This work had resulted from CLAHRC research fellowship, undertaken by an Advanced Community Nurse Practitioner who had collaborated with a consultant geriatrician and researchers from the University of Cambridge Institute of Public Health.
Background
Published research carried out in Cambridge and Peterborough Foundation Trust (CPFT) had shown that:
- there was a general consensus regarding the concepts of frailty but that different professions focused on different aspects diversity of concepts of frailty, reflecting different disciplines’ views
- the frailty assessment was not being used to inform care
- the clinicians did not consistently work together across disciplines: rather there were duplications, gaps and poor communication about frailty. (https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1069-3)
This work had resulted from CLAHRC research fellowship, undertaken by an Advanced Community Nurse Practitioner who had collaborated with a consultant geriatrician and researchers from the University of Cambridge Institute of Public Health.
The intention at CPFT trust was to rectify the problems identified by the research, but early attempts to do so revealed the need for greater coordination between various strands of the of the task that embraced quality improvement, training, commissioning and research. Discussions between the ARC EoE Implementation Leads, a small group of senior managers and clinicians, and the original research team suggested that one way to synthesise these various strands would be to implement a ‘practically-focussed integrated training and development programme that enables staff to understand and manage frailty in a coordinated way that meets not only the patients’ and staff’s needs but also the organisational and QI needs’. They agreed that the best way to achieve this was to convene a community of practice consisting of patient and public representatives, the university researchers, the trust education lead, senior and practising physiotherapists, occupational therapists nurses, doctors and health care assistants from different services and care teams across the wider local geography.
Implementation activity
The CoP met in January 2020, with 14 attendees in addition to the ARC facilitators. They started by establishing that the research findings did indeed reflect the experience of those present, and that improved training might help solve the problems. It also emerged that there was confusion about the different measures of frailty that were available, and that many patients object to the term.
The CoP participants agreed that a better, more integrated and holistic approach to education about frailty was needed. Frailty training should be delivered in multidisciplinary environments. It should entail a combination of (1) upfront training, e.g. at induction sessions, (2) follow-up e-learning and (3) regular routine guided reflective multidisciplinary, face-to-face discussions about patients who are frail at, e.g., team meetings. Patient stories and real case studies should be the focus throughout. Existing staff who would not be exposed to the upfront inductive training would also need to be catered for as part of this, preferably mandatory, training. Aspects of the e-learning course should be open to others outside the MDT teams, including staff in other relevant organisations, and possibly also to patients and carers. Representations should also be made to local higher education providers to include frailty in their syllabuses.
The trust’s education department undertook to develop such a course. However, the CoP members agreed that training would not solve the problem alone. System problems also needed to be tackled by higher management. A key step would be to establish frailty champions in all relevant services, who would not only promote the consistent use of ‘frailty’ in practice across the whole team, but also structure local training to ensure that all aspects of frailty are systematically covered in multi-disciplinary team meetings, handovers and other settings over the course of a year. This would require managerial agreement to invest ring-fenced time at meetings (which – it was suggested – should repay itself many times over if conducted properly).
The CoP also agreed the criteria by which they would judge the success of this programme of work. Their aspirations would be met, for example, when frailty was part of mandatory training, when time was regularly set aside for multidisciplinary activities as part of routine practice, and when frailty assessment was routinely a key part of (a multidisciplinary) holistic comprehensive geriatric assessment that feeds into a unified multidisciplinary care package.
Outcome
The agreed actions, and further CoP meetings, were pushed aside by the Covid crisis, which absorbed the time and energy of all the key players in the trust. However, the Education Lead, when returning in 2021 to the task of designing the training programme, identified that in the meantime Health Education England and British Geriatric Society has recently produced courses on frailty that would serve some of the above requirements. Discussions are underway to adapt those courses for CPFT directly, before also – once the Covid crisis has receded – pursuing the other goals that the CoP had set itself