Re: The challenge of ageing populations and patient frailty: can primary care adapt?
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)
Competing interests:
No competing interests
31 August 2018
Shibley Rahman
Academic physician and researcher in frailty and dementia
International fellow, England Centre for Practice Development
Faculty of Health and Wellbeing, Canterbury Christ Church University, North Holmes Road, Canterbury CT1 1QU.
Rapid Response:
Re: The challenge of ageing populations and patient frailty: can primary care adapt?
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)
Competing interests: No competing interests