NHS England » Transforming the frailty pathway

Organisation objective

NHS Mandate from Government

Working with people and communities

What approaches have been used to ensure people and communities have informed this programme of work?

recruited Patient and Public Voice (PPV) Partners
consultation / engagement
quantitative data and insight, for example national surveys;
partnership working with voluntary, community and social enterprise organisation

Action required

The purpose of this paper is to provide an update on NHS England’s plans to improve care for older people living with frailty by shifting care from hospital to community settings, delivered though a neighbourhood health service.

Shifting care from hospital to community

1. The proportion of healthcare resources used by people living with frailty is increasing significantly, as discussed in the 2023 Chief Medical Officer’s report ‘Health in an Ageing Society’. A different approach is needed to support this population group to manage this demand, improve patient experience and improve outcomes where possible.

2. We have continued to see increases in non-elective acute activity and spend, driven in large part by increased healthcare usage by individuals with complex needs, particularly people living with frailty. We believe a community-based approach would be better for patients, the NHS and tax payers.

3. Optimally managing increasing demand as demography and complexity of presentation changes, alongside addressing delays to flow of care is required to deliver a shift to more care in the community for patients who would benefit. This would help to reduce the use of Temporary Care Environments in winter and free up hospital capacity for other patients, as well as helping to achieve urgent and emergency care performance.

Delivering a neighbourhood health service

4. The Government’s commitment to deliver a neighbourhood health service should help to unlock progress on this agenda. Neighbourhood health aims to deliver a system-wide coordinated offer for people living with complex needs, supported and enabled by national, regional and local action. To deliver neighbourhood health, all parts of the health and care system – primary care, social care, community health, mental health, acute, and wider system partners – will need to work closely together to support people’s needs more systematically, building on existing cross-team working, such as primary care networks, provider collaboratives and collaboration with the voluntary, community, faith and social enterprise sector.

5. Working together at a neighbourhood footprint, providers will help to assess and address health and care needs in a coordinated way, involving the range of expertise that is needed for the patient. This will help to reduce health exacerbations, ensure optimum use of health system resource when exacerbations do occur and improve patient experience across England. The existence of integrated care boards (ICBs) and the NHS operating framework provides the opportunity to enable this join up of services at scale for patients living with complex needs, including a specific focus on achieving this for older people living with frailty.

6. As detailed in the Neighbourhood Health guidelines for 2025/26, ICBs and local authorities are asked to jointly plan a neighbourhood health and care model for their local populations that consistently delivers and connects the initial core components of neighbourhood health at scale, with an initial focus on people with the most complex health and care needs. The 6 core components include:

a. Population Health Management

b. Modern General Practice

c. Standardising Community Health Services

d. Neighbourhood Multi-disciplinary Teams

e. Integrated intermediate care, with a ‘home-first’ approach

f. Urgent neighbourhood services

7. A national implementation programme for neighbourhood heath is being designed for all parts of the health and social care system involved in delivering neighbourhood health. The initial phase of this programme will aim to work with at least one place in every system. These places will already be demonstrating a more developed approach to delivery at local level, with clear leadership across the ICB, local NHS and local authority. System partners in these places will be provided with facilitation support, as well as support to ensure robust evaluation and monitoring of progress. This test and learn approach will help to identify what is working most effectively and the conditions that are required to deliver a set of target outcomes. The national implementation programme will sit alongside a very small number of learning and evidence sites, which will test the model at scale, including its impact on flows in and out of an acute hospital.

8. Alongside the focus on neighbourhood health, a priority focus remains on reducing length of stay for those who no longer need to be in hospital by working to improve flow of care and resolve the capacity gap in community-based services, including social care through neighbourhood health. Additional harm, specifically institutionalisation and deconditioning, can be caused by unnecessary admissions or long stays. This will remain a key focus of work for the NHS.

Next steps

complete insight, analytical and evidence work underway on frailty
progress frailty site selection as part of Neighbourhood Health programme
launch implementation support for this agenda as part of Neighbourhood Health programme