National Context and Drivers: Why focus on frailty in the community?
The Wessex Community Frailty audit (WCFA) was developed to compliment the Wessex Acute Frailty Audit run in 2018.
The WCFA has the overall aim of providing an overview of frailty pathways across the whole health care system. A panel of frailty experts and system leaders from the Wessex AHSN Community and Primary Care Expert Group supported the development and trial of the approach.
The 2019 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 and recognises that services are not consistently joined-up or responsive to the needs of older people living with frailty with an overall aim to support people to age well and to stay independent at home for longer.
Why Primary Care Care Networks?
PCNs are the vehicle for the delivery of the frailty elements long term plan, keeping patients at home
and independent for longer, so the audit was developed at PCN to provide a baseline of frailty
What did the audit include?
To mirror the Wessex Acute Frailty audit, the WCFA comprised of 28 questions relating to five key areas:
When did the audit take place?
What has the audit shown?
An interactive workshop was held in February 2020 and provided a forum for PCN Clinical Directors, frailty leads, service manages and Clinical Commissioning Groups and STP leads to review overarching themes form the community frailty audit and to identify potential service improvement projects.
Key areas of focus for the community include communication, multidisciplinary team meetings, and collaboration with the social and voluntary sector.
Presentations from the workshop have been made available.
A summary of outputs of the workshop and a video of Dr David Atwoods' key note speech has been made available. These resources can be used within your organisation.
An evaluation of the approach will be published by June 2020.
We are fortunate to have three Health Education England Trainee Frailty Consultant Practitioners working with the Healthy Ageing Programme to deliver quality improvement projects across 6 Wessex PCNs. Following the workshop event, a programme of work to deliver rapid improvements will be identified and scoped.
In the meantime, we as a programme we have begun to identify best practice resources to support colleagues in the community deliver an MDT (multidisciplinary team) approach to individuals living with frailty. This is live document and can be downloaded from the resource section.
Dr David Atwood, keynote speaker at the Community Frailty Audit workshopBrowse all videos