Ewa Pickersgill describes the success of a scheme aiming to reduce variation in care for people living with frailty
I am an advanced nurse practitioner working in West Leeds Primary Care Network (WL PCN), leading the Home Visiting and Aging Well Team. I qualified as a registered nurse over 22 years ago and have spent over 10 of them working with the frail population.
Over the years, I have a gained a lot of experience working both proactively and reactively as community matron in Bradford and Leeds, including a virtual frailty ward.
When PCNs were first formed in 2019, I was appointed to develop a service to support practices in delivering care as part of the enhanced frailty scheme. This scheme was introduced to optimise frailty care in primary care.
NHS England recognised that the number of people living with frailty is ever-rising, but the care they were getting was depending on where they lived. The enhanced frailty scheme was developed to reduce variation in care for people living with frailty.
The initial stage of the scheme was establishing patients’ level of frailty using the Rockwood score and eFI and obtaining comprehensive geriatric assessment for patient deemed severely frail (Rockwood 7 and above).
Challenges quickly emerged as patient coding that had been done by practices varied widely, and some had better systems then others.
Some patients were coded using information already in individual patient medical record and others have been coded during clinical intervention. The latter had better chances of accuracy but depended on clinician skill set, familiarity with Rockwood score as well as patient wellbeing on the day.
We recognised that frailty can be fluid and vary between moderate and severe. Often frailty worsens during an episode of acute illness.
When we started visiting patients coded as severely frail in their own homes, we soon found that many were in fact moderately frail and not actually housebound. Following this, we introduced clinics for moderately frail that are held in GP surgeries. Bringing patients to clinic helps encourage patients to remain active and allows us to improve efficiency and see larger population.
All assessments look at the patient including a falls assessment and medication review. We do not hold caseload, but treat every assessment as an intervention. Each intervention is completed when a plan is achieved – by us or other appropriate team within primary or secondary care, community teams or third sector. We liaise with stakeholders in view to deliver high standard care which is comprehensive and joined and reduce unnecessary duplication.
We have weekly MDT meetings led by a consultant geriatrician where we can discuss any cases, we have concerns about. This allows us deliver fully comprehensive care and reduce risk of admission. Patients often are referred to other professionals depend on their needs both acute and chronic.
The main purpose of West Leeds PCN frailty team become supporting both frail groups in living independently as long as possible. We put big emphasis on health promotion and education including advanced planning and resuscitation.
Having recently audited the service: has it been worthwhile? The simple answer is yes.
Without intervention, both health and quality of life are likely to have deteriorated in this group of patients; as a result they are likely to have suffered an adverse reaction such as hospital admission or trauma related to falls. This puts additional pressure on hospital, GP and care services.
Patients with frailty are very complex, it is hard to evidence improvement by looking at numbers taken from reports alone. We found that in the year following frailty intervention, the amount of healthcare contacts the patient received didn’t change. There could be lots of factors affecting this; the main one is the natural progression of frailty and approaching the end stage of life. However, we can see massive differences in the patient’s quality of life as well as increased trust in healthcare professionals. They become ’seen’ and ‘heard’ by the healthcare system and have a chance to discuss plans for the end of life.
I believe that this work is essential for everyone, and that moderately frail patients are likely to benefit more. Prevention is better, both financial and on resources. By giving patients and their families the skills and tools to prevent and pick signs of frailty and ownership of their health we can improve population health as well as NHS services. Working proactively in this way is also rewarding for staff, something not currently the case in other areas of the NHS.
Ewa Pickersgill is advanced clinical practitioner; home visiting and aging well team leader for West Leeds Primary Care Network
