Nationally around 10% of people aged over 65 and 25-50% of those over 85, have a diagnosis of frailty. Approximately 5-10% of people attending accident and emergency departments are older and living with frailty, leading to more than 4,000 daily admissions for falls, minor infections, medication side effects and other conditions related to frailty. However, frailty is not an inevitable part of ageing. If identified early, proactive and anticipatory care can minimise the risk of deterioration and associated loss of independence.
In Lincolnshire, 12.5% of the county’s population meet the electronic frailty index criteria for mild, moderate or severe frailty (August 2023). Lincolnshire integrated care system (ICS) recognised that different services and care pathways designed to support people with or at risk of frailty were not coordinated and medical care was focussed on managing patients with single conditions. To tackle this, the ICS’s clinical and care directorate identified a need for a system-wide frailty strategy that would support the Lincolnshire community to ‘live well, age well and die well’.
The approach
Lincolnshire ICB commissioned Arden and GEM’s clinical support team to help develop the frailty strategy, working closely with the head of strategic development for frailty. Our shared intention was to create an integrated strategy that would bring together disparate services and pathways and provide coordinated, patient-focused care that would improve quality and outcomes for Lincolnshire’s growing frail population.
We engaged with a wide range of stakeholders who we identified as crucial in co-developing the strategy content. This included leaders and representatives from the ICB’s population health management, engagement, strategy, planning, data and analytics teams. Primary and secondary care services and the third sector were represented by:
- A matron from community services
- Consultant nurses for frailty
- Surgery frailty coordinators
- Special interest GPs
- Ambulance services
- County council older adults services
- Age UK.
We set up five themed workshops to enable collaborative input into the strategy, including hearing directly from service users thanks to support from Age UK. Specialist input was also sourced from outside the system, including:
- Learning and best practice from Nottinghamshire ICS’s Ageing Well Programme Director, drawing on their established frailty strategy
- Insight from the Getting it Right First Time (GIRFT) programme from the clinical lead for geriatric medicine at Guys and St Thomas’ NHS Foundation Trust
- Expertise from NHS England’s national intensive support team.
The workshop outputs included agreement on strategy objectives, a roadmap of how to achieve these and frailty performance metrics.
Leadership and workforce
Recognising the importance of ongoing system-wide collaboration, we established a leadership group to take the strategy forward. This includes senior leaders from the ICB, county council, primary care, community services and acute care, all working to agreed terms of reference. This group was responsible for decision-making throughout the strategy development and continues to oversee implementation now it is in place.
Outcomes
The system-wide Lincolnshire Older People’s Five Year strategy is now in place. It sets out how the system will deliver proactive care to help keep over 65s living well and independently for longer and provide appropriate and seamless care when further interventions are needed.
The strategy clarifies how people experiencing frailty will be identified and the care that will be provided by a community multidisciplinary team using evidence-based tools and assessments including the comprehensive geriatric assessment. Crucially, the strategy recognises the importance of an integrated workforce to support care pathways that cross organisational boundaries.
The strategy also makes provision for additional support where population heath needs and inequalities indicate it is required, such as in care homes, some geographical locations and for some population segments.
Since adopting the strategy, we have already implemented two key roadmap initiatives:
- Falls prevention training for staff in 80 Lincolnshire care homes, focusing on the use of new lifting equipment used with residents who have had a fall.
- Standardised frailty tool use. The Rockwood Scale is now in use across the ICS, which is aligned with the new strategy and pathway, and uses a simple approach to categorisation to enable GPs to spend less time recording and more time talking with patients.
Outcomes and learnings
With a new system-wide frailty strategy in place, patients in Lincolnshire can now be referred into the right service, with equity of access and improved health and wellbeing outcomes. The resulting transformational change programme has improved quality of care and patient experience and strengthened prevention and early intervention.
Ongoing monitoring captures the impact on a range of patient outcome metrics including reductions in frailty severity and non-elective care as well as increases in access to preventative care. Wider impacts are also being assessed including improved patient and family experience and better workforce stability.
Key learning
In developing this strategy, the following elements stand out as critical to its success:
- Co-development with stakeholders: The time invested to ensure all key stakeholders had an opportunity to input was crucial in developing a strategy that would work in practice, recognising the silos and overlaps that existed prior to the new approach.
- Data-driven decision-making: Including senior analysts throughout the process helped to ensure discussions and decision-making were data-driven and that metrics were meaningful, covering patient outcomes as well as service and workforce measures.
- Integrated workforce: Planning for how the workforce would need to change and be supported to work differently has helped enable initial roadmap initiatives to be delivered swiftly and successfully.
- Collective leadership: Senior level, system-wide leadership has been crucial in driving forward key decisions and ensuring individual organisations adapt to support the new integrated approach to managing frailty.
By Sarah-Jane Mills, Director for primary care and community and social value, NHS Lincolnshire integrated care board and Roz Baker, clinical lead nurse, NHS Arden and GEM CSU
