Sarah Zaidi
Welcome to the Transforming Primary Care podcast everyone. It’s lovely to see all of you today. I’m just going to introduce myself. I’m going to be the chair for this session about focusing on frailty, helping the most vulnerable in our community. My name’s Sarah Zaidi. I’m a GP by background. I work down in Essex, but I also work with the community health services trust leading on frailty and end of life for the last 15 years. So had a lot of experience seeing all the changes that we’re doing to try and make things better for our frail population.
Joining me today I’ve got some amazing people.
We have got Dan Harman, who’s a community geriatrician, clinical lead for the Jean Bishop Integrated Care Centre over in Hull and East Riding.
Julia Clifford, Advanced Practitioner, Occupational therapist in frailty.
Lesley Bainbridge, who’s a nurse and clinical lead in the living and aging well area of North East and Cumbria ICB.
Heather Smith, who’s a consultant pharmacist in older people at West Yorkshire ICB.
Emma Olandj, who’s a GP with an extended role in frailty, Director of Community Services, Nimbuscare, also within Humber and North Yorkshire ICB.
So a brilliant array of people today. So I’m just going to kick off with the first question – What do you think we mean by frailty? And who wants to come in on that one?
Dan Harman
I don’t mind starting. So I suppose what do we mean by frailty? One way that we do try to explain it is by explaining what it isn’t, which it isn’t part of a normal ageing process. Being older doesn’t necessarily mean that one becomes frail. And historically, the frail elderly has been used as almost like a label without necessarily any change in care or an approach to an older person living with frailty. Treating frailty as a long-term condition with appropriate multidisciplinary team support.
So the way that we try to explain frailty is it means decreased resilience to stress and that stress event could be anything from urinary tract infection or a change in medication, but that it changes a person’s level of independence and engagement and interaction such that when that stress event is resolved, the person may never get back to their previous level of independence and function. So I think it’s quite a simple concept but is often poorly interpreted and understood and probably explains why the outcomes for people with frailty are not quite where we would want them to be nationally or internationally.
Sarah Zaidi
That’s a really important point, Dan, isn’t it? We need to see it as a noun, not an adjective. And I could see, Lesley, you were nodding there as Dan was talking. I mean, just give me your reflections in your expertise, what you see in terms of that sometimes misperception around frailty. What’s been your experience?
Lesley Bainbridge
I mean, firstly I would say I agree with Dan with that definition that he’s just given and I’ve spent most of my career working in older people’s services. So it’s perhaps not surprising that I do agree. But when I was listening to you speak there, Dan, I was reminded of a great bit of work that British Geriatric Society did with Age UK and what they did was they went out to people as they call them and they found’ what do you think about frailty?
And the categorised in those three key groups and the way that people understood and referred to frailty. So one was people like you and me, Dan, and the others on the call who specialise, if you like, in the care of older people. They consider it in the context of Dan, how you’ve just perfectly described it, defined it, I should say. And then there was another group of people of care workers who are non-specialists and that’s care workers in health and social care who use it in a different way. The other group was the older people themselves and the older people themselves tend to understand it as something that is an inevitable part of ageing, which of course it isn’t in the scientific sense and the definition type, the sense that you’ve just described there, Dan.
So that’s really interesting to think about the three levels of understanding because in our daily work we’re working with specialists all of the other people in the care sector who aren’t specialists and then the older people and the families themselves. So it’s useful I think to remember that little that bit of work and it helps focus on how we need to approach whatever is in in front of us at that moment in time.
Sarah Zaidi
Does anybody else have any other reflections on that? I mean, I think the key point, Dan, is that, you know, as you pulled out, is that we need to approach this as a condition in its own right, just like every other condition has its best practice management.
You know, I think the clinical world would understand there’s nine care processes for diabetes that produce better outcomes. And it’s kind of a similar approach, isn’t it, for people who are living with frailty, who don’t always have to be old by their birthday either, do they? We do see some people who are physiologically living with frailty, who might be in their late 50s or early 60s. So I mean, it’s that sort of understanding that it can be managed and it can be managed well and produce better outcomes. But Julia, you’ve got your hand up.
Julia Clifford
Yeah, I totally agree with what you said, Dan and Lesley. I think it’s really interesting. I just wanted to add about how frailty is dynamic rather than static. And I think it’s so important to recognise that because certainly in my clinical work, you can see how people can change and actually in some instances, frailty can be reversed. I think sometimes it can be sort of lumped together that you know, the importance of language is key, isn’t it? And actually recognising the kind of subtlety and the changes within people that we work with feels very important.
Sarah Zaidi
In practice I’m going to look at you, Emma, as a GP with an extended role, how do you think that perception is landing within the professional community? You know, the people that you work with, MDT, other specialists, people probably who are not doing much frailty work. How do you think the understanding is around that, you know, this is something that we can manage, that we can often improve, that we can prevent accelerated progression? Do you think that’s well understood from your experience yet?
Emma Olandj
Thanks, Sarah. So I’m definitely seeing an improvement in all the years that I’ve been working in this arena. But what Lesley was saying about the three levels of understanding and perception of frailty and what we mean by frailty really resonates with me in the day-to-day job. And with all of the people within community services, primary care, secondary care and the people that we support within all of our services. I’m sometimes still quite surprised when I’m speaking to other professionals of the level of understanding regarding frailty.
And actually, I still think there’s a lot that we could be doing to opening up the eyes to the fact that frailty isn’t a natural part of ageing. It doesn’t need to be seen as a natural part of ageing. And in fact, like Julia was making the great point, it absolutely is reversible if we catch it early enough.
So I think there needs to be more focus on frailty out there, especially as early as possible, so that we can intervene as early as we can in people’s journeys to try and impact change as much as possible on people’s outcomes.
Sarah Zaidi
That’s a really good point, Emma. And I think you’ve just segued into one of the other bits that we were going to cover about identifying frailty becoming normalised. Are there any tips that you can share from your role as how you’ve managed to get that embedded within some somebody’s normal practice, part of the wider MDT? What do you think? How do you think that’s going and anybody can come in on that one…
Lesley Bainbridge
I could give you a great example from the nursing world of where it’s working really well, but I guess it doesn’t strictly answer the question about how you identify it, because it’s once people have been identified as living with frailty, but in one area of North East and North Cumbria there’s been some practice-based frailty nurses appointed
Do you remember the £75 per head money that came in around a decade ago for the over 75s?
Sarah Zaidi
Yes, I do.
Lesley Bainbridge
So it was funding and I say that because it explains how they’re not in all of the practices in all of the PCNs. It was what some PCNs chose to do with their money.
So these people were already identified as living with frailty. Then they were case managed by the practice-based frailty nurses who went out into their own homes and they did a really good qualitative evaluation of it and found out what a difference that that made in terms of the nursing role, rather than being in the practice and having an allocated time slot, being out in the home, having the freedom to take as long as they felt they needed to undertake a good comprehensive geriatric assessment. And then you know everything that falls out of that, identify the problems, prioritise them and then and work to meet the needs that were there. But what was really interesting was, because that was a qualitative bit of work, but they did bring some quantitative into it as well in the evaluation.
So they looked at unscheduled care use, A & E attendance, hospital admissions, length of stay and then for the people in the first year that were case-managed by the practice frailty nurses, they compared it to GP visits in the preceding year – there was a reduction in unscheduled care use. But what was really interesting was in that same town there were another 20 nurses, community matrons, they were called at the time, also on paper look like they were doing the same thing. And then when they compared the practice frailty nurses with the community matrons, the data was different. So they didn’t see a reduction in unscheduled care use.
There wasn’t the qualitative element undertaken for the 20 community matrons. So it gets you to think about if we’re going to have additional roles in primary care, then maybe nursing hasn’t been one of the focuses, but maybe they are key and other HPs as well in having that case management role, rather than case managers in community health services, or at least having them work in the same way with this work collaboratively with the same job descriptions so that you would see the same outcomes and all of the people were getting the same benefits. And you know your next question, ‘Oh well, perhaps they weren’t as frail in that PCN?’ So they did all of that follow up work as well and they were living with the same levels of frailty or greater.
So perhaps they weren’t as complex in terms of number of LTCs – long term conditions. So if you took frailty out as a long-term condition and looked at the number of other long-term, same or greater, levels of deprivation, same or greater, in that PCN where those practice-based frailty nurses were. And I think it’s really interesting to start if you want to think about additional roles in primary care and what they might do in terms of the community of people living with frailty and I’ve given you an example of nursing, but I say again, it could be other AHPs as well could undertake that.
Sarah Zaidi
It’s a really good point about additional roles. I’m sure we’ve got a lot of all of us here have got a lot of experience with that. But Heather, what are your reflections on, you know, identification and staging of frailty?
Heather Smith
So in in Leeds we were lucky enough to have an enhanced frailty scheme in primary care for people living with severe frailty. So that was a three-year scheme that we had and the first part of that was about identifying people who were living with the severest form of frailty. So what we did was we identified people from their GP records who we thought had severe frailty using the electronic frailty index. And then what we did was we asked multidisciplinary teams to go and assess those people in person and just see if they were actually living with severe frailty.
And then after that, the rest of the scheme was around putting in a person-centred, whole person approach, really finding out what matters to the patient, putting in place things around them to help them live well. And that was all members of the multidisciplinary team, so GPs, nurses, community geriatricians, OTs, physios and the pharmacist aspect was around doing structured medications reviews for those patients.
So lots of different interventions in place, for example, falls prevention, also advanced care planning. So really thinking about what people wanted to happen in the future in terms of their health and care. So really, really good outcomes for people in terms of preventing people deteriorating or ending up in hospital.
Sarah Zaidi
Thanks. It’s a great example of initiatives that have been undertaken to sort of bring that together wider MDT with a consistent approach. Julia, you’ve got your hand up.
Julia Clifford
Yeah, I just wanted to really support everything that that Lesley and Heather have described based on our experience in Sheffield where we’ve used NHS England pilot funding to set up a dedicated frailty team working within primary care. So we cover five GP practices and we are using additional role staff. So there is a frailty nurse, we’ve got GP input, we’ve got care coordinator and occupational therapy support and we really feel that it’s working so well in being able to do that proactive outreach approach.
So we are running screens and identifying patients for targeted input from the MDT and it feels so positive and all the feedback that we’re getting from GPs is around sort of improving the efficiency of amongst the practices in managing the complexity that patients often face living with higher levels of frailty and it does seem to work really well also around managing all the risks that that that patients can face. In terms of, you know We’re identifying patients who have fallen and haven’t actually raised it with their GP practices, issues around medication management, managing activities of daily living, cognitive decline. So we can really use that holistic approach to identify all the issues and build that infrastructure to support patients before it reaches a crisis point and they’re needing support from secondary care services.
Dan Harman
Yeah. And Sarah, if I could just come in on that as well. I mean, I agree absolutely with the examples that everybody’s given. I think that the challenge for us working within health and care sectors is that as we alluded to, not all older people are frail. And then we’ve got limited resources both within primary care and wider community team and hospitals to target interventions that have an evidence base for either, as Emma alluded to, either preventing or delaying or reversing the progression of frailty.
So there are things out there that can really help us, and I’ve heard the electronic frailty index mentioned already, and we use that within Hull and East Riding, I think to good effect alongside a suite of other tools within population health management. But essentially if we’re risk stratifying the population using things like the electronic frailty index or in hospital, the hospital frailty risk score, then we can get a more discrete cohort of individuals that might benefit from our interventions. And then the key is using the same terminology and the same diagnostic tools to diagnose frailties.
So you know, the Rockwood Clinical Frailty Score is almost universally accepted now as one of the best tools to use to diagnose frailty and then we know which interventions or certainly it’s merging which interventions support people in that progression of frailty from those that are fit to mild to moderate to severely frail, such that things like comprehensive geriatric assessment, the evidence base is strongest in those that are moderate to severely frail. So not everybody who’s older needs CGA – Comprehensive geriatric assessment.
Most exclusively, everybody that’s older needs to be given the opportunity to be involved in things that promote social and emotional well-being. And so there’s that sort of lower level to the greater population where we perhaps need to intervene now to try and prevent frailty progressing, but it starts with identification and NHS England and the British Geriatric Society support the use of population health management to identify that cohort. So that is absolutely what teams across the country should be using. Look at the proactive care framework, look at BGS’s ‘joining the dots’ blueprint and the’ be proactive’ evidence that that that they published last year as well. It’s all there.
Sarah Zaidi
I think what you’ve done is you’ve really succinctly described that we need to take a more kind of strategic approach. Prior to things like EFI and HFRS, you know, we had no idea of even having a clue – and you were on the back foot, weren’t you?
You were just finding people opportunistically and the ship had already sailed and some of the interventions that could have provided a benefit’s too late for that person. I think PHM segmentation is in a really exciting space now and I think there are lots of there’s lots of work going on, isn’t there, with other implementation models to enhance the power of the EFI because I think the challenge we’ve got with EFI is that it’s extracting from primary care systems in the main and you know and bringing in other systems, community providers and their linked data sets, it really kind of helps increase your radar and then you’ve always got to clinically validate it, haven’t you?
Because you know, data points are never going to be 100% accurate. You know, you can underestimate, overestimate. But bringing clinical frailty scoring or the Rockwood score, whatever one people know, it’s a habit, isn’t it? And once it’s a habit for frontline staff, it only takes a couple of seconds, doesn’t It. But it’s normalising that, isn’t it? And I think if you make it the business of everybody, because as you said, Julia, frailty is dynamic. The stage is often changing really fast. People move – people move across different geographies. I mean, as a GP I would often say my frailty population are moving all the time. I’m inheriting other people’s frailty patients because they’ve moved into a local care home in my area. I didn’t have them before, but it shouldn’t matter if everybody’s frailty scoring and you can follow, you know you get that radar, don’t you better and then you target the intervention.
So you know I want to talk about people’s experience about embedding system wide CGA because actually CGA we can all do, can’t we? But I wondered perhaps what some of the perceptions and challenges you might have faced with sort of other non -geriatrician frontline staff thinking, ‘oh, CGA, I can’t do that. I’m not a geriatrician’, but actually bringing it back to the basics of, ‘you know, it’s just a holistic assessment. We can all do that.’ Emma, I can see you’ve got your hand up.
Emma Olandj
Yeah, I think you make a great point, Sarah. And when you talk about CGA, you’re talking about comprehensive geriatric assessments, which in its word alone is, is fully comprehensive and it’s looking at a person in a fully holistic way. So I think coming back to the importance of CGAs, even a step before that, Sarah, is if we don’t with my GP hat on, identify people as being frail, we can’t tailor their prevention and chronic disease management appropriately in order to be able to identify those that have specialist needs and that we need to be concentrating on and tailoring their requirements for their health in a different way.
And we see it all the time in the reactive arm of our service that we have the same people bouncing in and out of crisis because we aren’t sorting out the problem what’s getting them to crisis in the first place. So I think if we start identifying and as you said before, Sarah, just making it that quick assessment, we know that the clinical has actually that great list of pictures – that even just looking down the list of pictures gives you a quick glance of where you think approximately someone sits within that scoring – is going to be a great way to sort of segue into the people that need to have their chronic disease templates within primary care amended because we need to be capturing frailty as part of every single conversation that we have within chronic disease all the way to these are the people that we can identify as using our data searches that will most likely benefit from a comprehensive geriatric assessment as a full MDT and as Dan said that that evidence base sits more with moderate to severe frailty.
But if we get that identification early enough, we can tailor that chronic disease management so that they may not get to that moderate to severe level of frailty and we can intervene earlier.
Lesley Bainbridge
Yeah, I agree with all of that, Emma. But what you’ve prompted me to think about now is workforce development, because tools and templates and data systems won’t do it unless you’ve got some knowledge and skills to use them. So workforce development is going to be key. Even if we go back to those two groups of people here, there’s those that are specialists in it who can talk the talk and understand exactly what you’ve all just said in the 30 minutes we’ve been together already today.
And then there are all of those other people who are meeting those same older adults living with frailty, who don’t understand about the tools and the templates, the evidence base behind them and why they exist and why it’s important that we do it. So workforce development to meet the needs of an aging population has got to be huge because the tools and templates on their own won’t do it. We can all fill a template in, we could all fill a CGA template in, but that’s not the end of it. It’s the process of what you found from filling that in, what needs to be identified, how do you need to prioritise them?
And so on. It’s a process, isn’t it, CGA? So you know, I think it’s important that we think about workforce development and getting the people prepared to be able to do what they need to be able to do.
Sarah Zaidi
Yeah, I agree. And I would be interested to find out if anybody’s got any experience on initiatives they’ve done for workforce development. Julia, you’ve got your hand up:
Julia Clifford
Yeah, it was just briefly to say again, I completely agree with what’s been said here. Mindful in primary care that frequently we’re finding patients are not being coded as living with frailty and also what level of frailty they’re experiencing. So we are looking to do some education work within the network. I just wanted to bring up something about the comprehensive geriatric assessment.
I mean we that’s what we use. We’ve got it on the electronic system that we use within our service. But I’m just very mindful that frequently systems don’t talk to each other across services and you know you’re not always able to access if CGAs have been done elsewhere, which I think is something that can be a challenge and that would be helpful to address.
Sarah Zaidi
Julia, that’s a really good point. I was actually going to look at that. Heather’s just put her hand up, but I might go to Dan first, if that’s all right, Heather, because Julia, you’ve touched on something really important about digital systems talking to each other and teams working the same system, Dan, I know you’ve got quite a lot of experience in what you do up in Hull and East Riding and I just wanted to ask you to share some of your reflections about what things help in terms of working off similar EPRs, any evidence of the impact of those evidence based interventions because I know you’ve got some fantastic data on outcomes and so I just would like to get your views on that sort of digital connectivity as being so helpful or not, as the case may be.
Dan Harman
Yeah, no problem. First to say is we don’t have all the answers, but we have been doing this for about 7 1/2 years now. So I’ll just if it’s OK, just briefly explain what we do in Hull and East Riding because then it’ll give some context. We opened the Jean Bishop Integrated Care Centre back in 2018, so that’s a physical building with the aim of improving positivity around ageing, ageing well and then addressing the needs of people living with frailty in our community. We risk-stratified the whole of the Hull population using the electronic frailty index plus practice intelligence.
So there was data sharing between ourselves and the community service and primary care at that point. And then we invite people for a comprehensive geriatric assessment based on the risk of living with severe frailty. As part of that CGA, it is delivered by a multidisciplinary team, all the disciplines that are on the podcast today you’ll be pleased to know are represented, but in addition to that, you know, having local authorities as a key partner in the delivery of care – and they’re on a different electronic patient record to go back to your EPR discussion – the ambulance sets feeding into that, the Fire and Rescue service feeding in and the voluntary sets and carer support and information service.
So you’ve got all this enriched data that’s out there and the challenge is how do you see that information of the patient touches base in hospital, etc. We haven’t cracked it. We’ve got the Yorkshire Humber care record which is developing, where multiple provider organisations will be able to feed into the information there and then view it elsewhere in the system. I wouldn’t say it is in the truly functional state yet where it’s making a huge impact on our delivery of care. So what we did is – and a lot of this is relational you know – you get alongside your system leaders in your acute trusts and primary care and other providers and you agree ways of sharing information in the interim related to the CGA.
So when we complete a comprehensive geriatric assessment that information shared with the patient, with the GP practice and we also input that data into the hospital electronic patient record. What’s the impact been of that over the last 7 1/2 years? If we track people 12 months before a comprehensive geriatric assessment and 12 months afterwards, you see about a 50 to 70% reduction in ED attends and admissions.
The patient feedback is extremely positive in terms of statistically proving that they feel emotionally and physically better after a comprehensive geriatric assessment. So the system benefits, but more importantly for myself as a hospital-based geriatrician, but now based fully in the community, patients have a positive experience of living with frailty and a positive experience of health and care and part of that is around information sharing. But there are so many other things that are important. I mean, Lesley’s point about workforce and training and development is so important and it isn’t just about specialist services being skilled at that sort of Tier 3 level of training.
There’s lots of things that can be done in terms of upskilling your care home workforce, for example, not just the identification frailty, but supporting people living with frailty. There’s tools that exist out there already, isn’t there, in terms of nationally available tier one training tools. The British Geriatric Society do their free online training materials, but we found that working with our 220 care home providers, actually getting alongside them and delivering bespoke training to individuals is a nice compliment to sort of your didactic online training opportunities. So I think I’ve covered an element of what you were saying about data transfer. I think a lot of this is relational and having the right governance in place to share information between providers.
Sarah Zaidi
Definitely agree, Heather, sorry, I’ve kept you waiting.
Heather Smith
I’ve just got a couple of points to make on what we’ve discussed so far. So, in terms of shared records, we’re really lucky in Leeds. We’ve got the Leeds care record, which primarily shares information between GP systems and hospital data. So that is really, really helpful because what it means is if somebody is admitted to hospital for example, and they’ve been coded having a level of frailty in primary care, then that is visible to the people in the hospital. So they don’t have to repeat those assessments because they’ve already been done and they can see what the date was for example and vice versa. You know if hospitals have assessed people as living with frailty, again, that information can be shared back with primary care or community services. So, so that is all really, really helpful.
And also, you know, we can see what each other are doing so that we’re not repeating the same assessments or not reversing what other people have done, for example. And then I just wanted to make a point about workforce and training. So I agree with what Dan said. It’s really, really important.
Again, we’ve been really lucky in Leeds because we have a geriatrician who also works in the community called Sean Neenan and he set up the Leeds frailty education course. So this is a two- day course for any healthcare professional who’s looking after people with frailty, it’s really fun and it goes through the basics and he also developed a one-day course for care home staff as well. So, so really, really helpful in terms of describing what frailty is, how we can prevent it, what interventions we can make. So really important in terms of raising awareness and helping to upskill the workforce.
Sarah Zaidi
I mean, that’s a great example, isn’t it? Because we do need to upskill the workforce and improve awareness. And Dan’s absolutely right. People like care homes. They are an asset and can be such a contributor – they’re a member of our staff and it’s amazing what you can see even in residential care homes. I’ve got residential care homes that can, you know, they frailty score like it’s just normal and they will even spot medication. So they’ll get a new resident and they’ll say they’re all this medication and actually I don’t think, I think this XYZ is probably actually causing trouble for this person and they’re absolutely right.
And it’s amazing when you spread the awareness, then actually you get that kind of everybody mucking in together and you create more shared capacity that way. I agree with you, Lesley, you can create digital templates to provide consistency, something that I’ve done in my own ICB in Mid and South Essex and it has been hugely effective, but we had to hammer training and education first. You can give people a consistent way of doing things so that everybody’s sharing in that CGA digitally and there’s a consistent approach, but unless you upscale the workforce, they don’t really know what to do with it. But Dan, as you said, there’s the core competency framework for frailty, isn’t there?
On e-learning for health, it’s probably going to be going through an update, a review this year, but there’s also other sort of national resources and it’s about sharing those and sharing that sort of education and awareness. BGS is a great resource for so much educational material that’s successful to all of us, including urgent care situations. So we’ve got ARRS roles doing home visits now, don’t we? We’ve got a lot of people that have come from an ambulance service background, but they can learn actually that that proactive care actually reduces that reactive demand.
And I think, Dan, I think I remember from your Hull work you even showed benefits on reducing the numbers of GP appointments, medication costs, you know, through good deprescribing and polypharmacy reviews, which in itself actually can, you know, improve function, reduce falls and all of those things.
Dan Harman
May I jump back in on that, Sarah, because I just think that, you know, we start the conversation, we’re talking about what frailty is, but actually unaddressed frailty basically means a label presenting late and in crisis – often with a frailty syndrome like delirium or a fall. And almost exclusively ends up in a hospital-based, episodic, disrupted, disjointed episode of care that, you know, is dissatisfying for the person, not great for the system. What we’re trying to get to is an older person living with frailties, a long-term condition.
Timely interventions that are where the person wishes for them to be, which is often in the community that is co-ordinated, preventative and proactive in its nature with elements of self-supported management and family support in there. And actually we’re all probably somewhere in the middle of that i.e. on a bit of a journey, but we’re trying to go at a faster pace because the 10 year plan is exciting as it is challenging in the context of, you know, this whole ‘analogue to digital’ – really great space when you’re trying to deliver hospital at home virtual wards for people living with frailty, treatments prevention.
On a personal level, I’m sure we all recognise it’s much more fun to be preventing rather than responding to crisis and hospitals to community. I mean, most older people are not in hospital, so we’ve got to find a way of this workforce helping support care in the community and maybe even shifting out there as well. So I think it’s quite an exciting time to be caring for older people.
A lot of people in an AHP role, a geriatrician role, a GP role and it is great to hear that although we’re in different parts within our region, we’re all doing similar things and it’s how we scale it in the context of the 10 year plan that I think is really exciting.
Lesley Bainbridge
On that note, Dan, was it challenging for you to get out of hospital completely and into the community as a geriatrician?
Dan Harman
Yes, I mean, I’m conscious this is a brief podcast, but yes, it was challenging. On a personal and professional level, it’s quite an unusual thing to do, but I think it’s been absolutely the right thing to do, vindicated by the outcomes that have been achieved for patients.
But yeah, I think that now there are more than just a handful of community geriatricians. It’s almost like we can lay the platform for what worked well in this process and what was challenging moving between provider organisations in this way. But I also think it’s important to work across organisational boundaries. So like myself and Anna Folwell, the other consultant colleague we still do our on-calls in the hospital, which I think is vital for relationship building and also keeping acute clinical skills. If we’re going to deliver things like IV, antibiotics, oxygen therapies, etc in the community, you need a blended workforce. So I think our service doesn’t necessarily need to have geriatricians as clinical leads.
Emma’s a good case in point of that within York as well, but I think that having a blended workforce really helps in what can be delivered for older people in a community setting.
Sarah Zaidi
I agree. And I think we might be running short on time, but I I’ll come to Julia first and then I yeah.
Julia Clifford
I’m just going to say just really briefly – I just wanted to mention about the development of the integrated neighbourhood teams as well and how important that is as part of working with our population experiencing frailty. We’ve certainly worked really closely in terms of our frailty team and we link into our integrated neighbourhood team as well. I think it’s really important to recognise the resources from the different community partners that we work alongside. Certainly we work really closely with Age UK and I think it really helps in having that really comprehensive approach to providing that support on people’s doorsteps so that they can continue to live well and safely in their own homes.
Sarah Zaidi
Yeah, you’ve brought me to the point – Dan alluded to it and I wanted to sort of end on this point about the opportunities from the 10-year plan because it is an exciting space I think. The 10 year plan almost feels those 3 tenets were probably made for helping our adults with complex needs and it’s those opportunities that we’ve got now in terms of neighbourhood health, the analogue to digital, you know, uniting record systems enablers and that hospital to community shift is as Dan says, people do spend most of their.
Lives in the at home. What do you feel are the big opportunities that we’ve got to seize now, particularly in regard to neighbourhood health working and how do you think that’s going to change things, you know, particularly, you know, for primary care and for other providers in the community? Just wanted to get people’s reflections on that.
Emma Olandj
I can jump in there, Sarah. So we’re working or we’re part of community and primary care in York. As we start to develop the prevention arm of the community frailty hub in York, we are mobilising for frailty integrated neighbourhood teams.
So embedding our MDTs fully within planned community services in those geographies as well as working closer than ever before with our primary care colleagues. So hosting those local MDTs coming together to jointly talk in a multi-agency way about a cohort that can be incredibly complex and need that holistic view on their care and then being able to go out together to do to complete those the comprehensive geriatric assessments out in people’s own home environment and then coming back to engage back again to debrief and to come up with those personalised care plans that we know will make a difference to people.
But neighbourhood health is so much more than just INTs – integrated neighbourhood teams. INTs obviously is all about specialist work, integrated neighbourhood teams, all about specialist work and dealing with complexity. Neighbourhood working is about shifting that focus to that reactive element and looking to planned care that is truly integrated, making best use of all of our resources and all of our assets in each of our neighbourhoods so that we can truly deliver the care that’s most efficient and most effective for those that need it the most in people’s homes.
Sarah Zaidi
Brilliantly put, Emma, I couldn’t agree more with that. And Dan, do you see any kind of shifts as the neighbourhood teams or there is a difference as you say in between INTs and neighbourhood health, Emma, but do you have you seen any of that?
Dan Harman
Yeah, as a as a consultant geriatrician in the area, I’m trying to interface and successfully, I think with all the neighbourhood health partnerships that are developing across our primary care networks as well. Just to, I mean, I’m obviously very passionate about older people’s care and I’m very sure we should be focusing on older people as part of this work given that we’ve got.3 to 4% of the population who rightly utilise 30 to 40% of health care resources. But I think as this neighbourhood health emerges, one of the things that I keep sort of saying is that we need to try and avoid ‘pilotitis’.
You know, there is a strong evidence base around what works. So, I’m not saying don’t use quality improvement methodology, absolutely use QI methodology – use your data to drive a change process, but it’s almost like we don’t need to test to see if CGA works in this socioeconomic deprived area or this affluent area or this coastal town. It works and we know the building blocks for how it works and it is around as we’ve alluded to identification, enabling independence, training. We haven’t really talked too much about palliative care and the overlap between end-of-life care and frailty, which you know we’ve got a blended workforce in terms of skill mix and the way and where we can deliver clinical care there. And I think my final point in this and again I know more about Emma’s team than I probably do about the other teams, although I have worked with Lesley before as well.
But actually having some dedicated clinical and strategic leadership time as part of this sort of frailty agenda at place or within an ICB, regardless, regardless of who’s delivering that is key. We need some time to plan this properly and then share our stories with colleagues across the country as to what’s working well and I think this provides a good platform for that, as does, as I say, the British Geriatric Society as well. So my mantra to everyone, my ask for everyone will be sign up to the BGS if you’re involved in older people’s care and get some conferencing because it’s a great place to try and network.
Sarah Zaidi
Yes, I would echo that, Dan. And I was a late joiner. I don’t know why I didn’t bother joining, but I did about 18 months ago and it was, yeah, I think everybody can get involved with that, Like most people here, I’ve been a frailty nut for a long time. I think it’s the word BGS sometimes because obviously I’m not a geriatrician. So I just thought, oh, it’s just for geriatricians. It’s not. There’s such a broad church of people and such great people and actually meeting some fantastic geriatricians like yourself. I think just to finish on your point, Dan.
I think you’re absolutely right, we don’t need to test what the interventions are, we know what they are. I know of an area. It happens to be the where I work, where we’ve put together a neighbourhood blueprint for frailty, dementia and end of life. And so our generic CGA tool, which we haven’t called a CGA tool because it scares people because they don’t want to do a CGA. So we’ve called it something else. We’ve called it FREDA, which stands for Frailty End of life Dementia Assessment, but that’s almost provided.a blueprint for all providers who are involved in neighbourhood health to get out and deliver. And what’s been really exciting is that our fastest adopters have been in the community provider health space and the dementia teams.
They’ve run with it. And then that’s helped the PCN staff and the Rs roles to catch on and then it’s kind of like a spreading of a momentum. It’s amazing what you can achieve in a short period of time when you get a different group of providers and teams working together in a neighbourhood footprint because your reach is better. And you know, finding 20,000 more people with frailty and accurately staging them and delivering a CGA then suddenly becomes possible at scale within a year.
So we’ve got neighbourhoods as a framework. We’ve got a clear evidence base. We don’t need to test it. We’ve got great proactive care framework from before, from moderate to severe frailty, and now we’ve got almost like a blueprint to just crack on and deliver it but really sort of join forces in that united effort. It’s not just falling on one part of the system and then with specialists in virtual wards and those new models of care, then you have that good ecosystem, don’t you, of good care in the community.
Thank you, everybody. I think that brings us to the end of a fantastic discussion. I’m sure there’s a lot more that we could discuss, but I really want to thank everybody, Dan, Lesley, Julia, Emma, Heather, for bringing your amazing insights and hopefully some inspiration to all of us to get involved in this quite exciting space that I think we’re in now – which I think will be beneficial to the people that we serve and also for us, the workforce and the system as well. But thank you everybody.