 on the individual not the condition.

railty needs to be everyone’s business,” says Dr Pandora Wright, a consultant

geriatrician based at Charing Cross Hospital. That is the essence of the Trust’s

multidisciplinary approach to caring for the growing number of, mostly older, frail patients (see box) that is producing 

A dedicated frailty team that includes consultants, occupational therapists, nurses, pharmacists and healthcare assistants, working with our community partners, is helping to ensure we can  patients need.

“Fundamentally, it’s about putting in best practice as early as possible in a patient’s journey in hospital. That allows us to improve outcomes and to plan early for whatever support a patient will  hospital,” explains Pandora. “It means   to identify and properly assess frail patients wherever we have contact with them instead of just reacting when they are referred from specialist teams or only once they are acutely unwell.” The roll-out of early comprehensive geriatric assessment (CGA) across our hospitals has seen

4 /Trust

length of stay for frail patients halve. This entails reviewing an individual’s medical diagnoses, ability to perform everyday tasks, wellbeing and social circumstances in order to develop a goal-driven plan for treatment and recovery.

“This type of assessment helps us really understand our patients’ circumstances and needs, and to formulate a plan for addressing them.”

Initiatives such as

integrating pharmacists into frailty teams and the roll- out of the ‘red bag’ scheme for care homes – where a resident’s most important possessions and medical information are kept in one bag with them throughout their care journey – have also smoothed and sped up transfers and discharge from hospital.

Dr Pandora Wright

ASSESSMENTS AT HOME The Trust’s frailty programme is increasingly reaching beyond our hospitals’ walls. Pandora and her consultant colleague, Dr Aglaja Dar, each spend half of their time in the community, working with Hammersmith and Fulham’s Community Independence Service to assess patients at home or in care homes. A team of specialist frailty nurses are also


“F Kate Sendall

working seven days a week between the Trust and one local care home to help co-ordinate care in a pilot project. “We assess a patient’s needs at home, addressing underlying social, functional or health issues that might otherwise necessitate an admission. We aim to maintain independence at home wherever possible,” explains Pandora. “We can also undertake, for example, blood tests and basic diagnostics at home and treat medical issues such as simple infections. This means we collaborate closely with GPs and other community teams – the respiratory, heart failure and dementia teams – to provide social and therapeutic input to help maintain that


“If patients do need to come into hospital, we make sure we have a plan in place for their care and for a prompt,  communicated with hospital colleagues to ensure seamless transfers of care. “And most simply, from a patient perspective, being able to see the same faces between your home and the hospital provides huge reassurance.”


Supporting this work is a package of education and training which spans both the Trust and the wider community. Project manager and emergency

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