Proactive Ageing Well Service (PAWS)


The PAWS service that provides frailty assessments for moderate frailty is open.

The Proactive Ageing Well Service (PAWS) is an Islington-based, multi-disciplinary team, supporting identification of people living with moderate frailty and making an assessment to identify their health and social needs. These are predominantly around risk of falls, polypharmacy and other medicine-related issues and social isolation.

The goal is to address these needs with short-term interventions provided by the team or through onward referral and signposting to suitable services without the need for bounce back to the GP. The service aims to keep people with moderate frailty as well as possible, reduce risk of admission to hospitals or care homes for preventable causes and maximise quality of life.

The team consists of a nurse, physiotherapist, pharmacist and Age UK navigator.

PAWS works collaboratively with Whittington Health, the Islington GP Federation and Age UK Islington; breaking boundaries between primary, secondary care and the third sector.

The team aims to see patients at home for a holistic Comprehensive Geriatric Assessment (CGA), following this with evidence-based interventions and signposting/referral to appropriate services in the area.

The team on the ground

Dr Philly O'Riordan, GPwSI in Geriatrics

David Lincoln, Specialist Nurse

Ewa Grajcar, Specialist Physiotherapist

Rocky Gill, Specialist Pharmacist (being recruited)

TBA, Community Navigator

Wider team

Dr Clarissa Murdoch, Consultant Geriatrician

Local GP Surgeries

Age UK Islington

Islington GP Federation

Eligibility criteria


External referrals are not accepted to the service.

In order to proactively identify those with moderate frailty, the service works with local GPs; using their knowledge of patients, the Rockwood Frailty Index and telephone screening.

If you are a GP practice who has not yet participated and would like to, then please email the team.

How to refer

If you are a GP practice who has not yet participated and would like to, then please email the team.


Proactive Ageing Well Service

Provided By

Service Feedback


General Services

Adult Safeguarding

Child Safeguarding

Community Services

Navigating Self-Care

Urgent & Emergency Care

Urgent & Emergency Care for Children

Review date: Friday, 17 February 2023