MPFT and Uttoxeter GP practice supporting patients with frailty to stay well

MPFT and Uttoxeter GP practice supporting patients with frailty to stay well

A successful partnership between Midlands Partnership NHS Foundation Trust (MPFT) and a Uttoxeter GP practice is showcasing how patients with frailty are being supported to stop their condition from deteriorating.

MPFT’s Staying Well Service offers care and support to people aged 55 and over in South Staffordshire with mild to moderate levels of frailty, who are at risk of falls, are socially isolated or taking multiple medications.

Support is particularly focussed on eating well, staying active, preventing falls, incontinence, social inclusion, memory and mental wellbeing in older age.

The service has formed a particularly strong relationship with Balance Street Practice, in Uttoxeter, where more than 90 patients have been referred in and benefited from the specialist care it provides since launching in the town in June 2021.

A Care Coordinator within the practice helps to ensure referrals are both appropriate and timely, and Staying Well Facilitators have established links with the local pharmacy and Balance Street’s Social Prescribers, who support patients experiencing social isolation to explore services available to them locally.

Once referred in to the service, a Staying Well Facilitator will visit the patient’s home for an assessment, which may then lead to an invite to attend a local Staying Well Clinic. Clinics are located across South Staffordshire and are easily accessible to the communities they serve.

The clinics act as ‘one stop shops’ in which specialist clinicians, including a medical doctor, prescribing pharmacist, occupational therapist and memory service professional are on hand to offer the patient the opportunity to discuss their medication, mobility and social issues, alongside any other health concerns.

Following their clinic appointment, the patient will receive a personalised plan and receive a follow-up visit to review progress. 

Vicci Archer, Staying Well Facilitator and Occupational Therapist said: “There are many people, some of who may have health problems, but who rarely see their GP. Evidence shows that early and co-ordinated care can help keep those people living well, staying well and ageing well in their own home for longer.

“The Staying Well Service enjoys a particularly strong relationship with Balance Street Practice that we’re working hard to replicate across South Staffordshire. The key to this success is the partnership established between our local Care Coordinator and practice staff, which has helped to ensure patients with frailty are being referred in to the service and are receiving specialist support.”

Kerry Fisher, Practice Care Co-ordinator, has been working very closely on the Staying Well service and has stated that it has been a “great asset” to the practice: “The service is very efficient for both patients and the GPs as it ensures that both parties are constantly up-to-date and well informed. Patients are also seen to in a timely manner and are able to speak to facilitators in one place instead of going back and forth between different posts, which they have all welcomed and greatly appreciated.”

More information about the Staying Well Service can be found at

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