System’s neighbourhood health work delivers positive patient outcomes
When Margaret developed a severe lower respiratory tract infection, she was not able to manage basic daily activities at home. Rather than being taken to hospital, a paramedic engaged Cornwall's Integrated Frailty Support Service. This triggered a rapid, coordinated response.
The frailty team carried out a same day holistic assessment. They arranged support from across the local neighbourhood network. They arranged urgent care through the CHAOS care agency for daily support. To address safety risks in Margaret's home, this was followed up by input from the Trust's Home First Service. They can also provide any equipment needed. Frailty specialists reviewed Margaret's medication. This was to reduce the risk of falls and further complications.
Thanks to primary care, the frailty service, CHAOS, and Home First working together, Margaret received patient-centred care at home. This approach maintains healthcare capacity and supports her long-term independence. All were done quickly through a single point of contact.
Margaret's story is just 1 way of showing how our integrated neighbourhood health work is helping patients.
Those involved include clinical and professional teams; neighbourhood leaders; voluntary, community, and social enterprise (VCSE) sector partners; council colleagues; primary care; community services; acute providers; system leaders; and communities themselves.
All partners have shown what can be achieved through working together to deliver truly integrated neighbourhood healthcare and the best outcomes for patients. This work has received regional and national acclaim.
Award-winning work
The NHS Excellence Awards shine a light on local projects and teams, as well as the positive impact they have on patients and communities.
The system's neighbourhood health entry was named regional champion. It won the Improving Health Outcomes Award. The entry was also shortlisted at the national awards in Manchester.
The award aligns with some key targets in the 10-year health plan. There are 3 key shifts in the plan. They are moving care from hospitals to communities; switching from analogue to digital; focusing on prevention over treatment.
The award recognised a number of key factors. They include:
- the co-designed neighbourhood health and wellbeing blueprint shared across the system
- significant system investment to enable neighbourhoods to lead change
- at-scale delivery across 16 neighbourhoods
- tangible improvements in outcomes, including reductions in emergency attendances, admissions, and avoidable system pressures
- a pioneering, system-wide approach to evaluation, learning, and continuous improvement
Leighton Day is director of performance and outcome delivery for the Trust. He says:
"This is a strong endorsement of the scale, ambition and impact of the work being delivered across our system."
The system was also earned praise from the awards' panel:
"This is a fantastic achievement. It is a testament to the impact of your work."
This is the largest neighbourhood health transformation in England. It is also the only whole-system Wave 1 site in the country.
The award also shows how well this system works across the NHS, local authorities, and the VCSE sector. They all share a vision. A common model. A commitment to care around neighbourhoods rather than organisations.
Leighton adds:
"On behalf of the Cornwall and Isles of Scilly Place Team, we would like to extend our sincere thanks and congratulations to all partners who have worked on this.
"We are proud of what this means. This is something to celebrate and to build on."
The Trust has hosted the Cornwall and Isles of Scilly Place Team since 2025. Partners will continue to work together to develop our integrated neighbourhood teams. This is with the aim of delivering even more care at home or as close to home as possible.