Hello, my name is Renee
I’m delighted to write my first blog for the Partnership and especially around the important theme of frailty. Frailty is mainly related to the ageing process. It describes how our bodies gradually lose their in-built reserves, leaving us vulnerable to dramatic, sudden changes in health triggered by seemingly small events such as a minor infection or a change in medication or environment.
I have been working within frailty and older people services for over six years, as a matron, nurse consultant and head of frailty services whilst gaining my Fellowship in Older People at Kings College.
As you can imagine I am passionate about both frailty and older people and 100% committed to ensuring people live well with their diagnosis of frailty in their older years. It’s important to note that these terminologies are different as frailty does not mean you are old and being old does not mean you are frail.
It’s heartening to know that frailty as an area of service need is attracting a greater focus for organisations and services across West Yorkshire and Harrogate, similarly to other areas of the UK. As our population is ageing and developing increasingly complex needs, it absolutely makes sense to concentrate our collective efforts.
At Calderdale and Huddersfield Foundation trust (CHFT) we have responded to the increased needs of our community and invested heavily to develop our care for older people and frailty, working together to deliver the aspirations of the NHS Long Term Plan, and also the ambitions of the Partnership’s Draft Five Year Plan, which includes providing planned care for frail people in the care setting they choose be that their home, residential or nursing home or hospital.
I was keen to develop our services to improve the experience and health outcomes of people and their carers and have found that key to our success has been working in partnership with a wide range of stakeholders including those within the 3rd sector, and most definitely our expert patients and carers!
Calderdale and Huddersfield have a diverse population with a high level of older frail people. As a champion for older people, I feel our frailty journey at CHFT really picked up pace when we joined the Acute Frailty Network (AFN) in September 2016. Joining the AFN helped shape the service, and assisted me in keeping the patient at the heart of service redesign.
We focussed on people’s experience and walking the frailty patient journey to ensure all stakeholders within the network shared our vision. To embed quality as the driving force for service redesign we found it useful to develop initial key performance indicator (KPI’s) which were aligned to the frailty service. This enabled us to design a team focussed on quality improvement, driven by insight and expert knowledge to improve outcomes for people.
Key to the success of our developing services has been our approach to collaborative working. We brought together a team of experienced healthcare, social care, mental health care and voluntary sector professionals to form a robust multi-disciplinary meeting. These meetings discuss patients in our care twice a day from across all services that a frail patient accesses.
As the Head of Frailty Services these meetings have been critical to ensuring our goals are aligned, whilst remaining grounded on the aspects of life that are less easy for some people to control and without our support and those from other organisations they would struggle to live well with frailty.
A significant learning curve was to recognise the education requirements for colleagues and members of our community to be able to identify when someone is becoming frail.
I developed the team to deliver education to all acute hospital areas and new starters as a priority to improve care. This includes all medical teams too, and more recently this training has been available to community service colleagues too.
We now have an education programme for all healthcare professionals across acute hospital care, community, care homes and the hospice for advance care planning, and are in the process of designing an education package specifically for care home staff to support them in their care for people who are frail.
Through mapping patient journeys we know that our frail population are at times utilising various services at the same time – and it’s not always as joined up as we would like it to be. It also showed us that not all services speak to each other or share information. Importantly, this lack of communication was impacting on the patient experience, with multiple visits to emergency departments (ED), calls to community services and Yorkshire Ambulance Service all going on at the same time.
It’s also clear that we need to better understand what frailty is and where a person is on their frailty journey to enable them to live well and to ensure we are meeting their needs.
Early identification enables us to promote healthy living and signpost to the right services. This helps to prevent people reaching a crisis point. For this we developed a frailty specific same day emergency care service (SDEC).
The SDEC service was a priority area as this was our response to reducing the poor patient experience and long waits frail patients had in the emergency department. By introducing this way of working we have seen a 10% reduction (accurate at Feb 2020) in breach times compared to those prior to the formation of the SDEC, resulting in shorter and more comfortable waits for these vulnerable people. It has also resulted in an improved service for people who receive holistic care from a multiagency team of professionals and services, rather than one limited team in the ED. The development of the SDEC has been an intervention which really has delivered improvements for people in a timely and holistic manner.
Through working together we now have the acute hospital trust, community services, social care, Yorkshire Ambulance Service and voluntary partners identifying frailty using the Rockwood Score.
Put simply we are all identifying frailty the same and using the same language, which in practice prevents confusion and differing diagnosis of frailty.
Within the first 12 months of starting the service we had a designed a robust frailty service in ED, reviewing all people identified as frail and within the criteria set within 30 minutes of arrival. We were able to see the impact this had on both patient and staff experience, with staff reporting that they felt they were given support to help care for frailty patients that were previously perceived as very complex and sometimes in the too difficult box for them to deal with.
Staff told us that they did not know where to start to unpick the complicated webs these vulnerable people had to navigate and felt due to the complexity they were often admitted to hospital. Staff felt they did not have enough knowledge to identify and arrange additional services to support them at home with either declining frailty or wrap around support during an acute hospital event.
During the last three and half years the frailty service has developed to provide:
- A robust service in the ED as anyone identified as frail by YAS using the Rockwood score is brought to the Huddersfield. The frailty team see each person within 30 minutes of arrival and start a plan which includes a comprehensive geriatric assessment which is completed by the multi-disciplinary team. If the person is not going to SDEC then they will still be reviewed and stay under our care.
- We triage all people that can potentially be discharged the same day into SDEC. The criteria remains broad as some people are very poorly, with some needing end of life care which is why we have an MDT working in SDEC to deliver the care and future planning.
- Recently we developed a Perioperative Older People’s Service (POPs); this is all about setting up a proactive service to make surgery safer for older people. The POPS@CHFT team provides a multidisciplinary preoperative risk assessment and optimisation, as well as proactive support for elective and emergency admissions throughout by working closely with the surgeon and anaesthetist. Outcomes from this service enhance patient’s experience, reduce unnecessary length of stay, better outcomes post operation and reduction in surgery
- There is a 22 bedded area that delivers care under the frailty team for the first 72 hours of the person’s admission. As soon as people are medically well enough to be discharged we have wrap around social care hours, community response services to enable them to continue to recover at home. We know that people are far less likely to decondition at home, than when they are in hospital
- Our frailty service wants to really push the boundaries and increase the number of frailty patients being offered an Advance Care Planning. This is firmly about giving people informed choices, including the opportunity to talk about what they would like to happen during their care and continuing these conversations, even to the point where they are able to plan a ‘good death’
- Frailty syndromes are not very well recognised across all healthcare profession. Our aim is to provide training for all new starters to our hospital trust including medical teams. On-going training to acute ward areas with community services being able to access this. We are also looking at how we further support care home staff with training and education.
- We are about to pilot a frailty clinic in one primary care network in Calderdale and Greater Huddersfield. We recognise that not everyone is able to come to clinics and we are currently looking at the role of digital for community teams that are out on visits. There are lots of opportunities to explore and we are just at the start of this important journey.
As our journey continues we remain flexible to any new areas of work that weren’t originally in scope. It’s fair to say we are open-minded.
Within a few months of the frailty service starting we realised that our end of life frail patients needed our support too – so we changed the criteria. End of life care is absolutely central to good frailty care given the high level of vulnerability to adverse outcomes associated with the condition.
In response to this we are making radical changes with the intent to ensure frail patients are offered an Advance Care Plan at the earliest opportunity so they can have full involvement in their future care, whilst ensuring their end of life wishes come true.
Advance Care Planning is everybody’s business and we need to further develop the skills healthcare professionals have to ensure they feel confident to have these conversations. We are developing a solution which would enable organisations working with different technology platforms to be able to access and share one platform to better support our partnership working.
I am hugely proud of the work of all involved to improve care for frailty patients. On average, every month the team see around 650 new patients and help 280 people to avoid hospital admission. As we know all too well, hospital is not always the best environment to achieve optimum levels of health.
I am also incredibly proud of our efforts to be inclusive. Our criteria to be cared for under the care of the frailty team remains broad, as we feel strongly that we should care for any frail patients as well as older people and those on the end of life care.
One of my greatest challenges has been to identify the right people, with decision making ability and the drive to act in a timely manner across a wide range of stakeholders and bring them together on a monthly basis to review our joined up approach to caring for those experiencing frailty. Whilst I felt anxious at first my confidence has grown as these meetings have continued to identify areas where we can work more effectively across organisations and support one another across localities to provide a better service for our patients. I feel great joy and satisfaction when we meet, discuss an issue, agree and action and 48 hours later we have made a change to the patient pathway improving outcomes almost immediately.
My next challenge is to work more closely with community colleagues to redesign frailty services within the community, including understanding the specific needs of Black Asian and Minority Ethnic patients and their families so watch this space for the next instalment.
Have a good weekend
Renee
What else has been happening this week?
Children and young people programme
The Children, Young People and Families Programme Board met this week. Presentations were received from the Mental Health, Learning Disability and Autism Programme on the work being undertaken around children and young people and from voluntary sector colleagues on programme engagement and support. It’s essential we have third sector involvement in all our children, young people and families’ work streams.
Key updates were provided on the agreed priority work streams which included; a workshop being held on the 28 February on ‘narrowing the childhood obesity gap/ healthy weight’ with all of six local places to scope out opportunities where we can work together at scale and the expansion of the ambulatory care work in Bradford across West Yorkshire. Following the commitment from the West Yorkshire Association of Acute Trusts for the ambulatory care work to be rolled out, funding was agreed at the Board for a project manager and dedicated clinical leadership time to take this work forward.
A proposal for a Young Carers Forum across the Partnership between the Children, Young People and Families Programme and the Unpaid Carers Programme to amplify the voice of young carers to ensure their views and ideas inform the work and delivery of each of the programmes key priorities, was supported. An engagement workshop with young carers, with voluntary sector support, to co-produce and design this forum will take place soon.
The importance of the children’s voice being part of our key priority work streams and how we ensure this happens across our whole Children, Young People and Families Programme, was discussed as a priority.
Joint Committee of Clinical Commissioning Groups: Public, Patient, Involvement Assurance Group
Lay members from the clinical commissioning groups met on Monday to receive an update on the Partnership programmes which are part of the Joint Committee of the Clinical Commissioning Groups work plan. Members received an update on the mental health, learning disability and autism programme and there was an update on the communications and engagement plan to support this work. Members also received an update on primary and community care; and the improving planned care programmes.
The Primary and Community Care Programme Board
Board members received an update on dental and oral health commissioning, highlighting key issues around inequalities, access and variation. Members welcomed discussion about how we can capitalise on the work already taking place across Yorkshire, and how to accelerate ambitions such as improving access and oral health promotion given the links the board has to primary care.
An interim update on the progress of the primary care network (PCNs) development support offer was provided. Members were keen to explore a way to learn from PCNs and our six local places (Bradford district and Craven, Calderdale, Harrogate, Kirklees, Leeds and Wakefield) to capture the excellent work taking place. An update against programmes of work delivered through the WY&H Primary and Community Care Workforce Steering Group was provided linking back to the commitments outlined in the Partnership’s Primary and Community Care Strategy.
Board members received a presentation from the unpaid carers programme, noting the outcomes of the 2019 GP Patients Survey. The survey illustrates the impact on long term health across all age carers, but also demonstrated that carers (especially young carers) were higher uses of NHS services particularly when GP services are not easily assessable. Top tips for young carers were shared. Members were keen to continue to support the unpaid carers programme and strengthen links within primary care.
Members of the Programme Board will be taking part in a board development session to review our role and purpose. This will take place on the 13 March. Our next board meeting will take place on the 14 April 2020.
Leeds City Region Healthtech MoU Leadership Group
We are working with the Leeds Academic Health Partnership to improve people’s health and care, and drive inclusive economic growth through better and faster healthtech innovation across the Leeds City Region. The Association of British HealthTech Industries (ABHI), along with the regional enterprise partnership and five universities, joined West Yorkshire and Harrogate Health and Care Partnership last year in signing a Memorandum of Understanding (MoU) to work together to achieve this. At this week’s healthtech leadership group meeting, we agreed the vision, mission, purpose, and a brand concept which will now be developed and tested. We also explored how we will achieve innovation at scale, secure and develop the right skills and talent and maximise opportunities for achieving quick results while we develop the longer term plan
Mental Health, Learning Disability and Autism Programme Board
The Programme Board meets today. Chaired by Sara Munro, CEO Lead for the Collaborative Board and CEO for Leeds and York Partnership NHS Foundation Trust, the programme is made up of colleagues from the NHS, council and community sector. Members will be discussing support for children and young people; a holistic approach to mental health with primary care; autism work; forensic services and suicide prevention.
Digital programme
The Chief Information Officers across West Yorkshire and Harrogate are currently in the planning stages for undertaking digital maturity assessments of each of the six local systems (Bradford District and Craven, Calderdale, Harrogate, Kirklees, Leeds and Wakefield). This is a progressive step towards system working and system digital maturity. These assessments are supported by various funding opportunities including the work to progress integration to the Yorkshire and Humber Care Record from the Health System Led Investment scheme. Discussions are also taking place around organisational planning to identify gaps in digital capabilities to achieve the Partnership’s Draft Five Year Plan ambitions.
The ‘Aging Well ‘ programme offers opportunities for the digital community to support this important work, to improve systems to support people to age well and live independently for as long as possible. Organisations are progressing their migrations to the new Health and Social Care Network (HSCN) from the legacy N3 Network. This work is picking up pace with support across the area around good practice.
Taking care of business (support for carers)
Wakefield’s Director of Public Health’s Annual Report ‘Taking Care of Business’ is targeted at employers in the district and focuses on working carers, for example people who are juggling work and providing unpaid care to a family member or friend who cannot cope without their support. One in seven of our colleagues provide unpaid care. This can have an impact on physical health, emotional wellbeing, their finances and can result in people having to reduce their working hours or give up work altogether. This has big implications for workers, employers, our district and the economy.
‘Taking Care of Business’ encourages employers to recognise that identifying and taking steps to support working carers has business benefits. This includes reducing absenteeism, retaining skilled staff, reducing recruitment/training costs, increasing motivation and productivity.
To achieve this ambition, the council is supported by ‘employers for carers’ digital resource from Carers UK which is now available free for Wakefield based employers. The online platform includes useful guides, e-learning for managers and staff, sample policies, best practice information, case studies, resources and information to signpost working carers to. Watch this powerful film to understand why this is so important on the website at www.
BIG shout out and thank you to…
...all partnership organisations for doing all they can across the area to keep people safe and well during the very wet weather. Examples being when two home care staff were carried by West Yorkshire and Fire Rescue Service across water to reach people needing their care. Firefighters also rescued a one-year-old and two baby twins from a flooded house in Elland, watch the film here. Thank you.