Perspectives on integrated care for older people with frailty

Key messages

• People who draw on care and carers value integrated care primarily for relational continuity, trust and consistent relationships
• providers tend to prioritise coordination and integration across health and social care sectors
• successful implementation is influenced by how interventions are perceived, organisational readiness and wider system factors
• complex care needs and poor system navigation hinder effective integration
• limited involvement of people who draw on care and carers in decision-making restricts person-centred delivery
• organisational and system-level structures present ongoing barriers to integration.

Policy implications

• neighbourhood models should balance relational continuity with structural coordination
• people who draw on care and carers may need to be more actively involved in the design and delivery of integrated care
• organisational readiness should be assessed before implementing neighbourhood integration initiatives
• system-level barriers need to be addressed alongside local service change.

Gaps

• limited evidence on how stakeholder priorities are reconciled in practice
• lack of evaluation of neighbourhood-based integrated care models for people with frailty
• limited insight into long-term outcomes for people who draw on care and carers.

Commentary
This review highlights differing priorities among stakeholders involved in integrated care for older people with frailty. People who draw on care and carers place greatest value on trust, continuity and relationships, while providers focus more on coordination and system efficiency. From a neighbourhood health and care perspective, this misalignment has important implications for how integration is experienced on the ground.

Complex care needs and difficulties navigating fragmented systems create significant barriers for older people with frailty. Where neighbourhood models focus primarily on organisational integration without addressing relational aspects of care, they may fail to meet what people who draw on care value most.

The review also points to limited involvement of people who draw on care and carers in decision-making. This represents an equity issue, as neighbourhood health and care aims to tailor services to local needs but risks reproducing top-down approaches if co-production is weak.

Organisational readiness and wider system constraints shape whether integrated care initiatives can be implemented effectively. Without attention to workforce capacity, governance and system alignment, neighbourhood approaches may struggle to deliver meaningful change.

Overall, the findings suggest that equitable neighbourhood health and care for people with frailty requires integration that is both relational and structural. Aligning system coordination with continuity, trust and meaningful involvement of people who draw on care is central to achieving person-centred and equitable outcomes.