Managing Frailty Through Personalised Care Planning

My practice, Oxford Terrace and Rawling Road Medical Group, is situated in Central Gateshead. We support a population of about 15,200 patients in a community that is predominantly deprived, with high numbers of refugees and asylum seekers. We’re particularly passionate about managing patients with complex needs. Using a risk stratification tool, we identified that close to 2,500 of our patients with multiple co-morbidities were at high risk of being admitted to hospital. 100 of these patients were housebound and did not meet the criteria for access to community matrons.

Despite having community matrons attached to the practice the number of patient attendances and admissions to hospital was increasing.

What we did next

An experienced Older Persons Specialist Nurse (OPSN) was recruited by South Tyneside NHS Foundation Trust and released on secondment to implement the principles of Comprehensive Geriatric Assessment to achieve continuity of care for elderly patients with complex health and social care needs.

In the first 8 months of this project, 94 housebound patients with an average age of 85 years, were referred to the OPSN and had care planned and implemented. This role was based within the practice and provided the benefits of co-production with the core members of the team, patients and their carers working together to support our elderly population. Equally, there were many rewards to the practice in terms of opportunities for peer support, networking and sharing, and multi-disciplinary collaboration.

The appointment of a Nurse Specialist, as a clinical leader with knowledge and skills in the care of the elderly, wide experience of working in complex teams and awareness of the local and national drivers affecting the care of older patients, was key here.

Did it work?

Very early in this project  the outcomes were reassuring, showing a downward trend in the use of several aspects of unscheduled care and home visits.

Use of Unscheduled Care Findings in First Nine Months of Project

Unscheduled Care  9 months Pre Project  Post Project               Comments
A&E attendance 66 30 (54% reduction)
Admissions 63 29 (54% reduction) 3 patients had to be admitted by the OPSN
House call requests 318 63 (81% reduction)

In addition:

All patients on the case load had a comprehensive care plan that was uploaded onto the adastra system for external organisations to enable integrated working.

53 carers were identified and also received support and were signposting to appropriate services.


  • Reluctance of community service providers to base staff in GP practices and correspondingly lack of accommodation for community staff to be based in practices;
  • The mindset of nurses and staff working in general practice/community services and their desire to change;
  • Capacity and capability in general practice to support this type of change
  • Workforce pressures to free staff to become involved and undertake adequate measurement;
  • Lack of training to support the needs of people with complex care needs and frailty.


Future change is needed

This idea needs to go further. Especially, if we are to manage workforce challenges and improve integration of services around patient needs. In addition, the skillset for practice nurses will have to change going forward, to better manage long term conditions, demographic changes and frailty that lie ahead. The emergent impact of frailty being classified as a long term condition will also require nurses to work differently and move away from task-based care to personalised care planning. The approach we have taken has enabled us to become early adopters and inform commissioning of community services. The ideas are easily replicable with limited resource. There is also an urgent need to do this.

Sheinaz Stansfield is a practice manager with over 30 years’ experience in the NHS. She initially trained as a nurse and health visitor, and then worked in commissioning at PCT and strategic health authority level, concerned mostly with developing services outside hospital, for example, integrated primary and community services, integrated nursing teams and services in GP practices. She has also worked for a Primary Care Group as a primary care development and commissioning/contracting manager and helped set up clinical commissioning in Gateshead. She is an elected locality manager for Gateshead Clinical Commissioning Group, practice representative on the Gateshead Newcastle CCG Governing Body and the practice manager representative on the RCGP Northern Faculty Board.


  • Khulud Alharbi
    Posted at 12:11h, 05 March Reply

    I am a PhD student, I have interests to improve the care of frail older patient. My project is How is frailty understood and enacted by primary healthcare providers?
    I am looking for participant for 30 minute interview, it would be grateful if you would be able to accept my invitation and be one of my participants.
    For more information,

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