The guidance you can swear by for the 'F' word frailty

Current pressures on the acute sector of the health service provide a reminder of the importance of getting services right for frail older people.

Frailty is increasingly common with older age. Despite this, we don’t tend to discuss it as a “long term condition” even though it often accompanies such illnesses, as well as dementia.

‘For the over 75s, living with at least three long term conditions is the norm’

But whether we look at care home residents, older people using ambulance and emergency department services, making prolonged stays in hospital or using intermediate care or social care services, frailty is a common, or perhaps the common thread.

Recent publicity in the press about prolonged hospital stays resulting in disastrous effects for the individual, as well as increased costs to health and social care, at a time when budgets are stretched or shrinking, provides another timely reminder of the vital importance of getting services right for this group of people.

• Public Health England examines older people life expectancy ‘alert’
• HSJ/Serco Commission: Further evidence supporting commissioners’ key findings
• HSJ Commission on Hospital Care for Frail Older People: good practice case studies

Get the guide

This month the British Geriatrics Society, in association with the Royal College of GPs and Age UK, published the second half of its two part best practice guidance, Fit for Frailty.

‘It’s guidance on developing, commissioning and managing services for people living with frailty’

It provides guidance for GPs, geriatricians, health service managers, social service managers and commissioners of services on developing, commissioning and managing services for people living with frailty in community settings.

It’s a robust, well evidenced guide written in accessible terms and focuses on those services that are most likely to enhance the ability of older patients with frailty to remain at home for as long as possible.

Those people with early or mild frailty may slow up, stop going out so much, and become more reliant on care.

Those at the severe end will present to systems in substantial numbers. Falls, for instance, account for around one in three ambulance call outs in the over 65s.

Acute confusion or “delirium” affects similar numbers of hospitalised older people. Poor mobility or loss of function in the face of acute illness or injury often defines the oldest old in hospital or intermediate care.

The how to

Although there is much rhetoric about admission avoidance, there are relatively few services for which there is evidence that admissions can be averted - comprehensive geriatric assessment being one.

Every clinical commissioning group or provider wants to up the quality of care for those living with frailty, but to do so they need simple, off the shelf resources. To this end, Fit for Frailty provides guidance on:

• recognising frailty as a long term condition;
• how to identify those who are frail and assess its severity;
• the kind of services we need to support these individuals and the education, knowledge and skills staff might require; and
• the importance of ensuring that the patient and their family are at the heart of care planning.

The guidance identifies frailty syndromes such as falls, reduced mobility or delirium, which may require an urgent response, and for which an alternative to an acute hospital admission may sometimes be both appropriate and desirable.

We all know that admission to hospital with one of these syndromes may result in a long stay and unintended consequences, such as hospital associated infections or inpatient falls, and delays waiting for transfer of care frequently follow.

Informing decision making

Fit for Frailty also advises on services to ensure that when admission is necessary and appropriate, discharge is planned and enacted in a timely manner and emphasises the role that community services can play in “pulling” people out of hospital once their need for acute care is over.

The guidance points out that frail older people are those with most to gain from integrating services, but also highlights that the services that need to work smoothly together include not just health and social care but primary, community and secondary healthcare, including mental health services.

Several case studies give practical examples of how services can work on the ground, including some that demonstrate effective and innovative engagement with the voluntary sector: Age UK’s work in Cheshire and Warwickshire, and NHS Kernow’s Pathfinder project are examples of this.

We hope Fit for Frailty will become widely endorsed and used.

‘It highlights the need to work smoothly together’

Commissioners of services who are conscious of the impact of demographic change, who welcome advice that is not partisan but founded in a robust evidence base, and who are up for the challenge of doing things differently should find much here to guide and inform their decision making.

Eileen Burns is president elect of the British Geriatrics Society and David Oliver is professor of medicine for older people at City University London and a member of the HSJ Commission on Hospital Care for Frail Older People