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Focus on Frailty programme update January - March 2024

 

Overview

The Focus on Frailty programme is an improvement and implementation programme led by Healthcare Improvement Scotland.

The programme aims to improve the experience of and access to person centred and coordinated health and social care for people aged over 65 who are living with frailty. You can find out more information in the frailty change package.  

We are working with six teams made up of NHS boards, health and social care partnerships (HSCPs) and GP practices.

 

Why focus on frailty?

Scotland’s population is ageing. The number of people aged 65 and over is projected to grow by nearly a third by mid-2045 (National Records of Scotland, 2023).

Given the association between older age and frailty we need to plan for an increase in the number of people living with frailty in Scotland.

 

Progress so far

  • March 2024 data returns show that teams are establishing their measurement plans and have started to collect data for improvement.

  • Site visits to two teams took place in March with the remaining planned for April.

  • Two teams shared their improvement journey so far at the latest project surgery. 100% of respondents found the examples shared extremely or somewhat useful.

 

Highlights from the teams

The teams we are working with have; improved their understanding of their frailty system, identified improvement priorities and are testing changes.

South Ayrshire HSCP and NHS Ayrshire and Arran
  • The electronic frailty index (eFI) is being used in one GP practice to support the identification of people who may be suitable for the Ahead of the Curve service. The team have plans to spread this to other GP practices in South Ayrshire.
  • A wellbeing review of those identified, based on comprehensive geriatric assessment (CGA) is being tested with a community occupational therapy service. Referrals are made to South Ayrshire’s Ahead of the Curve service where necessary.
  • A review has taken place of the Ahead of the Curve service exploring the impact it has had on GP visits over a six-month period. Initial data shows a reduction in GP appointments following wellbeing reviews.
Moray HSCP and NHS Grampian
  • An early intervention “making every opportunity count” tool is being tested. This supports frailty identification and signposting to community-based support for people living with frailty.
  • The eFI is being used in primary care to identify people living with frailty who would benefit from a comprehensive review of their care with input from a hospital geriatrician.
NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary
  • The latest data submission shows an increase in the percentage of people aged over 75 who are screened for frailty at the front door.
  • The team began testing CGA huddles in February. They are in the process of gathering staff feedback to inform improvement.
North Lanarkshire HSCP and NHS Lanarkshire
  • University Hospital Monklands are focusing on reducing the time it takes for people with frailty to reach the Frailty Assessment Unit.
  • University Hospital Wishaw are testing the introduction of a frailty roving team to the emergency department.
  • The team have established a frailty network which meets fortnightly and provides an opportunity for a whole system frailty approach.
NHS Dumfries & Galloway and Dumfries and Galloway HSCP
  • An ageing well toolkit is in development with support from Public Health Scotland and Healthcare Improvement Scotland. This aims to support health and social care staff in educating the public on ageing well. The toolkit will begin with a focus on physical activity.
  • The use of the Rockwood clinical frailty scale is being tested in a community rehabilitation and reablement home team.
Perth and Kinross HSCP and NHS Tayside
  • The team aim to improve frailty identification and assessment in Perth Royal Infirmary and transitions of care into the community from the acute frailty ward.
  • Their improvement work is informed by patient experience through journey mapping.

 

Feedback from the teams

Interesting to see how others are on their journey and how they are feeling regarding different aspects." Project surgery attendee

Next steps (April to June 2024)

  • The second meeting of the delivery group will be held on the 29 April.
  • Remaining site visits are planned for April.
  • The third in person learning session will take place on 8 May.
  • The next meeting of the frailty and dementia advisory group will be held on the 13 May.
  • A webinar for the national learning system on ageing and frailty: draft standards for the care of older people, will be held on the 22 May.
  • The next round of data submissions are due in June.
  • The next project surgery is planned for the 12 June.

 

Contact us

Email: his.frailty@nhs.scot