NHS England defines frailty as a long term health condition characterised by a loss of physical and/or cognitive resilience that means people living with frailty do not bounce back as quickly as they used to after a physical or mental illness, an accident, or other stressful event.
Frailty is progressive, taking five to ten years to develop. There is often a trajectory of slow functional deterioration, which increases vulnerability and leaves individuals at risk of losing independence. People living with frailty are likely to have a number of different issues or problems that might not be very serious when taken individually, but have a large cumulative impact on health, confidence and wellbeing when added together. Older people who are frail have an increased risk of falls, disability, long-term care and premature mortality.
Prevalence of Frailty:
People living with severe frailty comprise around 3% of the population aged 65 and older in England. For moderate frailty it is 12% of those aged 65 and older and 35% for mild frailty. As the population of England ages, the prevalence and impact of frailty is likely to increase.
Identification of Frailty:
Early identification and diagnosis of frailty in primary care and tailored proactive interventions have the potential to help people to maintain their independence, enabling them to carry on living at home for longer and reducing reliance on health and social care resources. While severe frailty can be comparatively easy to recognise and diagnose, lesser degrees of frailty may be more difficult to differentiate from normal ageing. It is also important to note that in some populations frailty can be identified earlier in the life course.
The electronic Frailty Index (eFI) is a tool which allows GPs and primary care clinicians to routinely identify people living with different severity grades of frailty (mild, moderate or severe). The tool uses existing primary care data to calculate a frailty score on the basis of the accumulation of a range of deficits, which can be clinical signs (e.g. tremor), symptoms (e.g. vision problems), diseases, disabilities and abnormal test values.
 NHS England, Toolkit for general practice in supporting older people living with frailty, March 2017
Figure 57: List of 36 deficits in the Electronic Frailty Index
Source: Yorkshire and Humber Academic Health Science Network, March 2016
Like other long-term conditions, frailty can be effectively managed within primary care. Through the early identification (e.g., proactive case finding) and comprehensive assessment of frailty, we can seek ways to optimise care and support for adults with multi-morbidity and offer interventions to manage its progression effectively at key stages. These interventions focus on reducing the likelihood of crisis, or planning for the likelihood of crisis, and promoting earlier and optimal recovery.
 NHS England, Toolkit for general practice in supporting older people living with frailty, March 2017
In March 2018, NHS RightCare produced Frailty Story Boards for Sustainability and Transformation Partnerships. The Story Board for South East London showed that:
- Bexley’s GP registered population aged 75 years and older was similar to the national average in 2015/16
- Higher proportion of elderly population living alone.
- Injuries due to falls per 100,000 population aged 65+ was above the national average with the opportunity to reduce this.
- A key area of risk is the high prevalence of obesity and inactive adults.
- Bexley has very high success rates for smoking cessation.
- Bexley has a lower rate of alcohol specific hospital admissions per 100,000 population (541 in 2016/17) compared to the England average (636 in 2016/17) with the opportunity to reduce this further.
- Low asthma prevalence across South East London.
- Similar dementia prevalence in Bexley (0.8% of GP registered population) to the national average (also 0.8%) but one of the highest prevalence rates in London.
Data from the London Ambulance Service shows that there has been an increase in the number of falls-related call-outs for adults aged 18+ in Bexley over the last three years from 3,878 call-outs in 2015/16 to 4,738 call-outs in 2017/18. Those aged 65 years and over account for about 80% of all falls-related call-outs among the adult population. Within the older age groups themselves, about half of all call-outs relate to people aged 85+.
Figure 58: London Ambulance Service call-outs relating to falls in people aged 18 and over in Bexley, 2015/16 to 2017/18
Source: London Ambulance Service, SafeStats, July 2018
In 2017/18, the wards with the highest proportions of falls-related call-outs among the older population were in the Frognal and Clocktower GP localities.
Table 16: No. and % of falls-related call-outs by ward in Bexley for people aged 65 and over, 2017/18
|Ward Name (pre-2018)||No. of LAS falls-related call-outs (65+)||%|
|Blendon and Penhill||149||4%|
|Blackfen and Lamorbey||134||3%|
|Falconwood and Welling||85||2%|
Source: London Ambulance Service, SafeStats, July 2018
Data for 2017/18 shows that the top destination hospitals for falls-related conveyances for older people from Bexley were Queen Elizabeth Hospital (47%), Darent Valley Hospital (10%) and Princess Royal University Hospital (9%).
Figure 59: London Ambulance Service falls-related conveyances for Bexley adults aged 65+ by destination, 2017/18
Source: London Ambulance Service, SafeStats, July 2018
Falls are a leading cause of emergency hospital admissions for older people, and significantly impact on long term outcomes, e.g. being a major precipitant of people moving from their own home to long-term nursing or residential care. Data from the Public Health Outcomes Framework shows that there was no significant change in falls per 100,000 65+ population in 2016/17 and the position in Bexley has been similar to the England average over the last couple of years.
Figure 60: Emergency hospital admissions due to falls in people aged 65 and over
Source: PHOF and Hospital Episode Statistics, NHS Digital 2017
It is predicted that there will be a 45.7% rise in hospital admissions due to falls by the end of 2035. Of these, people over 75 account for the majority of cases (Figure 61).
Figure 61: People aged 65+ predicted to be admitted to hospital as a result of falls, projected to 2035
Source: POPPI, Crown Copyright 2016
What are we doing about it?
Integrated Care for older people: The CCG and the Council continue to invest in integrated care for older people from the pooled budget of the Better Care Fund. This provides for additional staffing capacity in our integrated care teams, notably rapid response, reablement, occupational therapy and Hospital Integrated Discharge teams. We continue to ensure a co-ordinated, person-centred approach to care planning. This includes working as part of Multi-Disciplinary Teams to carry out assessments of care needs and support integrated care planning. In addition, BCF funding for social care is supporting the provision of integrated packages of care.
Meadowview Intermediate Care Unit: Meadow View is an intermediate care unit at Queen Mary’s Hospital in Sidcup, which provides short term treatment in order to improve, restore or promote the patient’s daily living skills. Individuals may be admitted from home for short term 24 hour nursing help, or may be admitted from a hospital ward for extra nursing to facilitate a more safe return home. This provision has been successful in reducing length of stay in hospital and enhancing the independence of individuals following a period of illness. It has also enabled people to go home, who would in the past have been directed towards residential care.
Wolsley House: At Wolsley House, we provide seven rehabilitation flats, which have been designed to help older people or adults with disabilities to get back on their feet after a hospital stay or crisis, where they can stay short-term (4-6 weeks) if they are unable to manage at home. The intended impact of this service is to provide reablement support to maximise independence in a home environment, rather than in a residential care setting.
Two further flats provide emergency accommodation for older people who are homeless while suitable accommodation is found for them.
Multi-disciplinary team approach: GP practices are identifying high risk patients and cases are discussed in Multi-Disciplinary Teams, which is helping to prevent admissions to hospital because of very pro-active management.
Bexley Care: Bexley Care is developing its local service offer, which align to the Borough’s three Local Care Networks. Work is also being undertaken to develop a single point of contact for adult health and social care services and to implement a single assessment process. An enhanced triage system will ensure there is “no wrong front door”, enabling people to access the right service, first time.
Trusted Assessment: We have a local authority-funded nurse, who acts as a Trusted Assessor at Queen Elizabeth Hospital for care homes, supporting and facilitating early discharges.
Red Bag Scheme: In May 2018, the Red Bag Scheme went ‘live’. The scheme aims to improve communication and working practices between the NHS and care homes. Frail and seriously ill patients can often arrive at Accident and Emergency disorientated and unable to provide clinicians with their medical history or medications. Now, when a care home resident needs to go into hospital, a red bag containing their personal details, information on health conditions, medication and a change of clothes is packed for them. The information conveyed as part of the Red Bag enables faster clinical decision-making and a more personalised approach to meet individual needs. It is anticipated that this scheme will help achieve a reduction in length of stay in hospitals by preventing delays and ensuring a smooth transition into and out of the hospital. This is particularly important for frail older people because poor transfers from hospital have been linked to adverse events and increased risk of readmission.
Preventing Falls in Care Homes: Our Falls Prevention Trainer has worked with care homes and partner organisations to support the development of a robust Falls Pathway. This has included the development of training resources and provision of intensive training and support to care homes, which now enables them to address falls ‘in-house’ to prevent London Ambulance Service call-outs and admissions.
Telehealth Pilot: Our Telehealth Pilot aims to use assisted technology to prevent admissions to hospital. The biggest spikes in conveyances and admissions to hospital tend to be out-of-hours. We are working with Health Innovation Network (South London), who have linked in with NHS Digital to develop the out-of-hours offer. The idea is that information gathered via assisted technology during the day is available to NHS 111 and out-of-hours GPs to support clinical decision-making and prevent unnecessary admissions. We have recruited a 120-bedded care home at the top of the London Ambulance Service list of call-outs for South East London to participate in the pilot.
What works and best practice?
NHS England Resources and Toolkits: NHS England has published a range of information, including some useful toolkits and resources for GP practices to help in managing frailty:
- Guidance to GPs and Primary Care on the introduction of routine frailty identification for patients who are 65 and over from 1 July 2017.
- Toolkit for General Practice in supporting older people living with frailty offers a suite of tools to support case finding, assessment and case management of frail older people.
- Frail older people – Safe, compassionate care: This practical guidance document summarises the evidence of the effects of an integrated pathway of care for older people and suggests how a pathway can be commissioned effectively using levers and incentives across providers.
Recognising that different interventions may be needed at different stages of frailty, NHS England’s website provides supporting information, including guides and best practice examples, covering frailty awareness, identification, people at risk who remain fit, people living with early frailty, moderate frailty, and severe frailty, sharing information, and multimorbidity.
Electronic Frailty Index (eFI) : GP practices are required to identify populations at risk of being frail, by degree, using an evidence-based tool. NHS England has suggested that GPs should use the validated eFI, given that it is widely available in GP Electronic Patient Record Systems. The eFI has also been included as a recommended tool within the NICE multi-morbidity guideline. The tool enables identification of frailty using existing primary care data without the need for a resource-intensive clinical assessment. The eFI comprises of 36 ‘deficits’ (clinical signs, symptoms, diseases and disabilities) and calculates an overall eFI score by dividing the actual number of deficits present in a patient by the 36 total possible. This is used to identify people at risk of frailty and then requires clinical judgement to make a diagnosis of frailty, taking into account an individual’s complete clinical picture.
British Geriatric Society’s ‘Fit for Frailty’ Part 1: Fit for Frailty Part 1 provides advice and guidance on the care of older people living with frailty in community and outpatient settings and is aimed at all levels of health and social care professionals working in the community who may encounter older people living with frailty, including ambulance staff, nurses, therapists, social workers, etc.
 NHS England, Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders, February 2014
 Fit for Frailty Part 1, Consensus best practice guidance for the care of older people living in community and outpatient settings. A report by the British Geriatrics Society in association with the Royal College of General Practitioners and Age UK, 2014
British Geriatric Society’s ‘Fit for Frailty’ Part 2: Fit for Frailty Part 2 follows on from Part 1 and provides advice and guidance on the development, commissioning and management of services for people living with frailty in community settings. It is aimed at GPs, geriatricians, health service managers, social service managers and Commissioners of services. The BGS website also includes a toolkit on comprehensive geriatric assessment, examples of good practice, case studies and sources of clinical guidelines.
National Falls Prevention Coordination Group: The NFPCG has produced guidance outlining actions that the health, care, housing and voluntary sectors can take to help prevent older people having falls and fractures. The national falls and fracture consensus statement and resource pack are aimed at commissioners and strategic leads with a remit for falls prevention, bone health and healthy ageing. The guidance covers a range of effective interventions including:
- promoting healthy ageing across the different stages of the life course.
- evidence based strength and balance programmes and opportunities for those at low to moderate risk of falls.
- home hazard assessment and improvement programmes.
Later Life Training: A national training provider of specialist, evidence based exercise training for health and exercise professionals (e.g. Physiotherapists, Occupational Therapists and GP Referral Exercise Instructors) working with older people, frailer older people and stroke survivors. This includes courses for professionals to become Postural Stability Instructors, Chair-based Exercise Leaders, Otago Exercise Programme Leaders, and Exercise After Stroke Instructors. There are also a number of other courses offering training to health, other professionals and instructors, who wish to train their own Senior Peer Mentors, learn how to motivate older people to engage in physical activity, and promote physical activity and exercise for people with dementia.
Musculoskeletal, Falls, Fractures & Frailty: This guide showcases the extensive range of programmes being delivered by the Academic Health Science Networks (AHSNs) to improve clinical services in the areas of musculoskeletal (MSK), falls, fractures and frailty. Whilst many different clinical pathways and services are provided to manage these four problems, there are clear links between them. Across the 15 AHSNs there is a wealth of experience and practical skills in working with NHS organisations to improve clinical services in these clinical pathways with service evaluation projects that have been shown to improve patient outcomes and deliver more efficient use of resources. The guide aims to share learning and inform discussions with Sustainability and Transformation Partnerships, commissioners and providers about future work to improve services and patient outcomes in these areas.
 Fit for Frailty Part 2: Developing, commissioning and managing services for people living with frailty in community settings. A report by the British Geriatrics Society and the Royal College of General
Practitioners in association with Age UK, January 2015
 Falls and fractures: consensus statement and resources pack, produced by Public Health England with the National Falls Prevention Coordination Group member organisations, January 2017 and updated July 2017
 Musculoskeletal, Falls, Fractures & Frailty – A summary of projects from across the AHSN network, Oxford Academic Health Science Network, February 2018
Falls and Fragility Fracture Audit Programme (FFFAP): The FFFAP is a national clinical audit run by the Royal College of Physicians designed to audit the care that patients with fragility fractures and inpatient falls receive in hospital and to facilitate quality improvement initiatives. Commissioned by the Healthcare Quality Improvement Partnership since 1 June 2013 and delivered by the RCP, FFFAP has four overarching aims: (i) To improve outcomes and efficiency of care after hip fracture; (ii) To improve services in acute and primary care to respond to first fracture and prevent second fracture; (iii) To improve early intervention to restore independence; (iv) To work in partnership to prevent frailty, preserve bone health and prevent accidents in older people. The care that patients receive is measured through an audit comprised of the following three work streams:
- National Hip Fracture Database (NHFD) – The NHFD collects data on all patients admitted to hospital with hip fractures and improves their care through auditing which is fed back to hospitals through targeted reports.
- Fracture Liaison Service Database (FLS-DB) – The FLS-DB aims to evaluate patterns of assessment and treatment for osteoporosis and falls across primary and secondary care.
- National Audit of Inpatient Falls (NAIF) – This audit measures compliance against national standards of best practice in reducing risk of falls within acute care.
Effective Secondary Prevention of Fragility Fractures – Clinical Standards for Fracture Liaison Services: Fracture risk in a person with osteoporosis can be minimised through appropriate use of medical treatments and simple changes to lifestyle to improve bone health. Risk of falls, which can lead to fracture, can also be reduced through use of evidence-based interventions. A Fracture Liaison Service systematically identifies, treats and refers to appropriate services all eligible patients aged over 50 years within a local population who have suffered a fragility fracture, with the aim of reducing their risk of subsequent fractures. Evaluation of established FLSs has demonstrated this model leads to effective case identification, investigation and intervention to minimise future fracture risk through bone protection and referral into falls prevention pathways.
Age UK Information and Advice: Age UK has published a range of information guides and factsheets, including on Staying Steady, which is a guide to keeping active and reducing risk of falling. In addition, Falls Prevention Resources are available, including a guide explaining the evidence base for falls prevention exercise.
Joint working with Fire and Rescue Service: Working with partners, NHS England has produced a number of documents to show how commissioners can work with their local fire and rescue service to better support older people and those with long term conditions. Examples include published design principles for Safe and Well visits, which seek to expand the scope of the existing home safety checks by focusing on health and wellbeing, as well as fire risk reduction. Accompanying this is guidance on how health, social care and fire and rescue services can increase reach, scale and impact through joint working. A number of case studies have also been published to illustrate examples from across the country (e.g., initiatives to reduce falls risk in the home).
 Age UK, Falls Prevention Exercise – following the evidence, June 2013
NICE Guidelines and Quality Standards
A range of NICE Guidelines, Quality Standards and Public Health Guidance have been published. A selection are summarised below with links to the NICE website. Some of the guidelines are supported by a set of quality standards, which can be used to plan and deliver services to provide the best possible care.
NICE guideline [NG56] Multimorbidity – clinical assessment and management: This guideline covers optimising care for adults with multimorbidity by reducing treatment burden (polypharmacy and multiple appointments) and unplanned care. It aims to improve quality of life by promoting shared decisions based on what is important to each person in terms of treatments, health priorities, lifestyle and goals. The guideline sets out which people are most likely to benefit from an approach to care that takes account of multimorbidity, how they can be identified and what the care involves. It is accompanied by a quality standard, which covers clinical assessment, prioritising and managing healthcare for adults aged 18 years and over with two or more long-term health conditions.
NICE has also developed guidance and quality standards on patient experience in adult NHS services and service user experience in adult mental health services. These include statements on shared decision-making and coordination of care through the exchange of patient information, which are particularly relevant to the quality standard on multimorbidity.
NICE guideline [NG16] Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset: This guideline focuses on interventions and actions delivered at national, regional and local level to reduce risk of dementia, disability and frailty in later life. The guideline recommends:
- helping people stop smoking, be more active, reduce alcohol consumption, improve their diet and, if necessary, lose weight and maintain a healthy weight.
- reducing the incidence of other non-communicable chronic conditions that can contribute to onset of dementia, disability and frailty.
- increasing people’s resilience, for example, by improving their social and emotional wellbeing.
NICE Clinical guideline [CG103] Delirium – prevention, diagnosis and management: This guideline covers diagnosing and treating delirium in people aged 18 and over in hospital and in long-term residential care or a nursing home. It also covers identifying people at risk of developing delirium in these settings and preventing onset. It aims to improve diagnosis of delirium and reduce hospital stays and complications. This guideline includes recommendations on risk factors of delirium, indicators of delirium at presentation and daily observations, and preventing, diagnosing and treating delirium.
NICE Quality standard [QS63] Delirium in adults: This quality standard covers the prevention, diagnosis and management of delirium in adults (aged 18 and over) in hospital or long-term care settings (such as residential care or nursing homes). It includes a quality statement recommending that adults newly admitted to hospital or long-term care, who are at risk of delirium should receive a range of tailored interventions to prevent delirium.
NICE Clinical guideline [CG161] Falls in older people – assessing risk and prevention: This guideline covers assessment of falls risk and interventions to prevent falls in people aged 65 and over. It aims to reduce the risk and incidence of falls and the associated distress, pain, injury, loss of confidence, loss of independence and mortality. The guideline includes recommendations on multifactorial risk assessment of older people and multifactorial interventions to prevent falls in older people. It is accompanied by a quality standard describing high-quality care in priority areas for improvement. This includes:
- asking older people about falls when they come into contact with health and social care practitioners or present at hospital.
- offering multifactorial falls risk assessment and individualised multifactorial interventions to those at risk.
- safe handling of falls during a hospital stay.
- offering a home hazard assessment and safety interventions to older people who are admitted to hospital after having a fall.
- referring those with a history of falls for strength and balance training.
NICE Quality standard [QS50] Mental wellbeing of older people in care homes: This quality standard covers the mental wellbeing of older people (aged 65 and over) receiving care in care homes (including residential and nursing accommodation, day care and respite care). It focuses on support for people to improve their mental wellbeing so that they can stay as well and independent as possible.
NICE Quality standard [QS137] Mental wellbeing and independence for older people: This quality standard covers interventions to maintain and improve the mental wellbeing and independence of people aged 65 or older, and how to identify those at risk of a decline. It recommends that older people most at risk of a decline in their independence and mental wellbeing are offered tailored, community-based physical activity programmes and a range of activities to build or maintain social participation.
Public health guideline [PH16] Mental wellbeing in over 65s – occupational therapy and physical activity interventions: This guideline covers promoting mental wellbeing in people aged over 65. It focuses on practical support for everyday activities, based on occupational therapy principles and methods. This includes working with older people and their carers to agree what kind of support they need. It includes recommendations on occupational therapy interventions, physical activity, walking schemes, and training.
NICE Clinical guideline [CG124] Hip fracture management: This guideline covers managing hip fracture in adults. It aims to improve care from the time people aged 18 and over are admitted to hospital through to when they return to the community. Recommendations emphasise the importance of early surgery and coordinating care through a multidisciplinary hip fracture programme to help people recover faster and regain their mobility. A quality standard on hip fracture has also been published, which covers the diagnosis and management of hip fracture in adults (aged 18 and over). It includes a quality statement that recommends adults with hip fracture start rehabilitation at least once a day, no later than the day after surgery.
NICE Quality standard [QS136] Transition between inpatient hospital settings and community or care home settings for adults with social care needs: This quality standard covers admissions into, and discharge from, inpatient hospital settings for adults (aged 18 years and over) with social care needs. It recommends that older people with complex needs have a comprehensive geriatric assessment started on admission to hospital. For adults with social care needs, it highlights the importance of sharing existing care plans with the admitting team, allocating a named discharge coordinator, giving patients a copy of their agreed discharge plan before leaving hospital and involving family or carers in discharge planning if they are providing support after discharge.
NICE guideline [NG74] Intermediate care including reablement: This guideline covers referral and assessment for intermediate care and how to deliver the service. Intermediate care is a multidisciplinary service that helps people to be as independent as possible. It provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. It aims to ensure people transfer from hospital to the community in a timely way and to prevent unnecessary admissions to hospitals and residential care.
NICE guideline [NG67] Managing medicines for adults receiving social care in the community: This guideline covers medicines support for adults (aged 18 and over) who are receiving social care in the community. It aims to ensure that people who receive social care are supported to take and look after their medicines effectively and safely at home. It gives advice on assessing if people need help with managing their medicines, who should provide medicines support and how health and social care staff should work together.
NICE guideline [NG22] Older people with social care needs and multiple long-term conditions: This guideline covers planning and delivering social care and support for older people who have multiple long-term conditions. It promotes an integrated and person-centred approach to delivering effective health and social care services. The guideline includes recommendations on the role of the named care coordinator in care planning, supporting carers, preventing social isolation, and training health and social care practitioners. It is also accompanied by a quality standard which describes high-quality care in priority areas for improvement.
NICE Public health guideline [PH54] Physical activity exercise referral schemes: This guideline covers exercise referral schemes for people aged 19 and older, in particular, those who are inactive or sedentary. The aim is to encourage people to be physically active. This guideline includes recommendations on exercise referral for people who are sedentary or inactive and the collation and sharing of data on exercise referral schemes.
What are the gaps?
Management of Long Term Conditions: There is scope for improvement for patients with long term conditions to be better supported in having a care plan and making use of it to manage their conditions.
Bexley also has a number of opportunities to improve the management of long term conditions, particularly in regard to:
- high risk patients with atrial fibrillation to be treated with anti-coagulation therapy
- blood pressure management for patients with hypertension and patients with a history of stroke
- patients aged 65+ receiving the Pneumococcal (PPV) vaccine
- influenza immunisation of patients with diabetes and Chronic Obstructive Pulmonary Disease.
- reviews of conditions such as asthma, diabetes, dementia and rheumatoid arthritis.
Reducing non-elective admissions: Emergency hospital admissions during the last year of life for patients with cancer, dementia, respiratory and circulatory conditions are all above the national average, highlighting the potential opportunity to reduce utilisation of bed days.
There is high emergency spend on genitourinary conditions, particularly for Urinary Tract Infections in elderly patients, with the opportunity to reduce utilisation of bed days in hospital. There are some opportunities to reduce non-elective spend on injuries to elderly patients, arthritic conditions, and falls. Bexley also has a very high incidence of hospital admissions for primary diagnosis of disorientation.
Fracture Liaison Services: The Fracture Liaison Service Database (FLS-DB) is a clinically-led web-based national audit of secondary fracture prevention, commissioned by the Healthcare Quality Improvement Partnership as part of the Falls and Fragility Fracture Audit Programme (FFFAP). The audit demonstrates clear areas for improvement in order for existing FLSs to develop greater effectiveness and efficiency. In London, there are ten Fracture Liaison Services, including Queen Elizabeth Hospital, University Hospital Lewisham, Guy’s and St Thomas’ and King’s College Hospital (Denmark Hill site).
Data from the audit suggests that only 16% of the estimated total number of patients with fragility fractures in London were identified and seen by an FLS, based on data submitted to the FLS-DB. This highlights the need to improve data quality and participation in the audit. Nationally, only 40% of patients diagnosed with a fragility fracture received a falls assessment between January and December 2016. There also needs to be a focus on improving performance in the care, treatment and monitoring of fragility fracture patients, including:
- Timeliness of FLS assessments and (dual energy X-ray absorptiometry) DXA scans of patients with fractures.
- Monitoring and follow-up 12-16 weeks post-fracture.
- Commencement of bone therapy post-fracture and adherence to prescribed anti-osteoporosis medication.
National Hip Fracture Database: The ninth annual report from the National Hip Fracture Database shows that while more patients are receiving early surgery and surviving a hip fracture, some patients are not receiving all of the recommended elements of a hip fracture programme that represent ‘best practice’. In 2017, figures for Queen Elizabeth Hospital, Darent Valley Hospital and the Princess Royal University Hospital show that about one in three patients (30%) are not receiving all of the recommended elements of a hip fracture programme that represent ‘best practice’, compared to two in five patients (40%) nationally. The NHFD annual report includes a range of recommendations and links to individual hospital performance dashboards.
Table 17: National Hip Fracture Database Assessment Benchmark 2017:
Source: National Hip Fracture Database 2017
National Audit of Inpatient Falls (NAIF) Audit Report 2017: The audit was created to measure acute hospitals against the NICE guidance on falls assessment and prevention (CG161) and other patient safety guidance on preventing falls in hospital. It aims to improve inpatient falls prevention through audit and quality improvement. Prevention depends upon prompt assessment to identify potential risk factors, followed by clinical responses to ameliorate their effects. This is a complex task requiring a multidisciplinary team approach. One patient may require several individually tailored interventions. Round 1 of the National Audit of Inpatient Falls took place in 2015. The results of Round 1 were used to develop a guide to Falls Prevention in Hospital for Patients, their Families and Carers and a set of regional reports aimed at CCGs in England. Round 2 of the audit took place in May 2017 and the audit report was published in November 2017. The audit shows that there was substantial variation between hospitals and considerable room for improvement in most Trusts against key clinical indicators (see Figure 62). In all our local hospitals, the audit showed that less than 50% of patients received assessment for delirium and measurement of lying and standing blood pressure. Other clinical indicators were below the national average at Queen Elizabeth Hospital and Darent Valley Hospital. These related to appropriate mobility aids being within reach of patients and having continence or toileting care plans in place for patients who have been assessed as having continence problems. Patients’ having easy access to the call bell is a simple safety measure, which requires more attention in some hospitals.
 Royal College of Physicians, National Audit of Inpatient Falls: audit report 2017, London: RCP, 2017
 Royal College of Physicians, Falls prevention in hospital: a guide for patients, their families and carers, London: RCP, October 2016
 Royal College of Physicians, National audit of inpatient falls: commissioners’ report 2015, London RCP, June 2016
Figure 62: In-patient Falls Prevention – % of patients who received assessment/intervention across seven key clinical indicators:
Source: National Audit of Inpatient Falls, Royal College of Physicians 2017
Other quality and prevention opportunities: Looking at the picture across England, Bexley has lower average spend on hip and knee replacements and undertakes comparatively fewer procedures than other CCGs across the country. Bexley also has lower pre-op scores (indicative of patients experiencing pain) and average post-op scores (indicative of health gain) for both hips and knees, when compared to the national trend.
Social Care Market in South East London: Over the last 5 years, there has been an increase in domiciliary care agencies, which is similar to the position across London and England. With the exception of Bexley, there have been large losses of nursing and residential care home beds in other boroughs in the sub-region. Overall, the South East London health economy has higher A&E attendance, emergency admissions and length of stay than London and England. Across the three main acute trusts in South East London, the main reasons for Delayed Transfers of Care, attributable to social care in 2017/18 related to ‘nursing home placement’ and ‘awaiting package of care in my own home’.
- Develop and implement an overall frailty strategy covering the whole frailty trajectory from keeping people healthy and independent at home through to supporting them in hospital and at end-of-life, ensuring care is coordinated with smooth transitions between care settings.
- Ensure links are made with other relevant strategies (e.g., prevention, ageing well, carers, obesity, dementia, and end of life).
- Promote the early identification and diagnosis of frailty in primary care.
- Offer tailored proactive interventions to people with frailty, using a goal-oriented and assets-based approach to improve overall physical, mental and social functioning.
- Improve management of long term conditions and review the opportunities to reduce non-elective admissions to hospital, including during the last year of life.
- Use evidence based solutions to increase vaccination rates for flu and pneumonia among the elderly.
- Hospitals and Commissioners should review the findings and recommendations of the National Hip Fracture Database annual report each year and work towards ensuring all patients receive all of the recommended elements of a hip fracture programme that represent ‘best practice’.
- Review what secondary fracture prevention services are available to Bexley residents and the performance of Fracture Liaison Services. Engage further with hospital trusts, local clinical champions and the National Osteoporosis Society to identify good practice and areas for improvement to prevent further avoidable fractures for local patients.
- Consider the findings and recommendations from the National Audit of Inpatient Falls and engage further with hospitals and clinical teams to understand the steps being taken to improve clinical indicators.
- NHS Bexley CCG should consider the potential to improve health gain from more timely hip/knee replacements.
- Review the available evidence around genitourinary conditions, particularly Urinary Tract Infections in elderly patients, and consider options aimed at reducing hospital admissions (e.g., infection prevention and control, staff training in care homes, improving hydration in care homes, rapid response involving prompt diagnosis and better management of patients in the community).