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Meet the GP Awards shortlist: Gateshead Inner West PCN Frailty Service

Meet the GP Awards shortlist: Gateshead Inner West PCN Frailty Service

We caught up with the Nurse/Nursing Team of the Year Award shortlist ahead of this year’s General Practice Awards ceremony to be held on 8 December in London.

The sixth entry under the spotlight from this year’s shortlist of seven is the nursing team for the Gateshead Inner West PCN Frailty Service.

The frailty service provides services to promote health and wellbeing, encourage self care and deliver personalised health outcomes in patients’ own homes, in local surgery and in other community-based settings.

The nursing team strongly believes that individualised services, close to home, are the ‘future required response’ to managing the population’s health needs.

The nursing care provided supports general practice and district nursing teams with their rising volume and increased patient complexity. The frailty team predominantly receives patient referrals via one of the five practices within its primary care network. Reasons for referral vary but tend to be in response to a change in the patient’s baseline function following a hospital admission or decline in cognitive status.

The team completes a comprehensive geriatric assessment (CGA) and tailors the patients care holistically, in accordance with the CGA. It also collaborates with the patient to create rehab goals, falls prevention and reduction plans, medication optimisation and reconciliation actions, as well as initiating equipment ordering and handling often intimate discussions about preferred place of care or death.

Depending on the patients’ needs, some are discharged once goals are achieved, but others are added to the team’s caseload for ongoing care coordination and support at home.

Entry highlights

The geographical area the team covers between five GP surgeries is eight miles in radius. Despite the proximity of the surgeries, however, life expectancy varies by as much as eight years, and social determinants of health differ significantly and widely.

To address the varied needs on a structural and individual basis, specific nursing competencies are utilised, including skills in flexibility, as well as the ability to work in partnership with patients, carers and communities and in tandem with a range of other professional and voluntary workers.

The aim is to ensure that a ‘postcode lottery’ effect does not take place between the communities that are less engaged and less able to access the healthcare landscape within the PCN.

The team includes two care navigators, initially employed to support the patients with rehab goals and social isolation prevention via activity and social prescribing. One of them is now in her first year as a staff nurse, with the team supporting her through her career progression. The second is now a student nurse working at a greater depth to help further develop and expand the service.

Over the past year the team has received more than 700 referrals, with some of these patients being seen weekly, monthly or as the patient requires. This has been achieved with three team members, two of whom were often out of service on placement.

What they said

Samanatha Iveson, PCN assistant manager, said that the PCN was ‘lucky to have such a dedicated forward thinking nursing team’.

‘The Frailty Team deliver the gold standard in elderly care and promote NHS England’s 10-year plan of having patients cared for in their homes. The team has a big impact on the Surgeries Access and GP support as well as favourable patients outcomes.’

Families of patients have spoken in glowing terms of the support given by the Gateshead Inner West PCN Frailty Service, with one relative describing the service as ‘an absolute lifeline’.

Last year, Wales-based general practice nurse Janette Morgan won the Practice Nursing Award after demonstrating her impact on chronic disease management in her locality.

See here for more information about this year’s General Practice Awards and the gala dinner and ceremony, which will be at the Novotel London West on Friday 8 December.


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