The rapid evolution of our understanding of frailty and the move to recognise and manage frailty within the framework of a ‘long-term condition’ is starting to make an impact. There is increasing evidence that the early recognition and management of frailty in community settings can help to improve outcomes for older people. Such an approach can have a positive influence upon trajectories of need for people living with frailty AND a favourable impact upon the progression of the underlying condition of frailty.

In addition to more effective interventions to support people identified as having established frailty, the next important challenge is to take a wider, more inclusive and proactive approach that enables us to support healthy ageing and early intervention across a broader cohort of older people. This new comprehensive and inclusive approach is best founded in primary care because GP practices are in the unique position of having records for all older people on their registered practice list, whether they present to services or not. This contrasts with other services which are only ‘aware’ of the older people who present to them, very often at the point at which a crisis has already occurred.

Project Background

This project case example started as a pilot study at Madeley Practice in Staffordshire, targeting those people registered with the practice aged 75 years and over. In April 2013, following the success of the pilot study, the project was rolled out to all people aged 75 years and over across the 6 practices which make up Newcastle-under-Lyme South locality of North Staffordshire CCG. The total registered population of this locality is around 37,000, of who about 3,400 (9.1%) are over 75 years old. Around 800 people (2.1% of the total population) are over 85 years old and 2,600 (7% of the total population) are in the age range 75-84 years.

The project ran for 24 months through to March 2015. The budget was £90,000 of which £70,000 was actually spent. It was funded jointly by the Bishop Stamer Foundation (a North Staffordshire charity), NHS North Staffordshire CCG locality innovation fund, and Daiichi-Sankyo NHS Moving Beyond sponsorship. This funding met the staffing costs and expenses for the project, including the time for the visits and supporting clerical activities.

Numerous organisations were involved in the project from across the local public, private and voluntary sectors. These included:

  • NHS North Staffordshire
  • Newcastle-under-Lyme council and social services
  • Stoke-on-Trent City Council
  • Lions Club International
  • Knights Solicitors
  • Citizens Advice Bureau
  • Red Cross
  • Age UK
  • Newcastle-under-Lyme police and fire service
  • Volunteer drivers
  • Local geriatrician
  • Community services (in particular physiotherapy and occupational therapy but also including falls service, chiropody, district nurses and speech therapy).

A key feature of this project was linking up older people with existing systems and services that were already available to support them in their local area. No new services were put in place to meet the needs identified during the assessment visits; it was about making people aware of existing resources and helping them to access those most appropriate to their needs.

To read the full project report click here or see below

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