A New Approach To Frailty in Stockport - Truly Valuing Patients' Time Right Patient, Right Place, Right Time


Our frailty project commenced a year ago. Our aim is to implement a model care and pathway for our frail patients to ensure the right patient are in the right place at the right time. Our improvement journey over the past year has illustrated innovative collaborative working across the MDT in acute and primary care has provided high quality best practice care for our patients. Our achievements over the past year are to be celebrated and are the foundations of our future goals and plans

2.6 days average reduction in length of stay
for patients who have been assessed by the Frailty Assessment Team


We used Stockport NHS Foundation Trust QI methodology. Our improvement journey consisted of workshops with key stakeholders, completing driver diagrams, PDSA'ing all our small test of changes. We have co produced our model with our patient experience group.


Results: Our latest data indicates our length of stay has been reduced by 2.6 days for patients who have been assessed by the Frailty Assessment Team(FIT Team) compared to similar cohort of patients who are not assessed by the FIT Team. Our patients at the centre of the frailty journey have voiced nothing but positivity and praise for our new service. It has improved our patients experience whilst in hospital.

Conclusion(s): Our key achievements include early identification of our frail patients using the Rockwood at ED triage, working together with NWAS to gain the correct Rockwood score. Staff and patient engagement - everyone has been so enthusiastic and passionate about the changes made. IT developments phase one complete. Co produced a Comprehensive Geriatric Assessment (CGA) document which is being used daily. Launched our Frailty Intervention Team in Urgent Care (FIT Team - slogan 'See FIT before you admit!'). Finally the Frailty Education programme has commenced - staff completing a frailty masters module and developing a Frailty E learning module for all staff. Our future plans include, developing a business case for a robust medical model and additional MDT resources, embedding our frailty pathway, embedding the CGA and developing its links to the community, stabilising the frailty assessment unit, commencing a MDT educational forum where learning can be achieved through scenarios. Finally joint working with GM to develop a Frailty Collaboration with AQUA to develop and standardise frailty services across the North West. Our achievements are to be the foundations of our future goals and plans. We are proud to have overcome the challenges we have been faced with to enable Stockport to provide a high quality frailty service to our ever aging population. We are proud to be a voice for our patients and thrive to continue to develop, grow and improve our services for them.

Cost and savings

No further data


The impact of the project is very positive, both with reducing length of stay by 2.6 days and improving patients experiences. Going forward we are developing a business case to make the frailty team sustainable in our urgent care areas. Physiotherapists and other multi professionals are completing a Frailty Masters Module at Bolton University to continue to ensure evidence based practice is at the forefront of our future plans and decisions.

Top three learning points

No further data.

Funding acknowledgements

At present there has been no extra funding for this project. We have re aligned existing resources to support the test of change / improvement journey. As part as our winter pressure fund we were able to utilise Viaduct GP Stockport services to support our medical model in ED, each morning 5 days a week.