This publication outlines how to deliver proactive care against core components and key enablers, acting as a roadmap for implementing the NHS England framework and delivering proactive care services. This introduction includes a foreword, executive summary and an outline of the eight recommendations.
ForewordProactive care plays a vital role in delaying the onset of frailty, maintaining older people’s independence, and reducing avoidable periods of ill health. Last year, the BGS highlighted the importance of proactive care in Joining the Dots: A blueprint for preventing and managing frailty in older people by highlighting it as one of seven key touchpoints to support older people to age well. We were pleased that the long-awaited NHS England Guidance on proactive care was published last year. Previously known as anticipatory care, proactive care is one of the three original streams of the Ageing Well programme, as detailed in the NHS Long Term Plan. While we remain disappointed that the initial promised funding for the programme was cut, the guidance provides a crucial framework. In October 2024, the BGS published Be proactive: Evidence supporting proactive care for older people with frailty. This first publication provides evidence to help colleagues build business cases for proactive care in their locality. Our second publication, Be proactive: Delivering care for older people with frailty, acts as a roadmap to support the delivery of proactive care services for older people with moderate to severe frailty. With the NHS England guidance as an overarching framework, we propose colleagues use both BGS documents to deliver evidence-based proactive care. To deliver proactive care, we recognise colleagues require both appropriate infrastructure and policy locally and nationally. As such, our second report provides eight recommendations requiring action from commissioners, policymakers, providers and healthcare professionals at local, regional and national levels. We urge anyone involved in commissioning proactive care services to seek the expertise and resources available from the BGS. We know that the provision of proactive care services varies greatly across the UK, creating unequal health outcomes for older people. However, we also know there are many exemplary proactive care services across the four nations, and we believe the same principles apply to the organisation and delivery of proactive care across the UK. As with all our work at the BGS, we have been pleased to work with our multidisciplinary members who provided invaluable insights and content to inform the report. I would like to thank all those involved. Now, it is crucial that proactive care is prioritised and embedded across all primary and community settings to ensure older people live well and stay independent for longer.
Professor Jugdeep Dhesi |
Executive summary
Frailty is common in older people, affecting more than one in ten people over 65 living in the community1 and up to half of the total UK population over 85.2 As the UK population continues to age, these figures are expected to increase and likely to double by 2045 with associated implications for healthcare systems.1 Despite this, frailty is not an inevitable part of ageing.
As outlined in BGS’s Joining the dots: A blueprint for preventing and managing frailty in older people, older people need a comprehensive ‘wrap around’ health and social care system that supports healthy ageing and maximises functional independence.1 To achieve this, the blueprint sets out seven system touchpoints that should be included when planning and commissioning health and social care for older people.
One of these vital touchpoints is ‘population-based proactive anticipatory care’, which identifies older people at risk of ill health and poor outcomes and offers them personalised interventions to remain well for longer. This publication will explore this touch point in further depth, focussing on proactive care for older people with moderate to severe frailty receiving care in community and primary care settings. The document is aimed at healthcare professionals, clinical leaders, policy makers, and commissioners and acts as a roadmap for delivering proactive care for older people with frailty.
Building on the recent NHS England proactive care guidance, Proactive care: providing care and support for people living at home with moderate or severe frailty,2 this publication outlines how to deliver proactive care against the five NHS core components and three key enablers. It also outlines eight key recommendations for the successful implementation of proactive care services across the UK. It will complement BGS’s Be proactive: Evidence supporting proactive care for older people with frailty,3 which outlines the evidence base for proactive care. Users will be able to utilise all three documents when designing proactive care services, with the NHS England guidance document acting as key framework and starting point, BGS’s evidence document as a business case, and this document as roadmap for implementing the NHS England framework and delivering services.
Core components
Case identification
A wide range of different approaches can be used to identify people that may benefit from proactive care services. This includes using human knowledge; analysing admission, discharge and caseload data; receiving referrals; and using algorithms to identify people from databases. The electronic frailty index (eFI) is a tool that uses data from a patient’s electronic health record to identify and grade the severity of frailty and can be used alongside other criteria to identify a cohort. Once identified, tools such as the Clinical Frailty Scale (CFS) can be used to confirm diagnosis.
Holistic assessment
Once a patient has been identified, a holistic assessment, such as a Comprehensive Geriatric Assessment (CGA), should be used to assess their needs. The assessment should include physical, functional, social, environmental, and psychological assessments, alongside a medication review. The Geriatric 5Ms framework can be used as a framework for holistic assessments, focusing on mind, mobility, medication, multicomplexity, and what matters most to patients.4
Personalised care and support planning
Following on from holistic assessments, individuals should be supported with a personalised care and support plan. Proactive care services should develop a format for care planning, focussing on falls prevention, nutrition advice, social care support, medication reviews, advanced care planning, and emergency care plans, such as ReSPECT forms. Plans should include preventative strategies to address common issues associated with frailty, including vaccinations, regular screening, and proactive management of chronic conditions.
Co-ordinated and multi-professional working
At a minimum, the core proactive care team should consist of a GP with an interest in frailty, an Advanced Clinical Practitioner, and a Care Co-ordinator. If resource is available, the core team can extend to include professionals from mental health services, pharmacy, social care, therapy and Geriatric Medicine. Effective communications should be implemented, such as a regular multidisciplinary team (MDT) meeting, and sufficient training and development opportunities available.
Continuity of care
Continuity of care is essential to ensure that proactive care interventions are being implemented. The core proactive care team should liaise with service providers and the relevant members of the multidisciplinary team to ensure that proactive care is being delivered. Frailty is not a static process and therefore follow up is needed to see how the patient’s condition has changed over time.
Key enablers
Flexible workforce
It is important that the multidisciplinary proactive care team is supported to work across organisational boundaries, with sufficient capacity and training opportunities. The team should have an understanding of frailty and associated issues such as falls, immobility, delirium, incontinence, multi morbidity, and polypharmacy. A shared workforce plan across the partner organisations outlining ways of working and training opportunities for staff should be developed.
Shared care record
Information sharing is vital for proactive care services as it requires multidisciplinary interventions across a range of health and care organisations. It is important that the core proactive team has access to all electronic patient records, including general practice, community services, hospitals and social care. If this is not possible, they should have access to all the shared records available in the area.
Clear accountability and shared decision-making
Shared decision-making and governance between provider organisations are essential to the success of proactive care services. When designing the service, local leaders should agree on the aim of the service and develop shared values. Holistic care often consists of many overlapping services such as physical health, mental health, psychological services and social services as well as community and voluntary care services.
It is important that all these services work from shared values focussed on what matters most to the patient. Data collection and outcome measure should also be considered when designing the service. Services should consider using patient reported outcomes or functional measures, such as Activities of Daily Living (ADLs) and patient experience measures. As outcome measures for proactive care are difficult to implement, process measures may provide another approach to demonstrate the value of an intervention.
Recommendations for delivering proactive careRecommendation 1Proactive care services should be aligned to the approximate geography of a Primary Care Network (PCN)/Primary Care Cluster (PCC) or equivalent, with a dedicated proactive care team in each equivalent area across the UK. Recommendation 2Policy makers and commissioners should prioritise national funding and contractual arrangements to ensure that proactive care is available to all older people living with frailty in the community. Recommendation 3Leadership is vital to the delivery of successful proactive care services, and it should be supported and nurtured through training opportunities and protected funding. Recommendation 4Outcome measures are vital in evaluating the success of proactive care interventions and should always be implemented when new services are launched. National guidance on how to measure the impact of proactive care interventions should be published, and investment is needed in clinical research and IT infrastructure focussed on data collection and evaluation. Recommendation 5Proactive care services should be staffed by a core multidisciplinary team, consisting of at least one GP with an interest in frailty, one Advanced Clinical Pratitioner, and one Care Co-ordinator. A gold standard team would include professionals from social care, mental health services, therapies, pharmacy and geriatric medicine. Recommendation 6Local and national investment in training and development opportunities for the multidisciplinary team working in proactive care is needed, including mandatory frailty training, training in communication, leadership, and coaching, and education on the wider health and care system. Recommendation 7A culture of flexible and cross organisational working should be embedded in proactive care services, which requires good working relationships across services. A shared proactive care workforce plan across the partner organisations in each PCN/PCC or equivalent should be developed. Recommendation 8Services across the UK should use BGS’s Be proactive: Evidence supporting proactive care for older people with frailty3 to make the case for proactive care services in their local area, and use Be proactive: Delivering proactive care for older people with frailty as a roadmap for implementing services. (Refer to Appendix 2 for a diagram outlining this roadmap). |
