Third Sector Engagement in the Frailty Agenda in Leeds; Taking Stock and Identifying Next Steps

By Rachel Cooper, CEO, Leeds Older People’s Forum and Forum Central

On 30 April 2019 workers from third sector organisations met alongside representatives of Leeds Clinical Commissioning Group, Public Health and Leeds Teaching Hospitals Trust as part of the Third Sector Health Leaders Network focusing on Leeds’ work in developing a model that improves outcomes for people living with frailty.

This article outlines what would need to happen to enable us to realise the value of third sector involvement in a health system that supports people living with frailty.

Those challenges are drawn from the 30 April Health Leaders Network event, from which actions have been subsequently developed with the aim of moving the conversation forward. You can download the presentation (pdf format) from this meeting here…

These notes and action points should also serve as a crib sheet for third sector representatives discussing frailty within other arenas, and for our health colleagues in understanding how they can facilitate our involvement.

  1. Starting Points
  • There is widespread support for the third sector from health colleagues and the sector is regularly championed.
  • The third sector is included in all partnership meetings and workshops in relation to this agenda and has representatives involved in the Population Health Management Programme.
  • The frailty outcomes and outcome based approach is very person centred, which aligns with the values of the third sector.
  • There is a strong focus on frailty in Leeds and an existing commitment to funding third sector provision that supports this population group. This includes: Supporting Wellbeing/SWiFt, Neighbourhood Networks and Social Prescribing. New funding for frailty projects has been identified to support the existing Supporting Wellbeing projects and extension of the model into additional areas. Neighbourhood Networks also received an uplift as part of their new core grant, which could help support the additional capacity required to support people with higher level needs in their areas.
  • The third sector already provides services that address the preventative components of frailty, including; alcohol reduction, falls prevention, nutrition, physical activity, smoking cessation, reduction of social isolation and loneliness, and creating safe and warm homes.
  • There is a national focus on frailty from NHS England and funding expected through Leeds Clinical Commissioning Group.
  • Frailty is the first area of focus but the principles will extend to other groups, so all populations the third sector works with will be included as the approach is rolled out.
  • All Local Care Partnerships (LCPs) will have frailty as a priority.
  • New developments include; the new Local Care Partnership structures and related pilot projects in four areas; a shift to community based provision, preventative and person centred approaches; data driven interventions including the Population Health Management programme; and the development of the Virtual Frailty Ward.


  • Forum Central to continue to share updated information on developments with members and support third sector representatives.
  • Health to continue to include representative positions for the third sector on relevant partnership boards.
  • Leeds Older People’s Forum to continue to support the adoption of learning from the Supporting Wellbeing pilot into phase two / roll out of the model.
  1. Challenges for Third Sector Involvement
  • It is difficult to find the capacity to attend meetings and implement the work (across all sectors).
  • The landscape is constantly changing, it is hard to stay up to date with the changes and know whom we should be linking with.
  • LCPs are very different in terms of their structure and ‘readiness’ to deliver projects like these – most are driven by a small number of people e.g. one GP, Business Manager and rep from LCH. Again, makes it difficult to engage at this stage but this should improve in the future.
  • The third sector is included in partnership discussions but we now need to translate this into involvement as deliverer in the system, not simply to be signposted or referred to. There are some delivery partnership pilots with the third sector but we would like to see this extended to a greater number of projects.
  • The number of LCP areas and issues with footprint differences with Neighbourhood Teams and PCNs. This is a challenge for all organisations – neighbourhood based (their boundaries are likely to be different e.g. Neighbourhood Networks), for those organisations with particular specialism’s that aren’t geographically rooted (e.g. learning disability, carers), citywide organisations (as per previous point), and cross authority/regional/national charities).
  • Each area (currently deliberately) has different models, it isn’t yet clear if each area will continue to operate an individual model determined by the needs of their local area and as determined by the Population Health Management approach or if a consistent approach will be adopted. This adds to the complexity of involvement with a number of different areas.


  • The new Forum Central project supporting the third sector in the LCPs (led by Pip Goff) to facilitate involvement, as planned.
  1. Third Sector Identification of Frail Service Users
  • To note that there is an appetite (and possibly a need) for a two-pronged approach.
  1. For the third sector to have access to SYSTM One/Leeds Care Record and know whom in their area has been identified as frail.
  2. For the third sector to have their own tool/s to identify frailty (preferably not deficit based like the Electronic Frailty Index) to enable them to target interventions and refer / encourage those service users to go to a Care Co-ordinator for assessment and support.


  • Forum Central/Leeds Older people’s Forum, in partnership with Public Health to provide information and support to third sector organisations on the tools that can be used to identify frailty and consider how third sector data could be used.
  • Health has applied for funding to expand access to Leeds Care Record to a greater number of third sector organisations.
  1. Supporting People living with Frailty
  • Individuals will have access to their Person Centred Care Plan (Sam) via HELM


  • Third sector to see if they can access service users Person Centred Care Plan via the individual once HELM is in place.
  1. Data
  • Issues and actions as above, in relation to SYSTM One and Leeds Care Record.
  • There is lots of data, it requires time to understand and interrogate. The third sector doesn’t recruit staff whose job it is to understand and interpret data so external expertise will be required.
  • The Third Sector could contribute to data gathering via monitoring returns, this requires commissioners and providers to work together to understand what should and could be collected and to implement this.


  • Forum Central to explore the possibility of providing sessions that disseminates data analysis to third sector organisations.
  • Forum Central to encourage commissioners and member organisations to explore ways in which data collection could be more effective and contribute to Leeds’ data set.
  1. Defining Frailty – who it includes and excludes

The segmentation for PHM approach means that the focus is currently on those 32,000 living with frailty (as identified by the e-frailty scale).

This is not validated for under 65s, the group make up is generally those over 65. The PHM approach will be rolled out for the other groupings, this work (targeted at 32,000) is to test and learn what works for this particular group of people.

There’s a difference between setting spend per segment vs. when actually working with people (and the specific goals/needs they are presenting with).


  • Forum Central to monitor the roll out of the programme and ask members if their service user groups are included and if they still see relevance to them being included in the local definition of frailty.
  1. Commissioning

If is not yet clear what the new finding models will look like.


  • Forum Central to keep up to date with changes and disseminate this to members. There may also be merit in considering the types of models we would want to advocate for.

You can download this article (pdf format) here…