Joined up GPs and council teams find frail ‘frequent flyers’ who need help with bins

In Chorley, GPs and the local council worked together to help residents who had trouble putting out their bins and were also visiting their GP 10 or more times a year.

Working together the Lancashire and South Cumbria Integrated Care System (ICS) was able to offer these residents more health and social support likely to keep them well for longer. Thinking about frailty and bin collections together helped the partnership uncover a shared community of people who needed more help.

A frail patient to a GP practice was also a resident who needed an assisted bin collection to the council. These people were also moderately frail, aged 45 to 60 and 90% were obese; they often had limited mobility and some had fewer social links and were isolated.

The teams worked together to contact the residents and a social prescriber link worker visited them at home to uncover their unmet needs, thinking about their mental health, physical and social needs, all in one assessment and making personalised recommendations for that person.

These included putting them in touch with local groups to help with loneliness, a visit to the GP if medical needs were apparent, help with healthy eating or contacting the council team about any issue with their environment.

Find out more about Cheshire and Merseyside ICS.