A pioneering frailty programme in Richmond has demonstrated significant success in reducing hospital admissions for vulnerable residents, according to a report presented to the Health and Wellbeing Board. The initiative, which is part of a wider South West London model, focuses on delivering coordinated, person-centred care for individuals identified as frail. Richmond has become one of seven national sites participating in the National Frailty Collaborative, a programme that tests new ways of working and care bundles. The programme's approach is exemplified by case studies highlighting individuals who experienced prolonged hospital stays and deterioration due to a lack of proactive care, when their needs could have been met through alternative means.

A diagram illustrating five key areas for supporting earlier discharge and admission avoidance
Diagram of frailty support areas

Since its inception in 2023, the programme has seen positive outcomes, including a reduction in hospital admissions for frail individuals and an improvement in the quality of care provided in care homes. The report highlights the importance of a frailty-attuned care approach, which requires a shift in mindset among healthcare professionals.

Key to the programme's success has been the implementation of a proactive care model, where multidisciplinary teams, including GPs, social workers, and community nurses, discuss patients identified as at risk. This collaborative approach, coupled with a focus on supporting earlier discharge and avoiding unnecessary admissions, is contributing to better health outcomes for residents.

The programme is also working to improve the digital infrastructure that underpins the delivery of care, aiming to ensure seamless communication and data sharing between health and social care providers. This digital enhancement is seen as crucial for enabling professionals to deliver effective, timely, and person-centred care.

While the programme is ongoing, the initial results indicate a promising trajectory for managing frailty within the borough, with a commitment to continuous improvement and learning from national best practices. Further details on the programme's critical path and learning cycles can be found in the NHSE National Frailty Collaborative documentation.

A critical path diagram outlining the learning cycles and deliverables for the NHSE National Frailty Collaborative
NHSE National Frailty Collaborative Critical Path

For more information on the Frailty programme, refer to the Richmond HWB Frailty Cover sheet and Frailty for RHWBB March26.