Andy Clegg is a Clinical Senior Lecturer in the Academic Unit of Elderly Care and Rehabilitation, and Honorary Consultant Geriatrician, at Bradford Teaching Hospitals NHS Foundation Trust.
In this blog, he talks about Fit for Frailty Part 2, a new guidance document being launched by the BGS on Wednesday 14th January.
Fit for Frailty Part 2 has been written by the BGS and RCGP in association with Age UK, on developing, commissioning and managing services for people living with frailty. The guidance is aimed at those working with and commissioning services for older people with frailty, particularly GPs, geriatricians, health and social care managers and commissioners.
Currently, much of the effort within commissioning is focused on reducing hospital admission in those at greatest risk. However, very few of our ‘avoiding hospital admissions’ strategies have worked (ref. Oliver, BMJ 2014), and there are a range of reasons why targeting those considered at greatest risk of admission are unlikely to be clinically or cost effective (ref. Roland, BMJ 2012).
On the other hand, reviews of interventions for older people with frailty have demonstrated improvements in hospital stays, maintenance of independence and reduced care home admissions (ref. Philp, International Journal of Integrated Care 2013 and Beswick, Lancet 2008). A shift of focus away from trying to reduce unplanned admissions for those at highest risk towards commissioning evidence-based services for older people with frailty may help improve outcomes for this vulnerable group, including reduced hospitalisations.
Fit for Frailty Part 2 sets out the key ingredients for developing, commissioning and managing services for older people with frailty. These include:
- A system for recognising frailty when in the early stages – all staff in primary and community settings should be trained to recognise frailty using simple tests e.g. gait speed, timed-up-and-go test
- A system for organising holistic medical review of those identified as living with frailty, based on principles of comprehensive geiatric assessment
- A system for easy access to frailty expertise – geriatricians, GPs with special interest in frailty, specialist frailty practitioners.
- Commissioning nterventions with evidence of benefit in frailty, for example home and group-based exercise interventions.
- Establishing integrated systems of care for older people with frailty, spanning primary care, secondary care and social services, as those with frailty stand to gain most through an integrated approach
The guidance also sets out recommendations for evaluating frailty services, with an emphasis on outcomes that are relevant for this group, including quality of life, loneliness, pain and function. Outcomes that are relevant for local health services should also be considered, including reduction in excess secondary care bed days, reductions in primary care consultations and reductions in outpatient visits. The guidance also emphasises that desired outcomes, such as reduced unplanned admissions and reduced costs may take time to achieve and are unlikely to be seen in the immediate aftermath of a service or structural change.
Finally, the guidance describes how structural changes within primary care may help develop new models of proactive, person-centred care for older people with frailty. Modes of primary care such as GP federations have been shown to be a powerful enable of integration, service development and quality improvement. Capitation-based contracting, which requires providers to deliver a set of agreed quality outcomes, may have particular relevance in frailty, using the outcomes described above. The guidance also gives some excellent examples of novel and innovative approaches to identifying older people with frailty and commissioning services to meet the needs of this vulnerable group.
Fit for Frailty Part 2 can be downloaded on the BGS website from 14th January onwards.