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GPs to offer targeted support to frail patients to prevent admissions

GPs will work with community services to identify moderate frailty and enable earlier detection of conditions such as dementia, according to NHS England’s new long-term plan. 

NHS England said that, based on their individual needs and choices, people identified as having the greatest risks and needs will be offered targeted support for both their physical and mental health needs, which will include musculoskeletal conditions, cardiovascular disease, dementia and frailty.

As previously reported, the plan will see GP practices mandated to join networks of 30-50,000 patients, which will be aligned with community multidisciplinary teams.

The document said: 'Extending independence as we age requires a targeted and personalised approach, enabled by digital health records and shared health management tools.

'Primary care networks will from 2020/21 assess their local population by risk of unwarranted health outcomes and, working with local community services, make support available to people where it is most needed.'

The plan noted that GPs are already using the Electronic Frailty Index to routinely identify people living with severe frailty and said that the connecting of home-based and wearable monitoring equipment will increasingly enable the NHS to predict and prevent events that would otherwise have led to a hospital admission.

These include a location tracker for people with dementia, and home testing equipment for patients taking blood-thinning drugs.

The plan also outlined how new acute frailty services will help cut avoidable emergency hospital admissions.

The document said: 'Hospitals will also reduce avoidable admissions through the establishment of acute frailty services, so that such patients can be assessed, treated and supported by skilled multidisciplinary teams delivering comprehensive geriatric assessments in A&E and acute receiving units.'

NHS England said that the model should be embedded in every hospital during 2019/20.

GPs have been urged to assess frailty when creating care plans for older patients, with new guidelines issued in May last year warning that patients with type 2 diabetes, need to have frailty assessed as a priority when having individual care plans created for them.  

Readers' comments (6)

  • What a mega waste of money.

    - There are not enough GPs to do it properly.
    - There are not enough resources in social care to respond appropriately.

    Why not start by fixing those 2 areas, then this might actually work. What GPs need is more resources for current core work. That will actually drive GP numbers up and when there are more professional resources available, GPs will actually achieve something by identifying frailty.

    Social care needs the same investment otherwise identifying frail people is fairly pointless.

    Ideas like this can be really successful, but only if GPs and social care have enough resources to act appropriately.

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  • I would prefer targeted support to offer patients the best medical care, which may at times include a hospital admission, perhaps one where relevant investigations are done before discharge whilst the patient is there on the ward!

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  • 'Hospitals will also reduce avoidable admissions through the establishment of acute frailty services, so that such patients can be assessed, treated and supported by skilled multidisciplinary teams delivering comprehensive geriatric assessments in A&E and acute receiving units.'
    Obviously the patient will wait 14 hours on a trolley before being seen and develop pressure sores, hypothermia and malnutrition prior to being assessed and sent straight home for an urgent GP visit the next day

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  • will work with MDT if get paid to do so, otherwise why bother?, no evidence home monitoring works and often overused and abused by patients, many of the mdt staff don't understand how to interpret the stuff and refer back to GP at the slightest abnormal score, a BP of 151/90 is an example in an otherwise well patient as an emergency visit request by a care worker. frailty index scores pointless if there are no resources to support people in the community. if there are no GPs to refer back to, as many are leaving partnerships, who is actually going to do the work. having worked with MDT and admission avoidance teams all it meant was even more work for me with a reduction in pay as the money was taken off our budget to pay for it. one of the reasons i left being a partner in a practice. as rural practices require completely different resources to a city based one why not give the GP practice all the money and they decide what their patients need. if would be cheaper, involve less management and red tape costs, drive care to exactly where it is needed, would be quicker as no committee meetings etc and patient led. poor quality policy written by poor quality politicians and underlings who don't understand the NHS. again. perhaps we could ask to appraise our politicians yearly for evidence of quality care, performance, keeping up to date, effectiveness and competency to do the job. we have to.

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  • AlanAlmond

    people get old, they get frail and then they die. some of them will require hospital admission. with more and more of the population getting old there are more and more elderly frail people about. no government initiative can prevent this from happening, you can't stop old people getting frail and dying. today's prevented admission for an old frail person is tomorrow's unprevented admission with an even older and more frail one. perhaps technology can prevent this..i guess an iphone app might just do and apps will stop people getting old, frail and dying maybe? believe this and your likely a prize chump in rude health with the latest smart and a subscription to babylon

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  • There are many things we can do. But DoH and NHSE have to choose: Is their priority to have the limited GPs used in empty sunday EH clinics or Urgent treatment centres seeing self limiting minor illness in the worried well? (Even if it makes SoS sound dynamic with a snappy soundbite).

    Can't do everything.

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