The challenge of ageing populations and patient frailty: can primary care adapt?

Dr Fiskin makes an important point about not perpetuating stereotypes and stigma through inappropriate use of imagery to illustrate articles - we hope the BMJ design department takes note .

Although we did not have a patient as an author on our paper - which is an important omission on our part - we do summarise research based on interviews with frail people themselves in the article, and one of the BMJ peer-reviewers of our manuscript was a lay person living with frailty; their peer review can be accessed on this page. Our further work on the eFI is also being informed by the involvement of Public and Patient Involvement groups at our various institutions. Stigma concerns are very important to these groups, but so also is neglect of personal and social capacity issues (see the peer review), which we could not expand further on within the allotted word count.

It recent years, all countries are active in a resourceful search to find out healthier ways of establishing and supporting the health care system to deliver better health care. There are many models to deliver better geriatric care. The most common models for healthcare delivery are Privatization and liberalization. Why? Because healthcare delivery requires huge funding.

It is commonly observed that elderly people with psychosomatic illnesses often experience great levels of stress, which requires not only instrument support but also socioeconomic support. The most common manifestations which overwhelm them are Stroke, Cancer, Alzheimer’s, and Type 2 Diabetes with complications, arthropathies, etc. and their management. So here corporate social responsibility is one of the better models we focus on.

The corporation is an idea of responsibility without substance (1). It is mainly achieved by privatization of funding agencies and shifting accountability of care delivery from central to decentralized. Government has a responsibility to actively implement corporate social responsibility by allowing these organizations to bear the high cost of treatment, diagnostics, counseling, taking care of family members' psychological health as they are the first ones to have to deal with the problem. (2) In the US, agencies like the National Alliance for Caregiving (NAC) and the American Association of Retired Persons (AARP, 2004 ) delivers family caregiving services (3).

And if we go through the case study of China, China is renovating its elderly care by making it a subsidized system. (4)

So it is right for government agencies to think about proper utilization of corporate social funding for the betterment of geriatric health outcome and to reduce the rate of patient frailty.

References:

1. McMillan JJ. Why corporate social responsibility. The debate over corporate social responsibility. 2007 Apr 19:15-29.
2. Player S, Pollock AM. Long-term care: from public responsibility to private good. Critical Social Policy. 2001 May;21(2):231-55.
3. National Alliance for Caregiving. Caregiving in the US. AARP; Bethesda, MD: The National Alliance for Caregiving; 2005.
4. Woo J, Kwok T, Sze FK, Yuan HJ. Aging in China: health and social consequences and responses. International Journal of Epidemiology. 2002 Aug 1;31(4):772-5.

I felt that the analysis offered by David Reeves and colleagues (2018) is probably most dangerous for what it did not say rather what it did in the end say (1).

Let’s take one of the chief problems of their whole analysis first. At a recent King’s Fund event this year “Reimagining general practice” (https://www.kingsfund.org.uk/events/reimagining-general-practice), the RCGP’s own current Chair Dr Helen Stokes-Lampard confirmed that Allied Health Professionals (“AHPs”) will be “essential to the future of the NHS and GPs”. This meeting indeed ended up discussing the idea that general practices need teams of healthcare professionals working collaboratively to meet the challenges the sector is increasingly facing (2). So why did AHPs end up missing in action in this BMJ piece? The authors’ “analysis” did not discuss the role of AHPs in primary care at all (1), and this is a glaring omission. We actually know that allied health professionals are already having a marked beneficial effect on the delivery of frailty services in primary care. For example, a “FAB team” consisting of therapists, dietitians, pharmacists, specialist nurses and a specialist doctor at Ipswich Hospital has shown that an integrated team operating within a clear framework, and with clear objectives, can improve patient experience, reduce admissions and increase the whole system’s ability to manage frailty (3).

Resource allocation, and whether there’s enough money within primary care for frailty at all, was conveniently ignored as a topic for discussion. Penrose’s (1959) seminal work helped to establish a fundamental idea that the way people in a firm employ resources, and not just the nature of the resources, effects the success of the firm; “the services yielded by resources are a function of the way in which they are used” (Penrose, 1959: 25) (4). The comment that “the 2017 GMS contract for England introduced a new requirement for general practices to identify and appropriately manage all patients aged 65 or over with moderate or severe frailty”, made in the article (1), belies a crucial assumption that all people identified as frail using the electronic frailty index (“eFI”) actually turn out to be frail through clinical assessment. This needs decent funding.

The article comprehensively dodged the wider issue of whether resource allocation in primary care is sufficient at all, given the current ‘spending packet’ (1). The nuanced and sophisticated arguments on resource allocation, for example in addressing health inequalities, in primary care were simply not addressed at all. For example, the current health inequalities approach to resource allocation Is reported as being part of a wider strategy to reduce inequalities in health in England (5). As the frailty literature currently stands, there is already preliminary evidence that frailty is, in general, associated with social determinants and several quality of life domains, such as from the VERISAÚDE study (6). But the whole frailty literature also tells us that “frailty” does not just exist in the physical domain – it exists in social, cognitive, emotional and psychological domains, for example, and this is clearly relevant if you wish to tout that a tool based on physical frailty only, the electronic frailty index, represents “the whole person”.

It is true that several instruments have been developed to assess various domains of functional performance such as motor strength, mobility and balance (7). But the article makes somewhat flippant use of the word ‘case screening’ by the authors and this is undeniably problematic, whatever your precise views about the Wilson and Jungner WHO criteria – there is no reliable intervention, the ‘screening test’ do not meaningfully have any sensitivity or specificity in the absence of a gold standard, the tests are not necessarily cost effective, and so on. It is impossible to see how the mechanics of screening for frailty would satisfy the rigorous criteria of the UK National Screening Programme, for example. It is not screening – it is backdoor case-finding.

The BMA argument that GP work will not “increase overall bureaucratic burden” is indeed supported by the notion that calculation of electronic frailty indices can be automated from the summary care records, so easily it created a furore over “batch coding” (8). And the additional BMA argument also quoted in the article (1) that frailty work will not “undermine professional autonomy” raises serious questions about the cultural willingness of general practitioners to work with others, e.g. AHPs, in the delivery of integrated services. The genuine possibility remains that the eFI, rather than “manage” demand in primary care, could substantially stoke up demand in an uncontrollable way.

We already know from the excellent previously published work by Andy Clegg and colleagues that the calculation of the eFI comprises only deficits, and it has never been adequately addressed in my opinion why the frailty index does not merely represent a co-morbidity index. This is actually a huge deal. Assets or resilience do not appear in the calculation in any sense at all. We know that the complexity of comorbidities is a hallmark of frailty, as the authors themselves admit. The article, most dramatically, and for me completely unacceptably, makes no reference to assets or resilience. Focusing on physical deficits, such as loss of muscle bulk or bone strength, means insufficient attention is being paid to the existence of “health assets”. Surely a goal of primary care is health promotion or prevention of deterioration in frailty of patients? There was a minor sop to the case for assets and resilience which I with others have been arguing vehemently.

Above all, my biggest criticism of the whole piece is that I do feel strongly that resilience and “intrinsic capacity” are both absolutely fundamental to the whole discussion about frailty and “healthy ageing”. This approach can be understood by framing underlying physiological principles contributing to normal homeostatic or homeostenotic balance in the face of intrinsic and extrinsic stressors (9). This is even relevant if you take the narrow perspective of ‘avoidable admissions’ as the ultimate panacea. Put simply, the less resilient you are, the less likely you will be in bouncing back from minor shocks. We know intuitively from clinical experience that two patients with identical eFI scores can have markedly different trajectories, according to, for example, extent and utilisation of networks such as social networks or community resources such as housing and transport. This argument, articulated elsewhere by me (10), was simply missing from the analysis. I agree wholeheartedly that the frailty label, whether we like it or not, also carries substantial stigma for many people through association with loss of independence, and can deter people from seeking support or make them fear being denied sought after care. This is of practical issue in the adoption of self-management, and is not merely a vexatious academic quibble. I myself have made this argument in the Guardian (11) in urging for an approach which can harness assets and resilience in the frailty arena, which must include primary care. We have to think carefully whether X will realistically want to say to her friend Y in a proud voice,“I’m going to frailty clinic at my local GP this morning”.

In summary, I feel because the authors’ journey map for frailty in primary care is rendered unreliable due to missing destinations. But it does at least show what sort of terrain we might be up against. I genuinely thank them for their contribution, but it was as a whole extremely disappointing.

References

(1) Reeves D, Pye S, Ashcroft DM, Clegg A, Kontopantelis E, Blakeman T, van Marwijk H. The challenge of ageing populations and patient frailty: can primary care adapt? BMJ. 2018 Aug 28;362:k3349. doi: 10.1136/bmj.k3349.
(2) “Allied health professionals will prove vital to GPs”, http://practicebusiness.co.uk/allied-health-professionals-will-prove-vit... (accessed 31 August 2018)
(3) NHS England (2018). Allied health professions supporting patient flow: a quick guide, https://improvement.nhs.uk/documents/2485/AHPs_supporting_patient_flow_F... (accessed 31 August 2018)
(4) Penrose, E. T. 1959. The Theory of the Growth of the Firm, New York, John wiley.

(5) Barr B, Bambra C, Whitehead M. The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study. BMJ. 2014 May 27;348:g3231. doi: 10.1136/bmj.g3231.
(6) de Labra C, Maseda A, Lorenzo-López L, López-López R, Buján A, Rodríguez-Villamil JL, Millán-Calenti JC. Social factors and quality of life aspects on frailty syndrome in community-dwelling older adults: the VERISAÚDE study. BMC Geriatr. 2018 Mar 7;18(1):66. doi: 10.1186/s12877-018-0757-8.
(7) Diez-Ruiz A, Bueno-Errandonea A, Nuñez-Barrio J, Sanchez-Martín I, Vrotsou K, Vergara I. Factors associated with frailty in primary care: a prospective cohort study. BMC Geriatr. 2016 Apr 28;16:91. doi: 10.1186/s12877-016-0263-9
(8) Modsen, M. Mass diagnosing frailty does not meet contract requirements, GPs warned, 15 September 2017, Pulse magazine, http://www.pulsetoday.co.uk/news/clinical-news/mass-diagnosing-frailty-d... (accessed 31 August 2018)
(9) Kuchel GA. Frailty and Resilience as Outcome Measures in Clinical Trials and Geriatric Care: Are We Getting Any Closer? J Am Geriatr Soc. 2018 Aug 9. doi: 10.1111/jgs.15441. [Epub ahead of print].
(10) Rahman, S. (2019) Living with frailty: from assets and deficits to resilience, Oxford: Routledge Books.
(11) Rahman, S. (2011) Let's fight the stigma around ageing and frailty, Guardian, https://www.theguardian.com/social-care-network/2017/sep/01/frail-older-... (accessed 31 August 2018)

The new article by David Reeves and colleagues is a thoughtful analysis of the challenges and opportunities of routine frailty identification and frailty management in the UK primary care settings [1].

The question posed by the authors (“can primary care adapt?”) inevitably brings up a mirroring question – can the concept of “frailty”, however we agree to define it, adapt to primary care? And if yes, what are the tensions which need to be resolved, or at least minimised?

According to the 2017/2018 GP Contract by the NHS England [2], potential frailty should be identified in all patients aged 65 and over using the electronic frailty index (eFI) or another validated tool. “Clinical judgment to confirm or… give further consideration to the tool result” should be used for those with potential moderate or severe frailty. Finally, for those living with severe frailty, action should be taken, including an annual medication review, a falls risk assessment, and seeking informed patient consent to activate the enriched Summary Care Record (SCR).

The “clinical judgement” step is crucial, as simply counting the number of eFI-comprising deficits (out of potential 36) will result in overestimation among those registered with the practice for longer, as Figure 1 in the paper by Reeves et al. [1] clearly shows. On the other hand, frailty will be underestimated in those with limited opportunities to have eFI deficits registered in their primary care electronic health record (due to frequent transfer between practices, limited contact with primary care services, and a multitude of other reasons).

It is encouraging to see that the eFI-defined prevalence of severe and moderate frailty appears very similar across three primary care research databases: 3% and 12% in ResearchOne [3], 4% and 16% in THIN (The Health Improvement Network) [3], and 3% and 10% in CPRD (Clinical Practice Research Datalink) [1], respectively.

However, these reassuringly similar findings provide minimal indication of the proportion of patients who would be diagnosed with severe or moderate frailty after a clinical assessment. Hopefully, this issue is being addressed in the ongoing eFI improvement work by Dr Reeves and colleagues [1].

The scope and scale of the gap between eFI-defined and clinically validated frailty is confirmed by the NHS Digital data for the GP Contract Services for England, 2017/2018 [4]. The recent analysis of these data [5] optimistically emphasizes the rapidly increasing levels of frailty reporting across GP practices.

However, a closer look at the data suggests that this rapid increase occurred mostly in the last quarter of the reporting period. It raises a question whether GP practices interpret frailty reporting as yet another performance management exercise, and do not appear confident in the NHS England promise of not using these data “for performance management or benchmarking purposes” [2].

Even if we concentrate on the aggregate data for all quarters of the reporting period (April 1st 2017 – March 31st 2018), as presented in the recent report [5], multiple problems are obvious. In England overall, the proportion of people aged 65+ who have had a frailty assessment is far from the target 100% level (mean 26%, median 13%).

The proportion of people with a diagnosis of moderate or severe frailty (mean 9%, median 5%) [5] is lower than the eFI-defined proportions in SystemOne (15%) [3], THIN (20%) [3], or CPRD (13%) [1]. It could be due to the fact that after clinical assessment, the “false positive” cases of moderate or severe frailty are dropped. However, the ratios of moderate to severe frailty could be expected to be similar for the eFI-defined levels (3.8-4.0) [1, 3] and for the clinically confirmed levels of frailty. The latter ratio is considerably lower (mean 2.0, median 1.8) [5], which suggests either under-diagnosis of moderate frailty, or over-diagnosis of severe frailty, or both.

Among the indicators reflecting frailty management, the highest levels are reported for the proportion of severely frail patients who have received annual medication review (mean 66%, median 71%) [5]. This is not surprising, as regular medicines reviews are also required by the NICE (National Institute for Health and Clinical Excellence) guidelines, such as those on clinical assessment and management of multimorbidity [6] and older people with social care needs and multiple long-term conditions [7].

Of note, there is a discrepancy between some frailty care indicators (falls risk assessment, falls clinic referral, and seeking consent to activate SCR) originally outlined in the NHS England guidance on frailty and those collected and reported by the NHS Digital. While the former focus on people with severe frailty [2], the latter refer to both moderately and severely frail patients [4]. This discrepancy and potential misinterpretation could have negatively affected the reported levels of frailty care.

For example, the proportion of moderately or severely frail people who have had a fall in the past 12 months (mean 11%, median 9%) [5] is substantially lower than that suggested by the NICE guidelines on falls in older people (“…30% of people older than 65… falling at least once a year”) [8]. Only 25% (median 17%) of people with moderate or severe frailty and a recent fall are referred to a falls clinic [5]. The extremely wide range for the falls clinic referral (0-2300%) suggests that the indicator is misinterpreted. Finally, the consent to activate the enriched SCR has been obtained for only a fraction of moderately or severely frail people (mean 15%, median 5%).

The evidence from the NHS Digital 2017/2018 GP Contact dataset suggests a limited engagement of primary care with the currently used frailty indicators. It is encouraging to hear that Dr Reeves and his colleagues involve GPs in their ongoing work on eFI improvement [1]. Only with active engagement of clinicians and patients can we achieve the integration of frailty identification and management into primary care practice.

Time will tell whether the use of a revised eFI, or an equivalent new screening tool, can translate into the primary care buy-in, as reflected in the frailty indicators across all levels of reporting, improved health outcomes, and reduced professional burden.

REFERENCES
[1] Reeves D, Pye S, Ashcroft DM, Clegg A, Kontopantelis E, Blakeman T, van Marwijk. The challenge of ageing populations and patient frailty: can primary care adapt? BMJ 2018; 362:k3349.
[2] NHS England. Updated guidance on supporting routine frailty identification and frailty care through the GP Contract 2017/2018. 2017. Available at: https://www.england.nhs.uk/wp-content/uploads/2017/04/supporting-guidanc...
[3] Clegg A, Bates C, Young J, Ryan R, Nichols L, Teale EA, Mohammed MA, Parry J, Marshall T. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing 2016;358:353-60.
[4] NHS Digital GP Contract Services, England, 2017-18. 2018. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/gp-...
[5] Seymour D. One small step for older people with frailty, one giant leap for frailty care? An analysis of GP Contract Services data for routine frailty identification and frailty care through the GP Contract 2017/2018. 2018. Available at: http://fusion48.net/uploads/documents/Giant_leap_for_frailty_care_-_main...
[6] National Institute for Health and Clinical Excellence. Multimorbidity: clinical assessment and management (NICE guideline NG56). 2016. Available at: https://www.nice.org.uk/guidance/ng56
[7] National Institute for Health and Clinical Excellence. Older people with social care needs and multiple long-term conditions (NICE guideline NG22). 2015. Available at: https://www.nice.org.uk/guidance/ng22
[8] National Institute for Health and Clinical Excellence. Falls in older people: assessing risk and prevention (NICE guideline NG161). 2013. Available at: https://www.nice.org.uk/guidance/cg161