The Frailty Service

Supporting people in our community with symptoms linked to their long-term conditions, preventing hospital admissions.

We know that thousands of people in North Hertfordshire and Stevenage could, but don't, receive our care. Many of those are living with frailty, a condition widely believed to be the major public health challenge of the 21st Century - and not just in Letchworth, or Hitchin, or Stevenage, not even in the UK - but globally.

It's time we changed this. So on 2nd January 2024, following months of careful planning, we launched an innovative new frailty service. It is a first for hospices.

The modern hospice movement arose in the 1960s to serve an unmet need. This is a new, unmet need - so we need to evolve and do the same again. This is Our New Chapter at Garden House Hospice Care.

Carol's story

Carol's parents both needed support for the last few years of their lives. Her dad, Bryan, who had cancer, was referred to Garden House Hospice Care within a few weeks of being diagnosed. Her mum, Ann, who had frailty, was referred a day after she died.

In this raw and honest video, Carol describes the illness her mum lived with and why, years on, she's still struggling to cope with what her mum went through.

What is frailty?

Frailty is a term you may associate with being elderly and delicate. It actually means when you’re living with multiple health conditions, such as diabetes, heart failure, asthma, dementia. The more frail you are, the more difficult simple things like shopping or getting dressed become. You probably know, or have known, someone who this sounds like.

When someone has frailty, their health gradually declines. People are turning up to their GPs or A&E with symptoms linked to their increasing frailty. They may be experiencing breathlessness, pain, fatigue. They may be falling more often.

The impact

We were given access to patient notes (with their personal details removed) of:



local people with kidney failure, each contributing to their frailty




days collectively spent in hospital from August 2022 - August 2023



116 A&E admissions

132 emergency admissions

12% for urinary infections


3.5 beds every day were taken by a combination of these 50 patients.

It's bad for patients too. Common conditions such as colds and flu can turn into a crisis and require a hospital stay. Typically they will have worse outcomes due to the length of their stay, losing their motivation, confidence and their voice in planning their future care.

Our new frailty service

Our innovative and unique frailty service has been crafted with input from staff and external partners. It has the potential to revolutionise care for people with frailty.

We will use our expertise in symptom control and meet people with frailty earlier so they can live well at home. Our service will keep them out of hospital (saving the NHS money) and give people an alternative lifeline when symptoms flair up. Then one day, if they need it, they will have access to our palliative care services.

To do this, we are:


1. Identifing people suitable for our care, earlier.

A dedicated nurse is visiting our local hospital and A&E every day to identify patients we can support and move them into the Hospice or the community.


2. Expanding our community services.

Our clinicians such as physiotherapists and occupational therapists will start to deliver their services directly into people's homes, helping to prevent hospital admissions.


3. Opening additional beds.

These will be for people with frailty, to support them with symptoms and get them back home again. We now have 12 beds, instead of 8, in operation.


4. Expanding our Compassionate Neighbours team.

This will support in developing more of our popular and lively social hubs. These are a crucial way of finding more people who would benefit from our services.


5. Soon be providing 'ambulatory care'.

This means, for example, the administration of IV antibiotics or blood transfusions. People can come to us instead of hospital, have the treatment (and a biscuit) and go home.

How you can help

Every pound you can give will be used to continue to run our frailty service. It will mean people receive better care, admissions to hospital are reduced and more people can benefit from our range of expert services, earlier. It will allow us to:

  • Grow our workforce to staff our services at the Hospice and in the community - nurses, doctors, health care assistants and our allied health professional roles
  • Invest in more staff with specialist palliative care expertise, such as renal or heart failure and recruit a nurse who will link with the hospitals
  • Expand our Compassionate Neighbours hubs
  • Purchase new equipment to deliver the treatments required

Donate now


£19 could cover a nurse being in A&E for an hour, identifying people who this service can help


£40 could go towards the cost of the items needed for our ambulatory care service, such as monitoring equipment and comfortable furniture


£61 could pay for a physiotherapy session, focused on keeping someone independent for as long as possible

How much would you like to donate toward Our New Chapter?
Donate now

Founders of the Frailty Service

Any individual, company or trust who gifted over £5,000 in the first three months of the service became a 'Founder of the Frailty Service'. With special thanks to:

  • The Michael Cowan Foundation
  • The Childwick Trust
  • Letchworth Rugby Club
  • Lady Dixon
  • Val Aitken
  • Michael Brown
  • dormakaba UK & Ireland
  • The Etauliers Charitable Foundation
  • Alan and Lynne Janes
  • Menzies LLP Stevenage
  • Memoria North Herts
  • Anne Pink
  • Chris and Jane Phillips
  • Raymond James, Hitchin
  • Karen Williams
  • The Reed Foundation

"You gave him his life back again"


From volunteer to frailty service patient