Frailty (health and wellbeing needs in South Tyneside)

1. Carers for patients are a vulnerable group of society with additional pressures placed upon them. Anecdotally using audit data from South Tyneside Hospital, several admissions are due to carer breakdown.

Recommendations for increased support for carers include:

• Short break care
• Emergency service provision by community teams, particularly for carers of those suffering with dementia
• Increased advocacy services for carers
• Flexible long term support as an alternative to residential care
• Information about access to services and assessment / eligibility

2. There remains a large gap, in respect of communication and provision of services, between primary and secondary care regarding management of the needs of frail patients. Whilst community geriatricians for example are keen to pursue a community geriatric service, the lack of availability of staff from the trust prevents this from occurring. The employment of a General Practitioner with a specialist Frailty (GPwSI) or Elderly Care interest would help in bridging this issue.

Alternatively, a frailty nurse role is currently being piloted by a practice within South Tyneside. This aims to identify 'high risk' patients by way of various scoring systems, thereby optimising their medical care and instigating future care planning. Integrated care teams currently exist within the borough, however require additional staffing to be able to attend to the level of demand.

3. Proactive care, or 'prehab', is an important stage in addressing frailty, particularly with regards to falls. The current provisions in the local area can be used more proactively by the local community through promotion by health care professionals.

Occupational health waiting times are also long. Important, simple changes in environment for a frail individual can improve quality of life and promote independence, which will in turn reduce the potential healthcare costs associated with frailty.

Age UK are currently going through a restructuring process and it remains to be seen what the level of support provided will be in future.

4. Falls can be a significant risk for those with frailty, particularly in the elderly. A 2012 - 2013 Joint Strategic Needs Assessment in South Tyneside identified certain boundaries to minimisation and impact of falling:

• The rate of admissions for falls has increased in recent years.
• Issues included lack of primary care in the falls treatment and prevention process, and in secondary care.
• The development of an 'at risk' falls screening pathway was suggested. Funding is currently being provided by Vanguard to allow this to be implemented for approximately one year.
• A falls clinic provision exists, which looks at holistic care and incorporates a multidisciplinary team including occupational therapists and physiotherapists.

Further information and a more in-depth analysis can be found at the JSNAA Falls paper due to be published.