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PCN integrated approach to care and management of the frail

To develop the Primary Care Network Community Model and the development of neighbourhood frailty hubs.

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  • Proposal
  • 2020

Meet the team


  • Melanie Strachan
  • Caroline Upton
  • Dr Terri (Marie-Therese) Lovis
  • Katherine Saunders

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

Developing the Primary Care Network community model and neighbourhood frailty hubs are key priorities.

We know the proportion of the population aged over 65 is projected to increase to 25.4% in 2041, with the proportion of over 85s projected to increase to 5.2% over the same period. This will lead to an additional 112,200 over 65s in total with 34,500 more aged over 85. The projected demographic change will cause demand for services for older people to continue to rise over the next 25 years.

A multidisciplinary team approach to care home hubs during COVID has started to develop relationships between secondary care, PCNs and community that have led to more timely advice to support patients in care homes and improve outcomes including preventing admissions.  Early data shows a 30% drop in emergency admissions from care homes compared to PCNs not adopting an MDT approach.

What does your project aim to achieve?

The project can only be delivered in partnership with stakeholders from across the wider system.

We want to develop;

  • A shared understanding of how the system collectively can reduce health inequalities.
  • Neighbourhood frailty hubs and harness collaborative team working to support frail patients in their own homes to improve health outcomes and reduce inequalities.
  • Collaborative relationships between primary care practices, PCNs, secondary care, community and social care to develop a shared understanding of a good frailty hub.
  • Multidisciplinary teams, where teams and individuals can learn from each, share achievements and gain ‘insight’ into common challenges.

To achieve this we will ;

  • Build shared models of understanding.
  • Facilitate conversations to improve collaboration between the stakeholders and achieve more ‘togetherness’.
  • Empower teams and individuals from across different networks to build ‘lasting relationships’.
  • Create MDT working where teams and individuals learn from each, share achievements and gain ‘insight’ into common challenges.

How will the project be delivered?

This project builds on the work undertaken by the Kings Fund (July 2019- February 2020) where four groups, from PCNS within Sussex and Surrey, participated in six Action Learning Sets. There is a real desire to take this learning to another level by supporting groups to better understand one another whilst empowering MDT working, building ‘togetherness’ and gaining insights into common themes.

A PCN is trailing this approach to co-create a shared vision for embedding a PCN integrated approach to the care and management of the frail, elderly population. The learning from the pilot will be fully evaluated before it is rolled out wider. Any lessons learnt will be shared and used to inform the risk register.

Timing of this project is ideal as it will further cement the learning from our system-wide leadership programme. The theme of the programme is ‘Health is made at home’ and will be delivered by April 2021.

How is your project going to share learning?

Shared learning will take place across the whole system.

  • A collaborative and inclusive systems modelling approach will create a shared understanding of how to develop a frailty hub and raise standards in care of frail patients.
  • This project focuses on developing the communication and relationships within the teams to provide a strong foundation and give the team resilience to enable development of a robust model for their frailty hub. Learning is wider than the intervention and will also improve communication channels, encourage open feedback and encourage strategic planning as the hub goes forwards.
  • As Primary Care Networks around the country are tasked with working collaboratively there are frequently tensions between practices or with other organisations that limit the ability to make progress.  A combined approach of quality improvement and team coaching using systemic modelling has the potential to develop a model for building collaborative PCN MDTs which could implemented elsewhere.

How you can contribute

  • Review the application and give us feedback. We will use the feedback to make our business case even stronger.
  • Support our ambitions to develop and build strong Frailty hubs that are seen as best practice.
  • Help us measure our deliverables and 'challenge' our assumptions.
  • Be part of our development journey and share in our successes.
  • Be our 'critical friends' and help us make a real difference.

Plan timeline

30 Sep 2020 Finalise business case and reasons for change
30 Oct 2020 Agree ‘trial’ PCN and continually evaluate
30 Dec 2020 Engage with PCNS and wider stakeholders. Share feedback from pilot.
31 Jan 2021 Agree content for systemic modelling sessions - incorporate & build on feedback.
31 Mar 2021 Roll out wider programme.


  1. Valuable piece of work. You might want to check out Hull's Jean Bishop Centre.


  2. Guest

    michaela senek 1 year, 10 months ago

    I think this sounds like a very good idea and a well thought-out project.

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