As people become older they can become more frail, losing strength and becoming more likely to have falls and ill health.
Loss of energy, slow walking speed and poor muscle strength make people more vulnerable to health changes from minor events such as a small infection, change in medication or a minor operation.
In Greenwich, health and care professionals from different organisations are working together to support people living with frailty to help them turn their lives around and avoid serious illness and accident. It’s helping their happiness too, with 59 per cent of people treated by the service reporting improvements in their mental health.
Since launching in 2020 in a handful of GP practices, the frailty service has seen great results including:
- 53% – reduction in Emergency Department attendance
- 33% reduction in unplanned hospital admissions
- 21% – reduction in London Ambulance Service callouts
- An average of £143 saved per patient through medication reviews.
This equates to approximately £762,000 savings to the health and care system over the past 12 months based on the 622 Patients referred*
GP time has been saved as well – on average five hours per patient.
Referrals to the frailty service come from GPs, community teams, the same day emergency care centre and frailty service at Queen Elizabeth Hospital.
GPs also actively select patients who they think could benefit from the service.
The frailty service offers a home-based frailty review, using a tool called the modified comprehensive geriatric assessment. Medicines are reviewed, and a multi-disciplinary team develop a care plan with support from the patients GP, geriatricians and psychiatrists where needed.
Care navigators support patients and carers to put that care plan in place and follow-ups are conducted after six months to keep everyone on track.
NHS Providers chief executive Daniel Elkeles recently visited the Greenwich frailty team.
He said: “The more I see of what providers of community services are doing to make the ‘left shifts’ to community and to prevention real, the more convinced I am that the NHS really can do this.”
GP practices are working with partners from community, mental health and the acute hospital, as well as the voluntary sector within the four neighbourhoods in Greenwich to implement the service, as part of the area’s approach to bringing together integrated neighbourhood teams.