Frail & Elderly

The CCG frailty team is continuing its work to integrate services across the borough for all frail and elderly people.

  • Add patients at high risk of unplanned admission to the practice frailty register and refer to the Complex Care Nurse to help manage the patient.
  • The Neighbourhood MDTs have now started (see below and see Downloads for the list of practices and timetable). GPs and Practice Nurses are encouraged to visit and discuss patients. Please email before the MDT meetings to confirm the venue, as these sometimes change.
    • NW3 Neighbourhood – every 3rd Wed at Hampstead Group Practice
    • South & CHE(S) – every 3rd Wed at South Camden Centre for Health
    • NW5 Neighbourhood – every 4th Wed at Parliament Hill Surgery
    • CHE (W) – every 4th Wed at West Hampstead Medical Centre
  • All referrals to the MDT should be sent before 14:00 on the Tuesday before the meeting each week to
  • Care navigators are available in practices, supporting vulnerable older people to get the right care.
  • There are four education modules that can be completed – GP Education Frail & Elderly. Upon completion, a certificate will be issued.

For more information about prevention of falls, please refer to the Camden Integrated Network Checklist (see Downloads).


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Age UK Nail Care Service

Nail-cutting service for senior citizens

Audiology Assessment

Adult audiology services at local hospitals

Benefits and Tax

Services for advice and support with benefits and taxes

Bowel Screening

Bowel-cancer screening service for men and women aged 60–69

Camden Care Navigation and Social Prescribing

Helps patients with a range of complex social issues

Camden Home Oxygen Service (HOS-AR)

Oxygen for home use

Care Navigation Service

Ensuring elderly, vulnerable patients, aged 60+, receive the right health and social care

Catheter Change Clinic for Ambulant Patients (NW3 Pilot)

A pilot catheter change clinic for ambulant patients

CICS (Camden Integrated Care Service)

Multi-disciplinary community clinics for long-term conditions

Complex Care Case Management

Delivering effective care for people with long-term conditions and those with complex health and social care needs

Coroner's Service

Service of a judge responsible for investigating a death in Camden

Dementia Services

Personalised information and signposting to people with dementia, their families and carers

District Nursing Clinician of the Day (CNWL Senior Nurse)

Urgent service for patients already under the care of the district nursing service

Elderly Medicine

Elderly medicine services at local hospitals

Falls Diagnostic Clinics

Hospital clinics for patients who have had a fall

Falls Prevention Services

Assessments, support and rehabilitation to prevent further falls

Frailty MDT/Hub

Taking a multidisciplinary approach to assessing complex/frail patients

Henna Asian Women's Group

Befriending service for Asian women and men over 65 to reduce isolation and increase access to mainstream services

Inpatient Rehabilitation Unit

Support for patients whose physical abilities have been reduced through illness (e.g. stroke, fall, MSK condition).

Integrated Primary Care Teams (includes District Nurses)

High-quality nursing and rehabilitation care for complex housebound patients

Lee Silverman Voice Treatment – LSVT

Voice therapy for those suffering from Parkinson's disease

LGBTQI Service for Older People

Services for those over 50 who identify as LGBTQI

Memory – Camden Integrated Care Service (CICS)

Specialist service for early assessment and intervention for memory problems (including dementia)

Occupational Therapy

Provides physically disabled/frail Camden residents with adjustments to their everyday lives

Personal Health Budgets

Amount of money to support healthcare and wellbeing needs of individual

Rapid Response Admission Avoidance

Supporting patients managed in community but at risk of admission to hospital to remain in their home

Services for Ageing and Mental Health Community Mental Health Team (SAMH CMHT)

Community-based service for older adults with mental illness and/or memory problems

Social Services

For adults in need of social-care support

Speech and Language Therapy

Community SLT for adults with complex neurological need and mental health problems

TREAT HOT Clinic at the RFH

Promote and facilitate safe discharge from A&E for complex, frail and elderly patients