Geriatric Medicine

Each ICS/STP area should have an integrated system for preventing and managing frailty that includes secondary care, primary care, care homes, community services, ambulance services and paramedics, local authorities, third sector, patients and carers. Priorities should include avoiding inappropriate hospitalisation and progression of frailty, and improvement should be benchmarked with similar local footprints.

All trusts must assess all older people arriving in the emergency pathway for frailty using the Clinical Frailty Scale and use this to track them through the hospital if they are admitted. Wherever possible this should be an electronic system linked to the electronic patient record and used as part of a system-wide frailty strategy.

Trusts should identify patients with moderate frailty in all admission wards and take action to prevent them from becoming more functionally dependent. This includes providing space and equipment such as chairs and walking aids for daily mobility support, developing a culture where all ward staff can provide that support and where frailty is everyone's responsibility, and measuring progress against key metrics over a sustained period.

Each trust should appoint a senior member of staff who is the accountable officer leading on the quality of care for older people with frailty while in hospital, linked to ICS/STPs and local networks. They should report to the board across key frailty safety domains, and use this information to help develop and refine the system-wide frailty strategy.

All patient-facing staff within a local health system should be given basic training in frailty at Level 1 on the Frailty Capabilities Framework.

All trusts should have a clear pathway for delirium that includes assessing all older people admitted as an emergency using 4AT, a system for identifying delirium in elective admissions, and rapid and effective delirium response. Delirium awareness should be embedded in basic frailty training for all patient-facing staff.

ICS/STPs should work on a multi-agency basis to implement the new hospital discharge service guidance to improve outcomes for older adults and optimise flow and discharge rates.

ICS/STPs should develop targeted strategies to address specific barriers to safe discharge at the weekend and for patients staying more than 21 days (super-stranded).

Review readmission rates on a multi-agency basis to understand the causes and develop interventions to reduce them, including enhanced support for older people with frailty to prevent falls, delirium and multiple admissions, and targeted support for those readmitted within 7 days and 30 days of initial admission.

All local health systems should implement the Enhanced Health in Care Homes framework as part of the Primary Care Network (PCN) contractual obligations.

All local health systems should have identified older people in the last phase of life and offer them advance care planning, so they can be looked after and die in their preferred place of care wherever possible.

ICS/STPs should develop new ways of working to meet local service needs including: extended roles for nurses, allied health professionals, pharmacists and advanced practitioners; a greater role for consultants in acute, general and emergency medicine where capacity allows; more opportunities for portfolio career progression to attract and retain consultants and trainees.

ICS/STPs should develop and embed models such as virtual clinics, community assessment hubs, out of hours crisis response, same day emergency care and patient-initiated follow up to improve the effectiveness of ambulatory assessment for older adults as envisaged in the NHS Long Term Plan.

Attribution of specialty should be reviewed to ensure that geriatric medicine activity and the specialty of the person doing it can be identified.

Clinicians and coders should work together to improve capture of frailty-related diagnostic codes to give trusts a clearer hospital-wide data view of frailty. Trusts should be able to see which patients are living with frailty and how severe it is.

Consider how liaison and other shared care services could be recorded and reported more effectively.

Local health systems should address the prescribing and pharmaceutical care needs of older people to improve safety and optimise adherence.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice.

Reduce litigation costs by application of the GIRFT Programme's five-point plan.