Focus on frailty


Frailty is a key priority in the Greenwich strategy and we have benefited from an evolving engagement approach with patients, the public and communities in developing our programmes of work.

In October 2019 we launched a 12-month pilot to test a multi-disciplinary approach to managing frail patients in the community.  The project involves a small team of health professionals working closely with GPs to support patients identified as most likely to benefit from a  preventative approach to reducing their level of frailty.  

The project will take place in Riverview PCN, and will support around 250 patients over a 12-month period.  Patients will identify their goals and care plan with support from a frailty team member, who will then work with them to achieve their goals.  Additional support from the CCG's pharmacy team will be included, to ensure that where suitable patients will receive a review of their medication to reduce the risk of adverse impact.  The team will provide referrals and hands-on support, to ensure that patients get the right treatment at the right time.

Feedback from numerous patient and carer engagement events has been very positive, with input from patients and carers helping to design the approach.  The engagement approach has benefited enormously from the participation of a volunteer patient who developed the engagement approach and led on establishing links with community and faith groups.

Click here for more information on the project including I statements developed by patient and carers which we have used to create the measurement and evaluation of the project. This information with background and feedback on the engagement and evolution of the project has been presented at various events with community groups in accessible ways. 

The video below is a talking heads session with patient voice, community worker, commissioner and clinician feeding back on the frailty project in September 2019 at the CCG AGM. All our communities who were involved in developing the frailty programme were invited to be a part of the AGM.