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Better ways to manage patient frailty

Caring for frail older people is the core business of acute hospitals - improve care for them and you can improve it for everyone
Frail senior

Caring for frail older people is the core business of acute hospitals - improve care for them and you can improve it for everyone

With those aged 65-plus accounting for more than half of all admissions and three quarters of bed days in NHS hospitals, improving care for frail older people is a significant challenge for health services. Now a report published by the NHS Benchmarking Network combines financial, workforce, quality and outcome data for the first time, painting a detailed picture of whats happening in acute hospital care for older people.

Among the central findings of the report into services in England and Wales is that only a little over four in ten hospital organisations have a specific frailty unit in place, yet almost half of older people admitted to a specialist ward have a condition associated with frailty.

Expert ...

Caring for frail older people is the core business of acute hospitals - improve care for them and you can improve it for everyone

With those aged 65-plus accounting for more than half of all admissions and three quarters of bed days in NHS hospitals, improving care for frail older people is a significant challenge for health services. Now a report published by the NHS Benchmarking Network combines financial, workforce, quality and outcome data for the first time, painting a detailed picture of what’s happening in acute hospital care for older people.


Picture: Getty

Among the central findings of the report into services in England and Wales is that only a little over four in ten hospital organisations have a specific frailty unit in place, yet almost half of older people admitted to a specialist ward have a condition associated with frailty.


Expert view: Deborah Birch

United Lincolnshire Hospitals NHS Trust nurse consultant for frailty Deborah Birch hopes the report will focus minds. ‘We talk about the tsunami of aging as if we don’t know it’s happening. This report confirms that we need to look at how we manage frailty. We need to change the way we do things – and this starts to provide the evidence.’

What is especially interesting for Ms Birch is where money is being spent. ‘From the report, it seems that 70% goes on inpatient care, with just 1% spent on avoiding admissions,’ she says. ‘This funding is based on old models of care. We need to put more of that money towards identifying frailty at the front door. But one of the difficulties is that trusts don’t have the flexibility they need to move large chunks of cash.’

Among the major reasons for investing more in preventing admissions is that frail patients tend to fare far less well in hospital.

‘Currently, there is a large core group of people who don’t need to be in hospital and it’s actually detrimental to keep them there,’ says Ms Birch. ‘It’s not that we are doing a bad job, but for many it is simply the wrong environment. Everyone acknowledges that care should be closer to the patient’s home.’

While frailty is now viewed as a specialty in its own right, Ms Birch believes there is a gap in training for healthcare staff, particularly nurses.

‘Nurses want training and anything we can do to up-skill is good. Having more skills makes life easier,’ she says.

To that end she has written the first master's degree course in frailty for health and social care staff, available at the University of Lincoln.

Understanding what frailty means is fundamental. ‘I have never known a person consider themselves as being frail,’ she says. ‘They may describe others as frail, but they don’t see it in themselves. It’s for us, as professionals, to identify it. It is also not about someone’s age. You see 80 year olds running marathons now.’

For Ms Birch, frailty hinges on losing a reserve capacity to cope. ‘As you get older, this chips away until a small thing happens and you cannot manage anymore – physically or psychologically,’ she says. For example, the move from home to hospital, or even from one ward to another, can exacerbate symptoms.

All health and social care professionals should be able to carry out a comprehensive geriatric assessment (CGA), argues Ms Birch.

‘Although it has lived in the doctors’ world for a long time, this is a relatively new term for nurses,’ she says. ‘Instead, we usually talk about holistic or person-centred care. It’s the same thing, but perceptions can be different and we need to make sure that we are all thinking about the underlying philosophy – the person at the heart of it all.’


Expert view: Nicky Hayes

An extended skill set means nurses can play a leading role in carrying out assessments, insists Nicky Hayes, consultant for older people at King’s College Hospital in London.

‘There’s huge potential for nurses, working with the team. We are well placed to provide leadership, care co-ordination and oversight,’ she says.

King’s College London offers an older person’s nurse fellowship – a programme to lead innovation and quality improvement. ‘The identification of frailty and the application of the CGA are key concepts that we teach as part of the course,’ says Ms Hayes.

But where frailty screening is carried out in the first place is among the issues open to question. ‘We need more evidence about the best place. We might need to look more at primary care.’

It is clear that development is patchy, with wide regional variations. In practice, while some patients who fall frequently might be referred rapidly to a frailty team, others may not get the overview they need, with varying levels of access to specialist help.

‘There are emerging models and while there is a strength to that, we also need to find the most effective pathways,’ Ms Hayes says. ‘There is a danger of people not getting access to frailty screening – this report doesn’t explore the extent to which
it is not occurring.’

Indeed, the major limitation of the NHS Benchmarking report is its lack of outcome data, argues Ms Hayes.

‘While the report tells us that fewer than half of providers have a frailty unit, we still don’t have data to show how they make a difference. We need outcome data to provide the evidence that will help us establish a preferred model.’

Despite the gaps in knowledge, there are services that are getting it right for frail older patients – and setting an example for the care of all age groups.

Case study: Good practice

Frail patients are identified at the ‘front door’ of Victoria Hospital in Kirkcaldy, part of NHS Fife. ‘Everyone can see the benefits and why it’s so important,’ says nurse consultant for older people Joy Reid. Around 70% of those attending the hospital’s A&E department and admissions unit are frail.

‘It’s our core business, but the principles are relevant to everyone,’ she says. ‘Get it right for them and you get it right for all our patients.’

A positive screening for frailty triggers referral to her team, including physiotherapists, occupational therapists, nurse frailty practitioners and assistant frailty practitioners. The team works from 7am to 7.30pm,
365 days a year.

‘Originally staff finished at 4pm, but we found that was the peak time for GP referrals so we lengthened the day,’ says Ms Reid.

Team members carry out a comprehensive assessment to find the right pathway for the patient, with a variety of possible options – including the hospital at home team or transfer to a community hospital closer to the
patient’s home.

The system has been operating for the past 18 months, with data already showing improvements.

‘The length of hospital stay has reduced for patients aged over 65 and timely assessment means that outcomes are much better.

‘The real success is getting patients to the right place at the right time,’ says Ms Reid.

Twice a day, at 11am and 2.30pm, there is a ‘frailty huddle’ that brings together relevant staff throughout the hospital to discuss everyone identified as frail – their progress, what needs to happen next and how this can be achieved.

‘Frail older people have complex needs, so we can tap into everyone’s expertise,’ says Ms Reid. ‘It’s simple and effective – having really good conversations with other professionals.’

Looking ahead, they would like to be able to spot more people before they reach A&E. ‘Wouldn’t it be fabulous if we could identify them in the community?’ says Ms Reid.

‘Our long-term goal is to look at how we prevent them coming here in the first place.’

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