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 @
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.