BGS publishes recommendations on how to deliver proactive care

14 November 2024

The British Geriatrics Society (BGS) has published a guidance document on how to deliver proactive care for older people with moderate to severe frailty in community and primary care settings. Be proactive: Delivering proactive care for older people with frailty is aimed at healthcare professionals, clinical leaders, commissioners and system designers seeking advice on how to implement services in their locality.

The BGS welcomed the publication of NHS England’s Proactive care: providing care and support for people living at home with moderate or severe frailty in December 2023. While it is disappointing that the original Ageing Well funding for ‘anticipatory care’ never materialised, nevertheless the NHSE guidance acts as a useful framework.
 
Building on NHS England’s guidance, the new BGS publication outlines how to identify a target cohort, carry out holistic assessments, develop personalised care plans, work in a co-ordinated and multi-professional manner, and provide continuity of care to older people living with frailty. It also outlines the importance of a flexible workforce, using shared care records, and implementing clear accountability and shared decision-making.
 
To support the delivery of proactive care, the publication makes eight recommendations requiring action from commissioners, policymakers, providers, and healthcare professionals at local, regional and national levels. This includes a call for national funding and contractual arrangements, investment in outcome measures, and a focus on training and development for proactive care.
 
There are many examples of excellent proactive care services across the UK, which aim to slow the progression of frailty. These services vary in size and structure, but all identify older people at risk of ill health and poor outcomes and offer personalised interventions so they can remain well for longer. The publication showcases a range of these services, and it is hoped readers will find the learning points useful.
 
The publication follows on from Be proactive: Evidence supporting proactive care for older people with frailty, which outlines the evidence for proactive care. This document may be used to build a business case, while the second document provides a roadmap for delivery.
 

Professor Jugdeep Dhesi, BGS President Elect, said:

Proactive care plays a vital role in delaying the progression of frailty, maintaining older people’s independence, and reducing avoidable periods of ill health. We know there are many exemplary proactive care services across all four countries of the UK. Unfortunately, we also know that the provision of these proactive care services varies greatly, resulting in unequal health outcomes for older people. To aid those now planning and implementing proactive care services for older people living with frailty, we have published Be proactive: Delivering proactive care for older people with frailty and look forward to supporting better outcomes for all older people.”