Interested to know why over 75 was used as a cut off, this seems older than others?

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
We are trying to screen patients who are 65 years and older from care homes, and 75 years and over from other settings. There will be people with frailty who are younger. It is a starting point, and we recognise it has its deficits. We are being selective initially, recognising the disadvantages of that, to get us up and running. Hopefully, we can be broader in terms of our catchment in the future.

Are there any examples of the voice of social care being represented in the planning of frailty services?

Dr Elinor Burn, Senior Geriatric Medicine Registrar, Leicester Royal Infirmary:
Having structured quality improvement meetings throughout the development of frailty services, including the community voice, has been advocated by many sites consulted. Leeds demonstrates this well but recognises the added complexity and differing agenda when discussing from a health service perspective to a social care perspective.

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
Social care and partnership teams are integral to our work and represented as part of our frailty network and frailty strategy.

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
We have had social care representation in our key stakeholder group. We also have social care representation at our comprehensive geriatric assessment (CGA) Huddles.

Are there examples of good practice in smaller rural hospitals?

Dr Elinor Burn, Senior Geriatric Medicine Registrar, Leicester Royal Infirmary:
Wales based teams have some good examples of adapting to their more community-based approach. Other, more rural sites have used ideas such as creating a frailty unit in a community hospital, rather than the main hospital, or had a separate smaller area within the emergency department (ED) for assessment. It is what is suited to the environment you already have and accepting what your population base is, which is very variable across the four nations. What intervention can make the biggest impact to how your healthcare network functions?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
Our three acute sites are fairly large district general hospitals. These feed into 8 community hospitals, mainly for stepping-down patients We’re also exploring the option of being able to step-up more frail patients from the community and occasionally do so with Hospital at Home patients to avoid busy EDs where appropriate.

Could you explain what the district nurse frailty scoring is?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
Hazel Gilmour our frailty nurse consultant is targeting district nurse groups across Lanarkshire and educating on frailty work and promoting Rockwood clinical frailty scale (CFS).

Where is the CFS recorded for patients and how is this shared with the multi-disciplinary team (MDT)? Is it shared with patients too?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
This is a challenge we are facing as our electronic systems don’t talk to each other. We are trying to get the coding right so that frailty is shown up in past medical history following discharge, so the GP and district nurses are able to see this. 

Streamlining frailty screening so all acute sites are doing the same and non-medicine of the elderly teams are engaged with screening is a priority area but a work in progress. The frailty network is working with Trakcare staff to try and simplify electronic frailty screening.

Scottish hip fracture audit (SHFA) are developing CGA recommendations - does anyone have any policies already in place?

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
We have done some work on a frailty assessment proforma looking at the key components of CGA. We are keen not to make it a tick list and ensure that CGA is a process. It should be regarded as an information gathering exercise to inform the CGA process.

Is risk of malnutrition also being considered alongside Rockwood score in units? are you using MUST, patient association checklist? something else?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
We have been in touch with some dieticians in Lanarkshire to seek advice. Most will see a dietician as an inpatient if a high malnutrition universal screening tool (MUST) or food record chart and weight are concerning. This is harder to gauge in the community. There are no nutritional guidelines just now, however the strategy was created with dietician involvement. 

Do you have any SOPs or ways of working or documentation re CGA huddles between acute and community that you could share please?

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
We don’t have a standard operating procedure (SOP) for the CGA huddles, but some key things are to make them available and accessible for all, members can come along in person or via MS Teams. Also ensure an agreed structure, starting time and duration so people know what they are committing to and can plan to factor it into their day.  

Could the frailty assessment proforma you developed in Glasgow be shared please?

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
The frailty assessment proforma is a work in progress so maybe not quite the time to share, but certainly could in the future. The British Geriatrics Society website has some good details on key components of CGA which may be helpful.

Do frailty teams do nutritional screening /provide nutritional signposting or first-line advice? Are any measurable outcomes such as hand grip strength done within the teams - acute or community?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
We have been in touch with some dieticians in Lanarkshire to seek advice. Most will see a dietician as an inpatient if a high MUST/food record chart and weight are concerning. This is harder to gauge in the community. There are no nutritional guidelines just now, however, the strategy was created with dietician involvement. 

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
Within the acute setting, we record a MUST score and make dietetic referrals as required for each patient as part of the CGA. We do not use hand grip strength as an outcome currently within the acute setting.

What metrics are teams using to show benefit from front door frailty and CGA? Is there a standard recommended dataset?

Dr Elinor Burn, Senior Geriatric Medicine Registrar, Leicester Royal Infirmary:
Bed days saved is a common surrogate marker for efficiency saving, but frailty services manage a complex cohort which doesn’t easily fit into these metrics.

NHS Benchmarking are looking to expand their frailty dataset, but frailty services work is already being collated in other national audits e.g. society for acute medicine benchmarking audit (SAMBA), so there is concern with duplication of this dataset between audits. A national dataset bespoke for front door frailty is yet to be established.

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
We’re currently refining our own set of metrics which cover acute areas, off-site areas, rehab teams, social work teams, care home patients and frailty identification.

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
I would suggest frailty screening rates, time to CGA/specialist care, access to specialist bed/care, discharges with 24 and 48 hours, destination on discharge, length of stay and readmission at 7 and 30 days. Not to forget patient, carer and staff experience.

Are SAS playing a part in the community within Glasgow area? CGA is well within the capability of their advanced paramedics. They often are dispatched to patients who fall.

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
Linking in with our Scottish Ambulance Service (SAS) colleagues is going to be a key component.

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
Lanarkshire are looking to build relationships there to avoid admissions and give advice to start CGA as part of the flow navigation centre plus (FNC+) work and virtual wards as part of a joint approach. Also creating the correct pathways so that they can access support and do this safely. There is appetite there, but this is a work in progress.

Are you able to share your frailty sign competencies?

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
The frailty competencies have not been finally agreed at this stage, so, unfortunately, we are unable to share them at the moment.

Who makes up the frailty team? Is there a theme on the specialists involved?

Dr Elinor Burn, Senior Geriatric Medicine Registrar, Leicester Royal Infirmary:
No one size fits all and it is dependent on the staffing available and to complement the other teams and services are already established. Many sites consulted use ‘role-blurring’, e.g. between physio and occupational therapy, to ensure the breadth of a CGA review is deliverable even when staffing is not ideal.

Commonly teams can include a range from: consultant geriatrician, consultant physician with specialist interest (WSI), GP WSI, advanced clinical practitioners, frailty consultants, physiotherapist (PT), occupational therapist (OT), frailty pharmacist, discharge practitioners, speech and language therapists (SALT) to name a few.

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
Broadly multidisciplinary. On site on a day-to-day basis there are medics, nursing staff, allied health profession (AHP) staff, frailty practitioner. In terms of CGA huddles we link in with frailty practitioners in the community, and they in turn link in with the rehab teams. We have some links with our assessment and rehabilitation centre colleagues in terms of rapid access clinic slots. We link in with social work. We have pharmacy representation at the CGA huddle plus discharge coordinators and psychiatry colleagues. Lots of these people have been able to give us the context of what has been happening with these patients in the community, it has been really invaluable. We can also learn about each other’s services and way of working.

How could you enhance your community connections? How are your huddles progressing?

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
The huddles are progressing well, and engagement has been good. They have facilitated the development and enhancement of working relationships and helped promote partnership and integrated working. Further they have helped provide an early focus and goal setting plus early consideration of alternatives to admission. They promote a team approach. There are key partnerships still to build and partners to involve. It would be good to link in more with GP teams and primary care services and have a link with third sector representatives.

Where there any additional community services to support this team achieve the improvements?

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
No additional resource or support. It was about reaching out and linking in with our colleagues and building relationships. We have also just tried to change our way of working with the resource we have at the moment.

Admitted to ED from care homes is a risk factor, should it also include community hospitals?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
The option to step-up care home patients to community hospitals is something we’re looking at although our preferred model, which we have a lot of success with, is Hospital at Home supporting these patients and avoiding hospital conveyance.

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
Certainly think it would be useful to capture this with the caveat that the nature of community hospitals can be very varied in terms of the patient group/ set-up etc.

Did you have any additional resource for AHP's to achieve your outcomes with earlier AHP assessment etc or was this due to altering ways of working?

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
We have not had any additional resource so far for this work.  The Frailty Practitioner post was created out of money from a vacant post within the same team. Much of the success so far has been changing the ways of working within this area and we hope this will continue.

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
We have integrated rehabilitation teams in the north and south of Lanarkshire who help support frail patients at home. But there’s no denying rehab resource is tight both in acute sites and communities, so we need to be clever how we use this and avoid duplication of efforts. Our only extra resource has been a frailty AHP in one of our EDs who has made a fantastic difference with earlier CGA, increased frail discharges and reduced time to first assessment (TTFA). This is a one-year secondment which we’re trying to convert to a substantive post across the 3 acute sites.

Where do out of hours services sit within the systems?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
This is a work in progress. The interface division has been newly established and is linking in with out of hours. We are very aware of the impact the out of hours can have on the emergency department.

Is the FNC a single point of contact (SPOC)? If so, is it bidirectional i.e. SPOC into acute services plus SPOC out into community?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
FNC is a central point of contact from outside for all our referrals where there is a set of staff from various backgrounds who have experience of triaging patients and working out where to send them, but they are not clinicians. What we are trying to do is bolster it with clinician input and learn from the Tayside model so ED teams are now inreaching as are care of the elderly.

We don’t have a central point of contact for our localities yet, but we have locality response teams in North and south Lanarkshire which are a work in progress, but we see it as a good opportunity for trying to redirect admissions or discharge patients early with wrap around support that will prevent readmission.   

For the teams with established frailty systems - were there well embedded rehabilitation models in place alongside the developing frailty services? Capacity can be challenging for us all so it would be useful to understand if there was additional staffing resource for rehab in the community or if it was redesign of services?

Dr Elinor Burn, Senior Geriatric Medicine Registrar, Leicester Royal Infirmary:
Again, this is related to what the system has already in place. Whether an established community hospital network for rehabilitation where further investment for increased capacity is an option, or a network that focusses more on home-visiting and community therapy sessions where investment into a virtual ward or community therapy response has more traction.

Often the focus is primarily on the services at the front door of hospitals initially, and this then demonstrates the needs of the service and the factors creating exit block e.g. restricted community rehabilitation beds.

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
Yes we have integrated rehabilitation teams in the north and south of Lanarkshire who help support frail patients at home. But there’s no denying rehab resource is tight both in acute sites and communities, so we need to be clever how we use this and avoid duplication of efforts. Our only extra resource has been a frailty AHP in one of our EDs who has made a fantastic difference with earlier CGA, increased frail discharges and reduced TTFA. This is a one-year secondment which we’re trying to convert to a substantive post across the 3 acute sites.

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
We already have well established rehab wards offsite and community rehab teams.

How do you think the NHS frail strategy and the getting it right first time (GIRFT) report has changed the landscape in NHS England?

Dr Elinor Burn, Senior Geriatric Medicine Registrar, Leicester Royal Infirmary:
It helps to highlight the importance of these frailty interventions and demonstrate that it is a priority for NHS England. There is a focus that developing frailty services, including frailty same day emergency care (SDEC), is on the national agenda. This can be used as a motivator for developing trusts.

What has your frailty strategy enabled you to do that you didn't do before?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
It’s early days in our frailty journey but our main focuses have been around understanding what’s happening in the world of frailty in Lanarkshire and delivered by who; networking with other individuals and teams; opening up conversations around worthwhile work and stumbling blocks here and really looking to join up care/pathways across a wide, varied landscape.

What qualification is the frailty practitioner in GGC?

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
There are a number of advanced frailty practitioners in NHSGGC, mainly in community, but a few in acute sites. Most are experienced AHPs or nurses. They are working towards trying to pull together an MSc qualification. There are currently four MSc modules we are required to go through to be signed off as an advanced frailty practitioner.

In terms of resources, we are not as well staffed as we would like to be in terms of our frailty assessment area. GRI is slightly different in that we already had an existing front door frailty team, so this is in addition to that team. We are trying to do what we can with the staff that we have and show that that has a positive impact, which will hopefully lead to more resources in time.

What masters modules are you required to complete?

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
We are being asked to complete 4 modules at Glasgow Caledonian University, each worth 15 credits to gain a PgCert.

The modules are:

• Applied pathophysiology for advanced practice.
• Advanced clinical assessment and decision making in acute and primary care.
• Supporting anticipatory care for long term conditions.
• Work based advanced skills and innovative practices 1.

What is the range of AHPs involved in the frailty teams?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
We are trying to build on the interface model with frailty AHP and frailty healthcare support workers (HCSW) in EDs, supporting frail discharges with good community links to help with this. Early days with only one one-year secondment team at UHW so far but excellent data to support their work.

Then in our acute sites, University Hospital Monklands (UHM) and University Hospital Hairmyers (UHH) each has a frailty unit with one away to open at University Hospital Wishaw (UHW), with AHPs embedded here and key to trying to optimise function and pursue Home First approach where appropriate.

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
With us we have an advanced frailty practitioner (physio), and a Band 6 OT.  We also have links to the physiotherapists and occupational therapists in the downstream wards, Acute Rehabilitation Centre (ARC) and Community Rehab Teams.

Is there any advice you could give to smaller Health boards? Especially with a high population of over 65s

Dr Elinor Burn, Senior Geriatric Medicine Registrar, Leicester Royal Infirmary:
To focus on the systems that already exist and how to complement them, rather than trying to imitate an established urban frailty service where the makeup of the hospital system, community network and population is likely to vary greatly.

Wales based teams have some good examples of adapting to their more community-based approach. Other, more rural sites have used ideas such as creating a frailty unit in a community hospital, rather than the main hospital, or had a separate smaller area within ED for assessment. It is what is suited to the environment you already have and accepting what your population base is, which is very variable across the four nations. What intervention can make the biggest impact to how your healthcare network functions?

As the frailty services described appear to be a redesign of current services, what are the impacts on the other parts of service delivery that haven't been prioritised - what impact on patients?

Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty Associate Medical Director, NHS Lanarkshire and North Lanarkshire HSCP:
As part of our risk register, we consider potential harms with development of new services. However, our approach is pan-Lanarkshire and very whole system focused, looking at acute and community services so hopefully picks up on any neglected areas.

Dr Laura Duffy, Consultant Geriatrician, and Erin Walker, Advanced Practice Physiotherapist in Frailty, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary:
We continue to work under pressure and as with most places we absolutely require more resource to meet the demand within the system, but we are starting to see the benefits of pro-active AHP input for patients in terms of reducing length of stay etc.  We have seen that by streamlining these patients living with frailty more easily (because they have been correctly identified) they are reaching our downstream areas more promptly therefore are also then able to access specialist medical, nursing and AHP input more quickly in this way so there have been potential benefits for all patients within the system.