integration

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.

Following this process, there was broad consensus at Midlock GP practice that the eFI categories were accurate for their population. This prompted them to consider, how do we support people who are living with frailty? What does this mean for the individual? and how can we work collaboratively in the community to support them?

The case scenarios identified anticipatory care, crisis prevention and palliative and end of life care work as areas where the team could make a difference to support people to remain in their own home.

The team identified three stages of frailty to focus on initially:

people who are changing from mild to moderate frailty (anticipatory care),
people who are moderately frail with the biggest change in eFI score (crisis prevention), and
people who are severely frail with the biggest change in eFI score (palliative and end of life care).

Midlock GP practice has developed a virtual way of working within the multidisciplinary team and have used the Living Well in Communities falls and frailty intervention tool to guide the development of a falls and frailty collaborative working in the community. The team have found the tool beneficial to use during frailty case reviews, as it promotes holistic assessment across agencies and is a useful prompt that helps staff by signposting to partner agencies that could assist in care provision. Incorporating the tool in the case reviews highlighted five key interventions which should be implemented for every individual identified as frail (#Frailty5):

Frailty identification and coding on the GP system
Anticipatory Care Plans uploaded to eKIS
Key worker
Carer support and assessment
Falls & Frailty Conversation

These interventions had previously not been happening for every person, every time.

The impact so far

“The frailty tool is excellent guidance to follow and know where to signpost people.”

“There was a richness of information shared by the MDT and it’s amazing to know how many supports are there for people.”

All of the team at Midlock have made commitments to support the work. Community nurses are engaging more in anticipatory care planning conversations, and the third sector feel that they are an integral part of the work, and that their contribution is valued. The inclusion of housing options in the tool is valued by the team, and the tool has made them aware of all the supports that are available.

Supporting the Midlock team to test the efi and the falls and frailty interventions tool has helped the team to change the way that they work, with benefits for both staff and those who receive care.

Find out more about the Living Well in Communities frailty and falls work on the ihub website.

We also displayed a poster on our work at the NHSScotland event in June, which you can view here.

Neighbourhood Care national partners meeting

On 27th June we held our latest national learning event on the neighbourhood care work being tested across the country.

With representation from Health and Social Care Partnerships and national organisations, the aim of the workshop was as much about exploring the challenges to developing this model of care as it was about sharing learning and increasing knowledge across Scotland.

After welcomes and introductions from Ruth Glassborow (Director of Improvement Support and ihub), Chris Bruce provided some background on how Scotland became involved in learning from the Buurtzorg model in the Netherlands, with an overview of the work so far.

All agencies and partners involved in developing local models – using the principles of Buurtzorg (and in the spirit of self-organisation) – have worked together to develop tests and start building a national learning community.

The testing principles in Scotland

Promote independence
Continuity of support and carer – reduce fragmentation
Self-organising, flexible teams, focused on people
Back office / organisation focused on staff and people
Opportunities – accelerate integration at point of care, empower nursing and social care workforce, change commissioning practice

Each of the eight neighbourhood care test sites (Borders, Dumfries & Galloway, Highland, Stirling and Clackmannanshire, Angus, Aberdeen City, Western Isles and Cornerstone) gave an update on what they hoped to achieve from the model, what their progress has been and what challenges they’ve faced so far.

Common themes

There were a number of common themes across the test sites when discussing developments: governance, communication, engagement, change management and recruitment.

There was a feeling that some aspects of clinical and corporate governance were making testing more difficult than it needed to be. Should we take a risk proportionate approach, rather than risk averse? Do we have to be (more) brave?

Isn’t this the realistic approach to medicine?

The sites highlighted a need for regulations to be simple, straightforward, scaled-down, and to learn from the 3rd sector. Cornerstone rewrote and reduced their policies and procedures from more than a hundred to single digits.

The Cornerstone approach:

Start with nothing, then see what you actually need.

the workforce

There was agreement that for a lot of people working in the service there is strength to be drawn from the common goals of the neighbourhood care models.

It’s a way of working that empowers staff, promotes autonomy and self-management. It’s a model that can offer increased satisfaction for those working in it, leading to better recruitment, retention and less absence.

The importance of buy-in from all staff (including those in corporate and leadership roles) is hugely important to progress.

We are trying to introduce change in a complex environment. And for some this will lead to uncertainty, around themselves, their role, their workplace. Sharing success from the testing can help reassure people that this can work in Scotland.

Communication

Part of this will come from our internal and external communications, information sharing and engagement.

We will continue to develop the self-managing network for learning and sharing best practice across the test sites, as well as building a digital platform for updates and charting progress.

We’ll have key messages that can be use locally and nationally to help spread the word.

What ties all of this together is building trust between all the different agencies and people involved in health and social care.

Let’s talk about how we should co-operate together instead of competing; with other professionals, with informal carers and other organisations. How we make younger people enthusiastic for the profession and much more.

Jos de Blok, Buurtzorg founder

We want people to see the successes from the test sites and for them to want to be a part of it.

We want to share people’s stories, share learning and promote success more widely.

So check back over the coming months when we’ll update you more regularly on the work of the individual test sites, hopefully looking at the practical aspects of the models as well as the broader themes and issues.

Tag: integration

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