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The Frailty Fulcrum

The concept of frailty as a long-term condition brings with it the opportunity to adopt a much more proactive, person-centred, community-based approach to care.

Achieving this requires a new approach to care, particularly through supporting self-care.  This new approach will be enabled through a wider awareness of frailty and a greater shared understanding of the condition.

The ‘frailty fulcrum’ is an animated model for frailty that has been developed with these opportunities in mind. This model aims to provide a ‘common language’ for frailty that can be shared between individuals, carers and professionals.  It offers an interpretation of frailty that is meaningful, relevant and sustainable for people living with the condition, throughout their journeys of care.

frailty-fulcrum-model

The frailty fulcrum highlights the multi-dimensional nature of frailty.  It considers the many different aspects of our lives that contribute to our overall wellbeing through a series of domains. The domains identified in the model are:

  • Social environment, including our families, our friends, our communities, any of the people or places that are important to us.
  • Physical environment, which is our homes in particular but also the many places that we visit as we live our lives.
  • Psychological status, which includes both specific conditions, such as anxiety, or more general feelings like a loss of confidence or a lack of motivation.
  • Long-term conditions, such as diabetes, heart disease or respiratory conditions.
  • Acute health problems, including for example, infections or injuries.
  • Systems of care, which have a direct impact upon wellbeing, not just through the care that they provide, but also through the way in which they deliver that care.

Factors within each of these domains can either promote individual resilience or create individual vulnerability.  The frailty fulcrum shows how resilience and vulnerability in these various domains come together to create the holistic condition of frailty. It also shows how the dynamic balance and interactions between the domains influence individual quality of life.

The frailty fulcrum explains how keeping a good balance between all the different things going on in our lives becomes more difficult over time and that as we get older the likelihood of relatively small things causing bigger problems increases.  The model also highlights that these changes can occur more quickly for some people than for others and therefore explains both the association and difference between frailty and ageing.

The frailty fulcrum demonstrates that even though challenges in some areas of our lives might in themselves be difficult to overcome, a person’s quality of life can still be improved by promoting resilience in other areas, whatever the individual’s age or degree of frailty. It also highlights the important contribution that supporting individual decisions and choices, and supporting self-care, can make to improving quality of life for people living with frailty.

The frailty fulcrum, therefore, offers a shared language for frailty to enable a consistent approach to holistic assessment and action planning. It helps to identify and understand the multi-dimensional opportunities that exist to optimise quality of life for people living with frailty and is intended to empower these individuals to exercise choice and control over the care they receive and the ways in which they live their lives.

Watch the Frailty Fulcrum animation.

Dawn Moody

Associate National Clinical Director for Older People and Integrated Person-Centred Care for NHS England.

Dr Dawn Moody is a GP in Derbyshire who has a special interest in frailty and person-centred systems of care. She has worked with commissioners, providers and in research in this area and holds an MSc in Geriatric Medicine. Dawn’s current portfolio includes her directorship of Fusion48 being the Clinical Director for Health Education England (East Midlands) Nottinghamshire Frailty Toolkit and Training Programme. She is also Frailty Lead for the West Midlands Primary Care Workforce and Improved Patient Access Plan, Prime Minister’s GP Access Fund Wave 2 Scheme.

Dawn’s previous roles have included Clinical Associate (Frailty and Complex Care) at North Staffordshire CCG and Medical Director North Staffordshire Community Healthcare. She has been a Partner in General Practice for 16 years and GPSI Geriatric Medicine and intermediate care.

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8 comments

  1. Catherine Regan says:

    Hi Dawn
    I got onto this from the frailty twitter chat.
    It’s interesting that the same ideas emerge so far apart. In my PhD in 2006 I used a similar concept of scales and a dynamic balance but the weights on either side were conceptualised as Threats versus Buffers – implying that some social buffers could contribute to countering some of the physiological threats on the other side. To rebalance when it is threatening to reach a tipping point

  2. Dr. Chris Oleshko says:

    A simple and memorable concept that will stick in one’s mind.

    Very useful for teaching and conveying the issues.

  3. Naomi Campbell says:

    I am a front line nurse in Cornwall- developing a range of innovations to tackle the problem of dehydration in elderly care (linked to frailty and reliance on a carer to drink ..& eat). I read your about your work on frailty with great interest. And would welcome opportunity to share my work with you.

    • NHS England says:

      Dear Naomi,
      Thank you very much for your interest. I have read about some of your innovative work and would be very interested in learning more about it, if you would like to contact me directly.
      Kind regards,
      Dr Dawn Moody

  4. Professor Paul Stanton says:

    Dr Moody’s model is very helpful and is reminiscent of the work of (if I remember correctly) an Australian geriatrician, Trevor Philpott, who in the 1980s used the metaphor of a three legged stool to illustrate the concept of ‘frailty’. The three legs of a stool on which an elderly person balances are: physical health; emotional/psychological well being; social health and well being.
    Such holistic concepts are far better predictors of, for example, those older people in the community who are at high risk of unplanned hospital admission than are purely or predominantly clinical rating scales that measure the symptomatology of the individual in vacuo.
    What by the way has become of the Electronic Frailty Index work (http://www.nhsiq.nhs.uk/media/2630779/toolkit_for_general_practice_in_supporting_older_people.pdf)?

    • NHS England says:

      Dear Professor Stanton,
      Thank you very much for your interest. Regarding the electronic frailty index, I understand that very good progress is being made. Development and validation has been reported in Age and Ageing and at the British Geriatric Society Autumn Conference Professor John Young reported considerable ‘field work’ and practical engagement with a number of partners, including 35 CCGs. In my own research work I have also been using the eFI to investigate frailty trajectories and relationships between frailty, comorbidity severity and quality of life in primary care.
      http://www.bgs.org.uk/powerpoint/2015autumn/young_john_frailty.pdf
      http://clahrc-yh.nihr.ac.uk/our-themes/primary-care-based-management-of-frailty-in-older-people/projects/development-of-an-electronic-frailty-index-efi

      Kind regards,
      Dr Dawn Moody

      • Sarah De Biase says:

        Hello Professor Stanton, Dr Moody
        I am the Programme Manager for the Healthy Ageing Collaborative (HAC) with a primary role of developing a network or primary care professionals, academics, health and care professionals and social care to implement and test the electronic frailty index and its role in proactively case finding and developing new ways of working with people with frailty. I have included the link the the HAC website above which outlines the work within the network to date and would be happy to speak with you further – if this would be of interest to you, please just drop me an email to arrange.

        Dr Moody, we have Practice Nurses working in a rural area in North Yorkshire (Richmond, Hambleton & Whitby CCG with Dr Halina Clare) who would like to download the Fulcrum video onto their laptops, so they might show it to the patients they see at home as part of a frailty screening initiative. However, as they do not have WIFI access in all homes they visit, they wondered if a downloadable format of the Fulcrum video could be made available to them. Is this something they could access?
        Best wishes
        Sarah