Foreword: Reforming elderly and frail care pathways, including dementia

Mindy Simon

Designation

Co-Director, NHS Innovation Accelerator

The following is the foreword from Curia’s Reforming Elderly and Frail Care Pathways, Including Dementia Report, as part of the NHS Innovation Accelerator Conference Series. Find out below how to access the full report.

At a time of mounting pressure on the NHS and adult social care services, the second Sprint Workshop of the NHS Innovation Accelerator Conference turned its focus to one of the most urgent and complex challenge facing Integrated Care Systems (ICS): The reform of care pathways for the elderly living with frailty, multiple long-term conditions, and dementia.

Against a backdrop of persistent emergency department pressures, delayed discharges, and overstretched community teams, this workshop brought together a wide range of system leaders, frontline clinicians, voluntary sector partners, carers, and innovators.

Their goal: To reimagine care for the elderly in a way that prioritises prevention, personalisation, and cross-sector collaboration.

The session was shaped by real-world experience and grounded in examples of transformation already underway. The discussion built on the growing recognition that reactive models of care are no longer sustainable, and that system resilience depends on fundamentally rethinking how support is delivered to the elderly – particularly those with frailty and cognitive impairment.

The session also built on work already undertaken by policy institute, Curia, in 2024 with NHS Northamptonshire ICS and Northamptonshire Carers.

The report, Enhancing The Dementia Care Pathway, built on work delivered by the Dementia Commission in 2023 and sought to provide solutions to improve the task that faces NHS commissioners, elderly patients, carers and clinicians.

What emerged from the NHS Innovation Accelerator sprint was a powerful consensus: That the future of elderly care must be proactive, community-based, and co-designed with those who use and deliver services.

Contributors from Northamptonshire shared compelling evidence that shifting from hospital led to relationship-based, preventative care models can reduce emergency attendances, improve patient experience, and boost professional morale.

In particular, their Urgent and Emergency Care (UEC) Strategy – underpinned by a six-pillar model – has delivered measurable reductions in hospital admissions among the elderly, despite a growing and ageing population.

Participants highlighted the need to move beyond the episodic management of frailty and dementia. Instead, elderly care should be anchored around people’s values and what matters to them, with consistent, multi-professional teams supporting individuals before, during, and after a crisis.

GPs were given the time and space to lead holistic 45-minute home visits, supported by Age UK, carers’ support workers, and community health professionals. These investments not only improved care quality but also reinvigorated primary care teams – some of whom credited the model with restoring their sense of purpose and preventing early retirement.

Equally important was the session’s attention to the lived experience of carers and families. Several contributors shared personal and often emotional accounts of navigating a fragmented care system while supporting loved ones with advanced dementia.

These stories underscored the critical importance of timely, reliable support for informal carers, and the value of services like Admiral Nurses and dedicated helplines that offer guidance outside traditional working hours.

Northamptonshire’s approach – co-producing services with a People Advisory Group and embedding dementia support into weekend and urgent care response – was widely applauded.

A recurring theme was the essential role of culture and leadership in sustaining change. Participants spoke candidly about the barriers posed by rigid workforce structures, disconnected IT systems, and fragmented commissioning. Yet they also described how these obstacles could be overcome by fostering trust, empowering staff, and investing in relationships across organisational boundaries.

There was strong support for enabling professionals to work beyond traditional job descriptions – deploying dementia and palliative nurses in urgent care, integrating voluntary sector workers into care teams, and embedding general practice into co-ordination hubs.

Throughout the discussion, technology was acknowledged as both an enabler and a frustration. While many teams are innovating with shared care records, remote monitoring, and digital templates, others remain trapped by outdated tools and cumbersome procurement.

The call was clear: ICSs and national bodies must invest in interoperable, user-friendly technology that supports joined-up care and lightens the administrative burden on already-stretched teams.

This report captures the insights, innovations, and recommendations that emerged from the session. It builds on the momentum generated by the Curia workshop in 2024, reinforcing the message that system transformation requires not only strategic vision but also sustained cultural and operational shifts.

The task ahead is to embed these models of care at scale – moving from local pilots to system wide norms, and from reactive firefighting to preventative, people-centred care.

The full report, which can be accessed here, is free for subscribers of Curia’s Health, Care, and Life Sciences Research Group, public sector and registered charities.

For more information about Curia memberships, reach out to ben.mcdermott@chamberuk.com

Featured image via Ground Picture / Shutterstock.