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The Staying Well Pathway has been developed in partnership with key Staffordshire stakeholders.  Partner organisations include CCGs, Local Authority - public health, GP practices, GP Federations, voluntary sector, mental health/community (including social services) and acute trusts.

Inspired by Lichfield GP Dr Gulshan Kaul, staff from MPFT and other partner organisations showed a real appetite for integration and the development of a new pathway. The engagement of all partners from the very beginning has meant ownership of the process, implementation and governance.

The pathway:

Using primary care risk indicators, those living at home with frailty are identified by the GP practice. They are then referred to a Single Point of Access (SPOC) and each patient is offered a holistic assessment by an Elderly Care Facilitator (Elcaf) in their home where health advice, signposting and onward referrals can be made.

People may be offered a 1 hour appointment at a Staying Well Clinic, where they can be seen by a number of clinicians including a geriatrician, prescribing pharmacist, occupational therapist, a memory service professional, and a social prescriber who come to the patient rather than the other way around.  The citizen is put at the centre of their care planning and given the time to discuss their needs.  Following the appointment a personalised care plan is provided which is monitored and followed up by the Elcaf.

This preventative model demonstrates true integration, across a range of organisations and services. By supporting people with mild to moderate frailty it is anticipated it will reduce emergency admissions and reduce service pressures across the board. 

Nominated by Michael Fabricant, Lichfield MP, the Staying Well Service was recently successful in the NHS Parliamentary Awards and was named regional champion in the Health Equalities category.

Liz Latham (team coordinator for the Staying Well Service MPFT) along with Dr Gulshan Kaul (GP at Westgate practice) and Dr Bhaskar Mukherjee (Geriatrician) attended the awards ceremony at the House of Commons in London on 10 July 2019.

Dr Shammy Noor, Chair South East Staffordshire and Seisdon Peninsula CCG commented “I am really proud of the whole team and their well deserved success which is a credit to our local clinicians and community services”.

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Midlands Partnership NHS Foundation Trust

Trust Headquarters, St. George's Hospital, Corporation Street, Stafford ST16 3SR


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0300 790 7000
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