Community health services are spearheading innovative care for people with frailty, a new report shows.

The pivotal role community providers play in supporting older people living with frailty, including by launching new services to give more timely care at or close to home and to meet rising needs of an ageing population, is highlighted by the Community Network hosted by NHS Confederation and NHS Providers.

More than one in three older people in England live with some form of frailty, which develops as our bodies gradually lose their in-built reserves, leaving us vulnerable to dramatic, sudden changes in health often triggered by seemingly small events.

Half of hospital inpatients aged over 65 are affected by frailty.

The increasing number of people with frailty will have a significant impact on health and care provision, with community providers central to achieving national ambitions to support more people with frailty to live well at or closer to home.

Community staff and their system partners support people with frailty to stay well in their own home through preventative measures and crisis response initiatives, helping people to avoid attending A&E where appropriate, and delivering care to help people recover after a hospital stay.

Examples of good practice featured in the report include (see details below) from Blackpool Teaching Hospitals NHS Foundation Trust, Croydon Health Services NHS Trust, Harrogate and District NHS Foundation Trust, Kent Community Health NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Foundation Trust.

A relative of someone treated by the Kent Community Health NHS Foundation Trust service said: “We were over the moon when we realised he could have treatment at home rather than going to hospital. The service the team provided was second to none and he was so much better when he was discharged.”

A family member of a Tameside and Glossop Integrated Care NHS Foundation Trust patient said: “My mum got expert care and was involved all the way through the process. The reason why this experience was so important was that it meant her last days were spent with a team who really cared for her, and we could not have asked for more support, not just for her but for us too. The staff and doctors were outstanding in their attention to detail and high level of communication. Very thorough ward and services, lovely caring and kind staff. Much-needed holistic approach.”

Sir Julian Hartley, chief executive, NHS Providers, said: “It’s great to see the fantastic work by community service providers who do all they can to give people living with frailty the right care at the right time including help to bounce back from health problems.

“But too many frail people who need well-planned, joined-up care aren’t getting the support they need to live well at home, where many prefer to be. National policy-makers must support trusts and patients with far greater investment.”

Matthew Taylor, chief executive of the NHS Confederation, said: “There is so much positive work going on to care for people with frailty in or near their homes, which is making a dramatic difference to people’s lives, and those of their families. It is exciting to see community providers at the forefront of this shift to help people with frailty to live well closer to home, and with the right support they are keen to go even further.”

Siobhan Melia, chief executive of Sussex Community NHS Foundation Trust and chair of the Community Network, said: “Community providers all over the country are innovating to provide better care to people living with frailty and responding to the needs to their local populations. The feedback we have seen from patients and families continues to drive us to do better.”

More details of examples in the Community Network report:

• Blackpool Teaching Hospitals NHS Foundation Trust: The Community Frailty Service made up of a multidisciplinary team delivers personalised care plans, advice, education, and support to keep people well at home.

• Croydon Health Services NHS Trust: The Health Visitors for Older People team visits people in their home and provides a supportive service to vulnerable, frail and isolated older people to help them retain their independence and prevent avoidable hospital admissions.

• Harrogate and District NHS Foundation Trust: Community Care Teams integrate nursing, therapy, and rehabilitation, minimising hospital admissions and promoting independent living.

• Kent Community Health NHS Foundation Trust: The frailty hospital at home virtual ward provides an alternative to hospital care, ensuring comfort and support in patients’ homes.

• Tameside and Glossop Integrated Care NHS Foundation Trust: The Frailty Same Day Emergency Care Unit in the hospital’s A&E department screens all older patients for frailty, and those who need it are transferred for a comprehensive assessment and treatment. Where appropriate, same day community discharge is arranged to avoid an unnecessary hospital admission.