How Cornwall NHS kept Margaret out of hospital

When Margaret developed a severe respiratory infection, she could no longer manage basic daily tasks at home. The usual next step would have been a hospital bed. Instead, a paramedic made a single call, and a different kind of response began.

A same day response

The paramedic engaged Cornwall’s Integrated Frailty Support Service, which triggered a rapid, coordinated response. The frailty team carried out a same day holistic assessment and arranged support from across the local neighbourhood network.

They organised urgent care through the CHAOS care agency for immediate daily support. To deal with safety risks in Margaret’s home, the Trust’s Home First Service followed up, and that team can also provide any equipment that might be needed. Frailty specialists reviewed Margaret’s medication to reduce the risk of falls and further complications.

With the frailty service, CHAOS, and Home First working together, Margaret received comprehensive, patient-centred care in her own home. The approach is designed to maintain healthcare capacity and support her long-term independence. It was all coordinated quickly through a single point of contact.

Her story is one example of how integrated neighbourhood health work is helping patients across Cornwall. Those involved include clinical and professional teams, neighbourhood leaders, voluntary, community and social enterprise (VCSE) partners, council colleagues, primary care, community services, acute providers, system leaders, and communities themselves.

Award-winning work

The work has now picked up regional and national recognition. The NHS Excellence Awards highlight local projects and teams, and the impact they have on patients and communities.

The system’s neighbourhood health entry was named regional champion, winning the Improving Health Outcomes Award. It was also shortlisted at the national awards in Manchester.

The award aligns with key targets in the 10-year health plan, which sets out three shifts. They are moving care from hospitals to communities, switching from analogue to digital, and focusing on prevention over treatment.

Judges recognised a number of factors. These included a co-designed neighbourhood health and wellbeing blueprint shared across the system, significant system investment to let neighbourhoods lead change, at-scale delivery across 16 neighbourhoods, measurable improvements such as reductions in emergency attendances and admissions, and a system-wide approach to evaluation, learning, and continuous improvement.

Leighton Day, director of performance and outcome delivery for the Trust, says: “This is a strong endorsement of the scale, ambition and impact of the work being delivered across our system.”

The awards panel also praised the entry, calling it “a fantastic achievement and a testament to the impact of your work.”

Built around neighbourhoods, not organisations

This is described as the largest neighbourhood health transformation in England, and the only whole-system Wave 1 site in the country. The award shows how the NHS, local authorities, and the VCSE sector work to a shared vision and a common operating model, with care built around neighbourhoods rather than organisations.

Leighton adds: “On behalf of the CIOS 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 say they will keep working together to develop the integrated neighbourhood teams, with the aim of delivering even more care at home, or as close to home as possible.