Frailty image

Frailty Programme

Our Frailty programme is helping to improve the health, independence and well-being of High Weald Lewes Havens residents and supporting GPs and other health professionals to much more effectively identify and care for people with frailty.  In moving away from a reactive way of working, we are taking a much more proactive approach which is personalised and patient centred, as well as making better use of valuable resources and reducing people having to go into hospital unexpectedly.  A key aim is to support older residents to live independent and healthy lives.

A central feature of the programme is our Community Geriatrician Service. In place since 2014, initially as a pilot service in The Havens area,  Consultant Geriatricians support GPs to manage patients with frailty and complex needs through community clinics, home visits, and support to our community hospitals. A review in early 2016 provided evidence of the significant benefits of the Service, including reductions in both people going to A&E and having to go into hospital unexpectedly, which we presented at the British Geriatric Society 2017 Conference.  Following its initial success, we’ve now expanded the Community Geriatrician Service to cover the whole of the CCG. It’s now our intention to introduce Frailty Nurse Specialists who, working alongside the Geriatricians, will also offer specialist advice to GPs and their practices and provide comprehensive support to patients throughout the various stages of care.

While we want to support people in their own home for as long as possible, if this is no longer possible we need to ensure that the best possible care is provided to those in residential settings. The main focus of our new Enhanced Health in Care Homes service is to bring improved and proactive GP services to the residents of nursing homes in High Weald Lewes Havens.  Our aim is simply that nursing home residents receive the best possible care, in the right place, at the right time – by making people healthier and maintaining health, reducing unnecessary hospital admissions and enhancing care for people at the end of their lives.  The intention is that the Enhanced  Health in Care Homes service will be introduced gradually across High Weald Lewes Havens by spring 2018. 

Further information about HWLH CCG’s Frailty Strategy.


You can make a difference.

For more information or to get involved please email hwlhccg.enquiries@nhs.net or telephone 01273 485300.