WRITTEN FOR WhereIsTheCare – Feb 2016.


Over the past 2 years a major piece of work has been undertaken aiming to improve care for some of our most vulnerable patients.

In recent years the term “ Frailty “ has been used to describe a cohort of people who are liable to become incapacitated by relatively minor illness and at risk of unplanned hospital admissions which may not necessarily be the best way of looking after them . We all know that very often people prefer to be looked after in their own home if at all possible provided they can be supported by the right care when it is needed.

To improve the care for these people we have been working in Mid Essex in a joined up way across a number of organisations including the Clinical Commissioning Group ( CCG ) , General Practices , Social Services ( ECC ) , Acute Hospital ( MEHT ) , Mental Health ( NEPT ) Community Services ( Provide CIC ) , and Voluntary services ( Age UK ) and Community Agents.


The project started in an innovative way working with NESTA ( a health innovation charity ) & the Rapid Results Institute .

Initially three multidisciplinary teams based around GP practices in Braintree , Chelmsford and Maldon were given “ a free hand “ to find new ways of working together to identify and support these frail people in their localities.

They set themselves very challenging goals to be achieved in the short space of 100 days . Workshops were held to launch the challenge and subsequently to feed back on the developments and achievements of the teams . It was something of a friendly rivalry and certainly led to exciting and innovative ideas being launched and tried out . There followed several further waves of 100 days which further refined and tested out the ideas that had been developed.

The underlying aim was to reduce the number of unplanned hospital admissions and A&E attendances for the cohorts of Frail people identified.

From these teams several significant new ways of working proved hugely important and have now been adopted right across Mid Essex.


One of the teams came up with the concept of a patient owned record of their own circumstances and their wishes about how they would wish to be cared for in the event of becoming unwell or in need of help.

This is called the IAM Form ( Information About Me ). The person and their family and carers can write down their own preferences and concerns including statements about their health care towards end of life.

The form is recognised by community services, social services and hospital as a valid statement which should influence how professionals and the patient make decisions about their care. A copy of the form is kept in the patients GP record and also held centrally so it can be seen by other professionals including acute hospital clinicians ( if the patient has given their consent ).


The concept of multidisciplinary working is well established , usually comprising doctors , community nurses, social workers for example , meeting together to discuss patients and planning their care together.

In the Frailty Challenge this way of working was boosted to include a wider team who could contribute to planning the best possible care . Mental Health nurses were brought in and contribute particularly where the frail patient has a degree of memory impairment or dementia. Community Agents are now established across Mid Essex and provide a link between people in the community and voluntary organisations and agencies that can help to support the frail and vulnerable.

A key member of the team is the Community Matron. There are now about a dozen of these highly trained nurses across Mid Essex. They work alongside General Practices and community ( district ) nurses and are particularly skilled in supporting people with complex needs in the community which of course includes the Frail patients.

In the GP practices involved these enhanced MDTs began to be held regularly ( at least monthly ) to discuss and case manage the frail patients that had been identified in their practices.

One of the major benefits of this way of working was that informal networks and relationships grew up between the professionals that enabled them to break through some of the bureaucracy and paper work and “ get things done “ quickly and efficiently to arrange care when needed and avoid a crisis or hospital admission.


Broomfield Hospital, Chelmsford, is where many frail and vulnerable people all too often are admitted because they cannot be cared for in the community although they may not have an illness that really needs hospital care. Unfortunately hospital is not always a good place for them to be and they may even lose some of their previous independence as a result of the stay in hospital.

We worked with staff and clinicians at Broomfield Hospital to recognise these Frail patients when they attend A&E or are admitted to the wards. The aim is for the hospital to access the IAM form held in the central register so they can be more aware of the care that is already in place for the patient in the community as well as their wishes so that an admission may be avoided if possible or the patient discharged sooner and more smoothly back into care in the community as soon as they are well enough.

This has been well received by hospital staff and work is ongoing to increase awareness in the hospital and use the available Information Technology (IT) to access the IAM form. Hospital staff are also making assessments of admitted patients to identify Frailty and feeding this back to primary care in the discharge information.

In the future it is intended that there will be a dedicated unit and pathway to assess frail patients when they present to the hospital and work very closely with community services to provide best possible care.


Following the learning and success of the 100 day challenge and enthusiasm of the teams involved it became clear that this way of working is one which we should be spreading right across Mid Essex.

By spreading the word about the benefits of the IAM form and Enhanced MDTs with general Practice colleagues and supporting this with a modest financial incentive to practices we now have the majority of practices ( 45 out of 47 ) engaged in this activity, identifying their Frail patients, using the IAM form and holding regular enhanced multidisciplinary team meetings.

To date we have about 5,800 patients on the central “ Frailty “ register , the majority having an IAM form completed.

It is estimated that about 2% of the whole population could be identified as being “ Frail “ and that would therefore mean nearly 8000 people in Mid Essex so we are well on the way to identifying the vast majority already.


Anecdotally the feedback from those in the early challenge phase was extremely positive. Particularly as has been mentioned with regard to the working relationships and information sharing .

The IAM form has been very well received by patients their relatives and carers, by hospital teams , care homes and professionals.

In terms of reducing unplanned hospital activity for this cohort of patients the emerging evidence seems to be that we are at least preventing an increase whereas in areas where this type of work is not being done the rates of admission are increasing at a significant rate.
The most important benefit is hopefully for frail people and their families. That they are being asked about and able to record their wishes about how they wish to be looked after. That they are more involved with the professionals in making decisions about their care and that people working to support them are working better together, avoiding duplication being more proactive to avoid a crisis or breakdown that may lead to an unwanted hospital admission.

Dr Bryan Spencer
Clinical Lead MECCG