Abstract
Introduction
In 2017 NHS England introduced proactive identification of frailty into the General Practitioners (GPs) Contract. There is currently little information as to how this policy has been operationalised by front-line clinicians, their working understanding of frailty, or perceptions of impact on patient care. Evidence from international settings suggests primary care clinicians may have mixed interpretations of frailty, with important implications for their willingness to support different frailty interventions. We aimed to explore the conceptualisation of frailty, and how community-dwelling frail older adults are identified in primary care.
Methods
Semi-structured interviews were conducted with primary care staff across England, including GPs, physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 12).
Results 31 practitioners participated (12 GPs, 19 non-GPs). Frailty was seen as difficult to define, with uncertainty in its value as a medical diagnosis. The most common working model was the frailty phenotype, associated with deterioration at end of life. There were a mixture of formal and informal processes for identifying frailty. A few practices had embedded population screening and structured reviews. Informal processes included use of ‘housebound’ as a proxy for frailty, identification through chronic disease and medication reviews, and holistic assessment through good continuity of care. Many clinicians described poor accuracy of the electronic Frailty Index, yet it was commonly used to grade frailty during protocolised chronic disease reviews. The Clinical Frailty Score, in contrast, was felt to be easy to use and interpret, but inconsistently recorded within electronic health records. Most clinicians favoured better tools for identifying frailty, alongside resources to support these individuals.
Conclusions
Concepts of frailty in primary care differ. Identification is predominantly ad-hoc, opportunistic and associated with terminal illness. A more cohesive approach to frailty, relevant to primary care, together with better diagnostic tools, may encourage wider recognition.
Comments
Really interesting study, Anna! Fascinating to hear insights from across of the range of HCPs that now see these patients.
What's your gut feeling on this? Is the eFI not useful because of the limitations of the tool itself or because of the healthcare system/current overstretched conditions that it has been implemented in?
Thanks for this. Very interesting to see such a variety of interpretations of frailty in primary care.
Interesting study, it's a shame that there were no other AHP's interviewed such as physiotherapists/OT's/SLT's as I think their perspective and knowledge on frailty may be a bit different. In my area we have all these professions working as advanced clinical practitioners in frailty. The EFI I think we all know is a bit of a blunt instrument, really frailty is a clinical diagnosis alongside some tools that may aid that. But seeing patients face to face is the vital part as you can miss so much over the phone.
Good work!
Thanks for your poster. Timely and acutely showing the issues around the identification of Frailty as a syndrome, the need for the right tools to identify people living with Frailty, and although not discussed openly, the clear need for Resources that must be provided by the government [whatever their political colour] to ensure this condition is diagnosed early and intensively managed -community and in hospitals.
The eFI is an interesting tool, yet it may be more useful to identify multimorbidity, mainly in those who present to their GP surgery for help -which in itself may leave out those with severe frailty, unable to reach the care services on a timely manner -as you pointed out in your poster.
It is not an option to carry on as we are, not been able to serve one of the most vulnerable sector of our communities. Building Resilience is costly at all levels. This has been shown by other pilot work done by other teams, as the Senior Health Clinic we trialled in Richmond prior to Covid-19, that showed the financial support required and the need for a fully funded, dedicated Geriatric multidisciplinary team [Geriatric MDT] to further develop the service. Preliminary data analysis showed reversibility of frailty in some cases -yet six months were not enough to consolidate the service as it was not fully supported by the challenged financial status of the involved CCG.
The high cost of Frailty is first, a human cost: people living with Frailty and their carers/relatives, care homes carers availability].
But it is also a financial cost: to social care and all healthcare systems, mostly the NHS.
However, it is not acceptable for any local or nationwide government to keep this no-action. These governments ought to supply the resources required to care for older people with frailty as part of their budget. A general government must support and facilitate local teams to create the proper integration of care systems to look after this vulnerable cohort. This seemingly lack of interest [hence, lack of funding] in itself, has led to some foundation trusts to stop their successful Acute Frailty Services in their own hospitals, and in its place, put a therapy-only service to "diagnose and manage" older people presenting with Frailty syndromes [falls, delirium etc], dismantling their front door Geriatric MDT. Politics at play at their worst? It appears so: ignoring the older persons needs appears to be "cheaper" for those trusts, rather than delivering the evidence-based care these older patients deserve. The outcome, high readmissions rates of the same older people with Frailty syndromes, eventually leading to hospital admissions, long length of stay consuming hospital resources unnecessarily [their so called "bed-blockers"] with then excess "outliers" in different wards [and young patients in the Geriatric wards are included].
Unfortunately, the above also cause the subsequent deconditioning and progression of Frailty and Sarcopenia in our older patients. We know the rest: high risk of hospital acquired infections, immobilisation, delirium, continence issues, and an ongoing vicious circle with the older person at high risk of death, and if not, of ending up in a nursing home. Or if lucky, end up back at home with increase input from social services, and the need for the community MDT support.
So, let's start from the beginning: we require a robust community / GP-led team, that have the resources [human, time and money to say the least] required to identify the older person with Frailty conditions/syndromes, refer to a community Geriatrician and Geriatric MDT [yet other resources that must be fully funded] and involve your MP and whoever else is required, to ensure the commitment of funding the services GPs and their teams require to diagnose and manage older persons at risk of Frailty or who may have Frailty conditions as a matter of urgency.
Your good work is really timely. Thanks for presenting it. Much more to do.
Dr Carmen Martin Marero
Consultant Geriatrician and Physician
London