Managing frailty in the community

Sheinaz Stansfield

Managing frailty in the community though personalised care planning

Oxford Terrace and Rawling Road Medical Group (OTMG-RR) is a GP practice, situated in Central Gateshead. The population of about 15,200 patients is predominantly deprived, with high numbers of refugees and asylum seekers. We have a particular passion for patients with complex care needs and using a risk stratification tool we identified that about 2500 of our patients with multiple comorbidities were at high risk of being admitted to hospital. 100 of these patients were house bound and did not meet the criteria for access to community matrons. Despite having community matrons attached to the practice our trajectory for attendances and admissions to hospital were increasing.

An experienced Older Persons Specialist Nurse (OPSN) was recruited by South Tyneside NHS Foundation Trust and released on secondment to implement the principles of Comprehensive Geriatric Assessment to achieve continuity of care for elderly patients with complex health and social care needs.


In the first 8 months of this project to May 31st 2014, 94 housebound patients with an average age of 85 years, were referred to the OPSN and had care planned and implemented, using the principals of Comprehensive Geriatric Assessment.

This role was based directly within the practice and provided the benefits of co-production with the core members of the PHCT, patients and their carers working as equals in collaboration to optimise the health and well- being of frail older people. Equally, there were rewards to the practice in terms of opportunities for peer support; networking and sharing, and multi-disciplinary working. The appointment of a Nurse Specialist as a clinical leader with knowledge and skills in the care of older people, wide experience of effective multi-disciplinary and interagency working and awareness of the local and national drivers affecting the care of older people was a key component in the success of this.

Referrals in first 8 months

This post has become substantive in the practice. In addition, we have negotiated with our community services providers to have our community matron directly linked to the practice, making her more visible, available and a core part of our multi-disciplinary working. innovation has enabled us to strengthen the nursing team with the right skills. She also use the practice clinical reporting system to ensure patient safety through improved communication.


Very early in this project  the outcomes were reassuring, showing a downward trend in the use of several aspects of unscheduled care and home visits.

In addition:

  • All patients on the case load had a comprehensive care plan that was uploaded onto the adastra system for external organisations to enable integrated working;
  • 53 carers were identified and also received support and were signposting to appropriate services.  

Similar interventions are normally provided through community services providers. However, access to these services is challenging as they are neither available nor visible in the practice. They have a reactive approach and referral criteria tend to exclude the group of patients we were targeting for this intervention. There is no incentive to manage these people proactively in general practice, other than the annual review required through the quality and outcomes framework. This is a process measure that evidences little improvement to outcomes for patients. With this intervention we aimed to move beyond the QOF, to manage patients proactively in their own homes. 

Challenges that may need to be overcome to further develop and/or implement the idea

  • Reluctance of community service providers to base staff in GP practices and correspondingly the lack of accommodation for community staff to be based in practices;
  • The mind-set of nurses and others working in general practice/community services and their desire to change;
  • Capacity and capability in general practice to support this type of change;
  • Workforce pressures to free staff to become involved and undertake adequate measurement;
  • Lack of training to support the needs of people with complex care needs and frailty. 

This intervention is easily replicable and has been shared with Gateshead CCG to inform future commissioning of community services.

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Charlie Kenward

This looks like a really exciting project and your initial figures are remarkable. I'm looking at the issue of GP care of frailty within a CCG context at the moment and would be great to hear more about your project, especially the data you have. Thanks

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