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Greenwich frailty team hailed for reducing hospital admissions
We were delighted to welcome Daniel Elkeles, Chief Executive of NHS Providers, for a recent visit to see the fantastic work being done by the Greenwich frailty team.
Set up in 2020, the frailty team started by supporting just one Primary Care Network in the borough. Now, they cover all seven. They work closely with GPs to identify patients with moderate frailty and agree care plans that aim to prevent or delay deterioration. One of the key questions they ask is: “Would you be surprised if this person was admitted to hospital in the next 12 months?” If the answer is no, the patient is considered a strong candidate for support.
Daniel was impressed by the team’s approach and the difference they’re making, and said:
The more I see of what providers of community services are doing to make the ‘left shifts’ to community and to prevention real, the more convinced I am that the NHS really can do this.
The team is part of a wider network of community-based services, from district nursing to urgent community response. They have access to a broad range of support, including NHS physical health services, hospital clinicians, mental health input like memory clinics, and a variety of social care services commissioned by the local authority. These include loneliness support via the Red Cross (Live Well Greenwich), practical help from handymen, and a network of clubs including knitting groups. The breadth of services they connect people to is remarkable.
The impact on patients has been impressive. While a full economic evaluation is underway, data from 2024 shows that patients supported by the team are phoning 999 less often, attending emergency departments less frequently, and are significantly less likely to be admitted to hospital. GP time has been freed up, and patients are taking fewer medications. Feedback from GPs has been overwhelmingly positive, with one describing the team simply as “brilliant.” Patients have also responded with strong praise for the service.
Daniel extended his thanks to Sarah, Rachel, Raj, Henrietta, Monica and the rest of the team for an inspiring visit and for their commitment to improving care in our communities.
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