Visit to Oxleas NHS Foundation Trust

Our chief executive Daniel Elkeles recently visited Oxleas NHS Foundation Trust to see the transformative work being done by the London Borough of Greenwich's frailty team. 

Daniel 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 small team, set up in 2020, originally covered one Primary Care Network (PCN) in the borough - as of this year, it covers all seven. Its focus is on working with GPs to identify patients with ‘moderate’ levels of frailty and agreeing a care plan with a package of interventions to prevent or significantly delay it becoming worse. They use a standard assessment process but with a twist: asking the referrer the question ‘would you be surprised if this person was admitted to hospital in the next 12 months?’ If the answer is ‘no I wouldn’t be surprised’ that makes them a prime candidate for the service!

The frailty team sits as part of a wider team of community based services spanning district nursing through to urgent community response. The range of services that the frailty multi-disciplinary team has access to is vast and includes all the usual NHS physical health services and input from hospital clinicians, but with access to a range of mental health services including memory clinics too and also to a range of local authority social care commissioned services, loneliness’s services provided by the Red Cross (Live Well Greenwich), handymen, a network of clubs including knitting. The range of services the team have connected people to is just vast!
 
The impact for the patients they look after is impressive. They are in the process of doing a full economic impact, but the data from 2024 suggests that the patients on their case load:
 
🔵 Phoned 999 20% less often.
🔵 Attended emergency departments 50% less often.
🔵 Were 33% less likely to be admitted to hospital. 
 
"The patents were taking up hundreds of hours less GP time and the number of medications they were taking were also much reduced.
 
"The GP feedback about the service is excellent. One of the GPs I spoke to simply said "this is a brilliant team." Patient feedback is also hugely positive.
 
"Thank you so much to  Sarah, Rachel, Raj, Henrietta, Monica and team for such an inspiring visit."