Do Mention the F Word: Frailty and Policy
David Oliver is a Consultant Geriatrician in Berkshire and a visiting Professor in Medicine of Older People at City University, London. He is President Elect of the British Geriatrics Society.
Frailty is something of an obsession for geriatricians. In a medical tradition based around "single organ" specialities and a branch of medicine which has sometimes struggled to make its identity distinct, its value clearer and its prestige higher, we know that older people with frailty and complex comorbidities are our bread and butter. And that applying skilled Comprehensive Geriatric Assessment, and whole systems, whole person care to a traditionally neglected group of service users defines what we do better than our non-geriatrician colleagues.
We should not, of course, under-sell our other role as highly trained general physicians who do a decent job of managing people with multiple long-term conditions. Consultant colleagues from other specialities often remark to me on the calibre of our trainees when it comes to busy acute medical takes for all-age adults. Compared to colleagues overseas, we are fortunate to be the most numerous internal medicine speciality and to be able to attract large numbers of high calibre trainees to the job, helped by standard national salary scales, numerous role models and good training opportunities.
My own critique would be that our perennial discussions about frailty have been far too solipsistic and abstract. How much navel-gazing can one speciality engage in? Endless academic debates about frailty as a construct, cellular determinants of frailty, complex tools and scales to define it have done little to "sell" the concept to those outside our inner circle. After all, we don't need to be marketing the idea that frailty counts to ourselves - we know that already!
Given rapid population ageing, there will never be a time when geriatricians can assess and support everyone who is frail - nor should we attempt to. In Britain, 40% of registered medical practitioners are GPs. They and their community colleagues have far more patient contact then we ever can. And colleagues across hospital-based specialities see many frail patients. Do we need more geriatricians (and other clinicians specialising in the care of frail older people) or more people skilled in this? Both.
Go back 3 or 4 years and most local or national plans around long-term conditions focussed on single diseases. These rarely included common conditions related to ageing (e.g. incontinence, immobility, dementia or bone fragility). They almost never discussed frailty syndrome as a long term condition in its own right. Mercifully this is changing. We have a national dementia strategy in England for instance. We have had increasing commentary on the need to shift away from the single disease model towards person centred coordinated care based on people with multiple co-morbidities. We have an acknowledgement that the current primary care offer is not fit for purpose for such patients. The RCP Future Hospitals commission has also highlighted the need to refocus our efforts on the older patients who actually use acute hospital beds.
And...glory be, increasingly commissioning plans for services in primary care are focussing on early identification and proactive support for frail older people. The Scottish government has also embraced the challenge with its programme of work on frail older people and long term conditions.
Frontline service leaders and clinicians who are not trained in geriatric medicine need practical resources and a clear story. And the wider public need to develop the same understanding of frailty as they have started to develop around Dementia. The article by Clegg et al in the Lancet has been a great boon - a readable punchy piece that puts the key evidence in one resource. "Fit for Frailty" is a great companion - co-designed with Age UK to ensure it is user friendly and public facing - the diametric opposite in fact of our traditional inward looking abstruse debates about frailty. Meanwhile, John Young, the current National Clinical Director for frail older people and integration has made the identification and support of people with frailty his core mission. He has encapsulated his thinking in the NHS England resource "safe compassionate care". Meanwhile, behind the scenes, he has developed the Electronic Frailty Index - to enable identification of older people with frailty at an earlier stage in their trajectory.
Best of all, he has succeeded in securing approval for three national codes in England for levels of frailty. Don't underestimate the key importance of these two practical tools which will help us describe our story and help the cause of older people better than any amount of internal doctrinal debate in the church and priesthood of geriatric medicine.
Meanwhile "Fit for Frailty" can help overcome the historical deficit in getting the public (including older people and their carers) and frontline community practitioners on board the F train. Bravo to all involved