Kingston & Richmond Frailty Programme Update Focuses on Integrated Care and Prevention
Kingston and Richmond residents living with frailty are set to benefit from a more integrated and patient-centred approach to care, following an update presented to the Kingston Partnership Board on Wednesday, 25 February 2026. The Kingston & Richmond Integrated Frailty Programme aims to enhance the independence of older people, improve health outcomes, and reduce reliance on hospital care.
The programme, which has been a priority for Kingston for some time, is building on existing work. Data presented at the meeting indicated that 23% of Kingston's over-65 population are coded as frail, a figure expected to grow by 25% over the next decade. The programme seeks to create a seamless care pathway across Kingston and Richmond, focusing on prevention, early intervention, and timely return to the community for those who require hospitalisation.
Key objectives include improving health outcomes for those over 65, aligning resources to reduce duplication, and minimising unplanned hospital admissions. A core element of the strategy is the widespread adoption of a comprehensive geriatric assessment and a universal care plan. The programme is working in partnership with NHS Digital on the single patient record to integrate data across multiple systems, ensuring that professionals have the right information at the right time. This is intended to support multiple professionals from different organisations in accessing data so they are better informed when working with people from other agencies.
Significant progress has already been made, including work at Kingston Hospital to prevent deconditioning in frail patients. Beyond encouraging eating, drinking, dressing, and moving, specific work is being done around the front door of the emergency department and the quality of care that frail patients receive in the same-day emergency care unit. The programme also focuses on 'frailty attuned' care, which includes preventing deconditioning and aims to help people stay independent at home. Efforts are also underway to improve the quality of care in emergency departments and care homes. The programme has also successfully rolled out and digitised the comprehensive geriatric assessment.
The initiative is aligned with broader strategic goals, including the NHS 10-year health plan and the local neighbourhood health model, which emphasize a shift from hospital-based to community-based care and from sickness to prevention. This includes strengthening hospital-at-home services, virtual wards, and discharge-to-assess models. As part of the shift from hospital to community care, the programme is implementing 'hospital-at-home' services and virtual wards. This includes work on the Better Care Fund, implementing frailty attuned hospital care, and supporting the 'home fur' scheme, which is a discharge to assess model that supports people to be assessed at home. There is also exploration into how virtual wards could be more strongly integrated into the London Ambulance Service and falls service pathways.
Public health efforts are also contributing through the aging well
theme of the local health and well-being strategy. This includes initiatives focused on preventing ill health and maintaining healthy life expectancy, with a particular emphasis on the link between healthy hearts and frailty, as risk factors for both conditions are similar. Within the 'prevention' zone, a framework for frailty prevention and staying well is being developed. This initiative aims to target those most at risk of poor health, with the goal of preventing them from becoming frail in the first place, or if they do become frail, keeping them as well as possible for as long as possible. Additionally, the programme is focused on promoting physical activity, balance exercises, and 'get active' programs suitable for the older cohort.
The programme is structured around five key zones: prevention, holistic falls and frailty services, support for carers, frailty and end-of-life care provision, and workforce education and training. Dependent work streams are also addressing critical areas such as the front door of emergency departments and hospital discharge processes.
Carers are a key pillar and a golden thread throughout the Kingston & Richmond Integrated Frailty Programme. The programme has committed to having a set of principles guiding decision-making and approach, with the outcomes and impact on carers being intrinsic to this. The work on the universal care plans and single patient record is also intended to support multiple professionals in accessing data, which indirectly benefits carers by ensuring better-informed care for their loved ones. The programme is also exploring how to support residents in accessing and keeping up with digital developments, such as the NHS app, which may include support for carers to upload contingency plans.
During the meeting, Councillor Diane White highlighted the importance of accessible pavements for older residents, noting that uneven surfaces can deter them from going out and increase the risk of falls. The board acknowledged this concern, referencing the ongoing age-friendly strategy which takes a holistic view of support for aging residents, encompassing transport and other environmental factors.
Discussions also touched upon the importance of mental health in frailty. It was noted that a significant number of older people with frailty also have diagnoses of dementia or depression, underscoring the need for a holistic approach to care. The programme aims to address these interconnected issues, ensuring that mental well-being is a key consideration alongside physical health.
The Kingston & Richmond Integrated Frailty Programme aims to reduce unplanned admissions and increase the use of comprehensive geriatric assessment and universal care plans, which are considered key to improving patient outcomes and facilitating smoother transitions between services. The long-term goal is to help those who are not frail to remain active and independent for as long as possible, thereby preventing or delaying the onset of frailty.
The programme is currently in its implementation phase. By the end of March 2026, the aim is to pilot the new integrated person-centered frailty model, followed by evaluation and refinement. The programme will then look to embed gold standards for community frailty services across the system. See the Public reports pack for more details.
