Personalised approaches in frailty service re-design
Snapshot of the challenge
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Over 100,000 Lincolnshire residents aged 65+ are living with frailty.
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Frailty reduces a person’s physical and mental reserves, making hospital admission more likely during illness or crisis.
Why this matters
As frailty progresses:
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Contacts with health and care services rise by approximately 35% at each stage (mild to moderate, and moderate to severe).
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Associated spend increases by 78% for moderately frail people and 87% for those with severe frailty.
What works: Proactive, personalised care
Taking action early makes a measurable difference. Approaches such as screening, comprehensive assessment, multidisciplinary input, and personalised care planning can:
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Reduce hospital admissions by 20%
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Cut falls by 10%
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Improve health and independence, which in turn reduces care needs
Our shared strategy
Partners across health, social care, public health, and the third sector, together with people, families, and the wider public, are co-producing a new strategy.
Ambition: integrate services for older people so care feels joined-up, timely, and person-led.
How the It's All About People Personalisation Programme Team is supporting this work
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Baseline surveys: we're mapping workforce knowledge and understanding of personalised approaches.
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Support for early-adopter PCNs: we provide practical training and guidance.
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Championing proven tools: we promote consistent, person-centred resources.
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Challenging intervention design: we're working to ensure that services reflect what matters to people.
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Advocating Our Shared Agreement: we're embedding Our Shared Agreements shared goals and language across the health and care partners we're working with.
What to expect next
As this work develops, this page will grow, adding resources, examples, and more person-centred language that reflects the strategy in practice.
Get in touch
If you have any questions or ideas relating to this work, don't hesitate to email us: lhnt.itsallaboutpeople@nhs.net
