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Integrated frailty services

Improving care for frail older people is a shared challenge; one that calls for system thinking, joined-up working, and support that understands the realities on the ground.

That’s where NHS Elect can help.

Building on the success of our Acute Frailty Network, which supported over 140 NHS sites, our flexible support packages to drive integrated frailty improvement offer expert guidance, facilitation, measurement and quality improvement support to help organisations and systems strengthen frailty care across the whole pathway.

Whether you need fresh eyes on your front door model, support for proactive community care, or help joining up services across settings, we’ll work alongside your teams to help you deliver improvements that last.

Arrange a call to discuss your needs

 

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Our impact

We’re proud to have supported a wide range of teams and systems to improve services for people living with frailty. Through initiatives such as the award-winning Acute Frailty Network (AFN), our work in Same Day Emergency Care (SDEC), and system wide patient flow programmes, we’ve seen real, measurable improvements, including:

Reduced admissions

Helping teams to identify frailty earlier and provide appropriate care in the community or same day settings.

Shorter hospital stays

Supporting more efficient pathways that allow patients to return home sooner and recover in the right environment.

Significant cost savings

Enabling smarter use of resources through streamlined processes and reduced pressure on acute services.

Improved partnerships

Bringing together colleagues across health, social care and the voluntary sector to design more joined-up, person-centred care.

Our services

We’ve designed five flexible packages of support to help systems focus on the areas that will make the biggest difference locally. Each offer has specific aims and outcomes that will be tailored to the needs of your patients. Each of our offers can be expanded to provide more in-depth support if needed.

Proactive frailty

Typically five days of support

Our proactive frailty services provide hands-on support to strengthen early intervention and preventative care. Typical interventions include site visits, data reviews, stakeholder workshops, and tailored action plans. We work with neighbourhood teams, ambulance services, and Single Points of Access (SPoA) to improve frailty identification and coordination. By focusing on integration and early response, we help systems deliver more consistent, person-centred care, reducing avoidable admissions and supporting people to live well for longer.

Reactive frailty

Typically five days of support

Our reactive frailty services focus on improving urgent and emergency care for people living with frailty. We support services such as Same Day Emergency Care (SDEC), Hospital at Home (virtual wards), and front-door frailty models. Typical interventions involve pathway reviews, stakeholder engagement, maturity assessments, and bespoke improvement plans. We help systems respond more effectively and consistently, ensuring that patients receive timely, appropriate care and avoid unnecessary admissions whenever possible.

Scenario-based planning event

Typically two days of support

Our scenario-based planning events are short, focused sessions designed to support rapid, collaborative action planning. Through realistic system-level scenarios, we bring together stakeholders from across health, social care and the voluntary sector to explore challenges and opportunities in frailty care. A typical session includes facilitated discussion, shared learning, and immediate next steps. These events help build shared understanding, uncover practical solutions, and generate collective energy for improving integrated frailty services.

Pre-hospital improvement collaborative

12 months of support

Our pre-hospital frailty improvement collaborative supports ambulance and urgent care teams to build knowledge, confidence, and consistency in responding to people living with frailty. Through interactive learning sessions, shared resources, and real-world case discussions, we help teams improve frailty identification and decision-making in the field. The programme brings together clinical leads, managers and MDTs to strengthen care at the earliest point of contact, reducing avoidable hospital attendance and supporting more appropriate, person-centred outcomes.

System wide frailty support programme

12 months of support

Our system wide frailty support programme offers in-depth, tailored support over 12 months to help systems drive lasting improvement. We begin with a rapid stocktake to understand current practice, then work alongside your teams to deliver your priorities. Typical support includes stakeholder events, quality improvement coaching, workforce development, and support with data and measurement. This programme helps align partners, build local capability, and create the conditions for sustainable, joined-up frailty care.

Find out more

Why work with us?

A proven track record

We’ve helped systems across the NHS transform frailty services, from front door to discharge and beyond.

National recognition

Our work has won national awards for its impact on outcomes, flow, and patient experience, including the Improving Care for Older People Initiative of the Year at the HSJ Patient Safety Awards.

Over 140 organisations supported

We’ve worked with acute trusts, community services and ICSs across the country.

Practical, tailored support

We don't just advise, we work alongside your teams to understand your challenges and implement solutions that stick.

What people say about us

“The System Wide Frailty Team have been unfailingly positive and supportive in helping us to develop our work. I particularly appreciated the systematic quality improvement approach, with practical help to access a range of quality improvement tools.”
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System wide frailty services user

“Working with the System Wide Frailty Team has been invaluable for our Community Frailty Team. The team took the time for a detailed site visit during which they listened to our journey so far, reviewing our publications, data and service evaluations. They provided insight into our clinical delivery, reach of the clinical model, and helpful advice and support for modifying our measurement of success.”
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System wide frailty services user

Let's have a conversation

We’d love to hear about the challenges you're facing and share how we can help you. Please email us at hello@elect.nhs.uk to arrange a conversation or ask any questions you have.

Arrange a call to discuss your needs

 
Our services
Using NHS Elect
Contact Us
020 3925 4851
info@nhselect.org.uk
LABS Hogarth House
136 High Holborn
Holborn
LONDON WC1V 6PX
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