A new frailty model being implemented across Sutton is showing promising results, with early evidence suggesting a 50% reduction in unplanned hospital admissions and A&E attendances for those receiving proactive care.
The initiative, part of the wider Sutton Health and Care Plan, focuses on residents aged 65 and over who have moderate to severe frailty, multiple long-term conditions, or are at risk of deterioration. The specific criteria for eligibility include residents aged sixty-five plus with moderate to severe frailty, multiple long-term conditions, care home residents, housebound residents, and people at risk of deterioration or admission. The proactive care approach aims to identify individuals at an earlier stage and develop personalised care plans in collaboration with their families and carers.
Proactive care involves acting before a resident's health deteriorates rather than waiting until they become acutely unwell or reach crisis point. This process includes identifying people who are frail, housebound, or living with complex conditions and working with them, their families, and carers to agree a practical plan for keeping them well. These personalised care plans provide guidance to healthcare professionals on what is required for each individual, including escalation plans and their personal wishes. The plans may include regular check-ins, medication reviews, falls prevention, support with housing or finances, links to community activities, and clear arrangements for what should happen if their health begins to worsen.
This proactive intervention is designed to prevent crises, help residents remain independent at home for longer, and reduce the strain on health and social care services.
Michelle Rahman, Place Lead for Sutton for the Southwest London ICB, presented the update to the Health and Wellbeing Board on Monday, September 7, 2026. She highlighted that approximately 1,300 residents currently have proactive care plans, with a target to expand this to 8,000 residents over the next two years.
Early evidence indicates that proactive care plans have reduced the use of unplanned care, including A&E attendances, emergency admissions and urgent appointments, by around 50%,
Rahman stated, emphasising the significant success of the model.
The programme is being supported by investment in frailty care coordinators at a neighbourhood level. This additional funding, part of the business case for Sutton's Integrated Frailty Pathway, aims to increase capacity to manage growing caseloads, coordinate care, and support earlier intervention for residents at greatest risk of deterioration.
While the frailty model is showing positive early results, the report also noted challenges in ensuring seamless collaboration between NHS, council, and community services, and in meeting the growing demand with existing workforce capacity. The primary challenge is ensuring that these services work together rather than developing separate approaches to supporting people living with frailty. Success depends on identifying which residents require support and ensuring there is enough workforce capacity to meet demand. Strategies to address this include the aforementioned investment in frailty care coordinators.
Beyond the 50% reduction in unplanned admissions and A&E attendances, the partnership will assess the programme's impact on resident outcomes, service use, workforce capacity, and costs across partner organisations. An outcomes framework to measure these improvements exists within the Sutton Health and Care Plan, and a dashboard of key performance indicators is under development.^[1]^[2]
[1] Public reports pack 07th-Sep-2026 18.30 Health and Wellbeing Board.pdf [2] Agenda frontsheet 07th-Sep-2026 18.30 Health and Wellbeing Board.pdf
