Case Study 5: NHS South Devon & Torbay CCG – A Frailty Clinic

In a nutshellTransforming Primary Care policy (NHS England 2014 and the Department of Health) calls for safe personalised and proactive out of hospital care for those with the most complex needs. The recently published Five-Year Forward View indicates that “primary care of the future will build on the traditional strengths of ‘expert generalists’, proactively targeting services at registered patients with complex ongoing needs such as the frail elderly or those with chronic conditions, and working much more intensively with these patients".  A Frailty Clinic in NHS Devon &n Torbay CCG identifies people with severe frailty using the eFI who arelikely to benefit from targeted intervention and aims to drive up the quality of care for older people.

In Newton Abbot, NHS South Devon & Torbay CCG, a Frailty Service has been established to integrate the reactive (a complex care hub) and pro-active (a virtual ward) care of the most frail under one service. The Frailty Service delivers proactive case-management through a team of GPs, Community Nurses, Community Matrons, Physiotherapists, Occupational Therapists and Social Workers. Complex frail older people who require urgent and planned care are managed using a multidisciplinary approach. Additional services also provide weekly support including Torbay Care of the Elderly Physicians, Medicines Management, Older Peoples Mental Health and Palliative Care Nurses.

The service response to both urgent and routine referrals and a pre-defined criteria helps decide whether a patient would benefit from referral into the Frailty Service. The criteria include:

One of the key attributes of the Frailty Service is that GP and GP registrars will be actively involved as part of the hub. Also, a single assessment document minimises duplication of data gathering and documentation. The electronic record is used to assist in data sharing and a primary record of the Frailty Service input and MDT discussions are held within SystmOne providing real-time updates for GP practices.

The overall aim of the programme is:

Outcomes being used to measure impact:

Contact: Dr Paul Johnson, GP Partner Cricketfield Surgery Newton Abbot, NHS South Devon & Torbay CCG