Frailty Coordination Hubs & Integrated Neighbourhood Teams

In the previous section, we explored how Comprehensive Geriatric Assessment (CGA), continuity, and coordination support effective frailty management for people living with moderate and severe frailty.

This article explores how existing NHS services might be better organised to deliver coordinated, continuous frailty care at neighbourhood scale.

We explore:
• Why continuity remains central to effective frailty management
• Which parts of the NHS already deliver continuity well
• How Primary Care Networks (PCNs), frailty coordination hubs, and Integrated Neighbourhood Teams (INTs) may support neighbourhood delivery
• Which services and professionals need to work together around people living with frailty
• The workforce capability required to manage frailty and complexity in the community
• How acute frailty response can be delivered closer to home
• How this model aligns with emerging NHS neighbourhood health policy

Together, these approaches help neighbourhood systems deliver coordinated, continuous Comprehensive Geriatric Assessment over time rather than isolated episodes of care.

Frailty is dynamic.

People living with frailty often experience changing needs over time, influenced by illness, recovery, mobility decline, cognitive change, social circumstances, and carer support.

Effective frailty management therefore depends on continuity. This includes:
• Relational continuity, where trust, familiarity, and understanding develop over time
• Informational continuity, where clinical information, decisions, and personal knowledge follow the individual across services and settings

Within the NHS, general practice remains uniquely positioned to support this continuity because it provides:
• Near-universal population registration
• Repeated contact over time
• A longitudinal clinical record bringing together information from across services
• Ongoing involvement before deterioration, during crisis, and following recovery

General practice is therefore a natural anchor point for neighbourhood frailty care. Alongside continuity, it can support population-level frailty identification and prioritisation, helping bring together signals of deterioration from across the system so worsening frailty becomes visible earlier across neighbourhood populations.

This creates the foundation for more coordinated neighbourhood frailty activity across multiple services and organisations.

Continuity alone is not sufficient.

People living with moderate and severe frailty often require support from multiple professionals, organisations, and sectors simultaneously, including:
• General practice
• Community services
• Geriatric medicine
• Social care
• Mental health services
• Care homes
• Ambulance services
• Acute care teams
• VCFSE organisations

Without coordination, care can quickly become fragmented across referrals, waiting lists, organisational boundaries, and disconnected assessments.

Coordination is not about repeatedly moving people between services through referral and handover processes. It is about services organising themselves around the individual so that care feels joined-up, continuous, and coordinated rather than fragmented across organisational boundaries.

This requires neighbourhood systems capable of coordinating multidisciplinary care longitudinally across local populations.

Primary Care Networks (PCNs) provide a natural neighbourhood footprint for coordinating frailty care around registered populations while maintaining continuity close to the individual.

At neighbourhood scale, this creates the conditions for a PCN-based frailty coordination hub.

The hub is a way of organising existing neighbourhood teams and services around coordinated, continuous frailty management across a defined neighbourhood population.

Its role is to:
• Maintain a dynamic neighbourhood frailty register
• Identify people with frailty who are deteriorating and need prioritising for Integrated Neighbourhood Team support
• Coordinate care across the frailty pathway
• Support continuity across services and settings
• Enable proactive and urgent frailty response
• Bring together multidisciplinary decision-making
• Support earlier intervention and prioritisation
• Maintain oversight across the neighbourhood population

This creates a model where Comprehensive Geriatric Assessment can function as a continuous process rather than a series of isolated assessments completed by disconnected teams.

Co-location of teams in PCN-based frailty hubs is strongly beneficial.

Bringing professionals together helps build familiarity, trust, shared understanding, and faster decision-making between teams. It also supports the informal conversations and collaborative problem-solving that often underpin effective neighbourhood working in practice.

Neighbourhood systems should therefore actively explore opportunities to develop shared neighbourhood estates and co-located multidisciplinary working wherever possible, particularly across general practice, community services, social care, mental health, and voluntary sector partners.

If the frailty coordination hub coordinates care across the system, the Integrated Neighbourhood Team delivers it.

Integrated Neighbourhood Teams are multidisciplinary, multi-provider workforces aligned to local neighbourhood populations.

This may include:
• Community nursing
• Therapy services
• Social care
• Care home support
• Older People’s Mental Health services
• Palliative and end-of-life care
• Voluntary and community organisations
• Acute frailty and specialist teams

Working around a shared neighbourhood footprint allows teams to build:
• Shared responsibility
• Shared understanding
• Shared decision-making
• Continuity across organisations and settings

This supports:
• Earlier intervention during deterioration
• More proactive frailty management
• Reduced fragmentation between services
• More care delivered at home and in familiar settings
• Continuity across admission, discharge, recovery, and deterioration

Importantly, this model does not require creating entirely new services. It depends on organising existing neighbourhood resources more effectively around the individual.

Together, PCN-based Frailty Hubs and Integrated Neighbourhood Teams coordinate frailty identification, prioritisation, prevention, proactive care, and urgent response across neighbourhood populations.

However, some episodes of deterioration require a higher level of assessment and treatment than neighbourhood teams alone can safely provide.

Operating as a combined multidisciplinary workforce, this model supports:
• Rapid clinical assessment
• Early identification of deterioration
• Same-day diagnostics
• Intravenous therapies
• Daily multidisciplinary review
• Specialist frailty input within the community
• Avoidance of unnecessary hospital attendance or admission where appropriate

Closely aligned with Same Day Emergency Care (SDEC), this allows more people living with frailty to receive higher-acuity care at home while preserving continuity, coordination, and Comprehensive Geriatric Assessment across the frailty pathway.

Once stabilised, care transitions back to PCN Frailty Hubs and Integrated Neighbourhood Teams for ongoing neighbourhood management, rehabilitation, and longitudinal support.

Delivering coordinated frailty care at neighbourhood scale requires a workforce with the skills to manage complexity proactively within community settings.

This includes:
• Advanced clinical practitioners
• Senior community clinicians
• Skilled multidisciplinary professionals
• Consultant geriatricians working across community and acute settings

Band 7 and Band 8a practitioners are particularly important because they often coordinate care, respond to deterioration, support proactive management, and maintain continuity over time.

Consultant geriatricians also play a critical role, not simply by delivering specialist care directly, but by distributing frailty expertise across neighbourhood systems through supervision, mentorship, and shared decision-making.

This helps build wider frailty capability across neighbourhood multidisciplinary teams.

Neighbourhood systems across England vary considerably in maturity, workforce capability, digital integration, infrastructure, and provider relationships. This model is therefore not a description of current uniform reality across England.

However, national NHS policy increasingly supports proactive, coordinated, neighbourhood-based frailty care organised around continuity, multidisciplinary working, and Comprehensive Geriatric Assessment.

The NHS Ten Year Plan, Neighbourhood Health Framework, and NHS England Best Practice Guide for NHS Frailty Pathways increasingly emphasise:
• Active neighbourhood frailty case lists and proactive frailty identification
• Integrated Neighbourhood Teams operating across organisational boundaries
• Shared responsibility for multidisciplinary frailty management
• Single points of access and coordinated frailty pathways
• Integrated pathways spanning Urgent Community Response (UCR), virtual wards, hospital at home, Same Day Emergency Care (SDEC), and discharge services
• Shared digital records and shared, editable CGA across providers
• Home-based assessment, proactive care, and continuity following crisis
• Expansion of community-based frailty capability and Band 7/Band 8a workforce capacity
• Consultant geriatricians working across community and acute settings to distribute specialist frailty expertise
• Greater alignment of workforce, infrastructure, and resources around neighbourhood delivery

The NHS Ten Year Plan identifies frailty as a national priority area and states that “in many areas, the existing primary care network (PCN) footprint is well set up as a springboard for this type of working.”

Similarly, the Neighbourhood Health Framework states that services should be coordinated “around a person’s needs, rather than organisational convenience.”

The NHS England Best Practice Guide for NHS Frailty Pathways further reinforces the importance of neighbourhood multidisciplinary teams, active frailty case lists, shared care records, integrated urgent frailty pathways, continuity across settings, and coordinated community-based frailty care.

PCN-based frailty coordination hubs and Integrated Neighbourhood Teams provide one operational structure through which these principles can be delivered at neighbourhood scale.

They represent the convergence of:
• The evidence base for frailty care
• Current NHS neighbourhood policy
• Existing NHS neighbourhood infrastructure already in place across England

Coordinated neighbourhood frailty care cannot function effectively without shared digital infrastructure.

Identification, prioritisation, multidisciplinary coordination, continuity, and shared Comprehensive Geriatric Assessment all depend on systems capable of supporting shared visibility across neighbourhood teams.

The next section explores the digital infrastructure required to support coordinated, continuous frailty management at neighbourhood scale, including shared records, shared CGA, decision support, and population insight.

1. NHS England (2026) Best Practice Guide for NHS Frailty Pathways
2. DHSC and NHS England (2026) Neighbourhood Health Framework.
3. HM Government (2025) 10 Year Health Plan for England: Fit for the Future.
4. NHS England (2026) Medium Term Planning Framework 2026–27 to 2028–29.