The Getting It Right First Time’s (GIRFT) national report on geriatric medicine was published in 2021 and recommends a collaborative approach to help prevent frailty and reduce hospital admissions for older patients. This report is based on a recent webinar discussing implementation of the report recommendations.
The Getting It Right First Time (GIRFT) programme works on the principle that every patient should receive effective and timely healthcare across the NHS, irrespective of who delivers that care. Through a series of specialty-led reviews, it aims to improve outcomes and patient experience, without the need for radical change or additional investment.
The national report on geriatric medicine, published in 2021, calls for a collaborative approach across whole systems, including primary and secondary care, care homes, community services, ambulance services, local authorities, and the voluntary sector. It advocates a population-based approach to frailty, which is especially important in light of the Covid-19 pandemic.
This report is based on a recent webinar discussing how implementation of the recommendations can improve the quality of care for older people.
Getting care right first time makes a big difference to patients
The webinar was opened by Dr Jennifer Burns, president of the British Geriatrics Society, who said that the GIRFT report on geriatric medicine is a huge opportunity to understand variation in practice, and to learn what we can do to improve it.
She said we have known for years that getting care right first time makes a big difference to patients in terms of reduced mortality and reduced length of hospital stay.
“To do this, we need to be advocating for things that have been shown to work well,” she added. “Comprehensive Geriatric Assessment (CGA) has been trialled in randomised control trials going back for many, many years. Systematic reviews show that if you receive CGA in acute care settings versus standard care, you are more likely to be at home and alive for a year and the number needed to treat is only 13.
“In addition, over the past few years, the efforts to improve delirium care have really been transformative. Some things that make the biggest difference include explaining the diagnosis to patients and families.”
Population-based approach to frailty
The next speaker was Dr Adrian Hopper, GIRFT clinical lead for geriatric medicine, who said that one of the first challenges he had when he became programme lead was defining what geriatric medicine was.
“This is because it is hugely variable,” he said. “Some hospitals, at least in data terms, don't include any geriatric medicine, while in other hospitals it is the main specialty to manage older patients admitted as an emergency. As geriatric medicine was so variable, we decided one focus should be on frailty.”
So, what is frailty? Dr Hopper said this term describes patients who have falls, reduced mobility, and confusion often caused by delirium. It is also characterised by limited therapeutic reserves, so there is a disparate disproportion of functional change due to minor insults or impacts. Therefore, it is important to get hospital treatment right to prevent the complications of frailty.
He added: “Data shows a huge difference in length of stay by Hospital Trusts between frail and non-frail patients. As a patient’s frailty increases, so does the average length of stay in hospital. However, there is a huge variation in how Trust’s mitigate this.
“Equally, there is variation in who is the principal specialty looking after frail patients in hospital. About 40% of cases are managed by general medicine, with only 17% of patients managed in geriatric medicine. The skills of all specialities are crucial for the effectiveness of the frailty pathway.”
The GIRFT report states one cause of longer stays in hospital is delirium, but some older patients who arrive at hospital are not assessed for delirium, especially if they arrive out-of-hours or at weekends. A key recommendation is that Trusts have a clear pathway for delirium, which includes early identification and assessment, to help improve patient safety.
Dr Hopper said: “Delirium is the central syndrome for addressing frailty. On average, about 40% of patients are assessed for delirium. But we really want to get delirium to a stage, a bit like blood pressure, where this is just part of routine care. About 20% of our hospitals don't have even a basic delirium pathway and we want all hospitals to be at 100%. Assessment is just the start to create effective pathways.
“Bed utilisation is also important for this frailty pathway, and this is where a lot of NHS resources are going. From the Kent dataset, 50% of the total costs in the health and social care system are used by the acute sector, but the resourcing is largely linked to long hospital stays."
One of the biggest challenges to implementing the pathway, according to Dr Hopper, will be the workforce. He said there are not enough consultant geriatricians to supply the demand for this frailty agenda, so there is a need to develop advanced practitioners as part of a workforce solution to frailty. He also says that training will be crucial.
He added: “There are huge opportunities for large-scale change, but this is about a complex system. Let's collectively get the frailty agenda to mainstream because obviously the health service will not survive unless we can shift frailty care into much higher value, with better quality and lower costs.”
How do we drive this implementation?
In the second part of the webinar, Dr Tom Downes, Clinical Lead for Quality Improvement and a Consultant at Sheffield Teaching Hospitals NHS Foundation Trust, spoke about how we drive the implementation of the GIRFT report.
He said that improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. Citing research from Professor Susan Michie, Professor of Health Psychology at UCL, he added that this successful behaviour change needs three things: the motivation, the opportunity, and the capability.
The current GIRFT report, according to Dr Downes, provides a real stimulus for this. Healthcare professionals should ask where is that unwarranted clinical variation in the area that they work, and what potentially they can do about it? Also, what is the gap between where you are and where you want to be?
He added that opportunity is tricky in the NHS now as there is not much wriggle room – time and resources - to test ideas to move forward and that's a real leadership challenge. But it is still fundamentally important to create opportunities to redesign systems and processes.
“For capability, quality improvement can feel like a niche and something that somebody else does,” he said. “But let me share with you that actually the approach to quality improvement requires structure, and it is very similar to the structure we use with patients.
“When a patient walks into our service, we don’t just get the prescription pad out and write a prescription for them. First, we take a history, then we examine them, maybe undertake investigations, and assess what's going on before moving into the area of a differential diagnosis.
“Once we’ve identified the problems with the patient (and this isn't language we use with the patient), we test out treatments. And it is just the same with improvement work. As clinicians, we naturally use time series data. We look at blood pressure over time, temperature over time, oxygen levels and various other sorts of measures. Yet, when we go into quality improvement work, we sometimes revert to just trying to compare two things.
“Then when the patient becomes healthier, we want to stabilise them to keep them healthy. With improvement work, once we've got a prototype, tested it, and demonstrated that we have not just changed something, but that it is actually is an improvement, then we want that to become our normal way of working. We want to maintain and sustain that.
"All improvements have changes, but not all changes are improvements. It's relatively easy to change something, but to demonstrate an improvement requires rigor. The by-product of good improvement work is it makes the NHS a better place to work and something for staff to feel proud of. We need some of that for our wellbeing in the NHS now. So, quality improvement work is going to be fundamentally important in our recovery phase.”
Frailty as a collection of modifiable health and social needs
The final part of the webinar was given by Liz Boulton, Health and Care Policy Manager, Health Influencing, Age UK, who looked at the patient's perspective of frailty.
She said that there is often an assumption within the health and care system that home is best for patients, but that is not always the case. This is because not everyone has a home environment that is safe, warm and with access to nutritious food and supportive networks. For some people, home is not really a great place to be. As a result, healthcare professionals should have discussions about discharge as soon as a patient is admitted to hospital.
At Age UK, they use the term frailty to describe something a person lives with rather than what they are. They see it as a collection of modifiable health and social needs rather than an irreversible state.
"A few years ago, we conducted some research with people living with frailty and the older people we spoke to didn't consider themselves to be frail,” she said. “They talked about what they couldn't do anymore, or what they were fearful of doing. And in all the cases, reduced mobility was playing a part.
“We came up with four themes related to this. The first was that it was important for people to maintain their independence as much as possible. So, in many cases, adaptations were made to homes so they could remain living there. Moving beds downstairs to avoid stairs was common. They also talked about making use of the support and assets that they had. So, some had good support from family or neighbours, or regular or ad hoc arrangements and others have paid for support from carers as well as having visits from healthcare professionals.
“In adapting to their changing situation, some older people talked about the resilience they developed through either humour or faith, or both. They wanted workarounds to maintain the interests that they had, which helped them to keep hold of their identities. For example, people who had been very sporty maintaining some low level of physical activity and attending live sporting events.
“I think it's important to take a holistic view of the person's life and situation to understand the impact on them and also the opportunities for improvement.”
The full webinar can be accessed at the Getting It Right First Time website.