Improving support for people with frailty through Integrated Neighbourhood Teams

The Vale PCN supported 881 people living with frailty and at high risk of falls and social isolation in rural areas. They brought together an integrated neighbourhood team including health and care professionals from the PCN, voluntary sector groups and patients to offer volunteer Falls Buddies, 1-1 balance sessions, exercise classes and invitation to a one stop carousel clinic.


The Vale Primary Care Network, Dorset Integrated Care System.


The Vale PCN took a population health management approach, using a local linked dataset across health and social care and including additional indicators of frailty, falls risks and isolation to identify the group.

The need

They wanted to better support people living with frailty by proactively identifying health needs and any wider determinants impacting their health and wellbeing. They aimed to agree the approach using a multiagency and personalised approach, moving away from a medicalised service to create a holistic approach to wellbeing.

The solution

The Vale used the data triangulated from the Dorset Intelligence and Insights Service (DIIS) to define and stratify actionable cohorts of patients. DIIS is a real time data analytics tool pulling data from primary care, secondary care and some social care information using MOSAIC, as well as some community data and mental health data)

They used this information to build a core team with the skills to manage the needs of the population group and ensure engagement of all partners. Partners included local VCSE organisations, health coaches, patient volunteers, occupational therapists, local authority staff, social prescribers and pharmacists etc through communication and inclusivity.

This Multi-Disciplinary Team (MDT) holds regular service review meetings and implements a Plan–Do–Study-Act cycle to ensure learning leads to improvements in service delivery. The team discussed the population group, which was risk stratified through the data analytics tool into high, medium and low risk of falls and social isolation. They then proposed three interventions, including patient volunteers as part of the design and the solution.

The ‘Altogether better’ programme was a key approach to re-addressing attitudes to involving patients in service design and patients are now seen as critical supportive friends rather than passive recipients of services. The PCN also used Ageing Well funding to jointly employ, with the Community Trust, a long-term condition nurse and an Occupational Therapy assistant to the frailty team.

The interventions included:

1) For High-Risk Patients – Falls Buddies, volunteers trained in mindfulness and strength and balance skills matched with patients to work with them on a 1:1 basis to improve confidence and mobility, focusing on ‘what matters most’ to the patient, working with them in their own homes.

2) For Medium Risk Patients – a carousel clinic approach in a non-medical setting where patients see all members of the MDT and local voluntary sector organisations and meet socially.

3) Low risk groups are invited to workshops, included in educational maildrops, and invited to exercise classes.

Structure and partners

There is a system level governance approach to using data sharing agreements for developing and using the DIIS. A standard operating procedure is in place and this is updated every time the Plan–Do–Study-Act cycle is run. The challenge remains as to how we effectively bring VCSE and community assets under the data umbrella too.

They use Memorandums of Understanding and patient information sharing agreements together with DBS checks and confidentiality agreements where data sharing is required. Access to re-identification of the pseudonymised data is overseen by the PCN clinical director.

They employed an innovation lead to support transformation of services and support a joint employment venture with the local community trust, using funding from the ageing well programme. They top slice some of the ageing well funds to support patients to access strength and conditioning classes in the community clinic following on from visits to the carousel clinic.

ARRS funding and ARRS roles have made a difference to enable the changes along with small Personal Health Budgets. They have been able to second a physiotherapist with a background in falls to support development and evaluation of the carousel clinic and falls buddies outcomes by using support from the Complete Care Community.


  • Workforce has been the main challenge, recruitment and retention to roles remains the main cause for concern.
  • Staff from across different organisations do not have permission for true autonomy which is needed for transformative integration. ‘We all need to focus on one shared outcome that is the same across all organisations.’

The results: what was the outcome?

The feedback is overwhelmingly positive with 72% rating the clinic as excellent and the remainder rating it as good. 96% of those who responded felt that the clinic had offered them some benefit. 100% of the attendees who responded would recommend the clinic to a friend in a similar position. 

At the Carousel Clinic they have seen 313 patients, with an average attendance of 10 patients per clinic. This uses ARRS roles and Voluntary Sector support, no GP time. Improved outcomes include

  • A reduction in prescribed medication
  • People referred to positive movement programme subsidised by Personal Health Budget.
  • Identification of Atrial Fibrillation, poor BP control.
  • More signposting to CAB, Age UK
  • Better information on independence at home support aids
  • Anticipatory Care Planning
  • Reduced unplanned care requests
  • Long-term benefits

“It’s reassuring to know that support is there should you need it.”

Falls Buddies have seen 7 patient volunteers working with 11 patients and a focused 12-week programme of supportive home visits.

  • ‘Quality of life’ scores are improved together with increased levels of confidence to remain independently mobile.
  • Chris lost his wife and gave up his car last year. As a result his confidence has plummeted. He is matched with Melissa who is helping him do the exercises that will keep him able to maintain his small garden and get out to visit his neighbours.

Positive movement programme feedback includes the following:

  • ‘Have felt enormously better since attending the classes- quite up lifting and positive and exactly what I needed and thank you for giving me the opportunity – shall continue!!’

Learning points

Establishing good conversations with people in your neighbourhoods is critical to creating the space to do something differently and develop mutual trust without letting organisational barriers get in the way.

They used an established patient volunteer group to identify volunteer falls buddies and equip them with skills through a short training programme and risk management approach.

A clear change to ways of working focusing on the health and wellbeing of our communities has enabled a focus around a neighbourhood community one stop ‘clinic’ which includes Local Authority, Social Care, VCSE, and communities, all working together.

Next steps and sustainability

They are currently working with the National Association of Primary Care to develop an Out of Hospital / Community Integrated Care framework that has a focus on the health of older people. This framework will enable Dorset develop how they work across organisations as multi-disciplinary teams and in partnership with local communities.

From a commissioning perspective they will also think about how to shift from commissioning services to commissioning for outcomes.

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