The GP Awards 2025 shortlist: Newton and Haydock PCN Frailty Team

We catch up with the Nurse/Nursing Team of the Year Award shortlist ahead of this year’s General Practice Awards ceremony, taking place on 5 December at the Novotel London West in Hammersmith.

The frailty team at Newton and Haydock PCN has spent the past year strengthening its service to older people in the community, delivering highly personalised care and supporting patients through the most challenging stage of their lives.

Clinical lead Sara Hawkins lists some of the team’s achievements. ‘We have targeted NHS initiatives delivering a community-based approach, reducing GP consultations and increasing capacity through our support of the over-65 population.

‘We have also reduced hospital admissions significantly through the multidisciplinary team (MDT) working with patients at home and in a care home setting.’

The team is fully embedded in local general practice and linked with secondary care, palliative services, community nursing and social care

Built around an innovative primary care model, the Newton and Haydock frailty service was designed to meet the growing and complex needs of older people in the community, with the care required typically reflecting multiple conditions, medications and social challenges.

To address this, the PCN created its MDT, fully embedded in local general practice and linked with secondary care, palliative services, community nursing and social care.

As well as frailty practitioners, the team now includes care coordinators, an occupational therapist and a pharmacist, all working within a clear clinical framework.

‘We have an excellent mix of team members who all contribute fantastically to the patients’ journey and the care that we deliver,’ Ms Hawkins explains.

‘I am most proud of how we work as a team,’ she adds. ‘We go above and beyond, both for our patients and for each other as well.

‘The supportive team that we have is something that we pride ourselves on.’

Originally launched in 2020he service has grown in scale and impact, supported by Additional Roles Reimbursement Scheme (ARRS) funding, local business cases, and strong clinical leadership.

We have an excellent mix of team members who all contribute fantastically to the patients’ journey and the care that we deliver

The team has developed KPIs and standard operating procedures aligned to NHS ageing well priorities, and its approach has become a model for others in the region.

The work includes comprehensive home visits, coordination with palliative and community services, and a preventative approach that has demonstrably improved outcomes. In one patient survey, 100% said they would recommend the frailty team to others, while 98% said their concerns were addressed and the same percentage said their needs were fully met.

Patient testimonials underline the team’s impact: ‘Sara was very thorough with her assessment and put me at ease knowing my mum was now going to get the care she deserves,’ said one.

‘We weren’t expecting the care we were given – we are fully satisfied with the service,’ said another.

Being shortlisted for the award is, in Ms Hawkins’ words, ‘a chance of recognition for what this team has achieved’.

She adds: ‘How amazing would it be to say we are an award-winning frailty team? It would cement the hard work and the outstanding care delivery that the team has been pivotal in providing.

‘Each and every one of the team deserves this award and I am proud to be able to manage this wonderful group of people and drive them forward to continue to excel in their roles.’

Read more about the General Practice Awards 2025

This is one of 7 nurses or nursing teams shortlisted at the General Practice Awards. The winners will be revealed at the awards ceremony on Friday 5 December at the Novotel London West. If you’d like to be there on the night you can find out more here and book tickets here.