Be proactive: Delivering proactive care - Chapter three: Recommendations

In this chapter, the BGS sets out eight key recommendations which are crucial to the success of proactive care services across community and primary care settings in the UK. These recommendations require action from a range of commissioners, policymakers, providers and healthcare professionals at national, regional, and local levels and should be the building blocks for all involved in proactive care to aim and advocate for. 

There are a wide range of approaches to the delivery of proactive frailty care, tailored to location, population size, funding opportunities, workforce, deprivation and the infrastructure available. Examples include MDTs employed by community and acute trusts, PCN level services led by a single ACP, to practice level services using protected time for existing staff. In some locations, services are predominantly led by community teams incorporating primary care whilst others are solely led by primary care teams. Despite differences, the delivery of proactive care will require working across teams and settings to reduce duplication, facilitate shared learning, and improve the quality of referrals. Whilst it is important that proactive care teams must develop according to their local population, the following key recommendations should be applied across all services. 

In England, GP practices have joined together to form PCNs based around populations of 30,000 – 50,000 patients. Integrated Neighbourhood Teams (INTs) are starting to develop around PCNs, with the aim of shared ownership for improving the health and wellbeing of the PCN population. Teams from across PCNs, wider community services providers, secondary care teams, social care teams, and voluntary care organisations will work together to share resources and information, and form MDTs dedicated to improving the health and wellbeing of a local community and tackling health inequalities.⁶

In Scotland, GP Clusters are typically groups of between five to eight GP practices in a close geographical location. Their purpose is to encourage GPs to participate in quality improvement practices, and to contribute to the oversight and development of local practices.³³ Health and Social Care Partnerships, (HSCPs) deliver integrated services provided by Health Boards and Councils in Scotland, of which proactive frailty care would be one such service. Each partnership is jointly run by the NHS and local authority, with a total of 31 HSCPs across Scotland based upon geographical and population factors.³⁴

In Wales, there are 64 Primary Care Clusters (PCCs), which bring together all local services involved in health and care across a geographical area, typically serving a population between 25,000 and 100,000. These PCCs are instrumental in commissioning community-based services.³⁵

In Northern Ireland, there are 17 GP Federations with the aim to support practices and to deliver the transformation agenda. They work across a wide number of local health and social care agencies to implement innovative strategies to benefit the local population.36 The federations align geographically with Integrated Care Partnerships (ICPs) that serve approximately 25–30 practices covering 100,000 population. ICPs are groups of health and social care providers that work together to improve the health and wellbeing of their population focussing on improving services for people with long term conditions and older people with frailty.³⁷

The size of a proactive care service should align approximately with the local infrastructure as described in the four nations. A vital component of this infrastructure should be the utilisation of the MDT to provide proactive, personalised care to older people with complex needs, as highlighted in the Fuller Stocktake.⁶ This requires a shift from a psychosocial model of care to a more holistic population-based approach that supports the health and wellbeing of the whole community. Teams need to be co-located around the needs of the local population, with a mix of primary and secondary care expertise to wrap around older individuals at risk of frailty, as outlined in the BGS Blueprint.¹

Targeting proactive care services at older people with frailty will likely be a priority for many PCNs/PCCs or equivalents, especially as the UK’s population continues to age. This is particularly important for rural and coastal areas where the growth in the older population is expected to accelerate at a faster rate.⁷ The majority of healthcare that older people receive is in primary and community settings and many of the teams in community services, local authority services and voluntary organisations work with older people more than any other group. Therefore, services will already have the building blocks for an MDT to provide proactive care for older people. A dedicated core proactive care team for each PCN/ PCC or equivalent will create strong links between general practice, and the wider MDT, ensuring that the proactive care service is implemented and integrated across the PCN/cluster.

Across all four nations, there is a lack of funding for proactive care services with reactive services, such as Urgent Community Response, Hospital at Home and Same Day Emergency Care being prioritised. Currently, there is no national policy on preventing and reversing frailty, and therefore, proactive care services vary greatly across the UK. This has resulted in huge variations in funding opportunities, with some areas receiving funding through ICBs, PCNs, and Additional Roles Reimbursement Scheme (ARRS) funding whilst others using their core budget to fund protected time for existing staff to deliver proactive care services. In areas where no dedicated funding is available, it is often impossible to set up proactive care services. Recurrent national funding and guidance is vital to ensure that consistent and reliable proactive care services are available to all older people who need it. 

Proactive care is reliant on cross-organisational working. Contractual requirements on all stakeholders across acute, community, primary, and social care settings to prioritise proactive care in the community would help ensure organisations are incentivised to work together to deliver proactive care and remove referral barriers. 

Setting up proactive care services requires strong compassionate clinical leadership. BGS members inform us that proactive care services are often set up due to the enthusiasm of individual healthcare professionals and clinical leaders. For example, individual healthcare professionals who have persuaded ICBs and Health Boards that proactive care is worth investing in; Community Geriatricians who have worked with colleagues to create a proactive care service using existing resources; and PCN Clinical Directors and practice GPs who have encouraged colleagues to commit time and resources into setting up proactive care services. This often involves clinical leaders taking on additional unpaid work to set up and develop the service. Small services may depend on one individual to establish the service, create the processes, and develop the links across the system. This is a leadership challenge, requiring individuals with significant leadership skills and commitment. Clinical leaders should be identified, supported, and nurtured with protected funded time to carry out their leadership role. Training and development opportunities are also vital, such as structured leadership training through national or regional bodies and informal mentoring with other clinical leaders. 

Alongside leadership, an effective operation manager who understands the aims of proactive care is needed to support and steer service improvements. They also have a role in supporting team members to change and in negotiating new ways of working with external teams and organisations. Key qualities of operational managers include experience with service development and negotiating skills. 

Working in proactive care can be challenging, requiring flexibility and resilience. Clinical leaders and operational managers have a role to play in easing challenges through setting a good workforce culture, keeping morale up, and providing training opportunities.

It is vital that proactive care services measure the value of the service to ensure that the service meets the needs of the population and improvements are made. Decisions on how to measure outcomes should be made before the service is rolled out. It is difficult to measure the impact of proactive care, with commonly used measures, such as hospital admissions and early hospital discharge, less effective as this is not the primary outcome of proactive care. The primary aim is to maintain independence in older individuals, which is difficult to measure in the short term and often requires long-term data over three to five years. Additionally, suitable data, such as use of paid carers and care home admissions are not routinely collected. Options include patient reported outcomes, patient experience measures, and process measures. National guidance on how to measure the impact of proactive care would be beneficial, alongside clinical research evaluating the clinical utility of different approaches. 

Data collected should be reflective of the complex nature of CGA styled interventions and should involve patient centred outcomes and patient voices. Data collection and analysis is time consuming and should be supported by the broader health ecosystems to provide evidence of systems working in localities. Demonstration of effectiveness in a robust manner is difficult for complex interventions, but important for commissioners and funders. 

Proactive care in community and primary care settings requires a core team who work together to deliver what the patient needs rather than working to tightly defined pathways. At a minimum, the core team should include a GP with an interest in frailty, an ACP, and a Care Co-ordinator. A gold standard core team would also include professionals from social care, mental health, therapies, pharmacy, and geriatric medicine. 
 
Highly trained professionals, such as nurses, AHPs, therapists, and paramedics, are essential when managing complex caseloads but are in limited supply. Training and development of senior healthcare professionals to case manage complex cases should be a priority for the NHS workforce plan.
 
Many GPs are interested in working in proactive care for people living with frailty, but funding is often not available to enable this. In England until recently, GPs have been excluded from the ARRS funding used to employ staff across PCNs in England. A recent welcome change to this policy means GPs can now be employed under ARRS across PCNs, but only if they are less than two years post GP qualification. Currently still excluded are the significant numbers of experienced GPs (many active members of the BGS) who have been developing skills and interest in frailty. This is potentially a waste of an existing workforce resource. If the ARRS policy was extended to allow employment of any GP to proactive frailty roles across PCNs the impacts of this welcome change could be much greater for preventative frailty work.
 
Community Geriatricians would be valuable resource for proactive care services, however, there are currently not enough to meet the needs of the ageing population.³⁸ There is significant variation across the UK in the number of geriatricians available to care for older people. The BGS is calling for a UK-wide target of one consultant geriatrician per 500 people aged 85 and over. This would help to ensure that community geriatricians could play a key part in proactive care for older people across the UK. 
 
When working well, proactive care services have the potential to aid recruitment and retention as it allows staff to manage patients better which increases job satisfaction. 

Proactive care team members need not only knowledge and understanding of frailty and complex care but the confidence, emotional intelligence and flexibility to build relationships with people within their teams and in other organisations and to work across organisational boundaries. National bodies and professional organisations should ensure that fully funded training and development opportunities are available for people working in proactive care. This should cover not only knowledge of frailty and frailty syndromes but understanding of the wider health and care system, advanced communication skills, and training in leadership and coaching skills.

It can be quite challenging to change longstanding ways of working and work in an integrated team with people from very different backgrounds. Team building opportunities and joint training should be provided for newly created multidisciplinary teams to help them develop as a team. Networking events across regions are a good way to share new ideas and provide mutual support. 

Successful proactive care services rely on a united team that has a shared vision of person-centred care and permission to work outside of organisational boundaries. This is facilitated by trust and good working relationships within the MDT. At the heart of proactive care services is empowering people, both patients and staff, to deliver what is right for the patient. Healthcare professionals need to be equipped with the skills, agency, and flexibility, to work as a team to support each other in a new way of working. It is vital that time is spent while developing the service for the team to make links with external agencies to develop relationships and build trust. This will create a wider MDT who work together to avoid duplication, improve quality of referrals and ensure smooth coordination of care. 

It can take a long time to develop the skills and confidence to work in a different way. It requires a strong team, good clinical leadership, a supportive team manager and a consistent service. It is important to set realistic expectations during the early stages of the service to allow the team to develop into their roles. 

To ensure the proactive care team is supported with the appropriate staff resource, training opportunities, and ways of working, new services should create a shared workforce plan between partner organisations outlining how the service will work. 

NHS England’s Proactive Care: Providing Care and Support for People Living at Home with Moderate or Severe Frailty emphasises the need for systematic identification and assessment of individuals with frailty, enabling early intervention tailored to their specific needs.² It outlines five core components and three key enablers as a framework for delivering proactive care. BGS’s Be Proactive: Delivering Proactive Care for Older People with Frailty expands on this framework, providing a roadmap for the delivery of proactive care. It acts as a guide for services in personalising care plans, fostering effective communication and coordination among multidisciplinary teams, and empowering patients to take an active role in managing their health. By focusing on continuous monitoring and adapting care plans to reflect changes in patients’ conditions, organisations can not only improve health outcomes but also promote a more sustainable healthcare model that anticipates and responds to the evolving needs of older individuals living with frailty. It complements BGS’s Be proactive: Evidence supporting proactive care for older people with frailty, which outlines the evidence base supporting proactive care.³ Healthcare professionals and clinical leaders will be able to use the evidence document as a business case for delivering proactive care and use the delivery document as a roadmap for implementing services. Together, the evidence and delivery documents create a robust framework for delivering effective, person-centred care in the community.