About Focus on Frailty
The Focus on Frailty programme brings together NHS Boards, health and social care partnerships, GP practices, community and third sector organisations to spread improvements to services accessed by people aged 65 and over who are living with frailty or at risk of frailty. It builds on Healthcare Improvement Scotland’s 90 day learning cycle on frailty which outlined the key components of an integrated frailty system.
Examples of improvements to health and social care services accessed by people aged 65 and over who are living with frailty
This programme builds on previous frailty improvement programmes, examples of impact include:
- Midlothian Health and Social Care Partnership (HSCP). In 2015 the HSCP estimated that there were around 3,500 people living with frailty in Midlothian. They used the electronic frailty index (eFI) to pinpoint people with frailty and found that there were more than 8,500 people who were frail. The HSCP and the Midlothian GP Cluster then used the eFI to improve the quality of care of those most at risk from frailty.
- NHS Greater Glasgow and Clyde discharged more adults from unscheduled care within 48 hours, from 15% to 33%. They did this by improving how they found out who was living with frailty and used a comprehensive geriatric assessment (CGA). They enhanced their multidisciplinary teams. New pathways were developed within the emergency department and ambulatory care. Urgent social work services were put in place alongside quick access to intermediate care within 48 hours.
- NHS Fife set up a Community Health and Wellbeing hub with a focus on improving multidisciplinary assessment. This reduced the number of return attendances by almost 50% and 35% of referrals received a more specific and coordinated service provision.
- Edinburgh Health and Social Care Partnership improved the quality of care for people living with frailty by introducing a proactive approach to frailty coding, identification and management.
Participating teams will make improvements for people living with frailty or at risk of frailty. Teams can focus on one or more of the following three areas outlined in the programme’s driver diagram:
- Early identification and assessment of frailty.
- People living with frailty, carers and family members access person-centred health and social care services.
- Leadership and culture to support integrated working.
There will also be support for teams to engage with people with lived experience of frailty.
Resources to support Focus on Frailty
The following resources have been developed to support teams from NHS Boards, health and social care partnerships, GP practices, community and third sector organisations to develop and test change ideas which improve health and social care services accessed by people aged 65 and over who are living with frailty or at risk of frailty:
- Living Well in Communities with Frailty: Evidence for what works: This document is supported by high-level evidence for interventions in frailty. These interventions are community based and focused on the prevention of harms or poor outcomes.
- Think Frailty screening tool: This tool supports screening for frailty as an accompaniment to clinical judgement in hospitals. It can be used to screen all people over 75.
- Electronic Frailty Index (eFI): This collection of resources is for GP practices and community teams. This provides an introduction to the eFI tool and how to use it.
- Essentials of Safe Care: The Essentials of Safe Care is a practical package of evidence-based guidance and support that helps Scotland’s health and social care system to deliver safe care. It contains helpful tools to support staff wellbeing and psychological safety.