Frail & Elderly

Despite the Covid-19 epidemic, the multidisciplinary frailty and complex care team is continuing its work with across the borough for all frail elderly people, and those with complex needs.

  • Add patients at high risk of unplanned admission or with complex needs to the practice frailty register and refer to the Complex Care Nurse to help manage the patient – they will triage the patient remotely initially.
  • The neighbourhood MDMs continue virtually from 9.30 to 11.30am. GPs and Practice Nurses are encouraged to discuss patients. Please email before the MDT meetings.
    • NW3 Neighbourhood – every 3rd Wednesday
    • South & CHE(S) – every 3rd Wednesday
    • NW5 Neighbourhood – every 4th Wednesday
    • CHE (W) – every 4th Wednesday
    • Borough – 1st, 2nd and 5th (if there is one) Wed 09:30–11:30 with a small number of participants at Keats Group Practice
  • All referrals to the MDM should be sent by 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, and will also help facilitate food parcel deliveries.
  • 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 Camden – Dementia Befriending Service

Regular one-to-one visits for socially isolated older people with dementia or memory problems

Age UK Nail Care Service

Nail-cutting service for senior citizens

Audiology Assessment – InHealth

Adult audiology services at InHealth

Audiology Assessment – Royal Free

Adult audiology service at Royal Free

Audiology Assessment – Scrivens

Audiology assessments

Audiology Assessment – UCLH

Adult audiology services at UCLH

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 Carers Dementia Group

A monthly group for carers of people with dementia.

Camden Catheter Clinic

A catheter change clinic for ambulant patients

Camden Home Oxygen Service (HOS-AR)

Oxygen for home use

Check-in and Chat Plus Peer Support Service

A peer-support role, provided by Responders with an enhanced DBS certificate.

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

District Nursing Clinician of the Day (CNWL Senior Nurse)

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

Elderly Medicine – Royal Free

Elderly medicine services at Royal Free Hospital

Elderly Medicine – St Mary's

Elderly medicine services at St Mary's

Elderly Medicine – UCLH

Elderly medicine services at UCLH

Elderly Medicine – Whittington

Elderly medicine services at Whittington Hospital.

Falls Diagnostic Clinics

Hospital clinics for patients who have had a fall

Falls Prevention Service for Ambulant Patients

Physiotherapist-led service for ambulant patients at risk of, or having suffered, falls

Falls Prevention Services

Assessments, support and rehabilitation to prevent further falls

Frailty (TREAT) GP hotline

Consultant-led Frailty telephone hotline.

Frailty MDT/Hub

Taking a multidisciplinary approach to assessing complex/frail patients

Home Treatment Team – Mental Health Crisis Team for Older Adults

Specialist support and treatment for elderly people in crisis

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 Service

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

NHS Volunteer Responders

NHS volunteer response team formed to help those who are self-isolating

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

SLT for adults with communication or eating difficulties due to neurological impairment, mental health, learning disabilities or stammering

TREAT HOT Clinic at the RFH

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