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Community Health Services and Ageing Well Digital Project


In support of the development of an Ageing Well-focused Community Health Services digital Strategy and Implementation Plan, NECS Digital Transformation and Optimisation services are facilitating the collaboration across the North East and North Cumbria Integrated Care System (NENC ICS) community provider organisations and the NENC ICS digital care programme.

Whilst there has been an appetite in recent years for increased use of digital solutions as an enabler in providing older person and community health services, some ideas and proposals have not been able to gain traction and come to fruition. Part of the challenge includes understanding the complex landscape and the primary aims, objectives and potential benefits to organisations within the ICS.

Through engaging the most appropriate stakeholders and targeted collaboration, cohorts are being formed with a unified direction and purpose, seeking the best solutions and appropriate funding streams.

In the absence of any legacy strategies pertaining to the digital Ageing Well agenda, this piece of work is a first of type for the region. The strategy and implementation plan is being carefully aligned with the recently published NENC ICS Digital Strategy. Additional work is to be undertaken in line with the emerging direction from national NHS bodies in relation to the three primary national objectives relating to Ageing Well and Frailty:
• Enhanced Health in Care Homes (EHCH)
• Anticipatory Care
• Urgent Community Response (UCR) Community Health Services and Ageing Well Digital Project


The focus initially has been to join up a multitude of conversations within appropriate groups and to establish governance and tools, utilising NECS’ extensive experience and expertise. This involved listening, interpreting and bringing our corporate memory for best results.

Stakeholder engagement continues to build through the Ageing Well, Community and Digital workstreams.

A wide array of stakeholders is being consulted or informed regarding the developing work and the progress towards the completion of the strategy.

There are three emerging key strategic themes:

Finding People
• Anticipatory Care – commencing ICP and PCN activity baselining and exploration of the development of an ICS-wide approach.
• Exploration of developing an enabling tool to identify population cohorts.

Supporting People
• Digitised Personal Care and Support Plans – exploration of what can be developed to codify and enhance interoperability in the use of data that can be used to support people in their personalised Ageing Well journey.

Measuring What Matters
• Building on the and national measurement processes to understand better quality
conversations and associated impact across wellbeing, experience, and service use.
• Supporting the ICS Urgent Community Response work in line with providers, including reporting to the Community Services Data Set.


NECS has fostered strong relationships within the groups of key stakeholders, providing a firm base from which to build support for the development of a high-quality digital strategy and implementation plan. Momentum is gathering within each of the three emerging key strategic themes with regards to long-standing digital ambitions.

Strong organisational and negotiation skills have contributed to the formation of cohorts of key stakeholders with an array of knowledge and experience who are exploring what is possible with regards to:

• Development of an enabling tool for cohort identification – this could be used for identifying people with multiple life-threatening conditions and various stages of frailty; it could also be used in the wider setting of meeting key targets in line with the Health Inequalities agenda or other future priority groups of people.

• Digitised Personal Care and Support Plans – seeking to accelerate this work through the Great North Care Record on the Health Information Exchange platform will tie in with existing work including the Well-Connected Care Homes, EPaCCS and palliative care, Year of Care and digital Comprehensive Geriatric Assessment.

An extensive knowledge and understanding within NECS of the local and wider healthcare and digital landscape has been pivotal in developing this work in line with stakeholders and key partners across multiple organisations and agencies. Enhanced governance structures to support and accelerate the work are being investigated.

The initial benchmarking report for Anticipatory Care (AC) within the ICS has been described as comprehensive and useful in identifying gaps and opportunities. This will help inform the regional and national picture of AC and further emerging priorities.
Through the provision of digital and project management expertise, NECS has been instrumental in supporting the successful completion of first phase of Urgent Community Response providers submitting data to the Community Services Data Set (CSDS). This work will continue into the next phase, including onboarding further community providers to the data set.

As a trusted partner to lead clinicians and support professionals working in the field of older people’s services, we have been able to give confidence in pursuing a successful outcome in these varied and complex areas of work. The aim continues to be the publishing of the aforementioned digital strategy and implementation plan which is being informed by the work currently taking place. NECS is enhancing the collaborative links that are essential in achieving the ambitions of this work, adding value and the bedrock from which to build upon the work in the months and years ahead.

Download a pdf of this case study here: CHS and Ageing Well Digital Project Case Study