Senior leaders from across the Hounslow Borough Based Partnership came together at Hounslow House on 12 February for the first of two dedicated Frailty Board development sessions, marking a significant step in strengthening our collective leadership of the frailty agenda.
The sessions have been designed to further develop Hounslow’s Frailty Strategy, ensuring that our governance and partnership arrangements are aligned with delivery ambitions.
They also create structured space to reflect on where future collaboration is required to continue building and embedding the neighbourhood health model in Hounslow.
- London Borough of Hounslow
- West London NHS Trust
- Chelsea and Westminster Hospital NHS Foundation Trust
- NHS North West London Integrated Care Board
Leaders included Steven Forbes, Dr Christopher Hilton, Martin Waddington, Dr Sanjay Krishnamoorthy, Clare Miller, Sterling Rippy and additional colleagues from the wider health and care system.
- Reflected on examples of where the partnership has worked at its best and noted that these integrated projects shared collaborative planning and implementation, and organisations had supported joint funding to support system change.
- Explored what has enabled success and the progress made to date
- Shared appreciative feedback, recognising strengths and leadership qualities across the board had supported an increased confidence in creating a more collaborative culture
- Identified what partners ‘want more of’, and ‘less of’, in future ways of working
- Agreed focus areas to carry forward into the second session.
The discussion reaffirmed a strong, shared commitment to improving outcomes for residents living with frailty, reducing A&E attendances, and strengthening mutual support as system pressures intensify.
The second development session will take place on 18 May 2026 and will build on the priorities identified in February. It will focus on further developing the Frailty agenda and identifying where deeper collaboration is required to embed the neighbourhood health model across Hounslow.
Examples of Frailty outcomes so far in Hounslow include:
A data-driven approach
The Frailty Board uses the partnership’s shared population health dashboard to review outcomes, monitor and plan operational delivery across organisations. This enables partners to:
- Track hospital admissions and length of stay
- Assess the impact of prevention and community-based services
- Identify system pressures early and agree coordinated responses
- Maintain collective accountability for borough-wide outcomes
This focus on data has supported measurable improvements across frailty-related pathways.
Enhanced Dementia Care Service (EDCS)
- 17% reduction in Emergency Department attendances
- 29% reduction in non-elective hospital admissions
- 36% reduction in non-elective bed days
The service provides proactive, multidisciplinary support to stabilise residents at home and prevent avoidable escalation.
Bridging Care: Pentagon Model
- Shortlisted for a 2025 HSJ Award
- Strengthened integrated discharge and step-down pathways
- Improved coordination across hospital, community and social care partners
Falls Prevention and Bone Health Service, and Stay Steady and Active
- Early identification of risk and proactive community strength and balance support
- Integrated medication, bone health and home safety interventions
- Demonstrable contribution to reduced acute demand
Together, these outcomes demonstrate how early intervention, integrated community services and strong partnership leadership can reduce avoidable harm, improve quality of life and relieve pressure on emergency services.
For more information on the frailty programme visit - https://