Case Study 7: NHS Hambleton, Richmond & Whitby CCG –Understanding the Needs of People with Frailty through Proactive Primary Care Practice Nurse Led Frailty Assessments

In a nutshell: There is increasing evidence and guidelines with regards to the importance of recognising and addressing Frailty in terms of improving Quality of Life and reducing unplanned admissions and mortality in our increasing older population. The British Geriatric Society (BGS) in association with the Royal College of General Practitioners produced a guide ‘Fit for Frailty’  to aid the diagnosis and management of this syndrome. The guidance suggests it is not feasible for everyone with frailty (from mild up to severe, life-limiting frailty) to undergo a full multi-disciplinary review with geriatrician involvement. Nevertheless, all patients with frailty will benefit from a holistic medical review based on the principles of comprehensive geriatric assessment (CGA). NHS Hambleton, Richmond & Whitby are testing an adapted CGA model for people with frailty identified using the eFI delivered by a Practice Nurse.

In NHS Hambleton, Richmond & Whitby CCG a cluster of GP Practices including Doctors Lane Surgery are piloting a service which offers patients with severe and moderate frailty a home based modified comprehensive geriatric assessment (CGA) delivered by the Practice Nurse, who will shadow and receive support from the GP Cluster’s Community Matron. The team are using the eFI to identify patients with moderate – severe frailty. Backfill for open access clinics at the GP Practice will be provided by a Health Care Assistant.

The modified CGA will incorporate a holistic approach, including:


Practice Nurses will work alongside patients to develop individualised care and support plans. They will link patients with community services including MDT ‘hot’ clinics; Richmond Voluntary Services (which includes access to VitruCare); GP cluster based integrated MDT meetings, and the community matron for care and support planning.

The overall aim of the programme:

Outcomes being used to measure impact include:

The Team involved will have access to support from the Y&H Improvement Academy to support the evaluation and continuous learning throughout the initiative. The outcomes of the project will contribute to a CCG wide frailty pathway, as a greater understanding of the unmet need among people with frailty and the resources required to meet these needs will inform frailty pathway design, resource allocation for commissioners and most importantly, allow for a more proactive approach to healthy ageing for older people.

Contact: Dr Halina Clare, Doctors Lane Surgery, NHS Hambleton, Richmond & Whitby CCG