Collaborative working across the local area to design model of care for older people who are frail

  • 19 December 2018

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On 6 December, 160 representatives from our six localities, including GPs, community and acute services, Local Authority, ambulance staff, care home and domiciliary care providers, voluntary and charity sector organisations, and older people, came together to begin work on designing a community model of care for older people who are frail.   

The event opened with a video from Age UK highlighting older people’s experience of being frail and how little they want to be defined by this label, whilst at the same time sharing how much their life can be limited by the fear that things will only get worse.

The morning focused on our understanding of frailty, emphasising how we can halt people’s decline, supporting them to stay healthy and independent at home, enabling people rather than disable them, with the support we offer. 

There was a direct challenge to think about how better use of our existing workforce and estates could bring us into line with the best performing systems in the world (some of which are in the UK).  This was further backed up when some examples of the excellent work already underway in Bristol, North Somerset, South Gloucestershire, were presented.

In the afternoon, participants agreed the outcomes important to them, focusing on two key areas; ensuring nobody spends time in hospital just because they are frail, and supporting health, wellbeing and independence.

Participants began to work collaboratively to generate ideas for change to be able to deliver those outcomes and agree plans to test these ideas. 

This is the beginning of developing locality based delivery of integrated frailty services.  A frailty steering group is also being established to oversee these developments, learning from others, developing the underpinning need, demand and capacity modelling, and bringing the work together into a coherent overarching Bristol, North Somerset, South Gloucestershire model of care.


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