Case Study

Supporting people affected by frailty in Hull and East Riding

A re-designed community frailty pathway has transformed care for older people and reduced GP appointments and hospital admissions.

11 January 2022

A re-designed community frailty pathway led by local geriatricians and primary care staff has brought together consultants, GPs, advanced nurse practitioners, social workers, pharmacists, other specialists, and the voluntary sector, to work as a single system supporting vulnerable patients within Hull and East Riding. The service has transformed care for older people and reduced GP appointments and hospital admissions by providing out-of-hospital care and enabling residents to keep healthy and live independently.

Key benefits and outcomes

  • Reduction in emergency and GP attendance of patients with moderate and severe frailty by up to 50 per cent among the regular attenders.
  • Between 23 March and 31 May 2021, 63 per cent of patients that were referred to the service by Yorkshire Ambulance Service remained at home, when they would otherwise have been conveyed to hospital.
  • Cost savings of around £100 per patient through pharmacy reviews of medication.
  • Improved patient experience, treating people in the right place, at the right time and responding to their holistic needs.

What the system faced

Severely or moderately frail people make up around four per cent of the population of Hull and East Riding, yet account for up to 38 per cent of hospital bed days. They are four times more likely to die within a year, five times more likely to end up in hospital and six times more likely to go into a care home than others their age.

These figures are stark and posed a challenge to local health and care services in the region. Clinicians, passionate about older peoples’ care, wanted to improve the pathway and outcomes for these patients and ensure they were being treated in the right place for their care needs. Traditionally a patient would be seen and treated for a particular health condition by a single professional, and there was little attention given to the holistic needs of the person receiving care. However, if a more planned and measured approach could be taken, the resident could remain healthy and well, with the right support in their own homes, rather than being moved around the system and ending up in A&E when in crisis.

What the system did

Local clinicians illustrated how they could provide better personalised care for the frail and elderly through an anticipatory model.

The community geriatricians worked with the local CCGs and partners to secure funding for the creation of an integrated frailty pathway, which enabled clinicians from the community provider, 

City Health Care Partnership CIC (CHCP), and other services to treat frail and elderly patients from the specially commissioned Jean Bishop Integrated Care Centre (ICC).

By working closely with primary care, patients are identified through clinical systems, specifically the electronic frailty index (eFI) and practice intelligence, are invited to the ICC, where they spend time with a range of professionals including doctors, therapists and social care. They undergo a full MOT including diagnostics (including bloods and scans) and are given a comprehensive geriatric assessment, which also focuses their social and personal care needs. They even receive a free meal, provided by the voluntary sector, and there are services on site such as the carers’ centre, to help individuals plan for their health and care needs. Each afternoon a multi-disciplinary team (MDT) meeting takes place, and a detailed care plan is put in place and shared with the patient and their family, their GP and secondary care.

The ICC was launched in 2018 and has since grown from strength to strength. Over the years the model has expanded to include care home outreach. Services such as Parkinson's , COPD and diabetes MDTs are run from the centre and more recently an advice and guidance line has been set up for health and care professionals to ring for specialist frailty advice.

Results and benefits

The service is a partnership, truly focused on the holistic care of individuals. A few of the key benefits include:

  • Easy to adapt model:  Establishing an anticipatory care team approach meant that during COVID-19 they could quickly adapt the model and set up a frailty response line, pulling in existing staff, to offer professional advice and guidance to health and care professionals and keep the vulnerable out of A&E.
  • Supporting other areas of the system: This initiative has helped support other pressured areas of the system. It has reduced emergency and GP attendances by 10 per cent, and by 50 per cent in admissions among the most frequent attenders to hospital. It has also contributed to a decreased length of stay for those who needed to go into hospital by 50 per cent for those with dementia, diabetes and on palliative care.
  • For the ambulance service this has provided real time clinician to clinician consultation to rapidly agree interventions and care plans. There have been over 2000 ambulance service calls to the frailty line that have resulted in a marked reduction in patients conveyed to hospitals.
  • Cost savings on medication: As part of the pharmacy review, many people have seen unnecessary medication removed from their repeat prescriptions, saving around £100 per patient.
  • Improved person-centred care and patient experience.  Ultimately, this way of working has improved outcomes for Hull and East Riding’s frail and elderly. What matters to patients is at the centre of conversations. At the end of their visit to the ICC the patient is given their care plan to take home with them, knowing they’ve been listened to and having a plan and support in place which will be implemented and monitored.

Overcoming obstacles

As with any project, there are issues to overcome, but by working together and gaining senior backing, solutions were developed much faster.

  • Dedicated Clinical Leadership: The senior clinicians in the team have been given dedicated time, commissioning and managerial support to design, implement and evaluate the new model of care.
  • Trust: Initial scepticism regarding the impact of the new model existed across the system. However, by starting small and robustly evaluating as the model developed has meant that all partners are now engaged in the model and see it as part of the long term solution to supporting people affected by frailty.
  • Shared care records: It was important to facilitate the sharing of information between organisations, to ensure that the patients’ care plans could be seen by professionals involved in their care.
  • Funding: The strategic financial approach to frailty was as important as the clinical method. The pathway received an uplift in funding from the local CCGs (Hull and East Riding) and will be resourced in the future through the crisis response and ageing well funds from within the Integrated Care System.
  • Technology: System thinking around tech in care homes, funding and implementation has helped to deliver an improved care home response. By investing in tablets for the care homes, the frailty team could conduct initial assessments virtually, which helped protect residents during Covid. Around 70 per cent of the assessments delivered by the advice and guidance line are carried out over the phone or virtually. The team have also commenced a pilot of virtual CGA for some of the harder to reach geographical areas across East Riding.
  • Identifying patients in care homes: There are over 220 care homes across the Hull and East Riding patch. By building relationships, the team gathers information about new residents through the local authority placements, the enhanced care in care homes weekly ward round or via the advice and guidance line. There was a nervousness at first from the care home sector, however the advice and guidance line helped manage staff support and escalate where appropriate.

Takeaway tips

  • Build relationships and illustrate impact to get buy in.
  • Focus on anticipatory, holistic care, it will reduce future impact on services.
  • Share skills, knowledge and expertise to improve confidence across the sector.
  • Allow clinicians to lead in the development of new pathways.
  • Collaborate, collaborate, collaborate.

Further information

For more information on the work in this case study, please contact

Dan Harman and Anna Folwell, Consultant Geriatricians, City Health Care Partnership, Hull

Integration and Innovation in Action

This case study forms part of our Integration in Action series, a collection of publications, podcasts and webinars which explores how effective partnership working is helping to address the biggest challenges facing health and care.