Our evaluation of NHS England’s hydration pilots found promising signs of impact but also highlighted the practical and systemic challenges of delivering and sustaining change.

Older people admitted to hospital with urinary tract infections (UTIs) account for more than half of all UTI-related admissions in England. These admissions often result in antibiotic prescribing, contributing to the wider public health threat of antimicrobial resistance. While poor hydration is a known risk factor for UTIs, there is limited evidence linking improved hydration to reduced incidence of UTIs. To address this, NHS England commissioned eight pilot sites to test hydration-focused interventions. 

What the pilots involved

The aim of the pilots was to increase fluid intake among care home residents or older adults living in the community, reduce UTIs, lower antibiotic prescribing, and prevent avoidable hospital admissions. The pilots took place from October 2022 to March 2025 and trialled a range of approaches, including care home staff training, smart cups, hydration diaries, public-facing campaigns and digital apps. 

Our Strategy Unit team carried out a mixed-methods evaluation of the programme, commissioned by NHS England’s Antimicrobial Resistance (AMR) team. This included 97 interviews with staff and stakeholders over two periods of fieldwork and used an interrupted time series (ITS) analysis to assess impact. We produced individual case studies for each pilot site and a final report that drew together process and impact findings.

What we found

The evaluation revealed a varied picture. Four of seven pilots (one of the eight pilot sites withdrew after the first year) with usable data showed statistically significant improvements in one or more outcomes. These included reductions in UTI diagnoses, antibiotic prescribing, falls and emergency admissions. 

However, data collection challenges, small sample sizes and inconsistencies in metric definitions and data availability meant it was not always possible to attribute these changes directly to the interventions. Practical and systemic challenges also emerged, which included: some difficulties recruiting care homes and staff to test the interventions, limited digital infrastructure, and barriers to integrating good hydration practices into routine care. 

Despite this, staff across all pilot sites commented on the perceived benefits. These included reports of improved skin integrity, mental clarity and general wellbeing among older people, as well as more proactive hydration practices among care home teams, increasing the frequency or opportunity to drink more. 

Teams also reported that the interventions had contributed to reductions in UTIs, antibiotic prescribing and falls, even where this was not evidenced in the impact analysis. These perceptions were often supported by local evaluations, staff feedback and routine monitoring data, reinforcing the value of hydration-focused work even where statistical attribution proved challenging.

Recommendations for organisations considering hydration interventions

Our findings suggest the following:

  • Start small and tailor locally. Locally-led design boosts engagement, but ensure content and design are evidence-based.
  • Co-produce where possible. Involving care home staff and residents in design and delivery improves relevance, but time and resource constraints must be planned for.
  • Provide accessible training formats. In-person sessions support deeper learning, while blended approaches offer flexibility and sustainability.
  • Establish feasible monitoring plans. Define and measure baseline metrics before work begins, informed by data availability and reliable collection methods. Ensure consistency to track improvement over time and use personal stories to help demonstrate impact.
  • Design with sustainability in mind. Share materials widely, adapt for other groups, and consider how interventions can continue with minimal resources.

Recommendations for national policy or programme teams planning future work on hydration 

Based on these findings, we would recommend: 

  • Update and quality assure national materials. Ensure any nationally available or mandatory training, guidance and communication materials on good hydration care reflect the latest evidence base to support awareness, consistency and engagement across settings.
  • Address implementation and evaluation barriers early. Consider technical, organisational and systemic challenges before launching future programmes. This includes quality assuring local contingency plans, conducting feasibility studies of data availability and means of data collection (especially in care homes or domiciliary care), and avoiding variation in interventions where comparisons are required.
  • Foster cross-sector collaboration. Promote alignment of best practice in hydration and UTI prevention across residential, domiciliary and primary care, and support effective data-sharing to monitor impact.
  • Support continuous learning and improvement. Provide evaluation resources (such as data collection templates and dashboards), sharing evidence, and maintaining forums for staff to exchange good practices and lessons learned.

The Hydration Pilots offer practical, real-world examples of how systems and individual settings can improve hydration-related outcomes for older people. While formal impact analysis was limited by data constraints, these findings highlight the importance of combining robust evaluation with practitioner insight and lived experience. For systems looking to improve hydration and reduce antimicrobial resistance in their local populations, the pilots provide a valuable foundation to build on.