Setting up services as a new consultant Dr Tricia Moylan Consultant in Medicine for the Elderly Gartnavel General Hospital Glasgow

Some common feelings…….. Delight Relief Sheer terror Inadequacy Fear of failure Fear of success What now? Not really trained for this I’m a consultant…………………………………….

………get me out of here!

But….. Remember your training Remember you are not alone – use the team Make use of senior colleagues Developments don’t happen overnight Success will involve some failures along the way

Services you may need to develop Established sub-specialty interests Falls/GORU Stroke Movement disorder Community services Acute assessment services Liaison service Personal area of interest

Falls service development - Monklands Physiotherapist & OT employed via Integrated Services Team - June 2003 Jointly funded Lanarkshire Falls & Osteoporosis Redesign- July 2003 Lead Clinician (me!) appointed October 2003

Falls & Osteoporosis Nurse appointed June 2004 Multidisciplinary Falls Clinic commenced Coathill Hospital Sept 2004 Pilot project 3 months Fortnightly falls clinic commenced Carrickstone Day Hospital, Cumbernauld July 2005

SUPPORTING DOCUMENTS BGS Falls Guidelines (2001) National Service Framework for Older People-England & Wales (DOH 2001)- Standards 6 & 8 SIGN 56 (Hip Fracture- 2002) & SIGN 71 (Osteoporosis 2003) NICE Guidelines (2004) Local data on falls and fractures

Falls and fracture redesign group Consultant Rheumatologist with osteoporosis interest Consultant Geriatricians Falls nurse Osteoporosis nurse AHPs – acute and primary care Community nurses Local authority representative Separate osteoporosis steering group

Planning process Potential sources of referrals Community Nursing Team Home Care Services GP Alert Services Care Homes CPN Day Care Centres A&E/rapid response

Who to target? Those who have already sustained a fracture Those with falls but no fracture Those with risk factors for falling

Assessing people with falls in primary care Simple assessment tool developed to be used by different professionals Link falls nurse in each LHCC may be an option Link with screening for risk factors for osteoporosis

Think through each stage of process Referral criteria Components of evaluation Process following screening in community Onward referrals Communicate with target audience – patients and professionals Roles of professionals within team How will you measure progress?

COMMUNITY Community nurses, CMHTE, Homecare, GP PATIENT FALLS COMMUNITY Community nurses, CMHTE, Homecare, GP HOSPITAL Patient attends A&E In- patient treatment MIDAS Day Hospital This demonstrates our patient pathway. Patient may be admitted to the Acute Hospital - would be identified by ward staff or more commonly by the therapy staff and referred to service on routine discharge. May go home on a regular discharge, or with MIDAS, or with Early Supported Discharge Team – Both can help support the discharge and both have direct access to the Falls Team. We have done most work in the community…. as this is where the hidden fallers are. District Nurse, CPN or GP are all able to refer directly to the Falls Service from the community. We are also currently piloting a scheme whereby the home care service can refer to us direct. Also any referrals that are made to the Day Hospital due to Falls are passed directly to the Falls Service for screening and intervention. Regular discharge ESDT FALLS SERVICE

Our progress 25 referrals per month in first year 1/3 acute care, 2/3 community 35 per month by year 2 Need for expansion of service clear but limited by resources Financial limitations Competing interests Other priorities within organisation Need for review of whole service in Lanarkshire

What went well? Falls and Osteoporosis Nurse post Service User seen quickly in environment in which they fall Access to SWIS Good links throughout the acute hospital Good links with primary care (inc. managers) and osteoporosis service Specialist skills of team developed rapidly Falls and fracture clinical community

……..and not so well……. Limited knowledge of patients’ previous medical history etc Variable commitment from GPs and other primary care staff Cover for highly skilled staff on leave was difficult Limited by facilities

Inequality throughout Lanarkshire Support for service Senior management/public health level Pharmacy A&C Social work Inequality throughout Lanarkshire Management of frailer older people in community

Key factors for success Background work – redesign project Evidence base Personalities and skill mix of team Strong commitment from clinical community Raising awareness/education Promoting exercise Documentation in acute wards Latterly rehabilitation framework

Leading a team What is your style? Allow others to develop ideas and use their skills Be happy to make the final decision & take responsibility Meet regularly away from clinical setting to discuss Progress to date Objectives – short and long term Don’t miss opportunities to “fly the flag”

Relevant issues for specialty training Leadership/team working skills Understanding of organisation of community services NHS Finance / business plans

Summary Use your experience Use your team Provide the best service you can Use the evidence available Compare with other services Use audit to improve your service Developments need to fit local and national agenda

Good luck!