Evaluation of a New Frailty Care Pathway

11th August 2023

Often experienced by older people, frailty requires people to have access to high quality and well-planned care to help prevent and respond to any arising health issues. With an estimated 10% of adults over 65 in the UK living with frailty, a figure rising to between 25% and 50% for those aged over 85, there is a large population of people who need support to help manage their health.

The Yate and Frampton Primary Care Network (PCN) is piloting a new care pathway, which aims to provide additional support to patients with frailty, with a particular focus initially on patients who are severely frail and housebound. This pathway provides anticipatory care and aims to address the wider needs of the patients by understanding their individual circumstances, adopting a, ‘what matters to you’ approach and helping people stay healthy for longer.

After securing funding from the Ageing Well Programme, Yate and Frampton PCN and the West of England Academic Health Science Network (AHSN) commissioned Unity Insights to independently evaluate the new frailty service. The evaluation was conducted to present evidence regarding the effectiveness and sustainability of the pathway, while offering recommendations and insights as to how the service could be improved.

To achieve this, qualitative research was conducted to understand the impact of the pathway on the patients, and quantitative data was used to understand the impact of the pathway on primary and secondary care services. A cost-benefit analysis of the service was conducted, and results were presented in a final report and an infographic to share amongst both PCN staff and service users.

Results from the evaluation will help inform commissioning decisions regarding the further adoption and potential spread of the pathway, while providing recommendations as to how the service could be improved in terms of delivery and return on investment.

The evaluation demonstrated that the pathway is well received amongst patients, with 100%  (n=17) of survey respondents agreeing that they felt involved in their care decisions, and 71% (n=12) agreeing that the frailty service has helped them to better manage their health.

From the staff survey, 89% (n=8) reported that they agree about the pathway enabling shared decision making, and 90% (n=9) reported that they felt the patient’s quality of life improved because of care provided by the pathway.



Results from the health economic analysis demonstrate some cost savings within the pathway, however, for the service to generate a greater return, the volume of new patients seen by the dedicated staff would need to increase.




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