Analysis of early outcomes from Community Frailty MDT Pilot January to July 2026

Recognising a gap in community Frailty provision in Ealing, the pilot was designed to test a consistent, scalable community frailty service model focused on proactive multi-agency support meeting local needs in line with the NHS 10-year plan.

Key principles – data driven, proactive intervention and actions taken on by MDT members. Identify risk early – patients at greatest risk of escalation/admission using local dashboards and referrals by GP/MDT partners. Regular MDTs – partner representatives supporting virtual CGA. Co-ordinate care – dedicated care co-ordinator as a core MDT role. Enable action – direct referrals/interventions from the MDT. Maintain oversight – caseload management for around six weeks.

The core MDT includes GPwSI/Geriatrician, PCN support, GP, social prescriber, pharmacist, care co-ordinator, district nurses, therapies, mental health, and adult social care.

The pilot SOP describes a pathway from identification to MDT discussion, action planning, stabilisation and discharge. Key elements include full discussion and information gathering at MDT (completing a virtual Comprehensive Geriatric Assessment). With a problem list and action plan agreed, actions taken on by MDT members. Once stabilised patients are discharged with care co-ordinator oversight for an agreed period.

Analysis of outcomes for the first 30 patients (January to May 2026) shows average 11% reduction (range -41% to +14%) in frailty escalation risk score: 61.7 at baseline to 55.8 at week 6. In subsequent months 3 patients admitted to a care home and 3 died. 57% of patients had a UCP in place. Median CFS score 6 (range 4-8).

Learning included that the model is workable, but scaling requires dedicated capacity. Identifying appropriate skill mix from partner organisations is vital. CGA completion is constrained where teams rely mainly on existing records without a physical visit. Weekly MDT is optimal for patient flow and outcomes - scaling requires professional, nursing and AHP visit capacity, MDT administration and protected partner time.