Skip to content


Delivering a Virtual Frailty Multidisciplinary Team service during COVID-19

Transforming our 'multi-clinician' Frailty MDT clinics to completely virtual and offsite, based on adapting learning from our similar COVID-19 transition work, for our 'single-clinician' Diabetes and Dermatology clinics.​

Read comments 2 Project updates 2
  • Winning idea
  • 2020

Meet the team


  • Steve King - Change Project Manager
  • Dr. Alam - Frailty Clincial Lead
  • Simone Wilson - Independent workshop facilitator
  • Ash Vora - IT lead
  • Suzanne Cleary - Stakeholder Director Contact for Birmingham Community Healthcare Foundation NHS Trust

What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?

During COVID-19 we transformed our existing community clinics in Diabetes, CKD, Dermatology clinics to being completely virtual and delivered offsite. The clinics are delivered by a variety of clinicians including consultants from hospitals, consultants from community trusts, specialist GPs from outside of the city. Our clinicians have worked with us in a very collaborative and innovative way to make sure the current challenges did not prevent us delivering these services. We used a greater amount of remote working and virtual consultation technology to support this new way of working. We adapted our clinics to enable a greater degree of flexible working. In fact many other providers in the city had to cease their traditional community services but we knew that the pressures on the Hospital required our community services to be contributing more than ever. This project is going to not only embed these further but enhance this approach.

What does your project aim to achieve?

Our Frailty MDT service delivered with Birmingham Community Healthcare NHS Foundation Trust is the only one of our community clinics we have not yet been able to move this virtual design. This has resulted in the clinics being paused and key frail patient groups not getting the service that they would benefit from. The aim is to get similar positive impact to our other clinics, for example our Dermatology virtual clinic during the COVID-19 period reviewed over 400 patients and 98 percent of these service users were reviewed within 2 weeks and 90 percent did not need to go to hospital. Reducing pressure on secondary care, we will track impact of reducing acute admissions. The two key barriers were the technology to allow multiple clinicians to work this way and funding to cover cost of the pilot. We have resolved the IT barrier now we just need to source the pilot stage funding.

How will the project be delivered?

We will follow our methodology for delivering transformational changes. We will take lessons learned both what ‘worked well’ and ‘what we could do even better’, from our other pilots. We will form a design group of various stakeholders both internal and external from both clinical and non-clinical backgrounds. The group will work on brainstorming ideas for how we may pilot the concept including taking in views from service users. We will vote on the top two ideas and start with the first and have the second as the back-up to turn to if we feel the first idea is not progressing as we decide. These sessions will be facilitated by a impartial facilitator from our Transformation Team. Our Change Project manager will ensure we are working to a required schedule and involve the CCG support analysts to build a risk log, budget plan and an evaluation plan from the outset.

How is your project going to share learning?

For our existing transformation work we have previously held-face-to-face sharing sessions at our headquarters where representatives from NHS England, regional and local other organisations such as Primary Care Federations, Primary Care Networks etc have attended, to learn from our other pilots. Previously this has resulted in a great deal of spread and adoption of our work outside our own organisation. We plan to repeat this to share the learning from this project but on a virtual webinar platform to reduce the need for face-to-face attendance. We are members of our local STP groups and GP Provider alliances, where we will share the learning of this work. We will also publicise via various social media routes to help generate interest in our work along with Q member routes for sharing. We will utilise our communications team to share progress on our social media platforms and website.

How you can contribute

  • Experts in Frailty Patients and how to work differently with this cohort of service users would be welcome.
  • Help from those who have tried these new ways of working to improve services would be welcome.
  • Critical reviewers of our ideas and approach both of idea content and implementation would be welcome to strengthen what we do.

Plan timeline

10 Dec 2020 Develop evaluation plan
10 Dec 2020 Develop project plan, risk log and budget plan
14 Dec 2020 Adapt current data sharing agreements for these new clinics
14 Feb 2021 Collect feedback and ideas, service user feedback from similar pilots
2 Mar 2021 Hold virtual idea development and prioritisation workshops
15 Mar 2021 Hold virtual design workshops and meetings
22 Mar 2021 Develop testing rollout plan
24 Mar 2021 Work with IT provider on all IT aspects
29 Mar 2021 Engagement with internal and external stakeholders of plans, ongoing refinements
11 Apr 2021 Schedule and run test clinics with ‘dummy’ patient details
18 Apr 2021 Refinement and learning workshops and meetings
30 Apr 2021 Go live with first patient test clinic
2 May 2021 Ongoing refinement and expansion and evaluation

Project updates

  • 1 Oct 2021

    Transforming our multi-clinician Frailty MDT to a completely virtual offsite service came with specific challenges because of the COVID 19 pandemic  i.e. the re-engagement of stakeholders.  Because we already had an established service and designated MDT members it was thought that liaising with them would be straight forward.  However, the challenge came because the COVID pandemic meant that a lot of clinicians were either redeployed, committed to a pan Birmingham Programme to provide urgent assessment and treatment to people to avoid hospital admissions or they did not have the capacity to reengage with the service.  Therefore, a lot of our time was spent re-building rapport and re-establishing relationships to promote the service and publicise the outcomes that were achieved previously from the service. Re-establishing this shared purpose was key to rebuild foundation for success.  In addition to this we had to re-establish the concept of the service which was to contribute to the early assessment and identification and management of individuals living with frailty therefore delivering preventative care to avoid hospital admissions and supporting people living in the community.

    The fact that the service would now be delivered virtually was viewed a positive to engage existing and new clinicians to the MDT who commented on the advantages of this in relation to their clinical time.  We also organised internal engagement sessions with our Federation GPs to promote the relaunch and expansion of the service which would not include triage with specialist clinician to replicate the delivery model of our existing Diabetes, CKD and Dermatology clinics. This has consequently resulted in a larger volume of referrals to the service from across the Federation. So this has reinforced the need to set aside ample time in the planning process for stakeholder engagement and understand the different ways that COVID has affected services and the workforce.

    Having built the relationship with a range of stakeholders there is a need to understand how they work and their processes and how this will fit into delivering a virtual service. The assessment of each individual referred to the service with moderate and severe Frailty results in the gold standard Comprehensive Geriatric Assessment. This assessment takes 2 hours and generates a lot of information.  To enable a productive and efficient MDT, the cases for discussion were shared with the MDT prior to the meeting for their information and to check their systems to see if the individual is known to them.

    One of the voluntary sector organisations were initially overwhelmed with the quantity and the level of medical information.  Because there is an assumption that members have medical knowledge and will understand the details this was overlooked and resulted in emails and further discussions about what is and is not relevant for their organisation to be aware of prior to each meeting.  Also the use of technology and access to delivery of the MDT needed to be considered and agreed prior to arranging the MDT.   Consideration was also given to the governance of sharing the information in a secure way

    Now that the process is in place for referrals and assessment the next steps will be the expansion of the MDT to include other stakeholders i.e. Social Services and additional Allied Health Professionals i.e. SALT and Dietician.

    We have requested that clinicians give feedback at all stages of their involvement with the service to share good practice.  It is also important at this stage to get feedback from the patients and families about their experience of the service which will help shape the service going forward.  It is planned to use this feedback and patient reported outcomes to further promote the service to all stakeholders to encourage continued use of the service.

    The service has highlighted the need for training about frailty which has been requested by the voluntary sector for their link workers i.e. the Social Prescribers and also from community services. A series of training sessions will be arranged with these organisations using the Skills for Health Frailty a Framework of core capabilities.

  • 19 Feb 2021

    The project was delayed due to staff redeployment, we have now secured a modified restart of the project for the planning and design to start this month. The goals and objectives remain the same and we have recruited a lead experienced Frailty nurse who is going to help us accelerate the pulling together of the Clinical team and engagement sessions of key stakeholders to provide a strong foundation for success of this project.


  1. Thanks Emma for the feedback and the very useful connection with the other relevant ideas will definitely have a look and link in. We are keen to learn from others and share our learning to.

  2. Hi - great idea and well-thought out. I'm working with the Health Foundation to highlight where there might be opportunities for collaboration across  Q Exchange.  There are quite a lot of virtual improvement projects suggested but there is one that might be of more interest to you - From COVID to Frailty: Virtual ward.  It might be worth having a look to see if there is any possibility for cross-support or feedback on your ideas.  Similarly there is a digital special interest group which you could contact in Q to gain some feedback on how to use technology for quality improvement. Good luck with your idea, Emma

Leave a comment

If you have a Q account please log in before posting your comment.

Read our comments policy before posting your comment.

This will not be publicly visible

Please note that you won't be able to edit or delete comments once posted.