Shaping better health
REMEDY : BNSSG referral pathways


Checked: 12-11-2018 by vicky.ryan Next Review: 11-11-2019

Frailty & Type 2 Diabetes

See the Frailty & Type 2 Diabetes Guidelines (PDF) for clinicians developed by the H.G. Wells Project Team.

Frailty Service - South Gloucestershire

The service aims to minimise the impact of any health problems patients may have to support them in maintaining as much independence as possible.

Following referral, the team will contact the patient to arrange a home visit. During the initial assessment, the team will identify any concerns patients have about their health and wellbeing, as well as their goals.

Further visits can then be arranged with other members of our team.

Referral Guidance - South Gloucestershire

Patients can be referred by a GP at any of the following GP surgeries:

  • West Walk Surgery

  • Courtside

  • Kennedy Way

  • Wellington Road

  • Hanham

  • Kingswood Health Centre

  • Cadbury Heath

  • Close Farrm

Contact Us:

Leap Valley Surgery Beaufort Road, Downend, Bristol, BS16 6UG

Opening hours: Monday – Friday 8:30am – 5pm

01225 831404

Frailty Service - North Somerset

This service reviews frail older people through Comprehensive Geriatric Assessment - a holistic assessment of physical, mental and social needs. Recommendations are then made to support pro-active management and advance care planning to enhance well-being.

Patients must be registered with a North Somerset GP. For people aged 75+ or younger with any of the following:

  • 2 or more co-morbidities
  • Resident in care home or a patient in a community hospital
  • Edmonton frailty score of 10 or more/ Rockwood (Clinical Frailty Scale) of 5 or more

The Frailty Service can provide specialist advice to support clinicians to manage patients in the community without a specialist appointment. This is available by telephoning the Frailty Service on 01275  885778 or emailing and requesting clinical advice from the team. The service operates Monday to Friday, 8.30am-5pm.

We aim to respond promptly, however, please note that we are not an urgent service. If your enquiry is urgent consider contacting Community Rapid Response on 01275 888801.

Referral guidance - North Somerset

If you are a healthcare professional and need to refer a patient to the Frailty Service, please complete the referral form. Please note that we require a completed referral form and Edmonton Scale in order to triage your referral. Completed forms should be emailed to We will confirm receipt of your referral by return email