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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.  


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