How to map frailty provision in your neighbourhood

Frailty is top of the list for nearly every neighbourhood, and there is pressure to move quickly.

But in most areas, several services are already assessing the same frail patients. Community teams are going in. OTs are going in. FCPs are doing assessments in primary care. Hospital discharge teams are picking up frail patients on the way out.

Before commissioning anything new or stopping a service, the first step is to map what already exists.

This is how to do it.

Step 1: Get everyone doing frailty work in one room

Invite every service that currently assesses, identifies, or manages frail patients in your patch. That typically means:

• Community nursing and community matrons.

• Community therapy, including OT and physio.

• Hospital discharge and intermediate care teams.

• FCPs and health and well-being coaches in primary care.

• Care coordinators and PCN ARRS roles.

• Voluntary sector partners doing wellbeing or falls prevention work.

• The local authority adult social care team if they'll come.

• Care home liaison roles.

  
  

This meeting will feel unwieldy. That is the point. You need to see the scale of overlap before you can fix it.

Step 2: Ask five questions of each service

Keep it simple. For every service in the room, ask:

• Who do you see? (Which cohort of frail patients, defined how?)

• What do you do? (Assessment, intervention, signposting, ongoing management.)

• How does a patient reach you? (Referral source, self-referral, proactive case finding.)

• If you could change one thing, what would it be?

Write the answers on a wall or shared document as the conversation happens.

In this step, you are building a picture of the current state, not agreeing on a future state.

Step 3: Identify the duplication

Once you have the map, the duplication usually becomes obvious. You will commonly find:

• Two or three services assessing the same patient at different points in a month.

• Assessments are happening, but there is no clear pathway to intervention.

• Long waits for the services patients actually need, sitting behind plenty of capacity for the services they don't.

• Cohorts being served well (often long-term frail in the community) and cohorts being missed (often post-discharge frail and pre-frail).

Name the duplication in the room. This is uncomfortable but necessary. Services often don't know that others exist, or assume their versions are different enough to justify the overlap.

Step 4: Segment the frail population

Frailty is not one cohort. Before you can fix the pathway, you need to be clear on which groups you are designing for.

• Older patients with long-term frailty who need proactive management.

• Patients recently discharged from the hospital who are frail because of that admission, not their age. They need fast access to physio and rehab to prevent readmission.

• Housebound patients who need home visiting.

• Pre-frail patients who benefit from behavioural support through health and wellbeing coaches.

Each group needs a different pathway. A single neighbourhood frailty service that treats them as one will serve none of them well.

Whichever group you are designing for, the assessment itself has to go beyond a Rockwood score. Add a FRAX score, identify polypharmacy, check the risk factors for poor bone health, and direct the patient to the relevant members of the MDT.

Step 5: Identify the real gaps

With the map and the cohorts in front of you, and the gaps and, more importantly, the implications of the gap.

The gaps will be specific rather than general. Common ones include:

• Fast-access physio for post-discharge frail patients.

• A navigator role to move patients between services that already exist.

• A proactive case-finding mechanism for pre-frail patients.

• Home visiting capacity for housebound assessment.

• A frailty pathway that joins up primary care, community, and voluntary sector provision.

  
  

Step 6: Commission to the gaps, not the category

Once you know what's missing, the commissioning question becomes much smaller. You are not standing up a whole new frailty service. You are filling a specific gap.

For some neighbourhoods, that means adding fast-access physio.

For others, it means buying in FCP capacity to do frailty assessments in primary care, which has the added benefit that an FCP doing a frailty assessment can also do a comprehensive geriatric assessment.

For others, it means a coordinator role to stitch the existing pieces together.

Where Pure Physiotherapy fits in

Pure has built its frailty offer as a pick and mix precisely because frailty looks different in every neighbourhood.

They can supply FCP-delivered frailty assessments using the Rockwood score; one-to-one physio where local waits are long; health and wellbeing coach support; home visiting and care home work; and a frailty café modelled on their pain cafés.

If your mapping exercise identifies specific gaps and Pure's pick-and-mix covers them please get in tocuh with Vicky Maskill - vicky.maskill@purephysiotherapy.co.uk and Adam Davies -mailto:adam.davies@purephysiotherapy.co.ukare

We hope this helps.

About us

THC Primary Care is an award-winning healthcare consultancy specialising in Primary Care Network management and the creator of The Business of Healthcare. With over 20 years in the industry, we have supported more than 300 PCNs through interim management, training and consultancy.

Our expertise spans project management and business development across both primary and public sectors. Our work has been published in the London Journal of Primary Care, and we have authored over 250 blog posts sharing insights on primary care networks.

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