Reforming care for older adults living with frailty and dementia is no longer a future ambition – it’s an urgent necessity.
This was the shared conclusion of NHS system leaders, frontline clinicians, carers, and innovators who came together for Sprint Two of the NHS Innovation Accelerator Conference, delivered in partnership with Curia and IQVIA.
Building on Curia’s previous work with NHS Northamptonshire ICS and Northamptonshire Carers, the May 2025 workshop tackled the complexity and fragmentation that characterise current elderly care pathways. Instead of continuing with reactive and hospital-centric responses, participants explored how Integrated Care Systems (ICSs) can deliver proactive, relationship-based support rooted in communities.
“If I were 80, what would I want care to feel like?”
This question anchored the afternoon’s discussions and crystallised a shared vision: services designed around people, not process. It challenged attendees to reimagine care through the lens of dignity, autonomy, and inclusion.
Rethinking Care for an Ageing Nation
Against the backdrop of overstretched services and a rapidly ageing population, the workshop heard compelling evidence that shifting from crisis-led to preventive care can deliver real system impact. A flagship example came from Northamptonshire, where their Urgent and Emergency Care (UEC) Strategy – centred on a six-pillar model – has reduced emergency admissions in over-65s by 25%.
This transformation was not dependent on vast new resources. Instead, it relied on repurposing funding, aligning effort, and empowering frontline teams.
“We don’t need new ideas. We need the courage to scale the ones that work.”
Attendees shared a clear consensus: frailty and dementia must be seen not just as clinical concerns but as systemic challenges requiring holistic, cross-sector solutions. That means co-locating services, empowering GPs to conduct 45-minute home consultations, and embedding dementia expertise into urgent care teams.
What Good Looks Like: Community-Led Innovations
The workshop surfaced numerous practical interventions already making a difference across ICSs:
• Extended GP Reviews: In Northamptonshire, longer consultations supported by Age UK and carers’ workers have improved outcomes and boosted GP morale.
• Admiral Nurses in Urgent Care: Providing dementia expertise over weekends helped prevent carer burnout and avoid unnecessary hospitalisation.
• Shared Records and Templates: Standardising frailty assessments using tools like Ardens in SystmOne has supported consistent and timely interventions.
• Group Clinics and Peer Support: Participants highlighted the power of shared learning spaces that combine clinical advice with social connection.
• Service Co-Design with Carers: From transport needs to toenail-cutting services, carers helped identify gaps invisible to traditional service planners.
These changes are grounded in values as much as evidence. Delegates repeatedly returned to the importance of continuity, compassion, and dignity in older people’s care – principles often lost in today’s fragmented system.
“This isn’t innovation for innovation’s sake. It’s what care should have always been.”
Designing With, Not For, Older People and Carers
Co-production emerged as a cornerstone of effective reform. Northamptonshire’s People Advisory Group ensured that carers’ voices were heard in the design and evaluation of services. Contributors shared moving accounts of supporting loved ones with dementia and underscored the importance of 24/7 support, benefits advice, and early planning.
National speakers echoed the need to embed lived experience into governance and system design – not as a tick-box exercise but as a source of deep system insight.
“We can’t afford to keep designing systems in boardrooms and expecting them to work on the ground.”
Participants stressed that successful models start by understanding what matters to older people – whether that’s seeing the same nurse, being cared for at home, or simply being listened to.
Barriers to Scaling: Funding, Technology, and National Alignment
While local success stories were plentiful, attendees were frank about the systemic obstacles that threaten to stall progress.
One of the loudest calls was for long-term investment. Many of the most effective models – such as extended home visits or out-of-hours dementia support – were funded through short-term budgets. Without sustained financial backing, these initiatives risk being dismantled before they can take root.
Procurement emerged as another major challenge. Proven digital tools are often blocked by inconsistent safety case requirements or legacy IT systems. Participants advocated for national frameworks to fast-track validated innovations across ICSs.
“We need an ‘innovation passport’ – if it works in one system, it should be safe to use in another.”
Similarly, workforce structures need reform. Delegates described how rigid role definitions prevent staff from working flexibly across boundaries. National guidance that enables cross-role working – backed by training and employment reform – was identified as a crucial enabler.
A Blueprint for Transformation
The workshop culminated in a draft implementation strategy, which sets out how ICSs can reform care pathways for older people at scale. The strategy includes eight core actions:
1. Embed proactive frailty assessment in primary and community care.
2. Commission holistic, home-based GP reviews with wraparound support.
3. Integrate dementia support across diagnostic and crisis pathways.
4. Deliver co–ordinated, cross-sector community teams including social care and the voluntary sector.
5. Invest in peer-led group consultations and social prescribing.
6. Build resilience in carer support, especially out-of-hours.
7. Standardise data and technology to support frontline delivery.
8. Create feedback loops driven by real patient and carer stories.
“We are not starting from zero. We are starting from proven success stories that deserve national recognition.”
This approach was praised for its focus on practical, achievable steps rooted in lived experience. Crucially, the strategy recognises that reforming frailty and dementia care is not just about services – it’s about culture, values, and relationships.
“It’s Not About More Pilots – It’s About Scaling What Works”
As the workshop concluded, one message rang loud and clear: the time for small-scale pilots is over. The challenge now is to embed what works across every ICS, moving from local exceptions to national norms.
Participants called on NHS England and Department of Health and Social Care to champion proven models, reform commissioning frameworks, and ensure funding flows to preventative care. National bodies were urged to signal that relationship-based, person-centred care is not a luxury – it’s the foundation of a sustainable NHS.
“We know what good looks like. Now we need the courage – and the infrastructure – to deliver it everywhere.”
This Sprint Two report is both a wake-up call and a roadmap. It proves that reform is not only possible but already underway. But without national leadership and strategic alignment, these gains remain fragile.
The invitation is open: to policy-makers, system leaders, and care providers – to work together, listen harder, and build a future where every older person can age with dignity, support, and purpose.
For more information about Curia memberships, reach out to ben.mcdermott@chamberuk.com
