Harrow Health Board has endorsed a renewed focus on supporting residents experiencing frailty, as part of a wider strategy to integrate health and social care services through new neighbourhood teams.

The board agreed to continue prioritising frailty as the initial focus for the borough's three Integrated Neighbourhood Teams (INTs) – East, Central, and West. These teams bring together general practice, community health, mental health services, adult social care, public health, and voluntary sector partners.

A diagram illustrating the social determinants of health
Factors influencing health

Frailty was identified as a high-impact population group with complex, multi-agency needs, often leading to high hospital admission rates and significant costs to the healthcare system. This focus is intended to test integrated working and support the national ambition to shift resources from acute to community care. The initiative aims to support the national ambition to shift 1% of resources from acute to community care, with anticipated outcomes including reduced reliance on hospital-based services and fewer avoidable attendances/admissions. 1

Under the proposed model, each INT will operate through a Neighbourhood Coordination Point (NCP), led by a Frailty Fellow or GP Frailty Lead. These NCPs will be coordinated by a PCN/INT coordinator and will connect with wider system partners and acute services to reduce avoidable admissions, improve patient experience, and help residents live independently for longer.

The success of this renewed focus will be measured through several key metrics, including reduced avoidable admissions, improved patient experience, and enhanced support for independent living. The initiative will also track trends in acute resource utilisation and resident satisfaction. Furthermore, it will involve identifying and segmenting the frail population using risk stratification tools, delivering proactive multidisciplinary case management for high-risk individuals, and providing community-based rapid response services as alternatives to hospital admission. A home first approach will be used to support discharge and reablement, with a strong emphasis on the co-production of care plans in close collaboration with residents and their carers.

Integrated Neighbourhood Teams (INTs) have been operating in Harrow since 2024, with approximately two years of development. The current proposal aims to scale, standardise, and embed neighbourhood working as the core model of care, with frailty as the initial priority. 2

Organizational chart for Harrow BBP Governance 2026
Harrow BBP Governance Structure

INTs have already established successful partnerships with Voluntary & Community Sector (VCSE) organisations. A pilot programme that placed a welfare officer in general practice secured lottery funding for borough-wide expansion, demonstrating effective integration of VCSE partners into service delivery.

The board agreed to note the report on Neighbourhood Health and Frailty and endorse the continued focus on these areas.

  1. The initiative aims to support the national ambition to shift 1% of resources from acute to community care. The proposal is that this focus on frailty through Integrated Neighbourhood Teams (INTs) is intended to test integrated working across health and social care and support the national ambition to shift 1% of resources from acute to community care. The anticipated outcomes include reduced reliance on hospital-based services and fewer avoidable attendances/admissions, which are expected to provide the evidence base to shift further resource from hospital to community care. However, specific projected cost savings or efficiency gains in monetary terms are not detailed. (Public reports pack Thursday 02 Jul 2026 14.00 Health and Wellbeing Board.pdf) ↩

  2. The meeting information states that Integrated Neighbourhood Teams (INTs) have been operating in Harrow since 2024, with around two years of work in this way. The proposal is to continue prioritizing frailty as the initial focus for these INTs and to scale, standardize, and embed neighbourhood working as the core model of care. However, a specific timeline for the full implementation across all three areas is not explicitly stated, beyond the ongoing development and enhancement of existing INTs. (Public reports pack Thursday 02 Jul 2026 14.00 Health and Wellbeing Board.pdf) ↩