and prevention

Office for Health Improvement and Disparities, State of Healthy Ageing in Yorkshire and the Humber 2023

ONS Census 2021 Kirklees analysis

ONS, How life has changed in Kirklees: Census 2021

ONS population analysis, Living longer: how our population is changing and why it matters, 2018

ONS UK population overview, 2019

Skills for Health/NHS England/Health Education England, Frailty: A framework of core capabilities

West Yorkshire Health and Care Partnership: RightSizing Campaign

World Health Organisation: Age-Friendly Cities Framework

World Health Organisation: Ageing and health fact sheet

See also: KJSA sections on Dementia; Dying Well; Cancer; Cardiovascular disease; Diabetes; Respiratory disease

Date updated (and lead author initials): 23/07/25 (NC)

Ward	Aged 65+	% aged 65+
Mirfield	4781	24.2%
Holme Valley South	4418	22.7%
Denby Dale	4097	24.6%
Lindley	4034	19.7%
Holme Valley North	3963	23.6%
Almondbury	3888	22.0%
Liversedge and Gomersal	3794	19.5%
Kirkburton	3564	21.9%
Cleckheaton	3520	20.5%
Colne Valley	3385	19.3%
Ashbrow	3342	16.4%
Birstall and Birkenshaw	3244	19.2%
Golcar	3128	16.7%
Dewsbury East	3127	15.6%
Dalton	3084	17.7%
Crosland Moor and Netherton	3083	15.6%
Heckmondwike	2977	16.4%
Dewsbury South	2756	14.3%
Greenhead	2733	12.5%
Batley West	2718	13.5%
Newsome	2697	14.4%
Batley East	2475	13.1%
Dewsbury West	1987	9.2%
TOTAL	76795	17.7%
Workstream	Purpose
Cross-cutting enablers of system change A co-productive approach to enable our wider system partners to respond to our ageing population, including: Ø  Sharing information and recommendations. Ø  People themselves will be involved in defining quality and performance. Ø  Rigorous in our up-to-date understanding of data and insight
Proactive Care	Delivery of the national NHS England Proactive Care Guidance. The guidance aims to provide personalised, coordinated, multi-professional support and interventions for people living at home with Frailty. Improving the identification of Frailty and ensuring support mechanisms are in place to identify people’s needs earlier.
Age-Friendly	Working within the 8 Domains of The Age-Friendly Communities Framework to develop and adapt infrastructure and services that meet people’s expressed needs and solutions as they age.
Falls Prevention	Identifying people who are most at risk of falls and developing a knowledgeable community, including a well-trained workforce alongside increasing access to health promotion information to support improved lifestyle choices.
Care Sector	Support the development of a robust and resilient care sector delivering outstanding quality and tailoring care to the needs of individuals.
Home First Discharge	Embed and mature the home-first discharge approach to improve patient outcomes and improve patient flow out of hospital.
Hospital at Home	Enable patients who would otherwise be in hospital to receive acute care and treatment in their own home.
UCR	Provide urgent care within 2 hours of need to in people their own homes to help avoid hospital admission and enable people to live independently for longer.