Primary care is doing things differently for people living with frailty

sarahdebiase01by Sarah De-Biase
Improvement Programme Manager
Yorkshire & Humber AHSN’s Improvement Academy Healthy Ageing Collaborative

It’s no secret that more and more of us are living longer – but an increase in life expectancy does not necessarily mean that we are living well.

As we age, we become more vulnerable to the adverse effects of age related change. One in ten of us over the age of 65 years are likely to be living with frailty. This number rises to between a quarter and a half of people aged over 85 years.

Frailty is a distinctive health state in which even a minor event can trigger major consequences – the person may not fully recover, leaving them at risk of a loss of independence and needing increased support and more frequent hospitalisation.

People living with frailty are more likely to be greater users of health and social care services and frequently, they need to move between services and organisations. This can result in care that is poorly co-ordinated, fragmented and therefore not person-centred.

The growing pressures on NHS and social care services mean it is more and more important for people living with frailty to be supported to manage their health and wellbeing. Early diagnosis of frailty in primary care and proactive preventative interventions have the potential to keep people with frailty living at home independently and reduce reliance on health and social care resources.

This week the Yorkshire & Humber AHSN is receiving an award on behalf of the entire region after it was awarded ‘Reference Site’ status and a three-star rating for the European Innovation Partnership on Active and Healthy Ageing. This is the second time we have received this award in recognition of the area’s innovative and comprehensive approach to healthy ageing and its impact on patients’ health.

A key part of this success has been the introduction of the electronic Frailty Index (eFI) in primary care across the region. The eFI is an innovative tool that uses routine GP data to identify older people with mild, moderate and severe frailty. Primary care clinicians are using the eFI to proactively identify and diagnose frailty so that individually tailored, interventions and/or care pathways can be delivered for this vulnerable population.

For example:

  • A GP practice in NHS Bradford District CCG is providing self-management support to patients with mild frailty delivered by an Age UK Coordinator and trained Age UK volunteers.
  • NHS Harrogate and Rural Districts CCG aims to reduce inappropriate prescribing and prevent medication errors for older people living with frailty by offering evidence based medication reviews.
  • Practice nurses are visiting patients at risk of frailty in their own homes to offer a holistic assessment and co-produce care plans in NHS Hambleton, Richmondshire and Whitby (HRW) CCG.
  • North West London CCG is offering proactive care for patients at risk of frailty via community based integrated care teams.

The eFI has also been awarded the Healthcare IT Product Innovation category at the EHI Live 2016 Awards as well as being recommended within the recently published NICE Multimorbidity guideline

What is working for people with frailty in primary care – key learning

The learning from these initiatives is helping other primary care teams and CCGs to develop new ways of working for people living with frailty that is underpinned by evidence and considers the challenges of providing care for a complex population in a complex health and care system.

We are beginning to see early signs that identifying people at risk of frailty can lead to improved outcomes in primary care. For example, in the NHS HRW CCG project, patients in the moderate and severe frailty eFI categories were more likely to receive a frailty diagnosis and have health and care needs identified using a comprehensive geriatric assessment approach.

But new ways of working in primary care need to be considered in the context of the wider system. Changes in the way frailty care is provided in primary care could have repercussions in other parts of the frailty care pathway. If more people are identified to have a frailty diagnosis and further needs be identified on assessment, there may be an increase in demand for other services such as falls services, memory services and/secondary care specialist clinics. It makes sense for GP practices to work closely with CCGs and integrated care colleagues when implementing new ways of working.

The eFI is helping GPs and commissioners make a real difference to the care pathways for people living with frailty by enabling early diagnosis and timely intervention. The learning from the Healthy Ageing Collaborative is adding to the understanding of what does and what doesn’t work but more quantitative data is needed to build confidence and demonstrate impact. It is important that efforts continue to be made to share the learning if we are to build momentum and achieve more proactive care for people living with frailty in primary care and truly offer person centred care.

If you would like more information on any of the above, please contact or visit our Healthy Ageing webpage