We have put together answers to our most frequently asked questions about supporting older people living with frailty.
If you need any more information, please email us: firstname.lastname@example.org.
Frailty is a loss of physical and/or cognitive resilience that means people living with frailty do not bounce back as quickly as they used to after a physical or mental illness, an accident, or other stressful event. In clinical terms, frailty is characterised by loss of biological reserves across multiple organ systems and increasing vulnerability to physiological decompensation after a stressor event.
The population of England is ageing, and the absolute number of older people is increasing. By 2040, nearly one in seven people are projected to be over 75. Frailty may be associated with ageing, but it is not the same. Depending on their circumstances, people begin to develop frailty at different points in the adult life course and it progresses for individuals at different rates. Frailty (rather than a person’s age) can help predict the future risk of hospitalisation, care home admission or death.
Frailty is increasingly recognised as a long term condition that can be identified and managed to improve people’s quality of life and support them to live well for longer. The ageing population, coupled with a growing opportunity to support people living with frailty, means it is important for the NHS to take action. Routine identification of frailty in the whole population opens the door to better care and support for people living with frailty and the NHS in England is the first health system in the world to do this.
The diagram at Figure 1 shows the reality of how a relatively minor illness, such as an Urinary Tract Infection (UTI), can have an impact on an individual living with frailty (red line) through restricting their independence for a significantly greater time and degree than someone without frailty (green line). Importantly those with frailty do not always achieve complete recovery, leaving them even more vulnerable to lost functional ability, if further stressor events occur in the future.
Frailty as a progressively abnormal health state (ie a LTC)
Clegg, Young, lliffe, Olde-Rikkert, Rockwood, Frailty in elderly people. Lancet 2013
Routine identification in the population helps ensure people living with frailty receive high-quality care that is safe, effective and focused on patient experience. For example during an acute illness it is important to recognise that someone is particularly vulnerable to the adverse effects of avoidable deconditioning. This physiological loss of physical capacity, through inactivity, which if not acted upon will lead to delayed, or incomplete recovery with the risk of greater long-term dependency, and associated poor outcomes. For a person living with frailty, deconditioning may start within a very short time of being confined to a hospital bed. It can be prevented by proactively identifying their vulnerability early, and ensuring timely interventions such as early and sustained high quality rehabilitation, to support them to be as active as appropriate and maximise their likelihood of return to physical independence.
Supporting the sustainability of the NHS and meeting commitments within the Five Year Forward View. There are an estimated 1.8 million people aged 60 or over living with frailty. As frailty has not been routinely coded before we cannot yet fully assess or predict the financial impact of frailty on health and social care. However, it is likely to be significant: falls, which are one of the frailty syndromes increase in frequency and impact with the severity of frailty and are the most frequent and serious type of accident in people aged over 65. Every year more than one in three people over 65 suffer a fall, which can cause serious injury, and even death. The costs to the NHS and social care from hip fractures alone are an estimated £6m per day or £2.3bn per year.
Looking ahead, as shown at Figure 2, population ageing is set to gather pace. Over the next two decades the total number of people 65 and over is estimated to grow by nearly 50%. The fastest growing group being those aged 85 or over, which is estimated to grow by nearly 115%
Figure 2: Actual and projected number of people aged 65 and over in England by age group, 2015/16 to 2035/36
Source: Office for National Statistics (2016, 2016)
General practice is required to:
- Identify all patients aged 65 and over who may be living with moderate or severe frailty;
- For patients identified as living with severe frailty (around 3% of over 65s), undertake an annual medicines review, a falls risk assessment, if clinically appropriate, and promotion of the enriched Summary Care Record (SCR);
- For patients identified as living with moderate frailty (around 12% of over 65s), consider undertaking a medicines review, a falls risk assessment if clinically appropriate, and promotion of the enriched SCR.
The avoiding unplanned admissions enhanced service (AUA ES) has been discontinued and funding associated with it placed into the core contract. This new requirement will affect a smaller proportion of patients across England and has more targeted evidence based interventions.
- All these requirements can be delivered by any suitable clinician. Also where the practice is working with a wider health care team, (for example community pharmacy or as part of a network of practices) they would be able to deliver this care on behalf of the practice.
- Whilst clinical judgement is crucial to confirm identification of frailty, practices can use automated tools such as the electronic Frailty Index (eFI) to initially identify populations of people likely to be living with varying degrees of frailty.
- The expectation is that, for most patients identified as living with severe frailty, a specific visit for an assessment will not be needed as they will be seen in year as part of routine consultations
Better care and support for older people living with frailty is a key challenge and opportunity for the NHS as recognised in both the NHS Five Year Forward View and the Next Steps on the NHS Five Year Forward View. This is also reflected locally with many Sustainability Transformation Partnerships focused on better supporting older people who are living with frailty.
As with any condition, clinically confirmed diagnosis provides an opportunity for people to be aware, better understand, make informed choices and manage their health needs with the support of health and care professionals. It also supports clinicians to provide tailored, timely and high quality care to people recognised as living with frailty.
The electronic frailty index (eFI) uses the existing information within the electronic primary health care record to identify populations of people aged 65 and over who may be living with varying degrees of frailty. When applied to a local population it provides opportunity to predict who may be at greatest risk of adverse outcomes in primary care as a result of their underlying vulnerability.
The eFI uses existing electronic health records and a ‘cumulative deficit’ model to measure frailty on the basis of the accumulation of a range of deficits. These deficits include clinical signs (e.g. tremor), symptoms (e.g. vision problems), diseases, disabilities and abnormal test values.
It is made up of 36 deficits comprising around 2,000 Read codes. The score is strongly predictive of adverse outcomes and has been validated in around 900,000 patient records.
It presents an output as a score indicating the number of deficits that are present out of a possible total of 36, with the higher scores indicating the increasing possibility of a person living with frailty and hence vulnerability to adverse outcomes.
The contract requires general practices to identify populations at risk of frailty by using an appropriate tool. NHS England do not require any particular tool to be used. However, as eFI is available in all GP practices, NHS England anticipate this being used frequently as it:
- has been externally validated using routine primary care data and its use is recommended in NICE Guideline 56 on Multimorbidity;
- is available in all GP practices and therefore promotes consistency;
- uses existing GP data and therefore requires no additional resource.
The eFI is not a clinical diagnostic tool; it is a population risk stratification tool which identifies groups of people who are likely to be living with varying degrees of frailty but it is not able to do this for specific individuals. Therefore, when the eFI identifies an individual who may be living with severe or moderate frailty, direct clinical assessment and judgment should be applied to confirm a diagnosis.
Some GP practices may have batch-coded a Read code diagnosis of frailty based solely on an eFI score, without clinical judgement confirming a diagnosis. This may result in inappropriately targeted interventions and increased workload for a practice (the eFI, for example, has relatively high sensitivity and low specificity so tends to over-identify people living with frailty).
In response NHS England has issued a statement confirming the importance of clinical judgement.
There are 2 main options:
- A batch delete process followed by repeating the process in line with the guidance (i.e. applying clinical judgement before coding). If choosing this option it may be helpful to seek guidance from the relevant software provider.
- A clinical review of all people identified (and therefore coded) with severe frailty and removing the read code of severe frailty from those that were incorrectly identified. If practices have also batch-coded moderate, mild and/or fit then they may wish to review this too.
In terms of choosing between the 2 options, this depends on the list size and how quickly it is possible to go back through the list and do the clinical validation.
Based on the validation of the eFI, on average around 3% of over 65s will be identified as potentially living with severe frailty. However, in some practices this number may be significantly higher. There are three main reasons for this:
- Previous coding history – as the eFI is based on Read code data, practices that have undertaken activities resulting in increased coding of certain deficits (particularly those focused specifically upon care and support for older people) may increase eFI scores and therefore the proportion of patients identified with severe frailty. However, it is also likely that in such cases practices will already have greater clinical awareness of this cohort, which will facilitate their clinical validation of frailty diagnoses.
- Completeness/continuity of electronic patient records – where electronic Patient Records are more complete, for example because they have been in place for a longer time and are intact on a single software system, this can increase the likelihood that particular deficits are coded and therefore the proportion of patients identified with severe frailty.
- Demographics – where practices have a larger proportion of patients in the oldest age groups, or living in areas with high levels of deprivation, they are likely to identify a greater proportion of people living with severe frailty. This is like to be particularly significant if a practice has a large number of registered patients who live in care homes.
No. The same contractual requirements apply.
The aim of this approach is to support patients to live well for longer. We expect that this approach will help reduce unwarranted hospital admissions as it will reduce the risk of people experiencing two of the major frailty syndromes; falls and adverse effects of medication, which often result in hospital admission. It will also ensure that those most at risk of unwarranted outcomes from admission to hospital are identified early in their admission and their care appropriately tailored to meet their individual needs and preferences.
In addition, the enriched Summary Care Record can help ensure that people accessing care anywhere benefit from the professionals involved in their care having access to essential details about their healthcare. This includes information on whether the person is living with frailty or other long term conditions, their healthcare needs and personal preferences.
NHS England, in partnership with Age UK, Public Health England, and the Chief Fire Officer’s Association and older people themselves, has published a Practical Guide to Healthy Ageing, providing hints and tips on how to keep fit and independent.
Whilst the content aims to be simple and readable, the evidence base for the topics in the guide is based on a systematic review of 78 longitudinal observational studies that collectively identified 11 main risk factors linked with functional decline in older people living at home. By targeting these risk factors, the guide can contribute to supporting people to stay well for longer, particularly over the winter period, and improve the quality of life of people and their carers.
Locally, the numbers of people identified with severe frailty will vary depending on factors including local demographics. Nationally, we expect:
- Around 3% of over 65s, or 297,170 older people, with severe frailty identified and targeted with falls assessment and medications review and are helped to stay well and reduce inappropriate treatment burden.
- Up to 15% of over 65s, or 1,485,850 older people, will benefit from the availability of enriched summary care records supporting the sharing of safe, effective and efficient care across different settings.
NHS England has supporting resources available o the frailty webpage and the resources to support the older peoples programme page.
NHS England, Public Health England and Age UK have jointly produced a leaflet for patients “Keeping your independence”.
This explains what frailty is, how frailty identification can be helpful in supporting people to remain independent, and how they can find out more information.