The Frailty Specialist Review Service (FSRS) supports the NHS Long Term Plan to enable the ageing population living with frailty to live well and independently for as long as possible, focusing on proactive assessment and care in the community.

The FSRS delivers remote triaging and assessing patients with mild, moderate or severe frailty. Patients with moderate and severe frailty receive a Comprehensive Geriatric Assessment (CGA), the gold standard assessment tool. The CGA formalises an individual care plan identifying problems requiring early support to prevent escalation to hospital admissions, such as polypharmacy, falls, carer distress, social isolation or new incontinence.

The service is delivered with Birmingham Community Healthcare NHS Foundation Trust (BCHC) and a multi-disciplinary team (MDT) of clinicians who provide their expertise and specialist knowledge. A GP chairs a monthly MDT where complex and challenging cases are discussed with representatives from example members:

  • BCHC
  • Birmingham and Social Mental Health Trust
  • Gateway Family Service
  • AGE UK
  • Alzheimer Society
  • Birmingham City Council – Community Network Support Officers

An advice and guidance service is also available for non-clinicians, i.e. Social Prescribers and Link Workers, to support their work with patients outside our Primary Care Networks (PCNs).

The patients who would benefit from this service:

  • Who is at risk of disability or hospital admission
  • Who has had a recent admission to the hospital and would benefit from ongoing support in the community
  • With multiple hospital admissions in a short space of time
  • In need of preventive care
  • With complex multi comorbidities

How do you get this service?

The service is available to all our GP practices, member practices, social prescribers, pharmacists, and community and voluntary organisations working with patients within our PCNs.

Want to know more?

Call: 0121 483 2128