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Frailty and the NHS Long Term Plan

The NHS Long Term Plan outlines several important changes to the way the NHS should work to support patients and their carers. Improving care for older people living with frailty or multiple long-term conditions is one of its priorities.

What is the NHS Long Term Plan?

In the 2018 Budget the Government agreed a five year funding settlement for the NHS, including £20.5 billion in additional funding by 2023/24. In return NHS England, the body responsible for running the NHS, was asked to produce a plan setting out how the additional funding would be used to improve healthcare services.

NHS England published two documents in January 2019: the NHS Long Term Plan and the Personalisation Plan.

Together they outline a number of important changes to way the NHS should work to support patients and carers in future – particularly in relation to GP and community health services.

The changes are intended to ensure that: everyone gets the help they need to stay as well as possible for as long as possible; and have access to the right care at the right time when they need it.

What the Plan means for older people

The NHS Long Term Plan recognises that services are not consistently joined-up or responsive to the needs of older people living with frailty.

It includes three ambitious new service models:

  1. Improve NHS care in care homes.
  2. Identify and provide proactive support to older people living with frailty in the community.
  3. Enhance rapid community response at times of crisis.

The aim is to support people to age well and to stay independent at home for longer.

The Personalisation Plan aims to change the way NHS services and health professionals work to give everyone living with long term conditions more choice and control over their care. There are six key 'components'.

Some relate to how care is delivered, aiming to make sure people can work together with their health team to make decisions about, and plan, their care and make meaningful choices about services.

Others aim to roll out services that connect people with support outside of the NHS that can provide practical and emotional help – such as exercise classes or advice about housing and benefits – and expand access to personal health budgets.

Enhanced Health in Care Homes (EHCH)

The NHS Plan promises to 'upgrade NHS support to all care home residents who would benefit by 2023/24, with the EHCH model rolled out across the whole country.'

Older people living in care homes have not always been able to expect equal access to NHS services, despite the fact that care home residents are among the most likely to be living with complex health needs.

The EHCH programme was developed as part of the NHS Five Year Forward View to pilot new approaches to providing wrap around services for residents.

These include:

  • named general practice support
  • timely access to emergency out of hours support
  • access to regular clinical pharmacist-led medicine reviews
  • support for care homes to share information relevant to residents' care.

Evidence from the six EHCH 'Vanguards' suggests that this model can reduce A&E attendance and emergency admissions from care homes by around 25%.

Urgent Community Response

The NHS Plan anticipates that more NHS community and intermediate health care packages will help free up over one million hospital bed days.

Too often, older people find themselves admitted to hospital during a crisis, or stranded in hospital longer than needed, simply due to a shortage of services in the community that could support them at home.

The NHS Plan has pledged to significantly increase the capacity and responsiveness of community services over the next five years. The aim is that older people can get urgent access to GPs, districted nurses, mental health teams and allied health professionals – such as physiotherapists – to reduce the risk of them being admitted to hospital. In future people should be able to access help within 2 hours of being referred.

The NHS Plan also pledges to improve access to recovery, rehabilitation and reablement support. At the moment, older people often experience long waits for support after an illness or injury meaning critical opportunities to regain function and independence are lost. Delays can also mean people remain stranded in hospital. The Plan aims to provide access to these services within two days of referral.

Community Teams

The Community Teams service model aims to seek out older people with moderate frailty to offer proactive personalised care.

Poor health and frailty in later life is not inevitable. Healthy behaviours throughout our lives can help avoid many long-term health problems. However it's also never too late to improve health and wellbeing.

There is good evidence that providing proactive support to people with moderate frailty or existing conditions can have a big impact – helping them stay active, build their mental and physical resilience and ensure their care is both effective and well-coordinated.

More about the Community Teams model

The Community Teams model will provide access to a wide range of appropriate clinical and non-clinical services through multi-disciplinary teams, including targeted support for musculoskeletal conditions, cardiovascular disease, dementia and frailty.

Making sure services work for older people living with frailty

Local NHS services will not be meeting the aims of the NHS Long Term Plan if they are not providing a better service for older people, particularly those living with frailty.

Here, you’ll find important resources that can help local services make sure they are delivering effective, person-centred care for older people.

Frailty Core Capabilities Framework

Local service providers are responsible for making sure their staff have the skills and experience to meet the needs of older people living with frailty. The Frailty Core Capabilities Framework describes the skills, knowledge and capabilities which should be present across the health and care workforce.

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NHS RightCare Frailty Toolkit

The NHS RightCare Frailty Toolkit has been developed by NHS England with support from Age UK and a number of partners to provide advice and guidance on how to commission and provide the best system-wide care for people living with frailty.

Its aim is to reduce variability between different areas of the country, outlining what older people should be able to expect regardless of where they are living. The toolkit can be applied to health and social care in all settings, from care home to primary care to hospital, and signposts to relevant further guidance.

NHS RightCare Frailty Toolkit

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Best practice care for people living with frailty

Fit For Frailty: Consensus guidelines for the care of older people living with frailty

Sets out consensus best practice guidelines on how local services can best meet the needs of older people. Part one looks at direct care of older people in the community and outpatient settings. Part two covers effective management and commissioning of services for older people living with frailty.

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Delivering high quality urgent and emergency care

Acute care toolkit and Silver Book Guide

Many older people living with frailty experience poor care when seen in urgent and emergency care settings, often because their needs are not properly understood or because specialists such as geriatricians are not being properly involved in their care. The Royal College of Physicians (RCP) have produced an acute care toolkit to support hospitals in delivering effective care.

There's also a guide, sometimes referred to as the “Silver Book”, which outlines best practice for older people living with frailty receiving all types of urgent and emergency care.

Acute care toolkit

Silver Book 

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Last updated: Jul 21 2020

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