ITEM 9 IJB Frailty Strategy Update 2025
North Lanarkshire Council · 19 March 2025
Back to Health and Social Care Integration Joint Board — 19 March 2025 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 IJB Reporting Template REPORT Item No: 9 SUBJECT: Frailty Strategy Update TO: Integration Joint Board Lead Officer for Report: Hazel Gilmour Frailty NMAHP Consultant Author(s) of Report Dr Helen McKee Associate Medical Director for Frailty Contact details for Author(s) of Report Helen.McKee@lanarkshire.scot.nhs.uk Hazel.Gilmour@lanarkshire.scot.nhs.uk DATE: 19 March 2025 1. PURPOSE OF REPORT This paper is coming to the IJB to provide an update on the Frailty Strategy to note. This paper is coming to the IJB for: For Approval: ☐ For Endorsement: ☐ To Note: ☒ 2. ROUTE TO THE BOARD This paper has been prepared by Hazel Gilmour, Frailty NMAHP Consultant, and Dr Helen McKee, Frailty AMD. This has been reviewed by some key members of the Frailty Strategy Implementation Group.
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2 Prepared By: Dr Helen McKee and Hazel Gilmour ☒ Reviewed By: Frailty Strategy Implementati on Group ☒ Endorsed By: ☐ 3. EXECUTIVE SUMMARY The NHS Lanarkshire Strategy for Preventing and Managing Frailty has been in circulation for a year, with significant progress made in implementing and embedding its initiatives across Lanarkshire. This report outlines the work completed to date and sets out the key next steps for advancing the strategy in 2025. 4. RECOMMENDATIONS 4.1 It is recommended that the IJB: (1) Acknowledge the content of this report (2) Acknowledge the Frailty workplan for 2025 5. VARIATIONS TO DIRECTIONS? This section outlines if the report requires a direction to be issued to the Local Authority, the Health Board, to both, or that no direction is required 6. BACKGROUND 6.1 In 2023, NHS Lanarkshire developed the Strategy for Preventing and Managing Frailty 2023–2028, which received approval and endorsement from NHS Lanarkshire and North and South Lanarkshire Integration Joint Boards (IJBs) by the end of 2023. Implementation of this strategy and creating a work plan began January of 2024. 6.2 The strategy’s primary aim is to ensure that: Yes ☐ No ☒ N/A ☐
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3 “Every older person in Lanarkshire with, or at risk of, frailty is supported to achieve better health, maintain independence for longer, and live their best possible lives. Partners work collaboratively with older people, unpaid carers, families, and communities to prevent, identify, and manage frailty proactively through personalised, coordinated support delivered at home or close to home, alongside integrated, age- appropriate acute and community services”. 6.3 Following the launch of the strategy in 2024, various work streams have been created to support its implementation across Lanarkshire. Key activities included extensive stakeholder engagement with internal and external partners and the establishment of the Frailty Network and Frailty Strategy Implementation Group. These groups have driven the development of workstreams aligned with the strategy’s three objectives: Promoting Health and Wellbeing, Tackling Inequalities, and Delivering Sustainable Healthcare. 7. SUMMARY OF KEY ISSUES 7.1 In November 2024, the Frailty Strategy Implementation Group held the One Year On event to review progress on the NHS Lanarkshire Strategy for Preventing and Managing Frailty. 7.1.1 The event’s objectives were to: • Showcase the progress made in implementing the strategy throughout 2024. o Frailty and FNC+ o Frailty in Acute – Establishment of the Frailty Units in all acute sites o Carers Academy in Lanarkshire (carer support for people living with dementia, in collaboration with Alzheimer’s Scotland) o Blantyre Life – Reablement and promoting independent living o Active Wards – Reducing deconditioning through mental and physical activity • Encourage partners to pledge their commitment to incorporating the strategy’s principles into their areas of work. • Collaboratively develop the 2025 work plan with partners and stakeholders. 7.1.2 The in person event was attended by 41 participants, fostering engaging discussions and inspiring numerous pledges from attendees. These commitments have played a key role in shaping our approach to implementing the strategy in 2025, highlighting shared priorities that are essential for the strategy's success
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4 7.2 The 2025 work plan will prioritise three focus areas each linked to one of the strategy’s objectives: • Promoting Health and Wellbeing: Enhancing public access to frailty information to support self-directed care. Alongside early identification of frailty. • Tackling Inequalities: Engaging with local communities with the highest levels of frailty to understand their priorities and improve early frailty identification within these areas. • Delivering Sustainable Healthcare: Collaborating with technology teams and universities to explore and share innovations that aid in identifying frailty and supporting individuals to live independently at home for longer. Improving frailty pathways within acute hospitals to support sustainable healthcare in secondary care. These three areas will be focused across Acute, Community and Locality settings. 7.2.1 All members of the frailty strategy implementation group have been asked to identify the focus area they are most passionate about or where their work aligns. This will help determine the composition and participation of each group. 7.3 The recent publication of the Ageing and Frailty Standards (2024) (Appendix 1) by Healthcare Improvement highlights several key areas integral to the frailty strategy. These 11 evidence-based standards highlight the critical importance of supporting and resourcing adequately the implementation of the strategy and emphasises the value of preventative measures in managing frailty effectively. 7.4 The Frailty Network will continue to take the lead in delivering the Frailty Strategy, under the oversight of the newly established Ageing and Frailty Programme Board. The new governance structure (Appendix 2) will not only oversee ongoing work but also integrate other key work groups, such as the Dementia Framework. This enhanced governance framework highlights the health boards commitment to prioritising frailty across Lanarkshire, and ensuring the strategy’s implementation is successful in enhancing the quality of life for the people living in this area. The Ageing and Frailty Programme Board will be chaired by the Chief Officer of the North Health and Social Care Partnership and will provide direction, leadership and guidance. The Ageing and Frailty Programme Board will follow a 7 step model, that will be created in collaboration with the expertise of the
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5 multidisciplinary teams and align with the Ageing and Frailty Standards (HIS, 2024). 7.5 The significance of delivering the Frailty Strategy was reaffirmed by the national letter by the Chief Officer for NHS Scotland, John Burns, which outlines key priorities for the next few years. The Scottish Government has emphasised key focus areas, including Frailty at the Front Door, including Accident and Emergency, Frailty Prevention and the enhancement of integrated community frailty pathways, all of which are central to the Frailty Strategy. Over the past 12 months, significant progress has already been made in improving frailty pathways within acute settings, including the establishment of Frailty Units across all acute sites. 8. CONCLUSIONS To fully implement the strategy and achieve its outlined aims, extensive stakeholder engagement was essential. Over the past year, priority was given to understanding Lanarkshire’s existing services that currently, or have the potential to, positively impact its residents. This foundational insight set the stage for informed progress. The One Year On event showcased the significant strides made in embedding the NHS Lanarkshire Strategy for preventing and managing frailty. It also reinforced the strong commitment of partners to its continued implementation. The pledges made by stakeholders demonstrate a united effort to align actions with the strategy’s goals: promoting health and well-being, addressing inequalities, and delivering sustainable healthcare. These pledges have enabled key stakeholders to focus on specific objectives, advancing the strategy to the next level. Looking ahead to 2025, efforts will focus on early identification of frailty in our communities to allow for early access to preventative frailty teams or services. This work will engage with community partners to address inequalities and how technology can be used to promote independent living. Work will also continue to refine frailty pathways within acute settings, while collaborating with community and interface teams to establish robust support systems that enable people living with frailty to remain in their homes. Strong partnerships across all sectors will be essential to the strategy’s success, driving meaningful outcomes for frail people in Lanarkshire. 9. IMPLICATIONS 9.1 NATIONAL OUTCOMES
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6 Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☒ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☒ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☒ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☒ Health and Social Care Services contribute to reducing health inequalities ☒ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 9.2 ASSOCIATED MEASURE(S) 9.3 FINANCIAL None This paper has been reviewed by Finance: Yes No N/A 9.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Frailty Strategy Implementation Group Medium Hazel Gilmour Dr Helen McKee 9.5 ENGAGEMENT & PARTICIPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details on the engagement and participation that was undertaken. Objectives Further details
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7 ☒ Involve stakeholders in the development work aimed at achieving the national outcomes ☒ Provide stakeholders with information on how to get involved ☒ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☒ Measure how well we involve community stakeholders in the planning, design and delivery of our services ☒ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery ☒ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☒ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☒ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership 9.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: Yes No N/A EQIA added to website: Yes No N/A
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8 10. BACKGROUND PAPERS Strategy for Preventing and Managing Frailty: 2023 – 2028 11. APPENDICES Appendix 1 Healthcare Improvement Scotland (2024) Ageing and Frailty Standards. Available at: Ageing and frailty standards – Healthcare Improvement Scotland Appendix 2 CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following;
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9 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction
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10 10 Performance Management / Governance arrangements 11 Date direction will be reviewed