National Medical Director Professor Frankie Swords visited Nimbuscare’s Community Frailty Hub in York on 23 July to see first-hand how an innovative, community-led model of care is helping frail older people remain safe, independent and supported at home.

Hosted by Professor Mike Holmes, Executive Chair of Nimbuscare, and Dr Emma Olandj, a GP with an extended role in Frailty and Director of Community Services, the visit showcased how integrated neighbourhood health teams are transforming care for some of the city’s most vulnerable residents.

Based in Holgate in the city, the York Community Frailty Hub has become a nationally recognised example of neighbourhood healthcare. Featured in the NHS 10-Year Health Plan, the service brings together primary care, community services, social care, voluntary sector organisations and other partners within a single multidisciplinary model.

During the visit, Dr Olandj led a tour of the hub and provided an overview of the clinical model, highlighting how the service has evolved from a small pilot into a seven-day, 24-hour operation supporting thousands of patients across York.

The hub was established in response to the challenges faced by frail patients navigating multiple services. Instead of moving between organisations and repeating their story to different teams, patients now have access to coordinated support through a single point of contact.

Its integrated approach encompasses three key elements: a Frailty Prevention Team providing proactive care and comprehensive geriatric assessments; a Frailty Crisis Response Team delivering rapid multidisciplinary support and a dedicated advice and guidance line; and a Discharge Support Team helping medically fit patients return home from hospital sooner.

The results have been significant. The Frailty Crisis Team has prevented thousands of unnecessary hospital attendances and ambulance conveyances, while the discharge service has reduced hospital stays and supported faster recovery for patients in their own homes.

L-R Dr Faisel Baig, Dr Emma Olandj, Professor Frankie Swords, Professor Mike Holmes and Dr Tori Blake

During discussions with Nimbuscare leaders, Professor Swords and Regional Medical Director for Primary Care for the North East and Yorkshire, Dr Faisel Baig, heard how the model aligns with the NHS ambition to shift care from hospitals into communities, move from sickness to prevention and deliver more personalised care closer to home. The team also discussed the learnings for colleagues delivering neighbourhood health across England.

Dr Emma Olandj said:

“The Community Frailty Hub demonstrates what can be achieved when health, social care and voluntary sector partners work as one team around the needs of patients. By bringing expertise together in a single multidisciplinary service, we are helping people living with frailty stay independent, avoid unnecessary hospital admissions and receive the right care in the place they call home.”

The visit also highlighted the importance of co-located multidisciplinary working. Frailty nurses, GPs, occupational therapists, dietitians, social prescribers, dementia specialists, social workers and voluntary sector colleagues work side-by-side, enabling rapid decision-making and reducing delays to care.

Professor Mike Holmes outlined how Nimbuscare’s GP-led structure has enabled the organisation to innovate, respond quickly to local need and develop services that improve outcomes while reducing pressure on acute hospitals.

He said:

“We were delighted to welcome Professor Frankie Swords to York and share the work of our Community Frailty Hub. The service is a powerful example of neighbourhood health in action – delivering proactive, preventative and responsive care through strong partnerships. Most importantly, it is making a real difference to patients and families by helping people remain safe, well and supported in their communities.”

The visit formed part of wider conversations about the future of neighbourhood health and integrated community care. Nimbuscare leaders shared their ambitions to further develop the service, including strengthening integrated neighbourhood teams, enhancing dementia support and expanding opportunities for innovation and research.

As healthcare systems continue to look for new ways to meet growing demand, the York Community Frailty Hub offers a compelling example of how collaborative, community-based care can improve outcomes for patients while easing pressure on hospitals. The visit provided an opportunity to showcase how local innovation is already delivering the ambitions set out in the NHS 10-Year Health Plan and helping create a more connected, person-centred health and care system.

Read more about the work of the York Community Frailty Hub