Professor David Oliver is a Past President of the BGS, clinical vice-president of the Royal College of Physicians, and a consultant in geriatrics and acute general medicine at the Royal Berkshire NHS Foundation Trust. Here he responds to Steve Parry’s recent BGS blog, The Frailty Industry: Too Much Too Soon? He tweets @mancunianmedic
Dr Steve Parry’s recent blog here, “The Frailty Industry. Too much too soon” certainly generated a great deal of hits and online responses. He is a well-respected geriatrician, has done sterling work for our speciality and we are friends in a speciality where solidarity and mutual respect are wonderfully the norm.
The more I reflect, the more I realise that none involved in the debate are a million miles apart in any case. We have all devoted our professional lives to the skilled multidisciplinary care of older people, especially those with the most complex needs; to the speciality of geriatric medicine; to the leadership of local services; to the education of the next generation of geriatricians and to developing the evidence base for practice. We’re all in this together. And In 2016 Current BGS president Eileen Burns and I set out in an essay for the RCP future hospital journal the range of roles geriatricians now play in UK services.
Steve advanced three key arguments. One being that Frailty has become an overvalued idea in our speciality right now and is dominating the dialogue and research agenda. The next being that the evidence base for a specific focus on frailty in services is poor. Finally, that perhaps we need to spend more time “upstream” of severe frailty and focus more on prevention, reversal and slowing the progression of milder frailty than we currently do.
Hopefully I can be an honest broker on this debate. I am not in any way a frailty researcher or frailty expert or part of that community of expertise, although I have unashamedly argued the case for better care of older people with frailty.
So why do I disagree with Steve’s abreaction to the “frailty industry”?
First, let’s look at what geriatricians do in our system. How do we differentiate those patients whom we are best placed to see at the acute front door, in rapid access multidisciplinary ambulatory care, or clinics, or care for on deeper inpatient wards? Now, as ever, whatever service model we work in, it tends to be those older (or sometimes not so old) patients, with frailty and related presentations (such as falls, rapid loss of mobility or delirium); with age related disability; with multiple long term medical conditions including those largely associated with age, with dementia accompanying their presentation. Such patients often rely on carers, need post-acute rehabilitation and support, access to community services and benefit most from skilled multidisciplinary assessment and care.
I am sure no-one is seriously suggesting that other doctors or the teams they work with are better trained for this task or that we should abandon the care of such patient groups to them.
Severe frailty does indeed drive much of this demand and is highly predictive of hospital presentation and admission. So do older people living with multiple life limiting long term conditions. Not all of these patients are frail. But “Frailty” is being used in most cases as shorthand.
So “Acute Frailty Units” “Frailty Clinics” “Frailty Rapid Response Teams” are basically good old fashioned geriatric medicine. Only with a welcome focus on expert support as early as possible in admission and a greater focus on getting patients home.
With regard to our role in prevention, well-being, active ageing and helping reverse the earlier stages of frailty, we must be realistic. Of course we can contribute to the evidence base around well-being and prevention and we can contribute local leadership and advice around systems of care for the mildly frail and pre-frail. However many of the wider determinants of health in older age lie with primary care (a much bigger workforce) community nursing, housing, local government, public health, wider universal services, the third sector and welfare. We are in no position to deliver most of this and the medical model is often not the answer.
Finally, with respect to the evidence base, I think it would be a serious mistake to assume that “evidence” equates to RCTs and meta-analyses. And that we shouldn’t get on with meeting serious pressing system challenges till they are available.
Our patient group aren’t always readily randomised and recruited. Much of what we do is about delivering different service models. And as Rowan Harwood so elegantly argued in the recent Clinical Medicine journal and in his Marjory Warren lecture, so much of what we do isn’t about hard numerical outcomes, it’s about prioritising treatment, recognising limits of intervention, supporting families, delivering good care toward the end of life, etc.
But if we do look at solid pragmatic quality improvement initiatives – for instance in studies on patient flow, in the data from Acute Frailty Network or RCP future hospital sites, from NHS England Care Home vanguards, there are examples a plenty of the benefits of getting care for frail older people right. And similar patterns emerge from “Big data” on national improvement drives. The National Hip Fracture database for instance has shown year on year improvements in mortality for the (generally frailer, older) people with broken hips.
In short, I think “Frailty Medicine” whatever the nuanced scientific arguments about its identification, classification and pathophysiology is being used almost interchangeably with “Geriatric Medicine”. I don’t imagine most readers would think we should stop providing geriatric medicine, or skilled multidisciplinary care.
If ‘frailty’ is encouraging attention, interest, debate and crucially investment in expert MDT care and research for older people with complex needs, then hear hear for ‘frailty’.
Thank you Dr Oliver!
Important for many non-geriatricians to understand the difference between numeric age and physiological ageing. Ignored at the peril of patients, carers and the service.
I would also like to point out that some of those leading the discussion on frailty have all made it clear that those with mild or moderate frailty are also important and so are those not yet frail and all have emphasised the need for preventative approaches and a focus on supported self management/community solutions/wellbeing – and the importance of community wide and asset based approaches rather than just medical models. None have claimed that all older people are frail, nor that severe frailty is all that matters
e.g. The BGS Itself with “Fit for Frailty” Parts 1 and 2
e.g. National Clinical Directors for older people and integration, Prof John Young then Dr Martin Vernon
e.g. NHS England itself with a range of resources on support for older people including those who are frail
e.g. Andy Clegg and his research group who have developed and validated the electronic frailty index
e.g. WHO Europe with its strategy document on healthy ageing
e.g. The NHS Confederation and partners in “growing old together” Age UK in “better healthcare for healthy active ageing” The Birmingham Commission on Healthy Ageing
e.g. NICE in its guidance on multimorbidity
However, if according to the Electronic Frailty Index around 7% of the population over 75 are severely frail and around 1 in 5 moderately frail, if older people with multiple long term conditions and/or frailty or dementia are driving so much of acute hospital activity, occupy most intermediate care beds and places and most of the 400.000 + nursing and residential homes, it strikes me that geriatricians and the specialist multidisciplinary teams they work with have their hands full. And if we have people lengthily and highly trained in general internal medicine, acute care as wells as geriatrics and it subspecialities, and if we aren’t going to pull out of the services we already offer then whatever we choose to call it, however we choose to classify it, the care of people who are in general living with moderate or severe frailty is what we will be doing (and I would argue should be doing) for the foreseeable future
I go back to the last century when frail meant someone who had problems that doctors could not help as they were due to age. The word frail was banned in our department. In this century things are clearly different. However I think we should be cautious ( however good a slogan for commissioning) in confining geriatric input, whether in hospital or the community, to people classified as frail. Conroy and Parker (Clinical Medicine 2017;4;350-3) suggested that about 20% of the over 75s in hospital may be frail. Our study (J R Soc Med 1995;88:629-633) suggested the proportion of over 75s admitted to hospital with multiple pathology or needing multidisciplinary management (now know as comprehensive geriatric assessment) was 85%. Perhaps the discrepancy lies in those patients whom hospital care makes frail even if they did not come into it with much evidence of frailty. It would be good to think that geriatric inpatient care can prevent frailty as well as mange it. When deciding which patients should be managed by geriatric teams perhaps we should have criteria for the ‘pre-frail’ and manage their care as well as those with established frailty.
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