Professor Kenneth Rockwood has published more than 300 peer-reviewed scientific publications and seven books, including the seventh edition of the Brocklehurst’s Textbook of Geriatric Medicine & Gerontology. He is the Kathryn Allen Weldon Professor of Alzheimer research at Dalhousie University, and a staff internist and geriatrician at the Capital District Health Authority in Halifax in Canada.
Last autumn, at a meeting of the Acute Frailty Network in London, I sat in on a discussion group about identifying frailty in acutely ill older people who come to hospital. Although some participants noted objections about such screening in some quarters, with this audience, there was no need to discuss why it makes sense to identify people at greater risk than their age peers of being harmed by usual hospital care.
Before moving on, let’s consider for a moment why anyone might object to screening for baseline frailty in patients who presented to A&E. For those who see it as reasonable to screen for frailty it almost seems that those who don’t believe that it somehow encourages frail patients unnecessarily to seek hospital care. In ways that seem clear to those who object, but remains obscure to others, screening for frailty is equated with concession to or even endorsement of the bad behavior of the frail. Such behaviour consists in not giving accurate histories, or staying too long, or simply not coping. They believe themselves to be acutely ill when they are merely socially discommoded. I make this point less to mock than to underscore the main issue. We must face up squarely to the fact that many frail patients are seen, by intelligent healthcare providers of high training and generally good will, as not being legitimate users of their services. Of course in this these service providers likely are correct. Physicians who see their mandate as focused on single and compelling issues have not the attitude, evidence, or training needed to treat patients whose array of additional complex problems makes a single issue focus often irrelevant and even harmful.
How do we address the competing priorities of the “ologists” and the generalists? What if, as seems likely, focusing on just one problem in a patient with several active issues makes things worse, not better? Without better evidence for some of the mechanisms of what we do – without knowing more what parts in the black box of comprehensive geriatric assessment work best – it can be too easy to believe that frailty is the same as the need for palliative and end-of-life care. Sometimes it is. Most often it is not. How to draw the line is not yet clear. The degree of frailty is clearly important, but the evidence base does not allow for definite answers about the effectiveness of our interventions in relation to the degree of frailty of the patients. And although we need more evidence, likely it never will. At present, there is a strong degree of operator dependence in the care of frail older adults. That too is a fundamental issue. As underscored by Leicester’s Jay Banerjee, who presented on Quality Assurance, we cannot scale up inspirational leadership or particularly good clinicians: we can only scale up processes.
To scale up processes means that we must focus on which processes work. We need to learn from ordinary care. We need to bridge the gap between well-funded, narrowly defined, highly observed, officially “research” studies and the mass of variable outcomes that arise from the variable ways that routine care prompts but escapes systematic observations.
These are critical issues.
Going forward, we must embrace the need for each of us becoming skilled in continuing quality improvement, in asking the difficult questions. We must not be satisfied in a few all-or-none decisions (e.g. do we adopt the x program provided by y company?) made by people distant from what actually happens. The energy that follows on arbitrary decisions is impressive: administrators exhaustively defending every quirk; the front lines consumed in adapting and silently bickering.
Here is one alternative, which I saw in the Acute Frailty Network: develop cultures that can focus on useful, least arbitrary, but still measurable outcomes. Develop cultures that seek to achieve those outcomes and rejoice in sharing best practices. Imagining that we can cope without changing, or with ways going in to the loudest or most powerful, is not how we will succeed. The Acute Frailty Network points as to how to make care better. If we are to succeed, we need to engage in recognizing the challenges, that we face, and meeting them.