Joining the dots: Chapter two - Setting the context

Blueprint working group
British Geriatrics Society
Professor Anne Hendry
Date Published:
06 March 2023
Last updated: 
06 March 2023

This chapter sets out why commissioners must focus on older people and frailty when planning services. It also talks about the role of comprehensive geriatric assessment, the workforce challenge and how the needs of older people are at the heart of our blueprint.

The organisation of health and social care services across the four nations of the UK seems to be forever evolving, with responsibility for commissioning services continuously moving between organisations. In England in particular, new Integrated Care Boards have been charged since July 2022 with the commissioning of health and social care services with a greater focus on service integration and population health.

The population of the UK is ageing with particularly fast growth in the oldest old age groups – by 2045, the number of people aged 85 and above will have almost doubled.6 It is therefore essential that commissioners ensure older people and their health and social care needs are central to the new strategic planning and commissioning processes. Older people are the largest user group of health and social care services. When services work for older people, they are more likely to work for the rest of the population. With this in mind, the primary audience for this document is system leaders and commissioners of health and social care services for older people. We hope that it will help these senior decision-makers to better understand the core features of age-attuned integrated care for older people. We intend to publish an abridged version of this document at a later date for a wider audience of healthcare professionals, patients and system partners.

A longer life brings many opportunities for older people, particularly when they experience good health, have strong social networks, and live in an environment which values their contributions and supports them to live the lives they choose. However, for many adults, later life brings declining physical and mental health, all too often compounded by inequity of access and missed opportunities for interventions that help to maintain their independence and wellbeing.
This means older people are more likely to experience frailty - a long-term condition in which multiple body systems gradually lose their in-built reserves, resulting in an increased risk of unpredictable deterioration from minor events. The consequences of escalating frailty are adverse outcomes such as disability and its consequences, frequent hospital admissions and increasing demand for long-term social care support.2
The COVID-19 pandemic shone a light on systemic ageism, exacerbated existing inequalities, and increased the harm experienced by older citizens from loneliness and isolation, deconditioning, poor mental and physical health and digital exclusion.7,8 These factors further increase demands on our health and social care systems that were already facing significant challenges from:
  • A social care system in crisis, contributing to older people staying in hospital longer than medically necessary due to the lack of care packages available in the community – this was highlighted through the BGS’s Timely Discharge blog series in 2021.9
  • An unprecedented elective care backlog, generating further dependency and increasing demand for social care, rehabilitation, mental health, primary and community services.
  • A workforce that is under-resourced, over-stretched and underpaid. While data about the full older people’s healthcare workforce is lacking, we know from analysis of the Royal College of Physicians census that vacancies across geriatric medicine are common.10
  • A growing number of older people experiencing fuel poverty and food insecurity.
  • Facilities that are not fit for purpose for older people with dementia or a physical disability.
  • Lack of interoperable IT and information governance arrangements across providers.
The pandemic also demonstrated what can be achieved when professionals and organisations work together more creatively and with local communities: better collaboration and trust, and an ability to pivot, innovate and make changes at pace, as highlighted in BGS’s two reports about beneficial innovations during the pandemic.11,12 The COVID pandemic and its ongoing aftermath have placed additional pressure on a system that was already stretched by years of under-funding. However, a significant opportunity to rethink how services are delivered now exists. As integrated care systems move to a statutory footing in England and corresponding arrangements evolve further across the UK, this is an ideal time for urgent action to prevent, identify and manage frailty to improve the lives of older people and those who care for them and to build greater resilience in our health and social care systems.

In this section we discuss why frailty is such an important issue for the delivery of older people’s healthcare and why all organisations responsible for commissioning health and care services should consider frailty as a priority.

While there are many health conditions that are common in older age, our members have specific expertise in the management of frailty along with other conditions. We challenge system leaders to consider the following questions about the impact of frailty on their communities and on the services they commission or provide.
How many people in your community are living with frailty?
Frailty is common – more than one in ten people over 65 years in the community live with frailty. Frailty also affects over half of adults in hospital or care home settings.13 Does your system understand the current demand associated with frailty?
How will this number change in the coming years?
Frailty is increasing as people are living longer with multiple long-term conditions.14 The number of people in the UK over the age of 85 is set to double by 2045,6 with up to half of this age group living with frailty.1
Does your system understand the complexity of frailty?

Many people with frailty will have cognitive impairment and dementia and vice versa, increasing the complexity of their care needs. As frailty is often associated with functional impairments, it requires a restorative or enabling approach beyond the scope of a traditional biomedical chronic care model. Older people with frailty often experience five common syndromes:

  • Falls (e.g. collapse, legs give way, found lying on the floor)
  • Immobility (e.g. sudden change in mobility, ‘gone off legs’, stuck on toilet)
  • Delirium (e.g. acute or worsening of pre-existing confusion, or short-term memory loss)
  • Incontinence (e.g. new onset or worsening of urinary or faecal incontinence)
  • Medication-related harms
Does your system understand the impact of frailty on individuals, families and society?
Frailty is life-limiting – even after adjusting for long-term conditions, socio-demographic, and lifestyle factors, the presence of frailty is associated with higher mortality.15
Frailty affects us all - If we do not change the way we support older people to age well, we can anticipate a dramatic increase in frailty-related disability and dependency, a negative impact on quality of life, morbidity and mortality, further escalation of acute and long-term health and care costs, and an increase in the human and economic costs of unpaid caregiving.16 This is an urgent call to change the way we provide care and support for older people and to make our health and care systems face up to frailty.
How well does your system currently manage frailty?
Frailty is generally not managed well – too often, early signs of frailty are not recognised, resulting in missed opportunities for early intervention contributing to higher numbers of older people presenting in crisis.
Suboptimal management of frailty is expensive – frailty and multimorbidity are strong predictors of healthcare utilisation.17 The extra annual cost to the healthcare system in England per person with frailty was calculated at £561.05 for mild, £1,208.60 for moderate and £2,108.20 for severe frailty, using 2013/14 reference costs. This equates to £5.8billion per year, across the UK.3
Case studies

The Kent Integrated Dataset (KID)18 links health and social care data for more than two million people. The KID analysis of health and social care spending on people aged over 65 by their level of frailty demonstrates the need for system-wide understanding and action on frailty.

Midlothian Health and Social Care Partnership applied the electronic Frailty Index (eFI) to their population over 65 years and linked this information with patient-level data on use of healthcare services. This resulted in costs for cohorts with different levels of frailty. The observed healthcare costs for over 65s in Midlothian were extrapolated to illustrate Scotland-level costs for older people with different levels of frailty.

Through use of data, both systems were able to show the impact of frailty on spending and proactively identify individuals with mild or moderate frailty whose condition could be reversed.

What steps is your system taking to prevent and reverse frailty?

Preventing frailty also improves brain health – modifiable risk factors for frailty are also risk factors for dementia so a health promotion and preventative approach will impact on both conditions.19

Frailty is potentially reversible, especially in its earlier stages, and can be managed well by comprehensive assessment and tailored interventions, rehabilitation, care and support.20 In addition to the direct benefits for older people and their carers, families and communities also benefit as preventing or delaying frailty and disability improves wellbeing and participation.

For all of the above reasons, it is important to ensure that older people’s health and care is considered as its own entity and not subsumed into general adult services. We know from the experience of the pandemic that a specific voice for older people is needed to ensure that their interests are not overlooked. Integrated systems must have cross-cutting leadership focused specifically on care for older people. This should include having a Board non-executive member or senior officer whose specific role is around assuring the quality of health and social care for older people and their carers. This individual should be responsible for co-creating a shared system-wide vision for healthy ageing and the prevention and management of frailty, and for the publication of an annual statement reporting on progress against this vision.
The experience of the COVID-19 pandemic showed that a specific voice for older people is needed to ensure that their interests are prioritised. The pandemic exposed an ageism within society and the healthcare needs of older people were not prioritised, despite evidence that they were at greatest risk.21 It should be obvious that frailty and ageing are everybody’s business. However, it is necessary but not sufficient to continually make this point. Predicated representation and leadership is required, supported by data emphasising the importance of a focus on older people’s healthcare. System leaders should have access to regular reports on how their system is performing to support this important overlooked majority.
Recommendation 1: Demonstrate strong system leadership that creates a shared vision for healthy ageing and preventing and managing frailty.

Recommendation 2: Appoint a senior officer or non-executive Board member with a specific role to seek ongoing assurance on the quality of health and social care for older people and their carers.

Recommendation 3: Publish baseline, then annual, State of Ageing reports on system-wide outcome indicators related to care for older people including feedback from patients and carers to reflect their experience.

One of the cornerstones of older people’s healthcare, with a strong evidence base, is the assessment and management process known as Comprehensive Geriatric Assessment (CGA). This multidimensional approach that includes physical, cognitive, functional, social and psychological components, is the gold standard, most evidence-based method to prevent and manage frailty syndromes and their complications using interventions tailored to the needs of the individual.22

It encompasses accurate diagnosis, discussion of prognosis and shared decision-making around interventions that include: exercise, particularly strength and balance training, adequate nutrition, management of long-term conditions focused on functional ability and enabling independence, and avoiding adverse events from inappropriate polypharmacy. Multi-component interventions are more effective than single interventions. The effective application of CGA for older people in acute hospital settings improves independence, reduces harms associated with deconditioning, delirium and polypharmacy, and reduces length of stay, unplanned re-admissions and the need for long-term care.23 These gains depend on having an appropriately trained multi-professional team of doctors, nurses, allied health professionals, pharmacists and social workers focused on holistic assessment of the patient’s needs and wishes with, where appropriate, involvement of those who matter to them. Assessment leads to a personalised care plan that prioritises and implements interventions in a coordinated way. The team manages the individual’s conditions and care needs in a balanced, holistic way, particularly where treatment of one condition may worsen another. Enabling independence, respecting autonomy, promoting shared decision-making and anticipatory care planning, with the appropriate support where cognitive or communication challenges exist, are important elements of the CGA approach.
While CGA in acute settings – whether in emergency and unscheduled care, perioperative medicine or cancer care settings – is highly evidence-based, the level of evidence is less well developed for CGA in the community and primary care settings,24 and in those with the most advanced stages of frailty. This probably reflects the operational complexities in bringing diverse community-based professionals together as a virtual team. Nonetheless, evidence is emerging for the judicious application of multidimensional assessment and interventions in primary care tailored to the needs of individuals living with frailty.25 There is growing international evidence of effectiveness and positive outcomes from a coordinated, interdisciplinary CGA approach in the community.26,27,28,29 Perhaps the best examples at scale are from the PACE Programme in the US30 and the PRISMA system in Quebec.31 A success factor in seven international case studies of effective models of integrated care for older people with complex needs32 was moving from a service-orientated care pathway to a population-orientated system model with comprehensive wrap-around care and support.

A systematic review by the European Joint Action Advantage concluded integrated care for frailty requires effective chronic care, timely acute care, plus enablement and rehabilitation to optimise functional ability, particularly at times of a deterioration in health, or when moving between home, hospital or care home.33 This review informed the integrated model of care and support to prevent and manage frailty developed by 22 European countries between 2017 and 2019.34

This integrated model comprises:
  • Screening to identify individuals with, or at risk of, frailty;
  • CGA and personalised care and support planning in all care settings;
  • Tailored interventions such as exercise (particularly strength and balance training), adequate nutrition, and structured medications reviews to optimise appropriate polypharmacy;
  • Reablement, rehabilitation and intermediate care to promote independence and recovery at times of transition from hospital and after illness;
  • Advance care planning that considers treatment escalation plans and preferences for end of life care;
  • Provision of equipment, adaptations and assistive technologies.
These elements are mutually reinforcing - individual elements are more effective when implemented together as a bundle of interventions across the health and care system and framed within an enabling environment and age-friendly community.
The World Health Organisation guidance to achieve Integrated Care for Older People (ICOPE) was informed by a systematic review of evidence35 and by a Delphi study to reach consensus on the key actions that would be needed to deliver the ICOPE approach.36
These actions map well to the European Frailty Prevention Approach37 and can be grouped as five themes:
  1. Engage and empower people and communities
  2. Support the coordination of services delivered by multidisciplinary providers
  3. Orient services towards community-based care
  4. Strengthen governance and accountability systems
  5. Enable system-strengthening

Commissioning services for older people starts with understanding the assets in local communities and the needs of the local population. Stratifying the population into groups with different levels of complexity helps to target interventions and resources to where they will have most impact.

The electronic Frailty Index (eFI)38 uses coded data extracted from the GP electronic health record to identify an individual’s risk of frailty, expressed as a ‘Frailty Index’ (the number of deficits present/the total number of deficits being assessed). Deficits include coded clinical conditions, disabilities, and relevant symptoms or abnormal laboratory results. The eFI categories have been validated against a range of outcomes for older people: emergency admissions to hospital; emergency bed days; care home admissions; and mortality. The eFI can be applied to the older population to tailor interventions to the four categorisations of frailty which range from ‘fit’ to ‘severely frail’:
  • Fit - a population-level approach with information and advice on active and healthy ageing
  • Mildly frail - as above plus personalised self-management information, advice and support
  • Moderately frail - as above plus holistic care and support planning, structured medication review plus CGA by a multidisciplinary team
  • Severely frail - as above plus case management and palliative/end of life care.
Case studies

This tiered approach to frailty has been adopted by Staffordshire and Stoke on Trent ICS. Their Healthy Ageing and Managing Frailty in Older Age strategy39 aims to improve healthy life expectancy and reduce health inequalities for older people in the area. It describes ambitions to develop new models of holistic care and a radically different workforce model with the right capacity to meet the changing patterns of illness as a result of population ageing.

One Devon’s population health management strategy for older people builds on a locally commissioned enhanced service for West Devon and on evidence from the Pathfields model.40 Use of this tool identified more patients living with frailty than use of the eFI alone and enabled more patients to receive earlier interventions.

Frimley ICS identified frailty as a priority and established a whole-system Frailty Advisory Board to drive an integrated approach to frailty within their localities. The group identified areas for improvement by benchmarking against the Right Care Frailty Toolkit.41

This approach to identifying frailty has helped systems to prioritise resources in their areas and may be particularly effective in areas with a high proportion of older people such as coastal communities and towns with many care homes.

Recommendation 4: Develop a system-wide strategy and costed implementation plan for a population health approach to the prevention and management of frailty, including a specific focus on dementia and falls.

Older people and their carers require timely access to a wide range of generalist and specialist care and support delivered by primary care, community services, acute care, social care, housing, community and voluntary partners as well as specialist palliative care services.

Rising demand from demographic change increases the need for more geriatricians, nurses, allied health professionals, pharmacists, GPs and social workers with specialist expertise in assessment and care for older people. At present, workforce shortages and the level of unfilled vacancies in some parts of the country are a particular problem for the delivery of healthcare for older people.
Whilst all members of the multidisciplinary team face major workforce challenges, the current state of the Consultant Geriatric Medical workforce is the most well described42 and likely reflects similar challenges facing other disciplines. Over two thirds of respondents in a UK survey by the Royal College of Physicians reported specialist vacancies and over 70% were working additional hours to cover gaps. Almost half of Geriatric Medicine Consultants are within 10 years of their intended retirement age. This ageing specialist workforce is compounded by an increasing trend towards less than full time (LTFT) working (currently 23%). LTFT working enables people to work more flexibly and allows them to balance their clinical workload with other aspects of their personal or professional lives. This is to be welcomed and encouraged.
There is an urgent need to train more specialists in older people’s healthcare to provide direct clinical care and to build the capability of generalists to prevent and manage frailty across the system. Yet it takes an average of 16 years from entering medical school to complete specialist training. The need for innovative and effective workforce solutions has never been greater nor more urgent.
Upskilling the workforce
Demographic change means that the majority of the health and care workforce will care primarily for older people and therefore need the knowledge and skills to be able to deliver care and support for older people, regardless of their specialty. Education and training in frailty as a specific condition, and enhanced knowledge and expertise in caring for people with multiple long-term conditions, are essential if we are to have a workforce that can meet the changing healthcare needs of our ageing society. Including guidance and competencies in the management of frailty in educational curricula and in quality standards for professionals who are not specialists in older people’s healthcare is needed to help skill up the wider workforce to deliver healthcare for older people.

The Skills for Health Frailty Core Capabilities Framework43 provides a single, consistent and comprehensive framework on which to base staff development. The framework builds on, and cross-references, other core skills frameworks for dementia, end of life care and person-centred approaches.

The 15 core capabilities in the framework are defined for three tiers of stakeholder:
  • Tier 1: Those that require general awareness of frailty
  • Tier 2: Health, social care and others who regularly work with people living with frailty
  • Tier 3: Health, social care and other professionals who provide expert care and lead services for people living with frailty.
BGS’s Frailty E-Learning module is a comprehensive resource that covers the skills, knowledge and behaviours expected of healthcare professionals involved in the health, care and support of people living with frailty. This course is aimed at Tier 3 capabilities and skills - all health, social care and other professionals who provide expert care and lead services for people living with frailty. This e-learning module has been in use for some time and organisations such as King’s College London University Hospitals NHS Foundation Trust have enrolled staff across several departments in the course. BGS has recently reached an agreement with NHS England to update the content and make it freely available to all NHS staff.44 E-learning modules for Tiers 1 and 2 are available via elearning for healthcare (elfhc).
The Diploma in Geriatric Medicine is a qualification run by the Royal College of Physicians and BGS which enables healthcare professionals to demonstrate their knowledge and experience of the healthcare of older people. It is open to professionals from any specialty and provides recognition of knowledge, skills and understanding of managing frailty and the chronic conditions experienced by older people.
Case studies

Frimley ICS has introduced:
- A system-wide e-learning package, based on Frailty Core Capabilities Framework (tier 1)
- Frailty training for ICT staff.
- An in-house degree module through University of West London (tier 3) run annually.
Future plans include developing a Tier 2 frailty training package for health and social care staff who regularly work with people living with frailty.

Dorset HealthCare’s online frailty module provides a basic level of information to increase the knowledge of all staff who come into contact with people who may have frailty. GP practices are encouraged to promote completion of this module by all reception/admin and clinical staff to help develop practice based and locality level support to identify people who have mild frailty.

Maximising the workforce

Investment to develop the right current and future workforce capacity needs to be matched by support to build effective interdisciplinary teams if we are to make the best possible use of scarce resources.

High-performing teams are characterised by people who respect and trust each other, and enhance each other’s contributions.45 Each member has the professional agency to operate at the upper end of what their skills and licences permit, rather than be constrained by overly hierarchical, siloed structures that limit their contributions.46 Development opportunities to enhance skills and scope of practice can strengthen the contribution of professionals to the MDT, improve their experience and enhance care outcomes. Teamwork and individual judgement are particularly important in care for older people with multiple health and social care needs, where benefits of interventions and potential harms have to be balanced carefully.
There are not enough healthcare professionals currently working in older people’s care and in the long term, more people will need to be recruited to all roles across the multidisciplinary team. In the interim however, there are steps that can be taken to increase capacity in older people’s healthcare. The promotion of newer roles such as advanced clinical practitioners and physician associates can help to alleviate pressure in older people’s healthcare. SAS Grade doctors should also be encouraged to specialise in older people’s medicine. SAS doctors comprise almost 20% of all doctors in the UK (rising to 30% when locally employed doctors are included)47 – this role is and will continue to be essential in the ongoing healthcare of older people.
In addition to this, there is a growing group of GPs who have taken on extended roles in frailty across a variety of settings. This enables them to champion care of the older population in proactive and urgent care settings working across different organisations. These new positions provide sustainability and resilience across the different workforces.
There has been substantial disinvestment in rehabilitation services in recent years. The opportunity to recover from illness and to regain independence should be seen as a right for all. It is essential that systems work to understand the rehabilitation needs of their older populations and invest in the workforce and estate needed to support both home and bed-based rehabilitation for older people.
Recommendation 5: Commission or deliver inter-professional education that is aligned with the Skills for Health frailty core capabilities framework and builds capacity for comprehensive geriatric assessment, quality improvement and integrated practice in all disciplines across the system.

Recommendation 6: Develop an integrated Workforce Plan to build adequate specialist and generalist multidisciplinary capacity and skill mix to care for older people with complex needs.

Recommendation 7: Protect and preserve the right to rehabilitation for all older people who need it, in line with the principles outlined by the Community Rehabilitation Alliance.48

The complex needs of older people are at the heart of our Blueprint. Older people are living longer than ever before. This is a triumph and should be celebrated as it reflects advances in medicine and healthier lifestyles throughout the life course. However, for many people, this also means more years spent in ill-health and increased numbers of people with frailty and multimorbidity.

The healthcare needs of this age group are complex and diverse and this must be taken into account when commissioning services for older people. The group of BGS members responsible for this document used their combined expertise to ensure that the recommendations in this Blueprint acknowledge the range of needs experienced by older people.
The BGS was pleased to participate in the core group that steered the I’m Still Me project5 and we have taken inspiration from it in developing the Blueprint. Older people have not had a sufficient voice in the planning and delivery of health services. The NHS has traditionally been organised by disease or condition and is not currently set up to care for the multiple complex needs that many older people have. The health and social care system was not designed to care for an ageing population. Systems and services have therefore grown without the automatic inclusion of older people in service design and evaluation. However, the population has changed with many more people living into old age with increasing health and care needs. Older people account for around 40% of hospital admissions49 and occupy around 60% of hospital inpatient beds at any given time.50 Failure to plan with the needs of this group in mind will result in a health and social care system that does not meet the needs of the population it serves.
One feature of stressed and disorganised care systems is the unintended muting of the patient voice.51,52,53 The principles of ‘what matters to me’ and the ‘Realistic Medicine’54 movements remind us to ensure a personalised approach to care, based on shared decision-making heavily influenced by the individual’s wishes and priorities for their care. Experience has demonstrated this can reduce waste and treatment burden – expressed in patient time, staff time, or other resources – and improve the experience for people who receive care and for their carers.55,56 For the sake of current and future users of health and social care, we cannot afford to tolerate systems that mute the patient voice, fail to support collaboration and personal or professional agency, or devalue the most effective forms of leadership and teamwork.
BGS calls for all Integrated Care Boards and their system partners from health, social care, housing, third and independent sectors to recognise that their core user group is older people. Well-designed systems take seriously the perspective and lived experience of people who use their services. Involving older people and their carers in the design, delivery and evaluation of care and support helps to ensure responsive, flexible services that respond to their needs.
Recommendation 8: Publish an older people equality and diversity impact assessment and action plan.

Recommendation 9: Engage and involve older people, carers and communities as equal partners with health and social care professionals in co-design, delivery and monitoring the impact of these services and support.

Recommendation 10: Provide support to enable the lived experience of older people and carers, including those with dementia and mobility, sensory or communication needs, to inform ongoing quality improvement and assurance.

The I’m Still Me5 narrative provided valuable insight into what older people want to see from health and social care. A more recent survey conducted by Yorkshire & Humber’s Older People with Frailty Applied Research Collaboration identified the top priorities of older people living with moderate or severe frailty.57

The top two priorities were:
  • Staying in my own home - living in my own home for as long as I can, with support if I need it.
  • Staying independent - being able to undertake daily and social activities.
Other priorities included:
  • Making decisions with family or friends, carers and health professionals about any care or support I might need in the future.
  • Having more joined-up care.
  • Health and care professionals having a better understanding of the experiences and needs of older people.
  • Having a better understanding of my physical or mental health conditions(s) and symptoms.
  • Having more information about my physical or mental health condition(s) and what I can do to manage my symptoms.
  • Worrying less about falling.
  • Doing more exercise/physical activity.
  • Having better support for vision loss or impaired vision.
  • Having a range of housing choices, where help is provided if I need it.
In light of the above, it is important for ICSs to consider how they can best support older people to be independent and live well for longer in their own homes. Some of the solutions may not appear to be directly related to healthcare. For many older people (and others) with complex health needs, healthcare may be a secondary consideration. Systems will therefore need to work with local communities and partner organisations to create inclusive communities that support older people to age well and live well at home for longer. Investing in prevention and supporting people to live independently for longer impacts upon their use of health and care services and will reduce costs in the longer term.
Recommendation 11: Work with public health, housing, community and voluntary sector partners to build social capital, mobilise community assets and adopt place-based approaches to create inclusive, compassionate age- and dementia-friendly communities.

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