NHS North West London has launched a review of the community services that are in place to support the frail population.
Frailty prevalence is a growing concern, particularly among the elderly population. According to local health data, approximately 10-15% of the population aged 65 and above in north west London are living with moderate to severe frailty. This equates to roughly 160,000 individuals who require comprehensive and proactive care.
The Community Frailty Service supports patients to live well alongside their long-term conditions. Long-term conditions are not curable but can be managed well with medication and lifestyle choices. The service includes a multidisciplinary team of health professionals (doctors, clinical practitioners, pharmacists, etc.) and works closely with GPs and hospitals. It aims to provide health and social care, as well as assistance with setting and achieving personal wellbeing goals.
British Geriatrics Society: “Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves.”
NHS England: “Frailty is where someone is less able to cope and recover from accidents, physical illness, or other stressful events.”
Currently, the level and type of care that you can receive can differ depending on which borough you live in. NHS North West London want to change this and wish to make sure there is a high quality and equitable community frailty service that is accessible for all residents aged over 18 and registered with a north west London GP practice.
Over the last few month’s local clinicians and partners have worked to develop a specification that establishes the proposed common core offer for the community frailty services that describes the types and level of service local residents can expect to receive wherever they live in north west London.
We now would like to invite north west London residents to get involved by providing feedback on what the common core offer and letting us know if you think we have missed anything or if there is anything else you would like us to consider.
NHS North West London will lead a community engagement programme from 22 October to 01 December 2024. Details on the schedule for the engagement programme can be found below and will be updated regularly throughout the duration of the engagement.
Please complete the online resident survey.
If you would like to speak to a member of the project team, please contact James Connell (Senior Involvement Manager) using this email address: nhsnwl.communications.nwl@nhs.net.
The proposed north west London community frailty common core offer aims to improve care for frail individuals living in the community. With a growing elderly population and increasing health inequalities, there will be a focus on delivering high-quality, proactive, and person-centred care.
The goal is to help people live well with frailty, reduce unnecessary hospital visits, and ensure everyone receives consistent care no matter where they live in north west London.
Key Objectives:
- Unified care approach: This service will ensure that everyone across the boroughs in Northwest London has access to the same high standard of care for frailty, based on national guidelines like the NHS Frailty Toolkit and the "Fit for Frailty" recommendations.
- Early identification and proactive care: Frailty will be identified early, using specialised tools and assessments. By doing this, the service can offer support before frailty becomes severe, helping to prevent falls, hospital admissions, and health crises.
- Integrated care: Different healthcare providers such as GPs, hospitals, social care, and community services will work together to deliver coordinated care. A team of health professionals, including doctors, nurses, and social workers, will meet regularly to ensure that patients get the care they need when they need it.
- Cost-effective and efficient: By providing care in the community and avoiding unnecessary hospital admissions, the service can deliver care more efficiently, reducing strain on hospitals while giving patients care closer to home.
Service Features:
- Multi -disciplinary team (MDT) care: Health professionals from different fields, such as doctors, nurses, social workers, and therapists, will meet regularly to discuss the care of frail individuals. This ensures a holistic and joined-up approach to care.
- Personalised care plans: Each person will have a tailored care plan designed around their specific health, social, and personal needs. These plans will be regularly reviewed and updated to adapt to changes in the person’s condition.
- Community-focused care: Frail individuals will receive the majority of their care in their home or local community. This helps to maintain independence and avoid hospital visits unless absolutely necessary.
Key benefits:
- Care closer to home in the community: By providing better care in the community, the service aims to improve clinical effectiveness and timely care.
- Improved patient experience: Patients and their carers will have a say in their care, with the aim to reach increased satisfaction rate for care provided.
- Regular reviews: Each person will have their care plan reviewed every regularly
- to ensure it still meets their needs.
- Support for carers: Carers will be involved in the care planning process and given access to support services.
The north west London Community Frailty Service will be designed to offer a compassionate, integrated, and practical solution to frailty care, helping people stay well, live independently for as long as possible, and receive the right care at the right time.
NHS North West London Community Frailty Service Model: A MDT approach
Weekly Multi-Disciplinary Team (MDT) meetings with mandatory participation of essential am members (below), ensuring comprehensive care planning and review:
- Lead GP (essential)
- Frailty nurse consultant/advanced nurse practitioner/matron with clinical skills in frailty (essential)
- Geriatrician (essential)
- Administrator (essential)
- Care coordinator (essential)
- Social prescriber (essential)
- Clinical pharmacist (essential)
- Community services representative (optional)
- Mental health specialist (optional).
The comprehensive care planning and review process includes:
Assessment and diagnosis
- Comprehensive geriatric assessment (CGA)
- Rapid response services.
Holistic assessment
- Evaluating the patient’s physical health, mental health, social circumstances and environmental factors via a holistic assessment.
Care planning
- Personalised care plans developed through a holistic assessment, including physical, psychological, and social dimensions.
Care coordination
- Integrated care pathways and use of digital solutions to ensure seamless communication and coordination between different service providers.
Discharge process
- Patients stepped down once care plan goals achieved or further benefits limited
- Return to GP care but accessing community services as needed, with flexibility for individual variability.
Monitoring and evaluation
Use of health dashboards, feedback mechanisms, collaboration with primary care, integrated neighbourhood team (INTs), community and voluntary sector, and linkages with general and highly specialised hospital care.
Community and social Support
- Lifestyle support,
- Public awareness,
- Integration with integrated neighbourhood teams (INTs)
To provide comprehensive and personalised care, this frailty model takes a joined-up approach with differing services and support (the key enablers) working together as needed. Exmaples of these include:
- Integrated neighbourhood teams
- Rapid response
- Community nursing
- Mental health
- Community rehab
- Community therapies
- Anticipatory care in-reach
- Dementia, delirium & memory
- Complex case management
- Neuro rehab, stroke ESD
- Inpatient rehab beds
- Nutrition and weight management
- Reablement
- MSK
- Falls
- Heart failure, cardiac rehab, respiratory rehab
- Others
Information to be added.