From Frailty Identification to Integrated Neighbourhood Care
How Spen Health and Wellbeing PCN is using SystmOne to deliver award-winning proactive care
At a Glance
- Population served: 54,000 patients across seven GP practices
- 40% of referrals actioned on the same or next working day
- 50% of patients with independence goals improved
- 2 mental health emergency admissions avoided
- 88% of actions completed outside GP practices
- Only 12% of MDT actions required GP practice input
With growing demand, an ageing population and increasing pressure on general practice, Primary Care Networks are looking for practical ways to identify patients earlier, coordinate care across organisations and reduce avoidable demand.
“The eFI helped us identify the right patients. Using SystmOne, we were then able to bring the right professionals around those patients, coordinate actions and track outcomes.
Within six months, 40% of actions were completed the same day or next day, and only 12 of our first 100 actions needed to be returned to GP practices.”
Dr Danielle Nimmons, Academic GP and Clinical Director, Spen Health and Wellbeing Primary Care Network (PCN)
Spen Health and Wellbeing Primary Care Network (PCN) serves a population of around 54,000 people across seven GP practices. Around 13% of the population is living with frailty, with approximately 7,000 patients identified using the electronic Frailty Index (eFI). The challenge was not identifying need, but deciding where limited resources could have the greatest impact.
By combining the eFI, population health management and the shared SystmOne record, the PCN developed an award-winning Integrated Neighbourhood Team (INT) that delivers proactive, person-centred care before problems escalate into crisis. In recognition of this work, the team received the TPP Neighbourhood Teams Excellence Award.
Rather than asking practices to work harder, the programme enables them to work differently—using proactive patient identification, shared information and multidisciplinary working to ensure patients receive support from the right professional at the right time.
Identifying the Right Patients
Rather than using the eFI simply to maintain a frailty register, the PCN used it as the foundation of a targeted population health management approach.
Practices developed local frailty registers using the eFI alongside clinical judgement. SystmOne reporting was then used to identify patients with moderate to severe frailty, at least one additional long-term condition and frequent GP contact. GPs reviewed the cohort to confirm that patients would benefit from proactive multidisciplinary support.
By combining frailty, clinical complexity and healthcare utilisation, the PCN focused resources on patients at greatest risk of deterioration, enabling earlier intervention instead of waiting for patients to reach crisis point.
As Danielle Nimmons, Academic GP and Clinical Director at Spen Health and Wellbeing PCN, explains:
“People with frailty experience disjointed care, in part due to a lack of integration.”
Bringing Teams Together
Once the cohort had been identified, the PCN established an Integrated Neighbourhood Team bringing together professionals from general practice, social care, mental health, community services, social prescribing and palliative care.
Meeting weekly, the team reviews patients with complex needs, develops coordinated care plans and allocates actions to the professional best placed to deliver them. Care coordinators provide continuity throughout the process, helping patients navigate services while ensuring agreed actions are completed.
Patients also helped shape the service through the PCN’s Patient Reference Group, ensuring the model addressed housing, mental health, independence and wider wellbeing alongside clinical care.
Before and After
| Before | After |
|---|---|
| Reactive referrals | Proactive identification using the eFI |
| Separate organisations | Integrated Neighbourhood Team |
| Multiple records and communication routes | Shared SystmOne record |
| GPs coordinating most follow-up | Actions allocated to the right professional |
| Crisis-driven intervention | Earlier, preventative support |
Why SystmOne
SystmOne provides the digital foundation that makes the model possible.
The PCN uses SystmOne reporting to identify and manage the patient cohort, while a dedicated INT Clinical Tree provides a shared record of multidisciplinary discussions, risks, agreed actions, care goals and outcomes. Built using existing SystmOne functionality and enhanced through the Clinical Development Kit (CDK), it provides every professional involved with a consistent, structured view of the patient’s care.
Rather than relying on separate systems, emails or duplicated documentation, professionals work from a single longitudinal patient record. Everyone can see the same information, understand their responsibilities and update progress in real time, improving communication, accountability and continuity of care across organisations.
The structured data captured within SystmOne also supports reporting and evaluation, enabling the PCN to measure outcomes, demonstrate impact and continually refine the service.
Delivering Measurable Impact
“All thanks to you, I am now one step closer to seeing the outside world.”
Patient
The programme was intentionally launched with a small cohort of patients with the highest levels of frailty, complexity and healthcare utilisation, allowing the Integrated Neighbourhood Team to refine the model before wider rollout.
During the first six months, the team proactively supported an initial cohort of 46 patients. Forty per cent of referrals and actions were completed on the same day or the following working day, enabling patients to access support more quickly.
The model has also reduced pressure on general practice. Of the first 100 actions generated through neighbourhood team discussions, only 12 required direct GP input, with 88% completed by the most appropriate professional across partner organisations.
Half of patients with documented independence goals recorded measurable improvements, while proactive intervention helped avoid two mental health-related emergency admissions. Early indications also suggest that patients enrolled in the programme require fewer GP appointments as they receive more coordinated support from a wider range of services.
One patient, previously unable to leave home independently, received coordinated support to progress referrals for an electric wheelchair following review by the Integrated Neighbourhood Team.
A Blueprint for Other PCNs
“One of the strengths of the model is that it doesn’t rely on new technology or complex infrastructure. We built it using functionality already available within SystmOne, which meant we could focus on bringing organisations together around shared patients. The fact that the model is already being replicated elsewhere shows how practical and scalable this approach can be.”
Dr Danielle Nimmons, Academic GP and Clinical Director, Spen Health and Wellbeing Primary Care Network (PCN)
Spen Health and Wellbeing PCN demonstrates that meaningful transformation does not require new technology.
By combining the electronic Frailty Index, population health management and the shared SystmOne record, the PCN has created a practical, scalable model for integrated neighbourhood working that improves communication, strengthens collaboration and delivers more coordinated care.
Already being replicated across other PCNs within the federation, the model demonstrates how existing SystmOne functionality can help organisations identify the right patients earlier, coordinate care across organisational boundaries and reduce pressure on general practice without introducing additional technology.
By combining the electronic Frailty Index, SystmOne and integrated neighbourhood working, Spen Health and Wellbeing PCN has shown how population health management can move beyond identifying risk to delivering coordinated intervention. The model demonstrates that meaningful transformation does not always require new technology – just better use of the technology already in place.