Breakout Session Overviews


Breakout Session One – overviews

Consider:  Care and support planning: A holistic approach to improving outcomes for people living with frailty

An interactive workshop, supported by Year of Care partnerships, reflecting on some of the work being done in Carlisle to implement a population-based care and support planning approach for people living with frailty.

Robert Westgate, GP, Carlisle Healthcare

Rachel Bradley, Year of Care Trainer and Assessor, Year of Care Partnerships  


Respond: Social Prescribing, Healthy Ageing, and enabling self-care

What makes us healthy – Person and community centred approaches to prevention, self-care and support in South Tyneside and the role of social prescribing in enabling healthy ageing and self-care. Jane Hartley, Chief Executive, VONNE and NE Social Prescribing Facilitator

Tom Hall, Director of Public Health, South Tyneside Council


Respond:  More than Dementia: Older People’s Mental Health

This workshop will discuss current thinking on care closer to home and also describe lessons from mental health services in delivering services in the community.  Participants will start to share learning on what is working well and gaps within provision locally

Dr Ruth Briel, Senior Clinical Director, Tees, Esk and Wear Valley NHS Foundation Trust

Dr Karen Franks, Clinical Networks Lead Older People’s Mental Health


Respond: Frailty Friendly Living –Aging in Place

This workshop provides an opportunity to consider how we can support the concept “Aging in Place”. We will consider not only the future of frailty friendly homes but also the wider conversation, how can we create health sustaining communities?

Interactive activities will allow us to explore some of this content including:

  • What makes a health sustaining community?
  • Think intergenerational what could this mean for homes and communities?
  • What is the right balance of tenure?
  • How can we make housing better for people to live in as they age?
  • Digital solutions to complex needs? What’s possible?
  • Is moving into a care home inevitable?

Dr Nichola Stefanou, Home Group’s Head of Clinical Practice will share an overview of the direction they are taking to provide housing that enables independent living well into retirement. She will also share the innovative work that is being undertaken with Northumbria University to embed digital solutions into building and service design.

John Thompson, Home Groups Head of PropCo (delivering specialist supported property) with share case studies of current schemes that aim to promote independence, community engagement and aging in place.

Nichola Stefanou, Head of Clinical Practice, Home Group

John Thompson, Head of PropCo, Home Group


Respond: Care Homes; from the periphery into the system

At one time those living in care homes would have resided on NHS long stay geriatric wards and been cared for by specialist medical teams and wider multidisciplinary team members trained or experienced in meeting the often very complex needs of these older people.  While the move to the independent care home sector brought a long overdue social model of care, it has become apparent over time that care home staff and their organisations may need support to provide some elements of health care.   This session aims to raise awareness of the valuable contribution care homes make to an integrated care system through sharing experiences of working in both the sector and supporting NHS services.

Paul Storey, Resident Experience Specialist, Four Seasons Health Care

Emma Flewers, Nurse Specialist Older People, Gateshead Health NHS Foundation Trust

Breakout Session Two – overviews

Involve:  Engagement; what do older people really think about frailty? 

It has been documented that older people don’t like being referred to as frail and this is often repeated by care providers and commissioners. What isn’t clear however is whether the views of older people change when time is spent with them increasing their understanding of what frailty really is and what it could mean for them as an individual. With this in mind, Newcastle Gateshead Clinical Commissioning Group in partnership with Involve North East undertook specific engagement events testing whether raising the awareness of frailty could in fact improve understanding and change views.  Come along and find out what happened.

Dan Duhrin, Involvement Coordinator, Involve North East

Nora Stevens, Patient & Public Community Development Lead, NHS Newcastle Gateshead CCG

Lindsay Pearson, Patient & Public Community Development Lead, NHS Newcastle Gateshead CCG


Respond: Medicines optimisation and frailty: an integrated approach to safer care

Problematic polypharmacy is a concern in frail older people and is associated with poor quality of life and harm. Of the 237 million estimated errors in the NHS in England, 45% are in frail older people in care homes. Local examples of good medicines optimisation have shown a improvement in quality of life, reduction in risk and significant savings to the system.  In this workshop the issues around problematic polypharmacy will be discussed. Delegates will be supported to develop local solutions using learning from national programmes (e.g. Vanguards).

Dr Wasim Baqir, National Pharmacy Lead (Care Homes), NHS England


Evaluate: Outcomes and Metrics; without data we’re just another person with an opinion!

The challenge was set to develop a regional outcomes framework for frailty by producing a relevant suite of validated measures that would support the Frailty Community of Practice to identify and share best practice and areas for improvement.

A ‘long-list’ of metrics was shared for consultation and prioritisation with frailty experts both in the North East and North Cumbria and across England and a short-list of 23 metrics has now been produced, thought to be the best reflection of the broad recommendations of the frailty framework.

The aim of the first draft of the metrics report is to demonstrate current achievement levels across the 23 metrics and to obtain feedback and input in order that it continues to be an iterative process, is led locally and is based on regional priorities.

The list of metrics will be refined in line with improved data availability as this is an evolving process. Community of Practice members will also contribute to the development of the outcomes metrics by highlighting key interventions that have been introduced and are planned through the various care approaches across the NE&NC.  Your thoughts and feedback are of huge importance and will be welcomed in this session.

Dr Andrea Brown, Epidemiological Analyst, NEQOS, Measurement Programme Lead, AHSN NENC

Fiona Ottewell, NHS RightCare Delivery Partner, NHS England


Respond:  Implementing Discharge to Assess through Integrated Discharge Pathways

HRWCCG have worked collaboratively with NYCC to redesign processes to deliver integrated discharge pathways focussed on safe discharge of patients from hospital to the most appropriate setting at the earliest opportunity.

  • Three Discharge to Assess (D2A) Pathways have been developed: Pathway 1 Home, Pathway 2 Community Bed Base, Pathway 3 Complex Care Placements.

The Integrated Discharge Pathways include:

  • Trusted Assessment
  • Joint Assessment documentation to provide greater clarity and avoid duplication.
  • Increased communication between Health and Social Care

The workshop will describe the three pathways and how we have worked to achieve success and managed challenges in implementing these throughout our system

Lynn Iveson, Clinical Lead for Therapy, South Tees Hospitals NHS Foundation Trust

Abigail Barron, Assistant Director of Integrated Commissioning, NHS Hambleton, Richmondshire and Whitby CCG


Consider and Respond:  Comprehensive Geriatric Assessment:   what’s it all about? 

Comprehensive Geriatric Assessment [CGA] is one of the best evidence bases we have for providing care to older people living with frailty.  Covering all elements of an individual’s life through the specific domains of physical, psychological, environmental, functional and social approaches it is a privilege to get to know people in this way.   Undertaking CGA requires knowledge and skills beyond information retrieval however and this session will introduce the concept of CGA for use right across the system, regardless of where care is accessed.

Deborah Mayne, Consultant Geriatrician, City Hospitals Sunderland NHS Foundation Trust

Lesley Bainbridge, Clinical Lead, Care Closer to Home