By stewartb

Scotland’s FM gave a speech (January 27) on actions to relieve pressures on NHS Scotland to the benefit of patients. Among the measures proposed, he referenced this:

‘By this summer, we will have specialised staff in frailty teams, at the front door of every A&E department in Scotland. This will mean that frail patients, often older patients with complex needs, will bypass our busy A&Es, in order to receive the specialist care and support they need, whether in hospital or back at home. It will mean better care for these most vulnerable patients while reducing the pressure on our A&Es.’  (my emphasis)

This blog post shares background information on this initiative and invites readers to form a judgement on the responses to it from opposition politicians in Holyrood.

Background

Medical professionals from Guy’s and St Thomas’ NHS Foundation Trust in England provide this in a recent peer reviewed paper (with my emphasis): ‘There is increasing impetus to improve acute care for older patients. NHS England has outlined quality standards for front door frailty services to deliver timely comprehensive geriatric assessments (CGA) by specialist acute frailty team ideally within a purpose-built frailty attuned area.’

Operationally, the authors report: ’We have brought our acute frailty service closer to the front door meaning patients have access to CGA and senior decision makers earlier on in their admission. The next steps will be to continue this trajectory and provide direct access to the acute frailty team for referring GPs, care homes and London Ambulance Service’.

Source: Law and Walker (2024) Front door frailty: improving acute frailty service via pathway design, doctor reallocation and proactive triage. Future Healthcare Journal vol. 11.

The British Geriatrics Society (BGS) states: ‘Evidence shows that older people wait longer than other age groups to be assessed in the ED and to be seen by a medical specialist.’

And advises: ’Identification of frailty at the hospital front door can help trigger early comprehensive geriatric assessment (CGA) and ensure that older people with frailty are diverted to the most appropriate services within the hospital as quickly as possible and, where possible, discharged home on the same day. As well as improving the experience and health outcomes of older people attending hospital, front door frailty services improve patient flow and reduce pressure on the whole hospital system.’

The BGS is pragmatic: ‘There is no ‘right way’ to do front door frailty – models vary depending on the staff available, the geography of the local area, the needs of the population and the hospital estate.’

Given this, the BGS focuses on offering five principles that should underpin front door frailty services. These include (point 4): ‘Identify frailty and trigger the start of comprehensive geriatric assessment (CGA) – ‘By prioritising the early identification of people with frailty in the ED, CGA can be triggered as quickly as possible, ensuring that older people with frailty receive rapid treatment by the most appropriate team. Most new front door frailty services use the Clinical Frailty Scale (CFS) as an admission criterion to a new service as the CFS is easy to use and can help to ensure that the service is deliverable in the early days. However, as the service matures and referring teams better understand which patients are appropriate for front door frailty services, staff may find that admission criteria can be less rigid.’ 

Source: The British Geriatrics Society (2023) Front door frailty: Advice on setting up services. (See https://www.bgs.org.uk/FrontDoorFrailty)

Meanwhile in Scotland ……

The Scottish Sun front page from 28 January above an article written by its Political Editor had this headline: ‘If your nan’s not down, you’re not coming is’ and ‘FM’s A&E ‘grannie bouncers’. From the full text in the online version,

‘John Swinney was tonight accused of deploying “granny bouncers” at the door of every A&E to turn away OAPs deemed not sick enough to come in. Rivals attacked the First Minister after he announced “frailty teams” will intercept older people arriving at casualty who could be treated elsewhere.’

More background – for contrast

To a report of an innovation at an NHS Wales A&E facility:

Source: Swansea Bay University Hospital Board: ’Hospital department just for frail older people opens’ (https://sbuhb.nhs.wales/news/swansea-bay-health-news/hospital-department-just-for-frail-older-people-opens/)

It notes: ’Previously, elderly patients were only referred to OPAS (Older Person’s Assessment Service) after they had been seen in the main ED, which referred them on when appropriate. OPAS now sees patients directly referred from the ambulance service and from ED triage. This has reduced waiting times for older patients and has helped the flow of patients through the Emergency Department.’

Consultant geriatrician Dr Liz Davies is quoted: “Traditionally we had elderly patients coming into ED with falls, minor injuries and medical illnesses. These were often triaged as low priority and patients often experienced long and uncomfortable waits for assessment and treatment. Once the pilot started they were triaged directly to us without delay, which helps the flow through the entire department.“Older people came to our specialist area where they could get a full assessment. The waiting time for them reduced by many hours.’

And from an NHS Board paper: ‘As people with frailty are at greater risk of hospital acquired harms, it is important that their frailty is assessed and identified early and managed through their hospital journey either through a CFS (clinical frailty scale) assessment, identification via HFRS (hospital frailty risk score) or the clinical identification of a frailty syndrome. This should occur within 30 minutes of arrival at hospital.’

Source: Swansea Bay University Health Board (June 24, 2024) SBUHB Frailty Strategy Department and Roll-Out. (https://sbuhb.nhs.wales/search-results/?searchFilter=&Keywords=frailty&strippedKeywords=frailty&display=search&newSearch=true&noCache=1&csrf_token=C33DC44E842465B0598D95A7A7829ACE&csrf_token_expires=250128114853926)

Meanwhile from a Labour politician in Scotland …

Back to the article in the Scottish Sun: ‘… he (the FM) was attacked for his approach to elderly patients, with Scottish Labour raising concerns it could put patients off coming to hospital when they are at risk.’

‘Health spokeswoman Jackie Baillie said: “The SNP must ensure that frailty teams do not end up punishing elderly patients by acting as bouncers to keep grandparents in need of care away from the door, but are meaningful support for older patients who are also among the most vulnerable.”

The negative framing is extreme – ‘punishing’, ‘bouncers’, keeping grandparents in need .. away’. Crafted carefully to imply ‘concern’, IMHO this is despicable stuff.

By the way, no sign of the British Labour Party government in Cardiff questioning the same sort of innovation in Welsh hospitals.

More background

The Royal College of Emergency Medicine devotes much attention to the initial assessment of patients on arrival at Emergency Departments (EDs).

Source: The Royal College of Emergency Medicine (February 2027) ’Initial Assessment of Emergency Department Patients (https://rcem.ac.uk/wp-content/uploads/2021/10/SDDC_Intial_Assessment_Feb2017.pdf)

It has a lengthy section on the processes involved in ‘streaming’ patients attending EDs: ‘Streaming is the process of allocating patients to different physical areas / services, pathways or processes, in order to improve efficiency and effectiveness. The main objective of streaming is to ensure that the patient is directed to the correct location / service and to the correct person to manage their clinical needs. … Patients may be streamed (redirected) to off-site services. For streaming to be effective it needs to be brief, in order to avoid queues developing.’

‘Streaming should be performed as soon as possible and ideally be within 15 minutes of the patient’s arrival in the ED. For this to be achieved capacity must be planned to meet variation in demand, and not average demand.’

Here is the definition of ‘streaming’ from NHS England: (https://www.england.nhs.uk/guidance-for-emergency-departments-initial-assessment/ )

Streaming: ‘A clinical activity to direct patients to the most appropriate service based on their presenting symptoms, chief complaint and acuity.’ And ‘Streaming is likely to be the first clinical activity the patient experiences when arriving. It focuses on determining who will see the patient next, and results in a transfer of care.’

The inclusion of ‘frailty’ as a key issue for initial assessment and support following arrival at an Emergency Department is discussed in peer reviewed research papers. Here is a recent example.

Source: Knight et al (2022) Frailty assessment and acute frailty service provision in the UK: results of a national ‘day of care’ survey BMC Geriatr. Jan 3. (https://pmc.ncbi.nlm.nih.gov/articles/PMC8721940/)

‘The incorporation of acute frailty services into the acute care pathway is increasingly common. The prevalence and impact of acute frailty services in the UK are currently unclear’ and ‘The provision of acute frailty services is variable throughout the UK. Improvement is needed for the aspirations of national policy to be fully realised.’

‘The concept of frailty has become central to the understanding of acute illness in older people. Frailty remains an evolving concept in terms of underlying biological mechanisms; however, a variety of tools can be used operationally to identify a patient cohort with poorer clinical outcomes in the acute care setting.’

‘The NHS (England) Long Term Plan states that all hospitals with a 24 h Emergency Department (ED) will provide an acute frailty service for at least 70 h a week, with the aim to complete a clinical frailty assessment within 30 min of a patients arrival in the ED or SDEC (Same Day Emergency Care) unit. The policy is designed to reduce unnecessary hospital admissions and reduce the length of stay by providing interventions, such as comprehensive geriatric assessment (CGA) at earlier time-points within the acute care pathway.’

‘NHS England and NHS improvement (NHSE/I) have published additional guidance detailing how the policy should be implemented and recommended metrics to measure performance. The guidance states all patients over the age of 65 should be assessed for the presence of features of frailty using the Clinical Frailty Scale (CFS), a validated tool designed to identify and grade frailty based on the severity of functional impairment.’

Meanwhile in Scotland a Tory MSP, who is also a medic, responds ….

Returning to the article in the Scottish Sun: ‘Scottish Tory health spokesman Dr Sandesh Gulhane added: “John Swinney’s plans to expand the use of frailty teams will make patients wonder if they will be greeted at A&E front doors by people giving off the impression of being ‘granny bouncers’.”

Of all the contributors to the article in the Scottish Sun, Gulhane should know better! He should know the background to and wider and increasing implementation across the NHS of ‘frailty teams’. And at a basic level, he should show NHS Scotland staff in Emergency Departments a good deal more respect – ‘people giving off the impression of being ‘granny bouncers’ indeed!

And finally on background

Source: NHS Improvements, Emergency Care Improvement Programme – ‘Identifying and managing frailty at the front door – Why is it important to identify frailty at the front door? (https://fabnhsstuff.net/storage/Rapid-Improvement-Guide-to-Identifying-and-managing-frailty-at-the-front.pdf )

The document notes: ’About 5-10% of all emergency department (ED) attendees and 30% of patients in Acute Medical Units are older people with frailty. Focusing on frailty is an exercise in risk stratification – identifying a cohort at especially high risk of adverse outcomes.’

Source: Local Government Association (December 12, 2024) High Impact Change Area C: Managing presentations in the Emergency Department – case studies (https://www.local.gov.uk/case-studies/high-impact-change-area-c-managing-presentations-emergency-department-case-studies)

The LGA describes a case study: ‘St George’s University Hospital NHS Foundation Trust: Front Door Frailty Service Plan’:  ‘Front door frailty services ensure that older people living with frailty are identified at the earliest opportunity when presenting to the emergency department. This service enables specialist review, triggering an early Comprehensive Geriatric Assessment (CGA) and either redirection to the most appropriate ward or if safe to do so, discharge home on the same day. St Georges Hospital front door frailty service has demonstrated a positive impact, improving patient flow and outcomes.’ 

And from the website of St George’s Hospital itself (https://www.stgeorges.nhs.uk/service/emergency-department/ ): on arrival at the hospital’s Emergency Department ‘patients are assessed by an experienced emergency nurse. This assessment is called streaming and is designed to ensure patients can be assessed early, prioritised in terms of their medical needs and directed to the most appropriate service to continue their care.

‘Such services may include advice to attend alternative services which may be more appropriate, including your own General Practitioner, your local Walk-in-Centre, your local Pharmacist, NHS 111 Helpline as well as specific walk-in-clinics.’

But meanwhile in Scotland ….

Also in the Scottish Sun’s article: ‘Scottish Lib Dem leader Alex Cole-Hamilton said: “Signposting patients to the most appropriate service is an important part of helping those in need, but John Swinney will need to be sure his granny bouncers don’t put people off from seeking treatment entirely.”

This is well below the level of the gutter – “his granny bouncers”!!!!!

End note:

Note the agreement between these three Unionist politicians on the term of abuse: ’Granny bouncers’. Note the pejorative and alarmist language: ‘punishing elderly patients’, ‘keep grandparents in need of care away’ etc..

Baillie, Gulhane and Cole-Hamilton have made carefully crafted responses designed to undermine and attack a political opponent’s proposal.  One might argue -‘that’s political life’. But on a matter of such critical concern as A&E services generally and on the treatment of the especially vulnerable in particular, they are to seeking to influence voters for electoral advantage by belittling, denigrating and seeking to cause alarm without foundation.  

The value of ‘frailty teams’ acting at the ‘front door’ of Emergency Departments is an innovation now in evidence in policy and practice in the NHS across the UK. In researching the topic, I’ve never encountered the charge of ‘grannie bouncers’ anywhere else – and yet it appears in quotes used by the Scottish Sun from not one but three leading opposition politicians from three different political parties in Scotland

Many readers may consider the journalism of the Scottish Sun and its Political Editor on this occasion typical of their reporting on the present Scottish Government. But let’s be clear: however much the journalist may have relished the task of writing this article on the FM’s recent speech, he was aided and enabled by responses from opposition politicians . They deserve to receive even greater opprobrium given their place in our Parliament!