Population Plans

Older people campaigning

Local commissioning groups and HSC Trusts developed Population Plans in May and June 2012.

The focus was to develop a comprehensive understanding of TYC at a local level and identify key initiatives, which would support the delivery of TYC around population groups. For the purpose of this table 8 of the 10 population groups were examined – older people; population health and wellbeing; long term conditions; physical disability; mental health; learning disability; acute and palliative and end of life.

McKinsey, Appleby 1 & 2 and PEDU Reviews have influenced the sections in the population plans on Finance, Workforce and Enabling Transformation. There is a Regional Social Care Group, which will develop a commissioning strategy in the medium term. The Quality Improvement and Cost Reduction Workstreams include social care reform. 

Plans reveal the extent of savings from reducing demand and the shift to lower cost social care provision.

Belfast HCST


  • 4 Integrated Care Partnerships (ICP)
  • 45 Residential Homes
  • 1270 Residential care places available
  • 6454 Domiciliary  care packages in place
  • 2667 people with Dementia registered with GPs
  • Significant health inequalities
  • 87 GP Practices with 423,863 patients registered
  • 7 Wellbeing & Treatment Centres
  • Projected Population change 09-20 +2%

Key Points - Older People

  • Devolved Allocation Panels for new requests/referrals and increases in care packages to assess each client; negotiate care rates to align with median NI market rates
  • HASP: Extend support for Voluntary & Community Sectors to meet psycho-social needs and practical support
  • Establish contact centre for wider services for signposting
  • Preventative strategies in place: falls, nutrition, medication reviews
  • 8 cross multidisciplinary primary care teams – referrals for reablement
  • Extend supportive housing and assistive technology
  • Review disease registers for early identification of onset of dementia
  • Extend Direct Payments
  • Falls prevention
  • Food first programme in nursing homes
  • End of life and palliative care close to home and choice of place of death.


  • Reduced Emergency Department (ED)  / hospital  attendances
  • Fewer continuing care packages
  • Fewer placements in nursing and residential care
  • Increased provision of home based respite
  • Earlier discharge from hospital
  • Increased proportion of care through direct payments
  • Reduced admissions to hospitals at end of life

South Eastern HSCT


  • 4 ICP’s
  • 53 GP Practices
  • Projected
  • 3,029 available places in residential accommodation
  • 8,036 care packages in effect
  • 466 meals on wheels
  • Significant health inequalities
  • Population change 09-20 +6%

Key Points - Older People

  • Develop targeted prevention programmes for older people: falls, active living, low level support, nutrition, benefit maximisation
  • Develop Partnerships for Older Peoples Projects (POPPS)
  • Implement MUST nutrition tool
  • Develop reablement programmes
  • Expand mobile e-Northern Ireland Single Assessment Tool
  • Implement Falls and Osteoporosis Strategy
  • Strengthen safeguarding arrangements
  • Introduce telecare
  • Improve identification of palliative and end of life care


  • Reduce demand for services
  • 20% of reablement clients diverted from statutory service to community services
  • Reductions year on year on attendances at ED and length of stays
  • 45% of new referrals through reablement will not require long term dom care
  • 10% reduction in admittances to residential care
  • 5% reduction in the length of stay for people who have had reablement (166 bed days)
  • Reduce statutory residential capacity in years by 15% in years 1 and 2 (80 beds)
  • Reduction in patient related travel costs
  • % of staff trained in falls prevention
  • Increase no of older people availing of telecare
  • Reduce no of end of life attendances at ED and number receiving care in acute settings

Southern HCST


  • 3 ICP’s
  • 77 GP Practices
  • 360 placements in residential accommodation
  • 1,297 Nursing Home Placements
  • 17,141 clients in receipt of domiciliary care
  • Significant health inequalities
  • Projected Population change 09-20 +15%

Key Points - Older People

  • Range of health and wellbeing initiatives for older people: falls, malnutrition, mental health social inclusion and support
  • Explore social enterprise models across all programmes
  • Pilot in ICP on enabling those over 75 to remain independent etc
  • Review of statutory residential care services
  • Reablement available across Trust localities
  • Increase diversity of domically care provision
  • Increase use of personalised budgets
  • Support for carers
  • Early intervention and wellness
  • Full implementation of palliative and end of life care service


  • Reduced ED / Hospital admissions
  • Reduce the number of people in residential care and the number in statutory facilities
  • Reduce demand for mainstream domiciliary care following reablement
  • Increase in numbers of carers assessments
  • Achieve a 12% shift to mixed economy of providers
  • Increase in direct payments
  • Increase options for partnership with V&C sectors
  • Increase carers assessments
  • Increase palliative and end of life support
  • Introduce a retail model for simple aids

Northern HSCT


  • 4 ICP’s
  • 78 GP practices with 465,601 patients
  • 1,410 residential places – 14 statutory and 45 independent
  • 2,967 care home placements
  • 948 meals on wheels
  • Significant health inequalities
  • Projected Population change 09-20 +7%

Key Points - Older People

  • Focus on health and wellbeing of older people; falls, malnutrition and mental and emotional wellbeing
  • Create reablement service (Trust Owned)
  • Reform and reduce residential care and replacement of statutory homes
  • Reform of intermediate care
  • Reprovision of statutory EMI services (Moylinney and Ferrad)
  • Raise awareness of palliative and end of life care


  • Reduce no of falls and ED attendances
  • 20% after reablement will require no domiciliary care and 30% reduction in size of long term care
  • Reductions on residential care places
  • Closure of 11 statutory residential home – 4 with advanced plans underway
  • Increased range of support to people in their own homes and supported living
  • Reduce length of stays for older people with dementia etc
  • Reduce admissions, attendances and length of stay in hospitals
  • Reduce no of people receiving end of life care in acute settings and inappropriate admissions to ED

Western HSCT


  • 2 ICP’s
  • 57 GP Practices
  • 1941 available places in residential accommodation
  • 4521 Care packages in effect
  • 1026 meals on wheels services
  • Dementia set to increase by 46% by 2021
  • Significant health inequalities
  • Projected Population change 09-20 +6%

Key Points - Older People

  • Revised contractual arrangements and the role and capacity of the V&C sector
  • Healthy Ageing: extend existing older people’s networks. Pilot currently being tested
  • Establish reablement model
  • Re-balance the provision of domiciliary care – reduce statutory care provision
  • Reform model of day-care and active ageing provision
  • Review provision of respite services
  • Reduce use of long term care institutional placements: (from 8 to 5) and cease statutory residential provision
  • Focus on carers support
  • Development of Memory Service
  • Reduce hospital stays
  • Falls Prevention Service
  • Re-design palliative and end of life care services and consider providing a day hospice


  • Reductions in secondary care referrals
  • Reduced ED / Hospital admissions
  • Fewer continuing care packages and reduce demand on residential homes
  • Reduce growth rates in long term care expenditure
  • Increase in numbers of carers assessments
  • Reduce length of stay and bed days


Next page:
Who Cares? The Future of Adult Care and Support

Age NI Advice Line:
0808 808 7575

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