We must recognise frailty as a long term condition

Since the publication of this blog John Young has left NHS England.

Professor John Young, NHS England’s Director for Integration and Frail Elderly Care, supports a more proactive approach:

Frailty is an enigma. It surrounds us in health and social care and we recognise it when we see it – but it is also invisible because as healthcare professionals we do not regard it as a diagnosis or formally record it.

We tend to use the term as a description – “the frail elderly” – rather than considering it a long-term condition.

However, frailty behaves just like a long-term condition. It is progressive, it impacts adversely on life experience and – if unmanaged – it can cause the sufferer to become very sick, very quickly.

Catch them before they fall

Frailty is related to the ageing process, that is, simply getting older.  It describes how our bodies gradually lose their in-built reserves, leaving us vulnerable to dramatic, sudden changes in health triggered by seemingly small events such as a minor infection or a change in medication or environment.

It’s because we do not pro-actively manage people with frailty, that they tend to become known to us in crisis. There is an over-reliance on secondary care responses, with over 650,000 people over the age of 65 attending hospital emergency departments each year after suffering a fall.

It is my belief that people living with frailty need improved support through the provision of preventative and individualised care. This should include everything from home adaptation and carer support to access to social networks, exercise promotion and nutritional guidance.

The Frailty Index

Frailty develops slowly over 5 to 10 years, so could more be done to help older people with frailty before a health crisis occurs?

Older people with frailty can be readily identified and are usually well known to local health and social care professionals. However, at present we do not formally diagnose frailty, making proactive care difficult.

The primary care electronic health record contains large amounts of health data which could be brought together with a simple slow walking test (an indicator of frailty) to form a “Frailty Index”. This would enable us to identify people with frailty and to grade their frailty state, allowing us to devise structured self-management plans for people with mild or moderate frailty and to move ahead with multi-disciplinary assessment and individualised care planning for people with moderate or severe frailty as quickly as possible.

A new model of care

Frailty is a late life adverse health state that develops over several years. Although frailty shares many characteristics of a long term condition, the current health service response is predominantly by urgent and emergency care rather than a preventative and proactive approach.

A new model of frailty care is needed and should be delivered through more robust primary care-based systems capable of routinely identifying people living with different severity grades of frailty and providing an appropriate response of supported self-management that is well integrated with community, mental, social and voluntary sectors.

John Young, National Clinical Director for Integration and Frail & Elderly Care

Professor John Young was previously National Clinical Director for Integration and Frail & Elderly Care, since the publication of these blogs he has left NHS England.

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  1. Mr Donald Shufflebotham says:

    My comments reference these proposals, are as follows
    I am a disabled OAP who has carers, plus District Nurse visits also, and the District Nurses are under enormous pressure,
    up to 25 visits to cope with, then go off sick, the result bringing back retired staff to fill the shortages,also because of the Nurses leave due to the pressure. Then sign up for agency work within the NHS where they are probably better paid, and can chose their hours of work, or return to the Wards
    Also being over 75 years the proposals via my Health Practice is that I will have an assigned GP plus Nurses and other Health support for my care needs, to keep me out of Hospital Admissions via A & E etc.
    In light of the points I have mentioned where then will you get all these additional staff from, to implement these proposals ?

    Kind Regards

    • NHS England says:

      Thank you for raising these important points. As a geriatrician, I have had close involvement with the vital work of district nurses. I fully understand the pressures they are under at present. It is hard to understand the paradoxical decline in the community nursing workforce in the face of pressing need. It may be partly that we, as citizens and health care planners, have become more alarmed and influenced by the frequent headlines about “the hospital is full” and not been offered the often more truthful headline that “the community is full.” Hence our collective understanding of health care has been overly biased towards hospitals. From all my various discussions within NHS England, there is a shared view that primary and community care needs to be delivered at greater scale if we are to succeed in providing the sort of care you are very reasonably describing.
      Kind regards,
      John Young

  2. David says:

    Bravo Professor. I do hope this is developed and deployed quickly. identification of the “frail” before they enter hospital is essential, but how do you feel about the use of the Index once they are admitted? One big issue is that the elderly frail are less likely to be looked after by a Geriatrician’s MDT now. Commonly they will be shunted around wards as new problems gradually unfold, then discharged inappropriately. We know the mortality associated with discharge of over 85’s, yet ambulances take them home on dark evenings to an obvious demise. Perhaps a new classification of those at most risk could be used to minimise transfers and poor discharge practice?

  3. Tim Sanders says:

    I absolutely agree that we should be identifying frailty and intervening to identify risks and promote well-being, particularly avoiding unnecessary and often distressing hospital admissions.

    I would just plead that we keep it as simple as possible – perhaps a GP practice can identify the frail older people on its practice list in a lunchtime meeting rather than by algorithms ? Perhaps you can see who’s walking slowly, or slower than last time you saw them, without a stopwatch test ?

  4. Anonymous says:

    Prof Young – I was very interested to read about a frailty index and would say that this might also be used wider for those who have multiple long term conditions who might not be so elderly but also “frail”. Although there seems to be an emphasis on secondary care it would seem to me that this is sometimes the problem for elderly people as often they have grown up with a different mind set about visiting the doctor. I am sure you are all too well aware of this. Combined with the difficulty of even getting to see a doctor or nurse then compounds the problem. I have seen my 86 year old friend start to become more frail over the last year and having difficulty swollowing her food something that I feel could be easily rectified. However, it needs a good doctor or nurse to spend time with her to encourage her to find out what is wrong so her life can be improved. Unfortunately I really don’t think this will happen at her local practice which seems to have far too many patients to cope. If I lived nearby I would take her there and insist on something happening. Then if there was an operation to have she could then choose to have it or not. At the moment there is no choice for her. Earlier intervention would no doubt put off her fraility as otherwise she is a very robust active 86 year old who still cooks, cleans and walks into town once a week.

  5. Mike says:

    Hi John – interesting article and one I can relate having elderly relatives that are very frail and wondered how the NHS/SC system identify and track such folk. From my background in NHS standards I was also drawn to the frailty index and wondered if you were investigating what exists in the current coding schemes used in the NHS to identify ‘frailty’?
    kind regards – Mike