Hospital Wide CGA

The above diagram illustrates the workstreams that we will use to deliver this programme of work their interdependencies and relationship to each other.  The diagram also illustrates that each workstream builds on previous and parallel workstreams:  the workstream that defines CGA will produce definitions that will be used by subsequent workstreams which identify characterise and produce implementation tools for CGA processes. This in turn will inform the characterisation of beneficiaries (as it will define that from which they benefit). Similarly the characterisation of the beneficiaries will inform the development of implementation tools (by defining the intended target population for the tools).

Once it is possible to identify those older people at highest risk, we will then identify those service models that are most effective and efficient in improving outcomes. There is already a significant amount of knowledge about which services might be useful, namely those based on Comprehensive Geriatric Assessment (CGA). CGA involves a team working together in a coordinated manner, typically doctors, nurses, therapists and others. We will review existing evidence and will undertake a survey of national practice; we will then bring this information together information and create a set of toolkits for use by clinicians, managers and patients to promote best practice, leading to immediate patient benefit. We will evaluate the implementation of these toolkits. Members of the study team are well placed to work with several relevant national societies and patient associations to ensure wide dissemination of the toolkits. Again, by drawing upon existing information, we can avoid duplication and reduce the cost of this research.

The purpose of any research should be to improve patient outcomes; it takes an average of 17 years for research evidence to reach clinical practice1. The challenge for HoW CGA is to improve upon this historical metric and achieve more rapid and sustained ‘knowledge translation’.

Workstream 1: What is Comprehensive Geriatric Assessment?

In this workstream we are examining the existing evidence about Comprehensive Geriatric Assessment, so that our research can be fully informed by recent literature reviews and up to date trials. By doing this we will see if we can identify the best and most cost effective models for hospital wide CGA from literature reviews of high quality trials.  We will identify the key elements of CGA, the main measure of outcome and the characteristics of the patients who have been shown to benefit from this intervention

This work will be combined with the evidence from the national survey in Workstream 2 to provide our research team and NHS decision makers with a description of the range and type of services of relevance to inpatient hospital care in the UK.

Workstream 2.1: Where is CGA provided in the UK?

In this workstream we aim to identify and provide a description of current provision of CGA in Hospitals in the UK, by performing a national survey of NHS Hospital Trusts.

We are working with the NIHR Clinical Research Network, the British Geriatrics Society and the Royal College of Physicians of London to obtain as comprehensive and complete as possible coverage of UK hospitals.  

This nationwide questionnaire will provide us with a map of the different forms of CGA in current use and their provision across the nation.

Workstream 2.2: How large is the need for Comprehensive Geriatric Assessment (CGA) in England?

In this workstream we are creating a series of basic information tools that aim to map out for individual local authority (LA) areas what we know about the numbers of older people living with frailty who may benefit from CGA. We think such information is an important step in helping a local health service (for example a hospital or local council) judge whether it has the right level of services in place to provide care for older people.  

To do this we are combining information on the number of older people in each area and looking at what we know about people’s health conditions and previous use of hospital services.  We can access large data sets of anonymised data that allow us to see the patterns of how older people have used hospital over a number of years. We are exploring new ways to summarise these patterns – for example by identifying a simple categorisation of say 5-10 groups that allows us to allocate everybody into that area depending on their level of frailty.  We also use more complicated statistical models that combine lots of patient-level information to test which are associated greater than expected level of hospital use in the next year. 

For each area we will also pull together information about how well each area seems to be looking after its older people – so we will look at things like how often people have to go to hospital as an emergency, how much time in the year they spend in a hospital or social care, or how quickly people recover from a health problem such as a hip fracture.  None of these measures are perfect descriptions of the health of people but we want to look across a number of them to see where they agree and then identify the extent to which there are differences between areas. We will also test if these differences are related to needs for CGA.

Finally we wish to create simple ways to calculate what happens in terms of the use of health services, overall costs and patient wellbeing if providers change the ways services are delivered by incorporating CGA into day-to-day practice.

Workstream 4: Produce, disseminate and evaluate implementation tools

Building on the work that has taken place in prior workstreams, this objective of this workstream is to begin the task of getting the findings of our research into practice. This involves producing a ‘toolkit’ of various materials—from written documents to population profiling tools to case studies showing how to achieve change—and then looking to implement this in two areas of hospitals where, until now, Comprehensive Geriatric Assessment has not generally been taken up. It also involves an evaluation of this approach to implementation, to identify areas where the toolkit can be improved, developed and refined, before being rolled out more widely.

The first stage in this workstream involves collating the information produced by the research programme to date, using our study team members, patient and public involvement group, and a wider panel of experts to consider the findings from the literature review and survey and reach a consensus on which models of delivering Comprehensive Geriatric Assessment look most promising, and which are likely to work in different areas of clinical practice. Building on this, our researchers will work together to develop a toolkit, again consulting with wider patient and professional stakeholders to ensure that it is as effective as possible. Finally, the toolkit is piloted in two areas of clinical practice—cancer care and surgery—where Comprehensive Geriatric Assessment has tended not to be used in the past. Alongside this pilot implementation, we are undertaking qualitative research to consider what clinicians and patients make of the toolkit, how they use it, and how far it affects the way care for older people is organised and delivered in practice.

Martin Bardsley is Director of Research in the Nuffield Trust, an authoritative and independent source of evidence-based research and policy analysis for improving health care in the UK. 

He has over 20 years’ experience in health services research and analysis.  He leads a team undertaking a research programme which includes studies on the development of predictive risk modelling and the evaluation of alternative models for delivering health services.  The team specialises in work that exploits the use of existing information and uses data linkage over time and across sectors to understand patient level outcomes and service costs.  Recent work has included papers on: a cluster randomised trial of telehealth technology, studies of social care use at the end of life, a person based model for NHS resource allocation, and a range of evaluations of community based care initiatives. 

Martin previously worked as Head of Screening & Surveillance at the Healthcare Commission where he led the development and implementation of innovative approaches to the use of information in risk based regulation.  He has also worked with public health, leading on a range of studies of health in London.  His early research interests included studies on outcome measurement and case mix classification.  Martin has a PhD from the London School of Economics and is a Fellow of the Faculty of Public Health.

Martin’s main involvement in the project will be leading the quantitative work around estimating the need for Comprehensive Geriatric Assessment and understanding the types of people who will benefit from the intervention.

Simon Conroy's ambition is to improve outcomes for frail older people by embedding evidence based medicine into clinical practice (‘campus to clinic’ translational research). Frail older people are increasing rapidly, complex to manage, and present a major fiscal challenge to cost-constrained health and social care systems. Simon’s research addresses different models of care for frail older people, assessing feasibility as well as clinical and cost-effectiveness. His educational activities take an interdisciplinary perspective on developing and teaching knowledge locally (frailty services), regionally (SHA), nationally (BGS) and internationally (EUGMS & EAMA). Implementation of research findings into clinical practice is key, and best exemplified by work on the Silver Book and the Acute Frailty Network.

Simon’s role in this project is to ensure that it delivers, on time and on budget, as well as ensuring that it remains inter-connected at all times.

Janet Hood provides administrative support to the HoW CGA Team, having previously provided support for a variety of Health Sciences research studies at the University of Leicester. She has recently enjoyed taking part in a University-wide yarn initiative, activities including visiting local community care homes and yarn activities with residents.

Sheila Kennedy is a Chartered Physiotherapist who has worked for 13 years in NHS hospitals in Derby, Cambridge, Norwich, Salford and Sheffield before moving to work in the community then primary care for 11 years. Sheila has a PhD in Medical Sociology from the University of Sheffield. 

Sheila’s professional research career began in early 2000, working on a project about health inequalities in the School of Health And Related Research (ScHARR) at the University of Sheffield. Since then she has worked mainly on research about palliative and end of life care, and the health and social care of older people, and become increasingly interested and involved in facilitating and supporting the active involvement of the public in research (PPI in research).  In 2009, Sheila was principal investigator and lead researcher of a project about the support needs of older carers looking after someone with advanced cancer which involved members of the public as research partners and advisers at all stages of the project’s development, delivery and dissemination as well as in its management. 

In September 2011, Sheila returned to the University of Sheffield to work with Professor Stuart Parker within the Health Inequalities theme of NIHR CLAHRC SY, contributing to the development of ‘Age and Ageing’ health-related research, and the promotion of PPI in research on older people’s health and health care. In this role, she contributed to several successful funding applications including an EU FP7 project about the development and implementation of social innovations to promote healthy and active ageing, was lead author of a briefing paper about ‘Ageing Populations and Age-related Health Inequalities’, was invited to be PPI lead for the research group I am based in (Rehabilitation and Assistive Technologies) and the co-opted PPI lead for the NIHR Ageing Specialty Group. 

Sheila is one of the co-applicants and lead the PPI work stream.  She is based at Sheffield, and have recruited over 40 older adults with prior experience of PPI from across the country to be involved in the project in a range of funded research and management-related tasks and activities.  In addition to developing, organising and co-ordinating the work, she is undertaking an ongoing evaluation of the professional researchers and lay research partners’ experiences and views of PPI during the project, the impact of their specific experiences of involvement on themselves / the project. 

Dr David Kocman is a Research Associate in the SAPPHIRE group. David is a sociologist of organisations and innovation. He has worked across a range of projects looking at quality and safety in healthcare, re-consenting for the use of tissue samples in biobanks, reporting of safety concerns by junior doctors, and implementation of clinical pathways.

Graham Martin is Professor of Health Organisation and Policy in the Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group in the University of Leicester’s Department of Health Sciences. He is a social scientist with interests in changing forms of healthcare organisation. His primary involvement in HoW-CGA is in workstream 4, where he will be leading the evaluation of the piloting of toolkits for use in novel clinical settings. He occasionally tweets from @graham_p_martin

Stuart Parker is Professor of Geriatric Medicine at Newcastle University and a consultant physician at Newcastle upon Tyne Hospitals NHS Trust in the UK, where he provides inpatient medical care for older people with acute illness.

He also works in the UK National Institute for health Research Co-ordinating Centre (NIHR CRN-CC) as the Theme Lead for Ageing, Dementias & Neurodegeneration, Neurological Disorders and Genetics. Previously he was acting chair of the NIHR CRN Ageing Group (2014-2015), associate director of the NIHR South Yorkshire Collaboration for Leadership in Applied Health Research and Care (CLAHRC (2008-13)) and Director of Research and Development at the Barnsley Hospital NHS Foundation Trust (2008-13).

He contributed to the FUTURAGE road map for ageing research in Europe and is a partner in the INNOVAGE project which is developing and testing, as well as surveying and cataloguing, social innovations that will have a solid impact on improving the quality of life and well-being of older people.

Jenny Neuburger joined the Nuffield Trust in 2016. Before that, she worked for six years in the Department for Health Services Research and Policy at the London School of Hygiene and Tropical Medicine (LSHTM) as a Lecturer in Statistics. She is particularly interested in working with clinicians to develop accessible and practical methods to measure the quality of care and evaluate improvements. Jenny is leading the validation of the HoW-CGA HES based frailty algorithm, supported by Martin Bardsley and Chris Sherlaw-Johnson.

At LSHTM, Jenny was previously involved in a programme of work to develop methods for using patient reported outcome measures (PROMs) to compare health care performance and assess equity of access to elective surgery.

Jenny has a background in social policy and research. She has a PhD in social statistics from the Institute of Education, an MSc in housing from the London School of Economics and she worked for several years in the voluntary sector, including the homelessness charity Shelter. She is a Visiting Research Fellow at LSHTM. 

Kay Phelps has been a researcher in the Department of Health Sciences at the University of Leicester for over 20 years carrying out research into health and social care for older people. Kay has been involved in many large scale national projects and lots of small local projects working with health care commissioners and providers in Leicestershire. Kay’s main area of expertise is qualitative research involving interviewing patients, carers, doctors, nurses and other health and social care staff. For this project Kay is part of the project management team who oversee the project and try and keep all the different organisations involved talking to each other and working towards the common aim of completing the research to a high quality, to time and budget. This involves being closely involved with the progress of each of the work stream teams; organising regular meetings with the research team, and also with external teams such as the Study Stakeholder Group and Steering Committee; ensuring reports are completed when necessary; helping out on the individual work streams when needed; being a central point of contact for the wider team and external collaborators. Kay is also involved in workstream 4 working with case study sites to evaluate the CGA toolkit.

Emma Regen has been a Research Fellow in the University of Leicester’s Department of Health Sciences since 2004.  With a background in medical sociology, Emma is particularly experienced in using a range of qualitative methods in both academic and applied research contexts.  Her research interests have focused upon the provision of health and social care for older people including several national Department of Health funded studies in this area.  Emma is part of the project management team which seeks to ensure that the various elements and objectives of this study are delivered in a timely and efficient manner.  This involves working closely with members of the work stream teams as well as the External Stakeholder Group and Study Steering Committee. Liaising with the NIHR, NHS partners and other key stakeholders including PPI representatives is also an important part of the project management role.

Helen Roberts is an academic geriatrician based at the University of Southampton. Her research interests focus on the identification and management of frailty and poor nutrition in older people. She is a faculty member of the NIHR Southampton Biomedical Research Centre (BRC) and principal investigator on studies of nutrition and sarcopenia in older people collaborating with colleagues from the MRC Lifecourse Epidemiology Unit in Southampton. Helen leads the Ageing and Dementia theme for the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC): Wessex.

She is the lead for the national NIHR CRN Ageing Speciality Group which is a network of clinicians who are active in research to improve the healthcare of older people. Helen is a co-applicant and involved in all phases of the study.

Chris Sherlaw joined the Nuffield Trust in January 2014 from the Care Quality Commission (CQC). At the CQC he ran their surveillance programme which involved the continuous monitoring of quality of care indicators across health and social care in order to identify potentially concerning patterns of outcomes that could then be followed up in an appropriate manner. This was a continuation of the programme he helped to set up within CQC’s predecessor, the Healthcare Commission, and which prompted the decision to investigate Mid Staffordshire NHS Foundation Trust in 2008. He also led the statistical analysis that supported the Mid Staffordshire Investigation.

Chris has not always worked within the health sector. His career began in what was the Department of Trade and Industry where he developed forecasting models of the civil aviation market in order to advise decisions for funding British aerospace projects. He later joined the Clinical Operational Research Unit at University College London (UCL) where he helped to develop tools that hospitals could use for monitoring outcomes, including the now widely used variable life-adjusted display (VLAD) approach.

He is an Honorary Senior Research Fellow with the Department of Mathematics at UCL and a Fellow of the Operational Research Society. Chris is working with Jenny on the validation of the frailty algorithm.

Paul Smith is a Senior Research Analyst at The Nuffield Trust, an independent source of evidence-based research and policy analysis for improving health care in the UK, where he works on a variety of research projects primarily harnessing large administrative datasets. He has over eight years’ experience in complex quantitative and qualitative analysis and consultancy to NHS organisations.

With particular expertise in health care datasets and financial systems within the NHS, Paul has worked with several health care providers and commissioners, regulators, government bodies and academic institutions.

Prior to joining the Nuffield Trust, Paul worked for McKinsey and Company for two years as a Healthcare Analyst. He has also worked for Humana Europe, the Care Quality Commission, and Newchurch Limited.

Paul is a graduate of the University of Manchester Institute of Science and Technology where he gained a first class honours degree in chemistry. He also holds a PhD in theoretical chemistry from the same organisation.

Paul will be producing most of the quantitative analysis for the project, particularly the work around estimating the need for Comprehensive Geriatric Assessment and understanding the types of people who will benefit from the intervention.

The Universities of Nottingham, Southampton and Newcastle have agreed to share some basic information about individuals in order to identify how best we can help older people who are most at risk of emergency admission to hospital. We hope that through studying your records and those of others we can make this service better for others in future. To allow us to do this work we would like to share some basic information about you with the Health and Social Care Information Centre.

The first principle of the Data Protection Act 2018 requires that personal data is processed fairly. To meet this requirement these organisations are under a duty to supply to individuals with a Fair Processing Notice.

In a sharing context, a Fair Processing Notice should at least tell a data subject:

• The identity of the organisation who controls the data you are sharing
• The reason it is being shared
• The agencies that your information is likely to be shared with
• The organisations controlling the data that you have supplied are the Universities of Nottingham, Southampton and Newcastle.

Personal data is being shared in order to enable design of better hospital services for older people, particularly those people most at risk of an unplanned admission into hospital or long lengths of stay in hospital.

The Health & Social Care Information Centre (HSCIC) is the only agency that your personal information will be shared with. The HSCIC will then remove any personal information that says who you are and share the anonymised information with the Nuffield Trust, so that it can carry out the evaluation. The research team at the Nuffield Trust will not be able to identify you personally.

All members of staff employed by these agencies are bound by the common law duty of confidentiality which means that information that you provide to us must be held in confidence and not shared with anyone else unless:

• Partners are legally obliged or permitted to disclose the information to another organisation or person.
• The data subject or carer provide consent to share the information

Taking part is voluntary and data subjects are free not to take part at any time without giving any reason, and this will not affect their use of the service.

Why we share personal information: We want to see how well national services work in addressing the needs of older people; in particular the Nuffield Trust is undertaking an analysis to examine whether the needs of older people are being adequately met in acute hospitals. In order to do this analysis, we want to be able to share some basic information about individuals with the Health & Social Care Information Centre, which collects information about all hospital treatment in England, and the Nuffield Trust, who will undertake the evaluation.

Who will be using personal information: 1. The Health and Social Care Information Centre (HSCIC) - a national government funded statutory body created to collate information on health and social care. 2. The Nuffield Trust, a reputable independent research organisation, will subsequently analyse anonymised information.

What information will be shared? Name, address, NHS number, sex, date of birth and a unique study number (assigned to individuals by this service) will be transferred securely from the Universities of Nottingham, Southampton and Newcastle to the HSCIC. The HSCIC will then remove any information that says who the person is and share the anonymised information with the Nuffield Trust, so that it can carry out the analysis. The research team at the Nuffield Trust will not be able to identify individuals personally.

How much information will be shared. For this evaluation, the information given to the HSCIC will only be enough to show whether the HSCIC holds any records of whether the individual has used a hospital. 

What happens after the data is shared? The HSCIC hold information on all hospital attendances in England and they will be able to identify if they have any electronic records about an individual. They will then be able to extract information about whether the person needed hospital care after receiving our services. This information will have anything that identifies the person removed and will then be sent to the Nuffield Trust. The findings from this study will be presented in a series of reports and publications available to commissioners, hospitals and the public. No information about individuals will be published.

How long will the data be stored? The HSCIC will destroy any information they receive from us once they have found if the person needed to be seen by the hospital and sent that information (without anything that could identify the person), to the Nuffield Trust.The information held by Nuffield Trust will be destroyed three years after receipt of the data. For more detail, see http://www.nuffieldtrust.org.uk/

Will the data be looked after safely? Yes. Information will be sent securely to the HSCIC, which works under strict rules to keep personal information confidential. 

What are the potential risks for the individual? The risks are that people working at the HSCIC may be able to identify that the person has received this service. The HSCIC already handles large quantities of confidential information as a national ‘safe haven’ for health data. The Nuffield Trust researchers will not be able to identify anybody personally and will not share individuals' information with external third parties.

Opt out of information sharing? An individual may object to his/her data being used in this study if s/he wishes, and is free to opt out at any time, without giving a reason. This will not affect the care given to him/her in any way, shape or form. The individual may contact either Paul Smith at The Nuffield Trust or Dr Simon Conroy at The University of Leicester and those records will be excluded from the analysis. 

Complaints and questions: Any questions about the evaluation of this service or concerns about the way it has been carried out, may be communicated to Paul Smith at the Nuffield Trust. Complaints may be directed to the Chair of Trustees of the Nuffield Trust, Dame Carol Black (59 New Cavendish St, London W1G 7LP), or to the Charities Commission (https://www.gov.uk/government/organisations/charity-commission). Any complaints about the HSCIC should be to their Contact Centre at 0300 303 5678 or enquiries@hscic.gov.uk
 
Under the Data Protection Act 2018 individuals have the right to request a copy of their information (for which a fee of £10 may be charged).

Patient and Public Involvement (PPI) is an integral and important aspect of the HoW CGA research project. This is because the professional research team recognise that PPI helps ensure: 

• Research topics and plans consider and are relevant to everyday lives and needs 
• Research methods are ethical and practicable
• Data analyses are reported clearly 
• Findings are disseminated widely 
• Research evidence-based recommendations are implemented appropriately and promptly, and 
• Impact is evaluated robustly and reported widely.

From the outset of this project, to ensure PPI would be a meaningful and influential aspect of it, the professional research team made a serious commitment to incorporate lay perspectives at every stage of the research process, all levels of the ‘organisation’ and across all its work streams. To help make this happen, the team agreed there should be a specific applicant responsible for the development of a dedicated, overarching PPI work stream with an experienced researcher and assistant appointed to lead, facilitate and co-ordinate the recruitment, organisation, support and evaluation of PPI once the project started.  

As a researcher with many years of experience of lay involvement and partnership working in health and care-related research and special interest in research around older people’s health care and support needs, Sheila Kennedy took on both senior roles.

In-keeping with the team's commitment to PPI, during the project development and funding application stage, three research advisory groups and several individual older adults with experience of PPI in health and health care-related research known to members of the team were asked for their views of the research topic and early drafts of the research proposal and plans.

Research tasks and activities

Since the start of the project, members of the Leicester and Newcastle LCRN (Local Clinical Research Network) PPI in ageing research groups, and more than 30 older adults with experience of PPI have been recruited from multiple locations across England and Scotland:  together, they have been contributing to a diverse range of tasks and activities relating to the project's research and management work streams, External Stakeholder Group and Study  Steering Committee and the dissemination of findings. 

To date, between them, the research partners have:

• Provided feedback on draft documents, including: recruitment and fieldwork materials, eg. participant information sheets, consent forms and interview guides; the literature review protocol and search terms; the CGA questionnaire survey, the impact strategy
• Attended validation workshops to consider and discuss key concepts and indicators being used or considered by the researchers in workstreams 2 and 3
• Participated in an AGE UK radio broadcast to talk about involvement in research and the project, and attended a residents meeting at their nursing home, to hear about the project and PPI, and to describe their experiences of acute in-patient care and understandings of frailty in that context
• Commented on and contributed ideas for the design of the project logo and volunteered to road-test the project website
• Co-produced a conference poster about the project and its PPI via email, teleconference and workshop meeting
• Provided four-monthly written feedback on their experiences and impact of being involved in the project (see below for further detail)
• Attended the 2015 British Geriatrics Society conference in Brighton to promote and discuss the PPI poster about the project displayed at the Ageing Specialty Group stand
• Attended the project's External Stakeholder Group and Study Steering Committee meetings

Support for PPI

As valued research partners, the volunteers are offered allowances and travel expenses for their contributions and time given to the project, in line with guidance from INVOLVE.  Support and or sign-posting to training is also offered to the research partners and to members of the professional team new to PPI in research.

Impact and evaluation of PPI in the HoW CGA project

The activities, experiences and impact of PPI for the professional researchers and research partners are being evaluated every four months throughout the project and the findings will be reported towards the end of the project.  Respondents are asked to describe their activities and experiences of PPI in the project during the preceding four months, and their reflections on its impact on themselves and or the project. They are also asked to indicate if they have any support or training needs, or issues they want to raise. 

What next?

As well as benefiting this project, we anticipate that our approach to PPI will enhance research capacity through enabling further community engagement in future research studies and or the implementation and evaluation of research evidence-based service innovations.   

To facilitate this, Sheila is starting to identify key contacts in the Clinical Research Network Ageing Specialty Group in order that research partners living in their area can link up with them and get involved in local ageing research initiatives.