Supporting frail patients beyond the hospital walls

It's well known that the UK population is getting older, and with this demographic change, health needs are growing more complex. The recently unveiled NHS Long Term Plan has set the course for how we need to adapt our care to meet that challenge. Here at Imperial College Healthcare, in partnership with others in the local health and social care sector, we have already been changing the way we work with frail and older patients to better provide the care they need, when and where they need it.

Here Dr Aglaja Dar, a consultant geriatrician at Charing Cross Hospital, explains how collaborative working beyond our hospital walls is key to providing the best possible care.


When you think of a hospital consultant, you probably think of a senior doctor carrying out ward rounds or holding outpatient clinics. But as health needs change, so must the role of clinicians. Frail, older patients are a group who can particularly benefit from rethinking the way we deliver and co-ordinate care.

One such patient is Anna Holder. Anna, 74, has a number of health conditions which she receives support with from a range of specialist doctors and carers, both in the community and at our hospitals. Co-ordinating that care across a number of different teams working for a number of different organisations, is a challenge many patients are familiar with.

For Anna, the community independence service has made a big difference. The service is a collaboration between local health and social care providers and run primarily by Central and North West London NHS Foundation Trust. Through this service GPs, community nurses, occupational therapists, social workers, carers, local charities and hospital consultants like me, work together to provide intensive, support to patients in their own homes for a period of up to six weeks.

Anna was referred to the service after a fall and describes her experience of the services as a ‘10+’. I was part of a multidisciplinary team that visited her at home to carry out what we call a comprehensive geriatric assessment – a detailed review of the patient's medical diagnoses, ability to perform everyday tasks, medication and psychosocial circumstances. We also assigned Anna a case manager to co-ordinate her care and act as a first point of contact to discuss her care plan.

Nowadays as a consultant, I spend half my time visiting patients at home as well as working with GP colleagues and other professionals from community health trusts to see patients before they need a hospital admission. Traditionally, a patient would only be seen by a specialist consultant in an outpatient clinic or by coming into hospital through the emergency department. More proactively managing a patient's care in this way can bring real benefits.

Avoiding admissions to hospital

In Anna's case, I decided she needed some additional tests to investigate significant mobility issues she was experiencing, including weakness in one arm. Again, until relatively recently, Anna would have needed to be admitted to hospital to get the specialist diagnostics and support she needed, but we know that lying in a hospital bed can lead to number of adverse outcomes as well as a functional decline in this vulnerable group of patients.

Anna wasn't acutely unwell, and so we wanted to avoid an admission. This was where the older person's rapid access clinic (OPRAC) at Charing Cross Hospital came in. The clinic gives access to rapid diagnostic tests, generally allowing a faster diagnosis and creation of a management plan, often all on the same day.

The team in OPRAC take referrals directly from GPs or the emergency department and has three slots a day, five days a week. As well as specialty doctors, the team also includes therapists – and by working together, we have shown that being seen in the clinic significantly reduces the chance of emergency admission to hospital.

A radically different pathway

Thanks to tests Anna had at the clinic, she was referred for neurosurgery for the weakness she's been experiencing. When I think back, compared to when I first started practising, this is a radically different pathway for a patient like Anna. She's avoided a hospital stay, we've continued to provide the vast majority of her care at home, and we have identified the ultimate intervention she needed more efficiently.

The community independence service and older persons rapid access clinic are just two of a number of initiatives we've started in recent years, in partnership with others, to improve our support to frail patients. As a hospital, we're used to treating people who come to us. But what we've learned is that by getting on the front foot and taking more of our care to the patients at home, we can prevent admissions and provide care more effectively. As our population ages and health needs become more complex, it's by working like this that we'll meet the challenge.

The Hammersmith and Fulham Community Independence Service is a collaboration between local health trusts and GPs funded by the CCG. Find out more here.