Summary
Strategic Issue 1
There is rapidly increasing demand linked to an ageing population. Hartlepool already has 20% of residents aged 65+ with growth projected through 2030 and 2040. There is a predicted 40.5% rise in hospital admissions due to falls by 2024. National evidence highlights that adults aged 85+ have the highest frailty risk, with over half living with moderate/severe frailty.
With an ageing population there will be higher numbers of residents at risk of falls. There is a need for encouraging prevention engagement through community interventions and supporting multi-agency identification and support of high-risk individuals (through mental health teams, housing teams and social care).
What needs to be done
Robust preventative services and prevention engagement within at-risk age groups through community interventions and supporting multi-agency identification and support of high-risk individuals.
This requires proactive, community-based, multidisciplinary approach that prioritises early identification, holistic assessment, personalised care and coordinated support. Neighbourhood-level services (rather than hospital) ensure frailty is identified earlier through systematic use of tools like the electronic Frailty index.
Effective pathways must integrate falls prevention.
With increasing demand, frailty pathways need to be competent with flexible delivery approaches to ensure equity across underserved groups.
Low educational attainment and health literacy create barriers to self-management, prevention and early help requiring accessible, tailored, community-based and non-digital interventions therefore this must be considered at each level of service and support.
Strategic Issue 2
Hartlepool has high levels of deprivation, with one of the highest IDAOPI scores in England (27.3%) and 4th most income-deprived English unitary authority for older adults. This is compounded with high levels of multimorbidity driving frailty progression. There are very high levels of MSK problems, physical inactivity, obesity and overweight, preventable sight loss and falls. National evidence shows people in deprived communities are twice as likely to experience frailty and deprivation accelerates frailty onset and transition.
There is a need to address modifiable risk factors such as poor housing conditions and lack of bungalows, lack of physical activity, poor nutrition and polypharmacy. Ensuring that targeted intervention reaches underserved communities as deprivation correlates with limited access to prevention.
What needs to be done
Addressing modifiable risk factors requires a targeted, preventative approach that identifies and intervenes early on the key contributors to decline (muscle weakness, poor balance, visual impairment, environment hazards and polypharmacy).
Services must actively prioritise those living with socioeconomic disadvantage, multimorbidity and limited engagement with primary care by embedding proactive screening in community settings and expanding outreach through neighbourhood health teams and tailoring support to cultural, social and environmental needs.
This combined approach can help close inequality gaps and prevent avoidable deterioration among those at risk. Particularly for women as there is higher risk among women. 53.7% of adults aged 65+ are women and 67.1% of older people living alone are women. National evidence shows women are more likely to progress into frailty at any level.
Strategic Issue 3
There is a possibility of hidden burden of frailty, in particular Falls despite low emergency hospital admissions rates. There is a need for improved community-level data and intelligence to capture non-hospital falls managed in primary care or at home.
What needs to be done
Improving data for frailty and falls requires building a complete picture of risk and incidence by collecting data on non-hospital falls, functional decline and early deterioration within community and primary care settings.
Integrating frailty and falls recording into routine community contacts, enhancing the use of tools such as the electronic Frailty Index and shared care records allows simple, accessible reporting.
Strengthening data requires linking information across services and pathways so that early warning signs are recognised before they escalate.