Over the past two years we have transformed the way we provide intermediate care, enabling more people to receive the care they need at home, or in their community, enabling them to live well and independently for longer. But what if we could do more to prevent, or slow down, health deterioration? This is now the focus of our HomeFirst programme - developing integrated community health and care models that will support people to live well and independently for longer.
The Leeds HomeFirst Programme stands out as one of the most impactful achievements of our partnership in recent years. Thanks to the dedication and collaboration of teams across the system, we’ve revolutionised how intermediate care is delivered in the city—resulting in over 1,000 avoided hospital admissions each year than we would have seen without these changes.
We’ve also significantly reduced the average hospital stay by around eight days, enabling hundreds more people to benefit from reablement services and return home sooner, with the support they need to live independently.
The scale of this transformation is remarkable. Leeds is now setting the standard for integrated care, with health and care systems from across the UK—and even internationally—looking to learn from our approach.
But this is just the beginning.
Not all areas of the city are yet experiencing the full benefits of the new model. That’s why we’re now working to expand Active Recovery to more communities and develop our Enhanced Care approach to support people at home rather than needing a hospital attendance or admission.
We’re also shifting our focus further upstream, investing in prevention and proactive neighbourhood care. By supporting people earlier, we aim to improve health outcomes and reduce the need for unplanned interventions.
The next phase – HomeFirst Phase 2 – brings together partners from the local authority, NHS, third sector, primary care, and independent providers, working alongside local residents to develop neighbourhood health and care services that work together to proactively prevent health and wellbeing deterioration, with the goal of enabling more people to live well and independently and be supported in their own homes.
What is the programme aiming to achieve?
- Implement a neighbourhood proactive care model that works with people and families to improve health outcomes for those most at risk (5-7% people living with frailty and long-term conditions). Develop our approach to Creating the Conditions for this way of working, contributing to the Neighbourhood Health model
- Build on HomeFirst and continue to develop our intermediate care offer so that people spend less time away from their own bed, can be supported closer to home, and enable smooth and timely transfers from hospital and community beds.
- Undertake a Prevention Diagnostic that aims to promote independence and avoid, delay or reduce people’s needs for care and support services and ensure that we improve our approach to targeting people that will benefit most.
What will these changes mean for people?
- Better outcomes and experience for people and families
- Better experience for staff
- Better meds optimisation
- Better Continuity of Care
- Reduce unplanned care activity across our partnership
- Reduce utilisation of No Reason to Reside bed days
- Improved use of shared resources and Leeds £