Tackling Frailty in Greenwich

NHS Greenwich CCG AGM The Panel

Lin Corbell, BEM

Ran Middle Park Community Centre for 30 years, now manages the Lottery-funded Middle Park Friends project

Jane Hopkins

Patient representative; frailty patient and carer engagement lead

Gemma O’Neil

Deputy Director, Commissioning, NHS Greenwich CCG

Amanda Lloyd

Project Lead, Frailty, NHS Greenwich CCG

Why is this important?

Frail patients have complex needs across health and social care. GPs are unable to manage a frail person’s day to day health and care needs on their own.

There are poor outcomes for people with frailty. They will have increased numbers of falls, infections, delirium and other issues, and attend hospital more.

Frailty is not an inevitable part of ageing. It can be reduced or prevented with the right interventions.

Healthy Life Expectancy in Greenwich is worse than both England and London averages.

Who will we focus on?

• Greenwich has an estimated 1,800 people with severe frailty and 4,100 with moderate frailty

• Our hypothesis is that we can prevent exacerbation of, or even reverse frailty if managed early on

• Therefore we will take a preventative approach which will target the ‘moderately’ frail population

• 12-month pilot will work within Riverview Primary Care Network area in Greenwich

Developing our approach

We are working with a wide range of stakeholders including users and carers, GPs, hospital geriatrician, therapists, discharge teams, community health services, voluntary sector, social care.

What is “Moderately Frail”?

• Rockwood score 4-6 on the Clinical Frailty Scale plus one or more of the following “frailty syndromes”:

• The person has fallen once or more in the last 12 months • The person is increasingly or suddenly less mobile • The person is confused, or has a worsening confusion or short term memory loss • The person suffers from incontinence • The person has four or more regular repeat medications

The views of patients and carers underpin our approach

Success criteria

The pilot will test a number of things including:

• Patient outcomes

• Patient, carer, staff experience

• Processes, including use of information sharing systems

• Service provision, use and gaps

• Value for money

• Opportunities for changing services in future to deliver better outcomes

• How we can apply an approach to reducing people’s frailty across Greenwich

“I statements”

We worked with a number of focus groups in Greenwich to identify I statements which describe what is important to people with frailty and their carers. We are using these I statements to measure the success of the project.