Some of doctors’ frailest patients in Bucks are being referred for additional assessments as part of NHS plans to reduce the number of people staying in hospitals for longer periods of time.
A total of five GP practices will select 10 of their most frail patients to refer to the frailty assessment service at the Thame and Marlow Community Hubs, which aims to help older patients avoid admissions to A&E or longer-term hospital visits.
Speaking at a meeting of Bucks County Council’s health and adult social care select committee this morning (January 29), medical director at Buckinghamshire Healthcare NHS Trust (BHT), Dr Tina Kenny, said the aim is to improve life for frail patients and prevent their conditions from getting more severe.
The plans form part of BHT’s work to “bring care closer to people’s homes” – which saw the removal of hospital beds in Marlow and Thame Community Hospitals in a controversial move to make way for the hub pilot scheme.
Services on offer at the hubs include outpatient clinics such as orthopaedics, falls and bones, general surgery, chemotherapy and a community assessment and treatment service.
Dr Kenny said: “This piece of work is not just taking patients on the day who need to have that sort of input, but going out proactively to practices and asking who the patients are that they think might be approaching frailty, and start to look at where we can put things in place before we get to the frailty stage that has prompted a crisis referral.
“We want to move it downstream so we are managing frailty at an earlier point in time.”
Dr Kenny said the new initiative is being trialled in GP practices nearest to the community hubs in Marlow and Thame, however it is open to other surgeries and patients in the county.
Patients referred to frailty service will be assessed by medical teams who will then provide a treatment plan, or if necessary, they will be referred to the appropriate community hospital team for ongoing care.
BHT also hopes to launch frailty cafes in the county this year which will provide people with the information to get advice on how they manage their conditions.
Councillor for Beaconsfield, Anita Cranmer, praised the scheme, saying: “What you are really doing is giving people a better life, that’s it.
“You are starting off with a need for GPs to band together, network and do referrals, and you will end with the frailty café, where people are self-referring.
“That’s your vision, which is a great vision to have. It is a model that I think people are using. There are memory cafes, dementia cafes, death cafes.”