Our Stewardship Programme has been shortlisted for Integrated Care Initiative of the Year at the prestigious 2025 Health Service Journal (HSJ) Awards.
This recognition highlights the exceptional work and innovation demonstrated by the teams involved and a testament to their dedication to driving healthcare excellence.
Dr Peter Scolding, Clinical Director of Stewardship, tells us more about the initiative:
The Stewardship Programme brings together teams of health and care staff and managers, to get the best value from our shared health and care resources.
Frontline health and care staff act as stewards and play a greater role in system decision making with the aim of improving population health and service quality – as well as enhancing staff motivation and pride in work.
The programme has built ‘Stewardship Groups’ across 10 care areas including Children and Young People, Cancer, Diabetes, Dermatology, Mental Health and Urgent and Emergency Care, enabling frontline clinical and managerial staff to collaborate and ‘steward’ our shared health and care resource. The approach has enabled teams across the health and care system in mid and south Essex to collaboratively tackle population-health challenges such as frailty, stroke, musculoskeletal care pressures and eye care pathways by using innovation, system-thinking and value-based techniques.
Some of our most successful stewardship projects started in smaller local areas before spreading across the mid and south Essex health and care system. Our Ageing Well Stewards are a prime example of this approach, improving palliative and end of life care through two groundbreaking digital tools.
The Frailty, End of Life and Dementia Assessment Tool (FrEDA) and Electronic Palliative Care Coordination System (ePaCCS) are designed to ensure adults nearing the end of life are identified earlier and receive joined-up, personalised care. Analysis shows approximately 2.6% of the 1.3 million residents in mid and south Essex could benefit from this earlier identification and support.
FrEDA was co-designed with frontline clinicians and over 800 patients and carers to overcome challenges including low data quality, limited staff tools, and inconsistent care delivery. Launched in 2022, this holistic digital tool enables earlier identification of people with frailty, dementia, or life-limiting illnesses and was quickly rolled out across mid and south Essex to GPs, community teams, hospices, and virtual hospital wards.
The ePaCCS register enables seamless real-time information sharing of care plans and wishes across all providers.
Since launch, the impact has been transformational:
- 18,000+ people identified for proactive care
- 40% increase in adults with palliative care needs added to ePaCCS
- 50% increase in Advance Care Plans in place
- over 50% reduction in older people with more than three unplanned hospital admissions in their last 90 days of life
- 5% reduction in people readmitted to hospital within 30-days
- 5% drop in deaths occurring in hospital (since 2019)
- 50% reduction in A&E attendances due to falls for frailty patients