NHS RightCare: Frailty toolkit
This toolkit has been developed by NHS RightCare in collaboration with NHS England’s National Clinical Director for Older People, Age UK, Getting It Right First Time and The National Institute for Health and Care Excellence (NICE). The toolkit supports systems to understand the priorities in frailty identification and care, and key actions to take. It provides opportunity to assess and benchmark current systems to find opportunities for improvement.
Optimising a frailty system
This NHS RightCare toolkit will support systems to understand the priorities in frailty care and key actions to take. It provides a way to assess and benchmark current systems to find opportunities for improvement. It is produced with reference to an expert group of stakeholders and is supported by NICE. Wider consultation has taken place with patient representatives, clinicians, social care organisations, professional bodies and other key stakeholders.
The national challenges
- Increasing numbers of people are at risk of developing frailty. A person living with mild frailty has twice the mortality risk of a fit older person.
- More people living with mild, moderate or severe frailty are attending emergency departments, with over 4000 admissions daily for people living with frailty.
- Older people living with mild, moderate or severe frailty are more likely to have delayed transfers of care. 45% of people experiencing delayed transfers of care are over 85 (approximately 50% of people aged 85 and over will encounter frailty).
- People living with mild, moderate or severe frailty could often have their needs met best in settings outside of acute hospital care. Severe frailty often brings over four times the costs of non-frailty.
The national NHS RightCare opportunity
- 29,000 fewer injuries due to falls in people aged 65 or over if CCGs achieved the rate of their lowest five peers.
- 25,000 fewer long stay patients aged 85 or over if CCGs achieved the rate of their lowest five peers.
This NHS RightCare toolkit supports the delivery of the NHS Long Term Plan for frailty
The NHS Long Term Plan sets out an evidence-based framework of care for older people with frailty to be delivered through the national Ageing Well programme. This focuses on delivering integrated personalised care in communities and addresses the needs of older people with three inter-related service models centred on clearly identifiable patient cohorts:
- Community multidisciplinary teams - targets the moderate frailty population10, people whose annual risk of urgent care utilisation, death and care home admission is 3 times that of an older person of the same age who is fit. This group are considered to be the most amenable to targeted proactive interventions to reduce frailty progression and unwarranted secondary care utilisation.
- Urgent Community Response – crisis response and community recovery for older people who are at risk of unwarranted stay in hospital admission and whose needs can be met more effectively in a community setting.
- Enhanced health in care homes – for which there is not a consistent health care support offer across England despite care home beds outnumbering NHS hospital beds by 3:1 and being an increasingly important place for end of life care; The Ageing Well programme and framework aim to support commissioners and providers of acute and community health services, social care and the voluntary sector to work together, turning what is currently urgent care into planned care for key groups of vulnerable older people