The Over 75 Service – Sandgate Surgery, UK

Julia Baldwin, Practice Matron, Sandgate Road Surgery

In 2015, NHS England introduced the Enhanced Service Programme, which is designed to reduce unplanned and emergency hospital admissions by improving services for vulnerable people with complex physical and/or mental health needs, who are at high risk of hospitalization. In Folkestone in the South East of England, the Sandgate Road Surgery has developed an “Over 75 Service” which goes beyond the scope of the Enhanced Service Programme to establish clear multidisciplinary care pathways and working practices into the local health and social care economy.

The main purpose of the Over 75 Service is to identify frail, older people and provide them with care that is person-centred and integrated in order to improve their health and wellbeing and maintain their independence for as long as possible.

Key stakeholders are family doctors, community nurses, social services, health trainers, health and social care navigators and voluntary services including patient and carer organisations. The Lead Nurse at Sandgate Surgery has been instrumental in driving the initiative and engaging stakeholders. The surgery’s Patient Participation Group have also been included in the service.

The initiative introduces a single assessment tool – the Dalhousie Frailty Screening Tool – for those over 75 years of age. Depending on the outcome of this assessment, a wide range of health and social care services can be offered such as a befriending service or regular telephone contact for those who are socially isolated, access to health training and care navigation as well as more complex care management involving multiple agencies. Anticipatory care planning is carried out for those nearing end of life. Carers’ needs are also assessed and supported. A review of medication is carried out by the surgery pharmacist which aims to reduce polypharmacy. Through the Over 75 Service, care is individualised and preventative with a focus on patient safety. No limit is imposed on the length of time people are able to access services and currently, around 200 older people are eligible.

Key, measurable outcomes are improved health and wellbeing, improved self-management, the prevention of deterioration and maintenance of health, the prevention of crisis, improved access to services, improved coordination and reduced duplication.

The Over 75 Service has the potential to be a great enabler of integrated care for older, vulnerable people in the local area. Staff working within the service are clearly person-centred and work flexibly by going beyond the service specification set by NHS England, enabling needs to be considered more holistically with a clear focus on improving the quality of life and wellbeing of older people.

Sandgate Road Surgery, Patient Participation Group

Shared training opportunities have been created for practitioners to raise awareness of each other’s roles and responsibilities. Better information sharing is enabled by well-attended, monthly multidisciplinary meetings for patients considered most at risk of unplanned admissions – shared care plans and shared assessments are seen as central to this more coordinated approach. Furthermore, good stakeholder engagement is being used to create a shared vision for the wider integrated health and social care economy with the team viewed locally as an excellent model of multidisciplinary team working.

Baseline data has been collected and the service is due to be fully operational from March 2017.

Thanks to: Dr. Julie MacInnes, Professor Jenny Billings, Esther De Weger, Julia Baldwin

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