Working together to make a difference for people with frailty in Oban


by Laura Dobie, Knowledge and Information Skills Specialist

In December 2017 some of our team went to Oban to learn about how partnership working and a focus on prevention and early intervention is having a positive impact on outcomes for frail older people.

The Oban multidisciplinary team

It is 20th December, and the meeting room at Lorn Medical Centre is packed with colleagues from across health, social care and the third sector. This is what it is like every Wednesday morning, except for the festive touch of the mince pies on the table. It is amazing to see the turnout for this frailty multidisciplinary team meeting, and to learn more about people’s backgrounds, and the skills and knowledge that they bring to the table.

The team meets every Wednesday morning to discuss patients with mild, moderate and severe frailty, and this work is bottom-up and clinician-led. The team is truly multidisciplinary, with representation from social care and the third sector: in addition to GPs, nurses, physiotherapists, occupational therapists, pharmacists and dietitians, a social worker, an exercise professional and the centre manager from North Argyll Carers Centre join the weekly meetings. The team are also supported by an administrative assistant and the practice manager, who runs the electronic frailty index (eFI) on the Vision system. They have also been looking at SPARRA and high health gain data.

The team reported that they get together every week to share information in this way because they find it valuable, not because they have been told to work in this way.

‘The hour spent is much more valuable time spent than the previous way of working where it could take you all week to get in touch with someone.  Now you can have that face-to-face conversation and many issues are solved more quickly.  It has prevented duplication of referrals and assessments.’

Reablement project

Derek Laidler, Physiotherapy Team Lead, gave us an overview of the Oban reablement project.

Reablement services in Oban are delivered by Healthy Options, a social enterprise. Healthy Options offer interventions for people who are pre-frail. People who are at risk are referred to Healthy Options, and the aim is to build resilience and support the person to prevent decline. The project was a response to funding constraints in primary care and the pressures of increasingly complex patients and an ageing population. It is a demand-reducing model, rather than capacity-increasing.

Healthy Options used to be very much based in Atlantis Leisure Centre. However, there are now classes in villages that people are able to attend. The support offered is both physical and social, and deals with the whole person. This collaboration with the third sector has been in place in the area for a number of years.

Staff use the eFI and the Edmonton Frail Scale to identify people with frailty and direct them towards appropriate support. 100 people have been identified through case finding, and people are referred into the project through clinician concern.

The Oban Living Well initiative is a mild frailty rehabilitation and reablement approach, and the Active and Independent Living Programme has been a driver for the programme.

Derek explained that most physiotherapy referrals are made at a crisis point, which is reactive, and that the benefits are not as long lasting as intervening at an earlier stage: if people go on an exercise programme to maintain the ability to walk 400m, they retain this ability for two and a half years, whereas the benefits of intervening at a later stage and helping people to regain the ability to transfer themselves from the toilet only last six to eight weeks.

The project staff consider that we should be intervening before people are on the Lifecurve, and have produced a list of activities above the Lifecurve, where people should be targeted with early interventions.

Lifecurve slide

Healthy Options would intervene when people are struggling to run half a mile, or run to catch a bus, and physios would intervene when people are having difficulties climbing stairs and getting up from the floor. There is still a role for Healthy Options with very frail patients, but it is limited. However, they can make people who are mildly frail better.

Derek presented some case studies, which demonstrated how exercise programmes delivered by Healthy Options are reversing people’s frailty scores and improving their health and wellbeing. One older gentleman has regained the ability to take the bus independently and engage in social activities again, while an older lady who was afraid of falling now has increased confidence and improved gait and posture after completing a 12-week exercise programme and attending strength and balance classes.

Lianne McInally from the team visited a lady who had been though the programme recently.  The lady had a one-to-one assessment by a specialist physiotherapist and support from an exercise instructor to complete a home exercise programme based on OTAGO. The lady reported that she had made improvements in her strength and balance and noted a difference getting in and out of her chair. She also reported increased confidence walking further distances, and has agreed to attend the local leisure exercise class now that she was more confident to go outdoors. A buddy system exists, whereby the individual is paired with someone else from the class. Motivation to attend classes can be poor, particularly when a person is not comfortable initiating conversation, and the buddy system appears to make a difference, encouraging people to attend.

Moderate frailty project

Pauline Jespersen, Advanced GP Nurse, described the moderate/severe frailty project, which is running from October 2017 to March 2018. It is being delivered by four GPs (three qualified GP trainers). The project lead is a district nurse, and a physio, OT and pharmacist are also involved in the project. So far they have scanned 80 patients.

Their referral pathway takes a whole-system approach:

  • Edmonton frail scale score 0-5 – Healthy Options
  • Edmonton 6-7 vulnerable, 8-9 mild frailty – physio, Lorn and Islands Hospital reablement team
  • Edmonton 10-11 moderate frailty – Lorn Medical Centre.

The team are aware of all the options in the third sector and can pass on a referral, where appropriate. Their assessment form records people’s conditions, social circumstances and medication, and they are also using the DeJong Gierveld Loneliness Scale as part of the assessment process.

They have a meeting at 9am on a Wednesday, where they discuss the patients that were identified the week before. The frailty team then have a huddle to allocate work. The team double up to mentor staff and support them with enhanced assessment. Visits for enhanced assessment are an hour minimum.

In the afternoon they have a feedback huddle. In some cases they may need to do de-prescribing, and pharmacy assistants help to manage the change and take away old medication. They have been carrying out evaluation with patients and staff. There have been clinical and MDT tutorials, and nurses are doing formal educational modules. Oban has lost a lot of advanced nurses in recent years, so upskilling staff has been an important part of the project.

The process is as follows:

  1. Advanced clinical assessment
  2. Edmonton frail scale
  3. Polypharmacy review
  4. Loneliness questionnaire
  5. Checking ACP and DNACPR are in place
  6. MDT discussion of findings
  7. Interventions
  8. Evaluation

Although the team have seen 80 patients so far, they reported that there have been a lot more than 80 contacts. The initial assessment that is conducted is accepted by everyone – they do not have different groups of professionals coming in and conducting their own assessments. Secondary care is involved in the management of moderate and severe frailty, and advanced nurses work across primary and secondary care. There is an emphasis on home care and avoiding hospital admission.

Healthy Options

We then went on to visit Healthy Options to learn more about their work. This social enterprise clearly demonstrates how a community-owned resource can meet public health needs. In addition to supporting the reablement programme, they also support other initiatives within the community.

Roy Clunie, one of the directors, observed that there is a growing number of people with chronic conditions, and many of these people’s conditions could be managed or improved through a change to a healthy lifestyle.

Healthy Options was established by the community, and staff are drawn from the health, business, fitness and community sectors. A public health dietitian, Jacqualin Barron is seconded to them one day a week. Healthy Options, Atlantis Leisure Centre and health professionals all work in partnership. The Healthy Options staff are highly qualified, and are entitled to attend NHS training courses.

We went on a short walk from the Healthy Options offices to Atlantis Leisure Centre, where we were able to see some of their staff working with clients. One older gentleman was working on the treadmill and cross trainer in the gym, under the instruction of trainer Kirsty, while two ladies were doing a seated exercise class in the dance studio. All of them were very enthusiastic about the support that they were receiving, and the beneficial impact that it has had on their health.

Healthy Options have worked with Atlantis Leisure Centre to make the gym more welcoming for people who are not typical gym goers. The centre manager removed some of the exercise bikes from the gym to create more space and make it easier for people with a high BMI to use the facilities. The consultation process is co-produced, and people can choose the activities that interest them, whether this is swimming, classes or going on the rowing machine. They offer supervised gym sessions and a healthy living outreach programme at the MS Centre.

In addition to delivering a reablement programme and self-management support, Healthy Options is also working with vulnerable social housing tenants, and they have a part-time health liaison officer. They are also working with partners on a healthy village pilot in Taynuilt, with falls prevention, Healthy Options exercise and classes, tai chi and a self-management class.

An example to develop in other areas?

It is clear that the Oban frailty project’s prevention and early intervention approach is having a positive impact on people with frailty, helping them to maintain their independence and keep up with all the activities that they enjoy, from singing in the choir to walking football. By working together across the whole system in a genuine partnership, and involving a third sector partner that is able to offer tailored support for people in the early stages of frailty, Oban is meeting the challenges of population ageing head on, improving the health of its inhabitants, and supporting people to live as well as they can at home, for as long as they can.


Testing the eFI in Scotland: focus on Midlock GP practice


Some members of the Living Well in Communities and Midlock teams at the NHSScotland event

The Living Well in Communities team is working with Health and Social Care Partnerships in Glasgow City, West Dunbartonshire and Midlothian to test the electronic frailty index (eFI) to identify people over 65 who are living with frailty in the community. The Living Well in Communities team have developed an assets-based approach to support evidence-based interventions that are tailored to the individual. This article looks at the work to date with Midlock GP practice in Glasgow.

The testing in Midlock GP practice

The eFI uses GP read codes to calculate an individual’s degree of frailty and stratifies them into fit, mildly frail, moderately frail and severely frail. The tool has been validated in England. The purpose of testing at Midlock GP practice was to determine if the tool was accurate in a Scottish context. We have been working with a GP and other members of Glasgow City HSCP, including housing and the voluntary sector. The testing involved stratification of the GP population for frailty and reviewing case scenarios to determine if the eFI tool fits with a Scottish population. Continue reading “Testing the eFI in Scotland: focus on Midlock GP practice”

Using a population screening tool to identify people with frailty in the community: the e-frailty index


by Laura Dobie, Knowledge and Information Skills Specialist

The Challenge

A person with frailty can experience serious adverse outcomes following even a relatively minor illness. Timely identification of frailty can help to reduce the likelihood of a poor outcome following an intervention (or eliminate the need for an intervention entirely) and support the long-term management of people’s health needs.

If we can identify people with frailty in the community, we can offer preventative support that could improve their quality of life and reduce the risk of unscheduled admissions.

There are a number of tools which professionals can use to screen people for frailty (see the British Geriatric Society’s Fit for Frailty guidance). However, many of these tools are based on questionnaires that require practitioners to have direct contact with individuals and can only be used to assess people who are actively engaged with services.  It would be resource-intensive and challenging for services to screen large population groups for frailty using these individual assessments.

The risk stratification tool, Scottish Patients at Risk of Re-admissions or Admissions (SPARRA) identifies individuals within the whole population at risk of hospital admission based on nationally-collected data on acute admissions and community prescribing.  However, it does not discriminate frailty from other high-risk population groups and can only identify individuals who are known to services, as they have had recent acute admissions or have been prescribed high-risk medications.  Alternative population screening tools are needed to identify people with frailty living in the community. Continue reading “Using a population screening tool to identify people with frailty in the community: the e-frailty index”

How care homes in Argyll and Bute are working to reduce falls

By Laura Dobie, Knowledge and Information Skills Specialist, Healthcare Improvement Scotland

On 5th December I went along to the Argyll and Bute Care Homes Quality Improvement for Falls Prevention event. It was a really interesting day, and it was great to hear about the work that care home staff are doing to reduce falls and improve quality of life for their residents.

PDSAs and data

Dr Christine McArthur, Project Lead, introduced the day and Sheila Morris, Occupational Therapy Care Home Lead, gave an overview of Plan Do Study Act cycles and the role of data in improvement. She emphasised the importance of carrying out small tests of change and having a clear plan.

The project participants then had the opportunity to discuss a case study of a 72-year-old lady who had had a number of falls, considering risk factors such as polypharmacy and multiple complex conditions, and reviewing the data in the falls diary to identify whether there was a pattern to her falls.

The care home staff observed that people are increasingly coming in to care homes with more mobility problems and multiple conditions and co-morbidities. Sheila commented that everyone in the care home sector is at risk of falling and should have a multifactorial falls assessmentContinue reading “How care homes in Argyll and Bute are working to reduce falls”

Scottish Ambulance Service Falls and Frailty Pathways Action Group first meeting


On 25th November 2016 the Living Well in Communities team from Healthcare Improvement Scotland’s Improvement Hub (ihub) supported the first meeting of the Active and Independent Living Improvement Programme (AILIP) and Scottish Ambulance Service Falls and Frailty Action Group. This Storify summarises the discussions from the day. Presentations and other resources can be accessed on the Falls and Bone Health Community site.


Preventing falls in Argyll and Bute: Cowal Befrienders’ exercise classes

Strength and Balance

In this article we look at a service which is aiming to prevent falls by supporting older people who have difficulty attending classes to take part in exercise.


Exercise has an important role to play in reducing the risk of falls among older people in the community. A recent BMJ review has indicated that exercise-based and tailored interventions are the most effective way to reduce falls and associated healthcare costs among older people in the community, while a recently updated Care Inspectorate good practice resource, Managing Falls and Fractures in Care Homes for Older People has stressed the importance of keeping mobile, doing regular exercise and being physically active.

The Cowal Befrienders’ falls prevention exercise classes are working towards the overall aim that “Older people have a reduced risk of falls that may affect their ability to live independently in the community”.

The classes

Cowal Befrienders host two strength and balance exercise classes per week for older people who require some help to get to the Befrienders’ drop-in centre where the classes are held and support to participate in exercise classes.

Classes are co-ordinated and delivered by Otago-qualified staff employed by Cowal Befrienders (the Otago  exercise programme is designed to prevent falls). Referrals and assessments are managed by the NHS Highland physiotherapy team.

Clients are entitled to six free classes, and can continue to attend for a modest fee of £2.50 per session. There is a small charge for clients requesting transport to their classes to help offset the additional costs incurred to provide this service (£3 return for individuals living within Dunoon, and £5 return for those living outside of the town).

In addition to health and wellbeing benefits, such as increased strength, balance and mobility, and helping participants to feel more confident and independent, the classes also have a social aim: to help older people to expand their social networks and foster peer support, and to increase access to health-promoting information that meets their needs.

The social aspect of the classes has been particularly valued by participants, with 97% citing this as one of the things that they enjoyed most about the classes. Clients also particularly appreciated the encouragement that they were given by staff and volunteers, and the pace of the classes. Continue reading “Preventing falls in Argyll and Bute: Cowal Befrienders’ exercise classes”

Improving Care for People with High Levels of Need


(Source: Information Services Division Integrated Resource Framework. Data from 2012/13)

The High Resource Individuals team within Living Well in Communities is supporting Health and Social Care Partnerships (HSCPs) through a series of data Deep Dives, to understand how those with the highest level of need interact with services.

Thomas Monaghan, Improvement Advisor, from Healthcare Improvement Scotland’s ihub, and Nathan Devereux, Associate Improvement Advisor, have been contributing to the wider work on High Resource Individuals by exploring ways of improving pathways of care, with support from the Local Intelligence Support Team (LIST) and Information Services Division (ISD).

These Deep Dives help partnerships explore their data on these individuals and identify areas for improvement.

Who are High Resource Individuals?

High Resource Individuals (HRIs) are the small number of people who use a high percentage of hospital and community prescribing resources and inpatient bed days.

Continue reading “Improving Care for People with High Levels of Need”

Managing Frailty The Fife Way: Summary and Resources


Managing Frailty the Fife Way took place on 17th March 2016 at the Carnegie Conference Centre. The event was an interesting and informative day which explored good practice in managing frailty from Fife, highlighting innovative ways of working and successful examples of integration. There was a lot of sharing and learning on Twitter throughout the day, and you can view a selection of tweets from the day on the event Storify. You can also view the agenda for the day.

Dr Graham Ellis, National Clinical Lead for Older People and Frailty, gave a lively introduction to the day and declared an ambition for Scotland to be the best place to grow old.

Professor Scott McLean, Chief Operating Officer (Acute Services) NHS Fife, gave an overview of acute care redesign in Fife. He argued that it is a myth that hospitals are places of safety and explained their decision not to open surge wards, commenting that they are not good for older people or staff.

Dr Seònaid McCallum discussed health and social redesign in Fife. She emphasised the importance of relationships and building bridges, and the continuous nature of the work.

Karen Goudie, Joy Reid and Louise Kellichan presented on Frailty at the Front Door, highlighting NHS Fife’s frailty screening tool, their frailty huddles and the Integrated Assessment Team’s journey to a 7-day service at the front door.

Avenue Care’s Francis Davidson discussed their work on the Short Term Supported Discharge project, which aimed to help people to recover in their own homes, eliminating the need for a stay in hospital or readmission to hospital. She highlighted the success of joint working on the project and argued that the project has demonstrated that integration really works.

Continue reading “Managing Frailty The Fife Way: Summary and Resources”

Managing Frailty The Fife Way

NHS Fife and the Fife Health and Social Care Partnership are hosting Managing Frailty the Fife Way (#fifefrailty), a learning event for managers and practitioners from acute, community and social care.  The event will allow NHS boards and health and social care partnerships to explore the health and social care system in NHS Fife and learn from examples of good practice and local innovation.

Healthcare Improvement Scotland is supporting the event and Graham Ellis (National Clinical Lead for Older People) will be introducing the day.

On the Day

The event, which now has a waiting list, is taking place on Thursday 17 March 2016 at Carnegie Conference Centre, Dunfermline.

There will be four plenary sessions taking place in the morning by a variety of speakers including, Professor Scott McLean (Chief Operating Officer, NHS Fife Acute Services Division) and Seonaid McCallum (Associate Medical Director, Health and Social Care Partnership).

The afternoon session will be made up of four breakout sessions and a further plenary session with Professor Brendan McCormack (Head of Division of Nursing / Head of QMU Graduate School) before closing with a panel discussion.

Continue reading “Managing Frailty The Fife Way”

Living Well With Frailty: Conference Outputs

The Living well with Frailty event, held at Heriot-Watt University in Edinburgh on the 27th of October brought together colleagues from across the health and social care sector to undertake a deep dive into the issues surrounding frailty.

The day comprised morning and afternoon plenaries, as well as eight breakout sessions ranging from ‘A focus on Dementia – personal outcomes in practice?’ to ‘Care Homes: My care, Your care, Our care – Designing a Care Home for the future’. For a full list of the sessions please download a copy of the agenda from the day. A comprehensive overview of each of the sessions is available below.

Breakout sessions
Timely identification and co-ordination of care for older people living with frailty
Presenters: Penny Bond and Karen Goudie

During this workshop, Karen and Penny from Healthcare Improvement Scotland led a discussion with attendees on what it means to be an older person with frailty going through our hospital system. Brief patient stories were shared to highlight opportunities and challenges as a starting point for discussion. Attendees then shared experience of testing and implementing different approaches to identifying and coordinating frailty care within acute care settings. The timely identification and co-ordination of care for older people living with frailty presentation can be viewed via the following link and you can watch a video of Mrs Andrews’ story on YouTube below.

Continue reading “Living Well With Frailty: Conference Outputs”