Frailty: A silent crisis

By Dr Jon Tose

The time for a coordinated, pathway-driven response to frailty is now, writes Dr Jon Tose, GP at Northern Moor Medical Practice and Clinical Lead at HealthPathways UK.

We’re facing a crisis that’s growing silently, relentlessly – and dangerously: frailty. It’s not a dramatic headline-grabber. It doesn’t spark protests or fill news cycles. But frailty, particularly among older adults, is quietly becoming one of the most serious threats to the long-term survival of the NHS.

Unless we act now with a coordinated, system-wide response, frailty could push our healthcare system to the brink – and cost billions in avoidable care.

The numbers are alarming – and getting worse

Right now, around one in 10 people over 65 and more than half of those over 85 in the UK are living with frailty, according to the British Geriatrics Society. And with the UK’s ageing population growing fast, the Office for National Statistics predicts that over a quarter of the UK will be over 65 by 2043. These figures are just the beginning.

Without urgent action, the number of people with moderate to severe frailty could double in the next 20 years. That means more falls, more hospital admissions, longer hospital stays, more care needs – and massive strain on already stretched NHS services.

Frailty isn’t just a health problem. It’s an economic one

The cost of ignoring frailty is staggering. Older adults living with frailty are far more likely to end up in A&E, often after a fall, infection, or medication issue. But, critically, NHS England estimates that up to 40 per cent of these emergency admissions are preventable.

Those admissions come with a price tag. One study estimated that frailty-related hospitalisations cost the NHS around £5.8 billion a year, and that figure is climbing (Gale et al., 2020). If we don’t shift from reactive, crisis-driven care to a proactive, preventative model, we’ll be pouring money into a system that can’t keep up.

The system is buckling

Right now, the NHS treats frailty like it does many complex health issues – after the crisis hits. We wait until someone falls, gets acutely ill, or becomes too weak to cope at home. Then we send them to hospital, treat the immediate issue, and discharge them – often without enough support.

This model isn’t just inefficient – it’s harmful. Hospital stays can actually worsen frailty, especially for older adults. Even a few days in bed can lead to permanent declines in mobility and independence. And when discharged into poorly coordinated community or social care, many bounce right back into hospital.

This revolving door is exhausting staff, draining resources, and failing patients. We have to do better.

We have the tools. We just need to use them

There is a solution, and it’s not theoretical. It’s already working in parts of the country. It’s called a frailty care pathway – a structured, evidence-based approach that identifies and manages frailty before it becomes a crisis.

Frailty pathways typically include:

Early identification using tools like the electronic Frailty Index (eFI).
A Comprehensive Geriatric Assessment (CGA) that looks at medical, psychological, and social needs.
A personalised, multidisciplinary care plan.
Regular review and monitoring to prevent deterioration.
A ‘map’ of the services that can promote ageing well and those that can step in if the patient deteriorates.

When implemented effectively, these care pathways don’t just improve outcomes – they save money. A Cochrane review by Ellis et al. (2017) found that proactive, structured geriatric care reduced hospital admissions and improved quality of life. It’s simple – the earlier we intervene, the more we prevent.

Policy is starting to catch up – but it’s not fast enough

There’s been some good news. NHS England’s Long Term Plan includes a strong focus on ageing well, frailty, and anticipatory care. Initiatives like Urgent Community Response (UCR) and the Enhanced Health in Care Homes (EHCH) model are helping local teams manage frailty without sending patients to hospital.

Primary Care Networks (PCNs) are now expected to identify patients with moderate and severe frailty and provide proactive care. That’s a great step. But implementation is patchy, and many clinicians still lack training, tools, or time to deliver it well.

As the British Geriatrics Society puts it – we can’t afford for these care pathways to remain optional or unevenly applied. This needs to become the national standard.

What’s holding us back?

Despite the evidence and policy momentum, uptake of frailty pathways has been inconsistent. Why?

Workforce capacity is stretched thin.
Many GPs and community teams lack specialised training in frailty management.
The Voluntary, Community and Social Enterprise (VCSE) sector is not used to its maximum.
Managing frailty is multidisciplinary and navigating the system is challenging for patients and those who support them.
IT systems don’t talk to each other, making coordination across services difficult.

However, these are solvable problems. What’s really missing is urgency. We need to treat frailty like the system-wide emergency it is.

What needs to happen now

If we want to avoid a full-blown crisis in the next decade, we must:

Make frailty identification and pathway implementation mandatory across the NHS.
Invest in workforce training so GPs, nurses, paramedics, and allied health professionals can deliver proactive care.
Integrate digital systems to allow seamless sharing of care plans and patient status.
Fund community, VCSE, and social care services that are critical to keeping people out of hospital.
Track outcomes and iterate – because good care pathways evolve as needs change.

This is a ticking time bomb – there is no second chance

Frailty doesn’t come with sirens. It doesn’t flood wards overnight. It builds slowly and quietly until the weight becomes unmanageable. But make no mistake – the frailty crisis is already here, and the NHS is on the edge of being overwhelmed.

We already have the knowledge, evidence, and tools to address this. We just need to act.

Because when it comes to frailty, doing nothing is the most expensive option of all – for the system, for society, and for the people we serve.

Primary care collaborative launches COPD early detection clinic

By Integrated Care Journal

Wirral Primary Care Collaborative and Chiesi partners have launched the community-based COMET clinic to accelerate COPD assessment and diagnosis, reduce system burden and improve patient outcomes.

A primary care collaborative has launched a new initiative aimed at improving early diagnosis and management of Chronic Obstructive Pulmonary Disease (COPD) in the Wirral area. Wirral Primary Care Collaborative (WPCC) and Chiesi UK and Ireland have collaborated to deliver the COMET clinic (COPD Targeted Management, Early Intervention and Treatment) in an effort to ease pressure on primary care and A&E services by offering early diagnosis and evidence-based interventions to at-risk populations.

COPD is a leading cause of emergency hospital admissions, with an average stay of seven days. It is estimated that up to 5,000 people are living with undiagnosed COPD on the Wirral, where prevalence is more than 40 per cent higher than the national average.¹

Individuals identified as high risk of COPD will be invited to attend a community diagnostic centre (CDC) for spirometry assessment and then a diagnostic clinic for immediate management (if diagnosed). These services will be delivered directly within the community, ensuring timely access to care.

*A patient in consultation at the COMET clinic*

Rachel Voller, Advanced Nurse Practitioner at Moreton & Meols PCN, said: “An estimated two million people live with undiagnosed COPD in the UK, with symptoms like breathlessness and chronic cough often mistaken for fatigue or ageing. These delays in diagnosis lead to reduced quality of life for patients, costly emergency hospital admissions and irreversible lung damage.

“The lack of resources and funding across the UK means diagnostics in COPD, such as spirometry, are not always readily available in primary care. By establishing COMET, we’re equipping the NHS and supporting patients to take control of their lung health, improving early diagnosis and accelerating access to care.”

COPD is not only debilitating for patients, but also places a growing burden on the NHS, costing an estimated £1.9 billion annually in England alone. The UK continues to have some of the poorest respiratory health outcomes in Europe, with higher mortality rates from COPD than in comparable countries. Despite the scale and severity of the disease, COPD can often be overlooked, meaning opportunities for early diagnosis are frequently missed.

Many cases are identified incidentally, through initiatives such as NHS lung health checks, or during emergency admissions for other conditions, by which point irreversible lung damage may already have occurred. On the Wirral, where COPD prevalence is 2.6 per cent compared to the national average of 1.8 per cent, the COMET initiative aims to address this challenge by proactively identifying those at risk and providing timely access to spirometry and clinical assessment.

COMET enables those with symptoms and/or CT scan findings consistent with emphysema to be referred for spirometry at local Community Diagnostic Centres before inviting them to the COMET clinic for a full clinical assessment and follow-up. Designed to deliver equitable, community-based care to over 1,000 people, the programme aims to equip patients with the support they need to take control of their lung health while also helping ease the pressure on overstretched GP practices and emergency departments in the Wirral, while identifying feasible approaches that the NHS can embed in the future.

The partnership builds on insights from FRONTIER, a hospital-based programme in Hull which demonstrated that targeted screening can tackle underdiagnosed COPD by improving access to testing and care. By contrast, COMET brings diagnostic assessment and management into Primary Care for patients taking part in the NHS Lung Cancer Screening Programme on the Wirral, expanding early detection and intervention beyond the hospital setting.

Harriet Lewis, Senior Director of Public Affairs and Communications at Chiesi UK and Ireland, said: “At Chiesi, we believe early action is key to improving outcomes for people living with COPD. COMET has been designed to ensure access to diagnostic services is simple, breaking the cycle of delayed diagnosis and avoidable hospital admissions. By delivering care directly within the community, this partnership is integral to improving access to testing and care, easing NHS pressures and demonstrating how partnerships can drive scalable and sustainable change.”

¹ Public Health Profiles: Public health profiles – OHID. Available at: phe.org.uk. Last Accessed April 2025.

First Community Diagnostic Centre Value Partnership with Siemens Healthineers set to improve health outcomes across Teesside

By Integrated Care Journal

A first-of-its-kind seven-year Value Partnership will see Siemens Healthineers support Tees Valley Community Diagnostic Centre to deliver up to 104,000 checks, scans and tests a year on the high street.

North Tees and Hartlepool NHS Foundation Trust and South Tees Hospitals NHS Foundation Trust have announced the first Community Diagnostic Centre (CDC) Value Partnership to be collaboratively delivered with Siemens Healthineers. The seven-year partnership will set a gold standard for CDCs, placing efficiency, scalability and patient care at its core. Once fully operational, the CDC is set to deliver up to 104,000 potentially lifesaving checks, scans and tests a year.

An impressive fleet of nine imaging systems will be provided, including a variety of CT, MRI, X-ray and ultrasound equipment from Siemens Healthineers. Support includes maintenance of the systems and additional services to bolster prostate cancer pathways and productivity including digital AI, consulting, workforce planning and education. The CDC represents an important investment to improve healthcare outcomes across the region where the proportion of people with major health conditions is at least 10 per cent higher than the national average.

“Integrating advanced imaging systems and AI solutions enables us to provide quicker, more effective diagnostics and treatment while the community setting brings essential services closer to our patients,” said Gail Griffiths, Diagnostic Services Lead for Responsive Care at North Tees and Hartlepool NHS Trust.

Delivered by the North East and North Cumbria Integrated Care Board, the CDC supports efforts to address health inequalities in the area by ensuring a collaborative, community-based approach, and aligns with government ambitions to move more care away from hospital settings. Access to care outside of a hospital setting means patients can receive more convenient health checks closer to home. The central location in the heart of Stockton town centre alongside a library and leisure centre not only improves access to care, but also encourages a wider transformation of the high street.

The NHS’ 2024/25 priorities and operational planning guidance identifies the opening of new CDCs as a key action for systems, and the upcoming 10-Year Health Plan is expected to reaffirm the value of CDCs for delivering the government’s desire to further shift care in community settings.

Tees Valley CDC will benefit from digital AI solutions as part of the partnership. Utilising AI-Rad Companion from Siemens Healthineers, standardised reporting of the scans will enable quicker, more effective prostate cancer pathways, helping to support both productivity and patient throughput. Support from Siemens Healthineers Consulting includes a tailored transformation programme featuring a project to help increase the daily number of patients receiving MRI scans by up to 40 per cent.¹ The partnership will also support upskilling the workforce with tailored training and education opportunities to meet the CDC’s unique requirements.

Among the range of CT, MRI, X-ray and ultrasound equipment from Siemens Healthineers are two SOMATOM X.cite CTs. Both systems are designed with patient experience in mind, equipped with the unique guidance of myExam Companion to automate results, as well as Tin Filter technology to optimise dose efficiency. Tees Valley CDC will also include two MAGNETOM Sola MRI systems, a YSIO X.pree X-ray and two ACUSON Sequoia ultrasound systems from Siemens Healthineers. The wide range of systems will support the delivery of care with the potential for one-stop clinics in the future for diagnostic tests conveniently based in the centre of Stockton.

Kelly Smith, Head of Radiology at South Tees Hospitals NHS Foundation Trust, commented: “In partnership with North Tees and Hartlepool NHS Foundation Trust and Siemens Healthineers we are making a significant step forward in improving healthcare outcomes across the Teesside region. By bringing imaging technology and comprehensive AI solutions to a community setting, we’re not only enhancing diagnostic capabilities but also ensuring more accessible healthcare for our patients.”

“Together with South Tees Hospitals NHS Foundation Trust and Siemens Healthineers we aim to transform healthcare delivery in our region and significantly improve outcomes, added Gail Griffiths.

Ghada Trotabas, Managing Director of Siemens Healthineers Great Britain & Ireland, stated: “This groundbreaking collaboration with North Tees and Hartlepool NHS Foundation Trust and South Tees Hospitals NHS Foundation Trust is the first of its kind for community diagnostics centres. Located in a high street setting, the centre will set a new benchmark for delivering efficient services outside of the hospital environment, bringing care closer to the patients who need it most.

“Our partnership ensures the CDC stays adaptable to the evolving needs of patients, contributing to the local healthcare delivery transformation initiatives across Teesside.”

To find out more about Value Partnerships, visit siemens-healthineers.co.uk/value-partnerships

¹ The statement by Siemens Healthineers Consulting described herein is based on projected results that may be achieved in the customer’s unique setting subject to all recommendations being implemented. Since there is no ‘typical’ hospital and many variables exist (e.g. hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.

Lead image caption: (From left to right) Lee Charlton – Regional Sales Manager at Siemens Healthineers Great Britain and Ireland, Gail Griffiths – Diagnostic Services Lead at North Tees and Hartlepool NHS Foundation Trust, Kelly Smith – Head of Radiology at South Tees Hospitals NHS Foundation Trust, Neil Lincoln – Head of Imaging Sales at Siemens Healthineers Great Britain and Ireland, with the new SOMATOM X.Cite CT scanner from Siemens Healthineers.

This article was kindly supported by Siemens Healthineers.

How combining data, curiosity and operational expertise is improving immunisation uptake

By Iona Rees and Harry Canty-Davis

By Iona Rees, Head of Improving Immunisation Uptake, and Harry Canty-Davis, Service Development Manager, Public Health Services, NHS South, Central and West Commissioning Support Unit (CSU).

Vaccination is one of the most effective public health interventions, but uptake is decreasing. It will require dedicated uptake improvement programmes to reverse this trend. Analysis and reporting of data is crucial in identifying vaccine eligibility and take-up, areas of highest need and potential barriers. However, in our experience of working with public health and NHS teams, operational insights – particularly around primary care – are essential to interpret that data accurately so that vaccination campaigns are appropriately targeted and resources are well spent.

Vaccinations reduce serious illness and hospitalisation, benefiting both individuals and health and care providers. The World Health Organization reports that childhood vaccines prevent between 3.5 and 5 million deaths every year across the globe and COVID-19 vaccines are estimated to have saved more than a hundred thousand lives in England alone. However, vaccination uptake was already in decline before the COVID-19 pandemic, and in the three years from 2020 to 2023, 67 million children globally were reported to have missed out on one or more vaccinations. NHS data for the UK showed that coverage for all 14 standard childhood vaccinations decreased in 2023/24, with uptake lower among children living in the areas of greatest deprivation.

To realise the benefits of better health and reduced burden on NHS services through improved immunisation uptake, it is necessary to understand what barriers exist and why, before deciding how best to direct staff and financial resources.

Key principles for vaccination programmes

Through NHS South, Central and West CSU’s work in delivering the National Immunisation Management Service, Child Health Information Services (CHIS) and wider operational and analytical support for public health, we’ve identified three core principles that can be applied across any geography to increase vaccination uptake while making best use of limited resources:

1. Making data meaningful

Regional screening and immunisation teams often tell us they are “drowning in data”. The challenge lies in making that data useful – getting, cleansing and interpreting the right data to enable robust, informed decisions. This requires regional teams, commissioners, GP practices and CHIS providers to collaboratively extract and process live data from operational systems to give a timely, accurate picture of vaccination status, rather than relying on information that may be several weeks out of date.

But we also need to ensure we are making recommendations and decisions on data that is accurate and complete. Building in mechanisms to fill gaps in data or improve how information is coded, such as insight reporting, can significantly improve an organisation’s ability to target the right cohorts in the right way. To improve quality of primary care ethnicity data in London, for example, we used a text message campaign to enable registered patients to select their ethnicity which was automatically coded into the practice record.

2. Understanding the issues

Being curious about what the data appears to show, and applying operational insights to inform interpretation, can make a significant difference to the direction – and ultimate success – of a vaccination programme. For example, when the East of England region was experiencing poor COVID-19 vaccine uptake among white working-class young males, it was easy to link this to typically low engagement with health services.

A contact centre campaign to call those who hadn’t responded to invitations revealed that the real issues were the high number of people on zero-hour contracts, who couldn’t afford to take time off work for appointments, and lack of access to transport to get to vaccination centres. By deploying vaccination buses to places of high employment, such as large warehouses and farms, take-up improved, benefiting individuals, health services and large regional employers who were able to avoid operational disruption.

Similarly, when COVID-19 uptake levels within the Chinese population in the North West were reported to be low, initial assumptions were that this was culturally motivated. By viewing the data through a primary care operations lens, however, we were able to discern that the issue was only among 20- to 30-year-olds, who had registered with practices near to universities, but had since moved areas or countries. It was a simple record-keeping issue rather than a more complex cultural issue, avoiding the need for a costly community engagement campaign.

3. Enabling multidisciplinary discussion

Real-time data and dashboards are useful tools but bringing together people to discuss and interrogate what the data means is incredibly valuable. Allowing time to talk though the ‘why’ helps to ensure that when organisations take action, it is productive and cost-effective. Useful questions to cover include: what are the key issues coming through? What are the continuing trends? Where is the evidence for this? What methodology is being used and is it sound? What could this mean operationally?

In the North West, the NHS England regional team uses monthly reports on the measles, mumps and rubella (MMR) vaccination campaign to bring together public health, screening and immunisation colleagues to share and work through the analysis, making time for important dialogue and collaboration on potential issues and interventions. This approach has proved so positive that it has now been commissioned for the entire 0-5s childhood immunisation programme across Greater Manchester.

Using limited resources effectively

Vaccine promotion must be targeted in the most effective way possible to benefit our patients and communities. This is as much about the activity organisations stop doing as it is the plans they pursue. In applying the above principles, we are seeing organisations develop cost and resource-efficient strategies based on a sound understanding of both the data and how it applies operationally.

Using this approach, Blackburn with Darwen ICS discovered that clinic locations and language were the main barriers to flu vaccine uptake among 2- to 3-year-olds in deprived and multi-ethnic areas. Adopting a collaborative approach with regional, ICB and GP practice colleagues, including arranging weekend clinics and sending out information in multiple languages, has helped to increase flu vaccine uptake by 10 per cent in 12 practices.

Bringing curiosity and operational expertise to data analysis has also avoided additional investment in a resource-intensive ‘call and recall’ campaign to improve MMR vaccination rates in young adults and teenagers. Although the data initially suggested the campaign was working, further analysis showed this was due to vaccination records being retrospectively updated within GP practices rather than vaccine uptake increasing.

The Darzi investigation urges the NHS to focus on furthering the shift from ‘treatment to prevention’. Ensuring our core public health interventions are optimised is a solid first step, and these principles apply not just to vaccines but also to screening and health checks programmes. More than 12 months on from the launch of the first NHS vaccination strategy, there is still much learning and best practice to emerge. But in our drive to progress, we must take time to challenge assumptions and fully understand what the data is telling us so that interventions are resource-efficient and deliver results.

Bridging the Gap: Connecting people with the stairlift grants they need

By Integrated Care Journal

Thousands may be missing out on stairlift grants worth up to £36,000. A new guide explains the eligibility criteria for accessing a grant, and how to apply.

Installing a stairlift into a property can provide residents with improved mobility, allowing people to continue to enjoy their independence as their mobility decreases.

The price to purchase and fit this equipment can put some people off investing in these mobility solutions though. According to a Which? survey of stairlift owners, the average sum that a respondent paid for a new stairlift as of December 2022 was £3,867.

Curved stairlifts provider Access BDD has created a guide, advising how to bring down the cost of these home modifications, by explaining who is eligible for any of these stairlift grants.

Disabled Facilities Grants

A Disabled Facilities Grant (DFG) is a source of financial aid that is available to disabled people across England, Wales and Northern Ireland when they need to make home adaptations so that a property can become more accessible.

Current uptake

The House of Commons Library’s Disabled Facilities Grants (DFGs) For Home Adaptations document has shed some light into how many people have been helped by this form of financial aid.

Although it has been voluntary since 2010 for local authorities to submit annual returns to the Department for Levelling Up, Housing and Communities about their DFG activity, a parliamentary question posed to the Minister, Luke Hall, in February 2020 found that the estimated number of DFGs delivered increased from 40,645 in 2014/15 to 53,500 in 2018/19.

What financial aid is there?

Here’s how much applicants can apply for when it comes to receiving a DFG:

In England, a grant of up to £30,000
In Wales, a grant of up to £36,000
In Northern Ireland, a grant of up to £25,000

Applicants may receive more than these amounts from some councils, though how much you get will usually be determined by your household income and having household savings that are above £6,000.

Take note too of the following caveats when it comes to applying for a DFG:

Disabled children under the age of 18 are eligible for a DFG without their parents’ income being factored into the decision.
A landlord will not have their income or savings considered if they apply for a DFG to make adaptations to a property they own. If the current tenant moves out within five years of this financial aid being received though, a council may request that another disabled person moves into the property.

Who is elible?

Anyone looking to join the thousands of people who have successfully applied for a DFG will be eligible for this financial aid if someone in their household has a disability.

This individual must also intend to live in the property throughout the grant period, which is usually set at five years but may be adjusted for circumstances such as someone being terminally ill.

The council which provides the DFG must be satisfied that any work carried out is necessary and appropriate for the needs of the disabled individual too, as well as being able to be done on the property depending on its age and condition.

Once a DFG has been approved, all work should be completed within a year. However, do not start this work before the council states the application is approved – a grant can be turned down by the council in this type of scenario.

How to apply

Applicants can apply for a DFG through their local council by clicking here. A decision must be provided by councils within six months of the application being submitted.

Scotland: Scheme of Assistance

Scotland is not included in the section on DFGs. This is because local authorities across this country are responsible for providing its citizens with stairlift grants through what is referred to as the Scheme of Assistance.

According to the Scottish Government’s Housing Statistics 2022 and 2023 publication, a total of 6,353 Scheme of Assistance grants were paid to householders during the 2022/23 period. This is up by four per cent when compared to how many of these grants were delivered in 2021/22.

Financial help in the form of grants or loans can be provided through the Scheme of Assistance, so that private housing can be adapted because one of its occupants is disabled.

Grants must be at a minimum level of 80 per cent of the eligible cost, though recipients might get 100 per cent if you receive one of these benefits:

Income-based Jobseeker’s Allowance
Income-related Employment and Support Allowance
Income Support
The guarantee credit part of Pension Credit
Universal Credit

It is to the discretion of a local authority to pay a grant that is more than 80 per cent of the eligible cost to a person who is not legally entitled to 100 per cent though. Circumstances which lead to this decision will be set out by the local authority in its Scheme of Assistance statement.

Eligibility in Scotland

Local authorities throughout Scotland must provide help in the following situations:

A property needs to be adapted so that it becomes suitable for a disabled person to occupy it. When these home adaptations will assist an individual to gain access to standard amenities, this financial aid must come in the form of a grant.
To reinstate a property that has been adapted previously.
When an owner of a property has been served a work order or statutory order.

It is also within the law that any help provided through the Scheme of Assistance must not discriminate against an individual in any of these ways:

A cognitive impairment
A physical impairment
Gender reassignment
Pregnancy or maternity
Their age
Their race
Their religion or belief
Their sex
Their sexual orientation

Anyone can apply for financial help through the Scheme of Assistance by filling in an application form. These will be available for download from local authority websites or in physical format at local housing officers, with local Citizens Advice Bureau advisers available to answer any questions while applying through this link.

RABI Independent Living Grants and SSAFA Help With Mobility

Specific stairlift grants may also be available to applicants depending on the type of industry they have worked in.

The Royal Agricultural Benevolent Institution (RABI) Independent Living Grants for farming families and the Soldiers’, Sailors’, and Airmen’s Families Association (SSAFA) Help With Mobility for those who have served in the Armed Forces are just two examples to take note of.

RABI states on its website that it awards an estimated £3 million of direct financial support annually, while SSAFA’s Annual Report and Accounts for 2023 detailed that it provided support to over 53,000 individuals through its services in 2023 alone.

Both RABI and SSAFA can assist individuals across the UK with adapting their properties to make a home more accessible. This is how you can be eligible for a stairlift grant through either of these charities:

RABI Independent Living Grants are available to support low-income farming families in the UK, as well as possibly those in the farming industry when there is a financial crisis.
SSAFA Help With Mobility services are available to any individual who has received a minimum of one day’s pay from the British Army, Royal Air Force, Royal Navy or Royal Marines, which includes the Reserves. Immediate family of a person who has served for these Armed Forces are also eligible to receive these services.

How to apply

To find out more about the financial assistance available through RABI Independent Living Grants, contact the charity’s support team on 0800 188 4444 to start an application.

To begin applying for SSAFA Help With Mobility, get in touch with one of the charity’s advisors via their Forcesline service.

Whether it is through a government source or a charity, there is plenty of help available when looking to achieve enhanced mobility around a property.

News, Population Health February 12, 2025

Managing the rising tide of polypharmacy

By Sima Jassal and Meera Parkash

Sima Jassal, Clinical Director at EMIS Health, and Meera Parkash, Senior Clinical Facilitator at Optum, outline the key findings from a new Optum white paper looking at how integrated care systems can strengthen their approach to managing polypharmacy and addressing cases of harmful overprescribing.

The increasing costs, complexities and clinical safety risks associated with polypharmacy make it an important issue for the NHS to address in 2025.

Around 40 per cent of people over 65 are on five or more medications today. Of these, between 10 per cent and 30 per cent experience adverse drug reactions, and nearly half are non-adherent. It is thought that the cost of adverse drug reactions alone could exceed £2.2 billion per year, while £300 million is wasted annually on unused medicines.¹ Thousands of preventable hospital admissions also happen every year due to complications related to medicines.

These numbers are likely to rise further as our population ages over the next few decades – so how do we start to manage this rising tide of polypharmacy and prevent more cases of harmful overprescribing in the years ahead?

Five key challenges

Optum recently facilitated a workshop at the HSJ’s ICS Medicines Forum, bringing together healthcare professionals from across England to explore the challenges and potential solutions.

What became clear is that polypharmacy is a complex, multi-faceted issue – and that there are no quick fixes. However, our discussions did arrive at five strategic challenges that need to be addressed.

These are discussed fully in our new white paper Connecting the dots: Action on polypharmacy and overprescribing – this blog provides a brief overview of each challenge.

1. The technology challenge – delivering a more connected picture for practitioners

First, we heard that one of the biggest challenges that practitioners face is accessing comprehensive, up-to-date patient information. When there is poor join-up between different healthcare record systems, it can be difficult for pharmacists and other primary care and community-based teams to get a full picture of a patient’s medication history, particularly when patients are treated across multiple settings.

Delegates therefore called for a new generation of digital solutions that enable better integration of patient information across different care settings. This would give pharmacists a more joined up and connected picture of the patient’s clinical history, making it easier to assess whether changes to a patient’s medication are necessary. Mobile technologies for community-based teams were also felt to be essential for putting this information into the hands of those working remotely.

2. The data challenge – setting the parameters for success across the system

Linked to this, many respondents also highlighted difficulties getting hold of reliable and meaningful data to shape decision-making. This was sometimes due to incomplete or inaccurate reporting, or technical challenges involved in navigating IT systems to drop down the right data. In some cases, practitioners also resorted to collecting their own data manually via spreadsheets – a ‘make-do-and-mend’ approach because they couldn’t access the right tools to help them.

At the other end of the spectrum, there was also concern about data overload, with too many competing dashboards and datasets. This led to an important discussion about how we develop a meaningful and consistent way of describing what success looks like and how we measure it. As well as improving data systems and tools, the conclusion therefore was that we need more consistent ways of measuring impact, specifically by agreeing common metrics to assess whether interventions are delivering against a given strategy.

3. The people challenge – putting patients at the heart of the process

Deprescribing is a deeply human process involving sensitive, nuanced judgement calls to balance the risks and benefits of changing a person’s medication. Practitioners need to understand the reasons behind a patient’s medication use, their health goals, and their preferences so that they can arrive at a solution that’s best for each individual.

In our discussions, we heard some inspiring examples of good practice – one that sticks out was the role of outreach professionals going into people’s homes to address medication issues in a way that reflected not just clinical considerations but the wider social and environmental factors shaping their health. However, it’s also clear that cultivating these deeper, human interactions to achieve personalised care becomes increasingly difficult when resources are strained.

Respondents described breakdowns in communication between healthcare professionals, particularly at point of transfer, resulting in conflicting advice or missed opportunity to deprescribe. They emphasised too that the process of deprescribing itself can also take time and energy to fulfil – and so, just as there is the New Medicines service to support patients on new medications, some questioned whether a Deprescribing Medicines service may be needed too.

4. The pathways challenge – ensuring continuity of care

A related challenge was the need for better continuity of care, particularly during transitions such as hospital discharge or in cases where patients straddle multiple care pathways. Delegates discussed the importance of having multidisciplinary teams (MDTs) and case management models to ensure better coordination.

Regular structured medication reviews (SMRs) were deemed critical for ensuring that medication is optimised as patients move through the system, while stronger communication between healthcare professionals and close monitoring during transitions were needed to help patients get the joined-up care they need.

To achieve this, delegates felt that funding and contractual models needed to be better aligned with the goal of reducing overprescribing and improving medication safety, so that organisations are incentivised to support patients throughout their care journey.

5. The training challenge – enhancing deprescribing skills

Finally, some professionals felt underprepared to manage polypharmacy and overprescribing challenges effectively. As one delegate put it during the conference: “Pharmacists are taught how to prescribe, but not how to deprescribe.”

Respondents highlighted the need for more robust training that focused not just on the clinical aspects of deprescribing, but on strengthening the interpersonal skills necessary to support shared decision-making with patients. Practitioners, in short, needed the right knowledge and capability to determine when deprescribing is appropriate, understand its impact, and identify and engage patients using population health management principles.

How Optum can help

At Optum, we understand that technology alone won’t solve all the challenges facing pharmacy and medicines management teams today. However, we believe that digital solutions can play a critical role in helping manage workload pressures and overcome some of the barriers preventing action on overprescribing.

Our Population360® product is designed to integrate with GP clinical records, helping pharmacy teams to rapidly stratify the patient population according to risk and identify patients who may benefit from proactive interventions. By streamlining these processes, Population360® allows pharmacy professionals to focus on helping patients get the most appropriate and effective medicines for their needs.

To find out more about how Population360^® can support your organisation, contact us at askoptum@optum.com

You can also download our full white paper, Connecting the dots: action on polypharmacy and overprescribing

This article was prepared by Sima Jassal and Meera Parkash in a personal capacity. The views, thoughts and opinions expressed by the author of this piece belong to the author and do not purport to represent the views, thoughts and opinions of Optum.

1. Source: Evaluation_of_NHS_Medicines_Waste, ©YHEC/School of Pharmacy, University of London

All news

Patients increasingly want access to personalised medicine, research finds

By Integrated Care Journal

Nearly two-thirds of UK adults believe that access to both standard and personalised medicine is important, as more than a third of UK adults say standard GP-prescribed medicines often fail to meet their health needs.

New research reveals over a third (36 per cent) of UK adults report that standard GP-prescribed medicines often fail to meet their health needs, leaving both patients and their healthcare providers searching for better solutions. The findings, released by Roseway Labs, a private compounding pharmacy specialising in personalised medicines, underscore the opportunity for personalised medicine to fill critical gaps in care.

Healthcare professionals on the front line see daily the challenges of overwhelmed GP services and mounting patient dissatisfaction with standardised treatment options; for patients, more than a quarter (28 per cent) feel resigned that 2025 won’t bring solutions for their health conditions.

The research underscores the potential of personalised medicine to tackle these pressing issues and highlights the growing demand for this choice. 73 per cent of people expressed openness to using a pharmacy that personalises medicines and supplements to better address their health concerns. While compounded medicine is accessible through private care, the findings indicate a growing number of NHS patients want access to greater choice over the medicines they use.

Additionally, 58 per cent believe having the option between standard and personalised medicines is important, rising to 80 per cent among Gen Z and 76 per cent of millennials. The demand for personalised care among younger generations is likely to grow as they age and encounter age-related conditions, highlighting the need for a step change now to ensure future healthcare options meet their evolving expectations.

The government’s cash incentive scheme highlights the urgent need for innovative solutions to alleviate growing GP and hospital waiting times. Compounding pharmacies like Roseway Labs can help ease this pressure by providing personalised treatments that address individual needs and reduce repeat GP visits caused by ineffective standard prescriptions. The average 10-minute face-to-face GP consultation currently costs £56, so it is hoped that providing more effective treatments first time will reduce the need for repeat GP visits, saving costs and alleviating pressure on general practice and wider primary care.

For healthcare professionals unfamiliar with compounding or personalised medicine, safety is paramount. All processes comply with the General Pharmaceutical Council (GPhC) guidelines and the Human Medicines Regulations 2012, ensuring all compounds are made exclusively from valid UK prescriptions as a fully regulated pharmacy.

Skin conditions and allergies are good examples of where compounded medicines can help patients. Simply changing the medication’s form – from pill to liquid – or removing certain ingredients in the pill that are allergenic, can be the difference between a patient finding relief from an allergy or even being able to take their medication as prescribed.

Miriam Martinez Callejas, Superintendent Pharmacist and Founder of Roseway Labs, commented: “With an ageing population and growing demand for tailored care among Gen Z and millennials, personalised medicine provides an essential option for those whose needs aren’t met by standard treatments. Often likened to the Savile Row of medicine, compounded treatments offer custom dosages, formulations, and combination of ingredients, much like a tailored suit fits where off-the-rack clothing cannot. Our goal is to collaborate with GPs and healthcare professionals to make personalised medicine a key part of future healthcare innovations in the UK.”

Compounding pharmacies play a crucial role in addressing medication shortages by formulating alternative solutions when commercially available drugs are unavailable. They can create customised doses, replicate discontinued medications, or offer equivalent treatments, ensuring patients have access to the care they need without interruption.

Elizabeth Philp, CEO and Founder of Roseway Labs, commented: “A one-size-fits-all approach often fails to address the complexities of individual health needs, leaving many patients feeling despondent about their future. While regular prescriptions work well for some, others face challenges such as inadequate symptom relief, adverse effects, or difficulty adhering to treatment plans. Personalised medicine can complement NHS treatments and care, offering tailored solutions that empower patients and help them lead healthier lives.”

Half of UK adults struggling to access trusted health information, report finds

By Integrated Care Journal

Research by PIF and Ipsos reveals inequalities in access to health information and the impact of misinformation, calling for greater signposting towards credible health information.

The Patient Information Forum (PIF) and Ipsos have today published new research into health information access across the UK. The Knowledge is Power report offers new insights on information access, trusted sources, communication with healthcare professionals and the impact of misinformation on patient awareness of health.

The report is based on a cross-sectional, nationally representative survey of 2,003 adults in the UK from May to June 2024 using the Ipsos KnowledgePanel.

It reveals the demand for the NHS to signpost trusted information and wide support for the verification of health information.

Key findings include:

Half of adults in the UK are struggling to access trusted health information, with 55 per cent feeling they cannot trust health information they find online
1 in 10 adults in the UK have been affected by misinformation, rising to 1 in 5 for ethnic minorities
8 in 10 adults in the UK agree access to trusted health information would help them manage their health
1 in 6 say adults in the UK say their views are not taken seriously by their health professional. This rises to 1 in 4 for ethnic minorities
Only 1 in 10 adults with long term conditions in the UK are signposted to patient organisations, yet these are highly trusted by their users
2 in 3 adults in the UK state independent verification of health information would increase trust
There is already recognition of the PIF TICK – the UK’s only independently-assessed certification for both print and digital health information – among the UK population

Melissa Moodley, UK Head of Healthcare Research, Ipsos, said: “This timely research reveals a critical gap in access to trustworthy health information, with half of UK adults struggling to find reliable sources. This challenge is particularly acute for those with long-term conditions and minority groups.

“The impact is clear: 8 in 10 adults believe better access to credible health information would improve their health management. These findings underscore the urgent need to improve the provision of verified, accessible health information. Doing so is not just beneficial, but essential for enhancing overall health outcomes across the UK.”

Knowledge is Power makes five recommendations on the right to health information, aligned with the three shifts proposed in the NHS 10-year plan. In summary they are:

A right to health information – Health information is provided as a core part of patient care
Tackle misinformation – Through robust content standards and effective signposting of credible health information via health professionals and the NHS Apps
Tackle inequality – Health information must be accessible and appropriate for all
Lived experience as a metric – Embedding patient experience as a measure of NHS performance using the NHS Apps and single patient record
Dedicated leadership – A mandate for the effective delivery of health information with a named lead in all NHS organisations

Sue Farrington, chair of PIF, said: “Credible information supports people’s health decisions, from childhood vaccinations to joint replacement surgery. For people with long term conditions, it is a core element of care.

“Our 2024 survey gives a clear view of how people want to access health information and the challenges they face. Resolving these issues will ensure everyone gets the information they need, supporting the prevention agenda and contributing to the delivery of positive health outcomes for all.”

View the full Knowledge is Power report here.

Public Policy Projects’ Patient Safety Programme

In partnership with the UK-based charity, Patient Safety Learning, Public Policy Projects (PPP) is developing a new programme, Harnessing technology to enable a system wide approach to patient safety, to position patient safety as a core purpose of integrated care systems. The programme is taking a collaborative approach, bringing together health system leaders, industry experts and patient/end-user representatives to discuss patient safety through the lens of technology, digital innovation and data-driven transformation.

To find out more about the programme and to register for the next roundtable, Safety design and user engagement: the power of digitally enabled people, please visit the website here or contact Samantha Semmeling on samantha.semmeling@publicpolicyprojects.com.

RPS calls for government action to tackle medicines shortages

By Integrated Care Journal

Endemic medicines shortages need urgent action, says RPS, as supply chain woes and manufacturing consolidation drive worsening outcomes for patients and extreme pressures on pharmacy sector.

A new report from the Royal Pharmaceutical Society (RPS) has called on the Government to create a national strategy to manage medicine shortages and to change legislation to allow community pharmacists to amend prescriptions when medicines are in short supply.

Backed by charities and patient groups, the Medicines Shortages: solutions for empty shelves report explains how medicine supply chains are global and complex, with shortages caused by manufacturing problems and disrupted, less resilient supply chains. The report finds that supply chain issues are in part due to the consolidation of manufacturing outlets and cost-driven pressures.

The report calls on the UK Government to create a national strategy to both prevent and manage medicine shortages that would streamline efforts across the NHS, reduce inefficiencies caused by duplication of effort and ensure information and guidance for professionals and patients is available as soon as shortages occur.

The findings also highlight that supply chain vulnerabilities have combined with unplanned spikes in demand, such as shifts in prescribing practice or increased diagnosis of some conditions, to create a perfect storm of unstable supply.

This has made it harder for patients to access treatment, causing frustration, anxiety and in some cases, harm to patient health. The report cites high profile examples of patients being unable to access hormone replacement therapy, antibiotics, diabetes drugs, and medicines used to treat epilepsy and attention deficit hyperactivity disorder, among many others.

“Taking a new approach to medicine shortages is essential. A properly resourced UK-wide medicines shortages strategy that helps prevent and manage shortages would greatly improve the resilience of the supply chain. This would relieve stress and anxiety for patients and free up time for pharmacists to focus on patient care rather than constantly chasing down supplies.

James Davies, RPS Director for England and co-author of the report

The report also urges the Government to legislate to allow community pharmacists to make minor amends to prescriptions when medicines are in short supply. This simple change would enable a different quantity, strength or form of the medicine to be provided. For example, changing tablets to a liquid version of a medicine, or substituting a pack of 20 mg tablets with 2 x 10 mg packs when necessary.

At present, patients have to return to their GP to get their prescription amended, delaying access to medication, increasing bureaucracy and intensifying pressure on an already overburdened system. This move already has support from medical organisations, patient groups and other pharmacy bodies.

Frontline pharmacy teams are also under added pressure due to medicines shortages; A 2024 Community Pharmacy England survey found that almost three-quarters of community pharmacy staff report spending one-two hours or more daily trying to obtain medicine stock or source alternatives. One acute hospital trust also reported that the number of staff required to manage medicines shortages has increased from one person to five in the last five years – a situation “likely to be reflected in trusts across the country”.

Ohter recommendations in the report include:

Improve reporting by manufacturers: prompt alert of the risk of shortages would transform the impact on patients, and those consistently failing to report should be fined.
Build supply chain resilience: strengthen NHS procurement contracts to ensure manufacturers can meet supply demands and respond to shortages quickly.
Improve data connectivity: Use better demand forecasting and share information across the supply chain to prevent stock issues before they happen.
Enhance systems for life critical medicines: improve collaboration across the health service to coordinate access to specific medicines.

James Davies, RPS Director for England and co-author of the report, added: “Community pharmacists must be allowed to make minor changes to prescriptions during shortages. The current outdated system inconveniences patients, wastes time and causes frustration. The Secretary of State for Health should give pharmacists the authority to act in the best interests of their patients, rather than remain subject to ‘empty shelf syndrome’.”

Bruce Warner, Chair of the advisory group for the report, said: “This report provides a comprehensive assessment of what is causing medicines shortages, their impact on patients, pharmacists and healthcare professionals, and what more can be done to mitigate and manage shortages.”

Sharon Brennan, Director of Policy and External Affairs at National Voices, a coalition of 200 health and social care charities in England, said: “We urge the Department of Health and Social Care to recognise the serious and worsening impact medication shortages are having on patients, and to commit the same level of urgency to improving the situation as it has to other NHS access-to-care issues such as diagnosis and waiting lists.”

Data-driven, proactive prevention. Are we finally ready for population health management?

By Simon Swift

As we navigate the complexity of modern healthcare, it is clear that preventative, data-led approaches can help solve some of the NHS’ major challenges. But ‘are we finally ready for population health management?’ asks Health Navigator CEO, Simon Swift.

I am sure every generation of health and care leaders think they face unprecedented challenges. I don’t think it is an error to say the current NHS leadership feels this, and with some justification. Urgent and emergency care services are under immense pressure, planned care waiting lists remain very close to the 2023 high of 7.7 million, while persistent health inequalities threaten the foundations of the UK’s universal healthcare model.

We must ask ourselves a crucial question: what, if any, proven approaches are there to deliver better outcomes for patients while ensuring the long-term sustainability of our health systems?

I firmly believe that the answer lies in harnessing the power of data. This data-driven approach takes different shapes at different points across the system. For example, optimising system design and service scale and location at the macro level, while at the micro level, there are cumulative marginal gains to be made through ‘command centre’ type solutions to operational management, optimising efficiency and safety for people in A&E or waiting for planned care. These are impactful uses, but not sufficient.

Another use of data is to enable a shift from reactive to proactive care models. Logically it is attractive; we stop people becoming acutely unwell, which is good for them. If they don’t become acutely unwell, they don’t need urgent and emergency care, reducing demand at the front door. This (in the UK system) means we can allocate resources to focus on other things, and there is plenty to do. If we are going to be responsible custodians of health services, this transition is not just desirable; it’s imperative.

The case for change: A closer look at the crisis

Waiting times for emergency care have reached historic highs, which is a miserable experience for patients, an awful work environment for staff facing intolerable moral hazard and probably dangerous.¹ Bed occupancy rates in many hospitals mean managers are in constant firefighting mode, with waits backing up into A&E and elective cancellations routine, without a bed to admit a cold patient into.

Though this pressure on hospitals is universal, emergency department attendance rates are more than twice as high for those living in the most deprived areas compared to the least deprived, demonstrating the deep-rooted inequalities in our health system and society. The inverse care law is alive and well.

The COVID-19 pandemic has exacerbated these issues, creating a backlog of need that will take years to address. Moreover, an ageing population and the rising prevalence of chronic conditions are adding to the complexity of healthcare delivery. These challenges are not just statistics; they represent real people experiencing pain, anxiety, and diminished quality of life for many.

A data-driven approach to prevention

I believe we must use preventative, data-led, approaches to address these challenges, finally taking a step away from sole focus on the traditional reactive model. The evidence base is growing that the logically attractive proactive, preventative approach, leveraging the data at our disposal, actually works.

By harnessing this data (how this works is a sexy thing to some – advanced analytics and machine learning algorithms), we can identify patients at high-risk of unplanned care needs months in advance. This foresight allows us to intervene early, providing personalised support that empowers patients: precision population health management (PHM). The potential of this approach is enormous, offering a way to improve people’s health and so reduce pressure on acute services in the short-term and planned care in the longer term.

At HN, we’ve seen first-hand the transformative impact of this precision PHM approach. Our Proactive solution has demonstrated significant reductions in emergency admissions and A&E attendances.

Empowering patients and supporting healthcare systems

With advice from the Nuffield Trust and with the support of several NHS trusts, HN conducted a randomised controlled trial.² It meticulously tracked up to 2,000 patient outcomes across multiple trial sites. We demonstrated a 36 per cent reduction in A&E attendances for patients supported by health coaching, which is in line with other studies. This isn’t just about numbers; it’s about people avoiding traumatic emergency visits and receiving care in more appropriate, less stressful settings.

The benefits of proactive, data-driven care extend far beyond reducing hospital admissions. We saw improvements in mortality rates, Patient Reported Outcome Measures (PROM’s), patient activation, and quality of life.

These outcomes are transformative on multiple levels. For patients, it means taking control of their health, understanding their conditions better, and enjoying an improved quality of life. For healthcare systems, it translates into reduced pressure on acute services, better resource allocation, and improved overall efficiency.

This approach helps to address health inequalities. By identifying at-risk individuals early, regardless of their socioeconomic background, we can provide targeted interventions that prevent health issues from escalating. This is particularly crucial in areas of high deprivation, where health outcomes have traditionally lagged. For those close to this type of risk modelling it will be no surprise that deprivation (income and health) is a significant risk factor.

The role of technology

As we navigate the complexity of modern healthcare, it’s clear that innovation and technology will play a crucial role. However, it’s essential to understand that technology is not a panacea. The true power lies in how we apply these tools to reimagine healthcare delivery. Those who have worked in this arena for any length of time know that implementing a technology rarely delivers benefit alone, and is often problematic and unhelpful. Carefully designing the change in process, behaviour, decision making etc. that the technology enables is the key to delivering value.

While the potential of data-driven, proactive healthcare is material, we must acknowledge the challenges in implementing the approaches. Data privacy and security are serious concerns that need to be addressed rigorously. We must ensure that as we leverage patient data for better care, we do so in a way that respects individual privacy and complies with all relevant regulations. However, the current red tape-bound and bluntly obstructive approach to information governance in the NHS needs improving if we are to derive value at a meaningful scale and pace.

Looking to the future

The opportunities are tantalising. By embracing data-driven insights and personalised interventions, we can create a more proactive, efficient, and equitable healthcare system that actively helps people live healthier for longer. This approach not only addresses immediate pressures but also lays the foundation for a more sustainable future.

The change from sickness to health care will require collaboration across all sectors of health and care – from policymakers and healthcare providers to technology companies and, most importantly, patients themselves. We need to encourage innovation, where new ideas can be tested and scaled rapidly.

At HN, we’re committed to being at the forefront of this transformation. Our work in AI-guided clinical coaching is just the beginning. We envision a future where patients receive personalised, proactive care that keeps them healthy and out of the hospital.

References

¹ Jones S, Moulton C, Swift S, et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emergency Medicine Journal 2022;39:168-173.

² Bull LM, Arendarczyk B, Reis S, et al. Impact on all-cause mortality of a case prediction and prevention intervention designed to reduce secondary care utilisation: findings from a randomised controlled trial
Emergency Medicine Journal 2024;41:51-59.