Frailty can have a significant impact on a person’s life, removing them from the comforts of their own home, their community and their family, while also causing strain on the NHS. Healthcare Improvement Scotland runs a national improvement collaborative that aims to improve identification and support for people living with frailty. Our National Clinical Lead for Frailty, Dr Lara Mitchell, shares her thoughts on what we can do to improve care in older life.
Right now, we are making decisions that will affect our future, older selves. We may not know it, but things we do today will affect how we grow old, what choices we are able to make and how we live. As we age, many of us may become frail, at least to some degree – whether it’s through a loss of mobility, a fall, confusion, or the worsening of an existing condition like dementia. As a result, frailty reduces our mental and physical resilience to bounce back from acute events, which in turn can have a profound effect on our later years.
Having worked as a consultant in Medicine for the Elderly for 20 years, and now in my role as National Clinical Lead for Frailty with Healthcare Improvement Scotland, I have seen first-hand the impact that frailty can have on a person’s life. I believe that if we take a proactive approach to frailty, making sure that people can make informed choices and promoting their sense of agency to make active decisions about their care, we will be able to not only improve peoples’ lives and alleviate some of the pressures currently placed on the NHS, but also make Scotland the best place in which to grow old.
What is frailty and why does it matter?
I think it is important to firstly understand what frailty is not. It is not age and it is not a disability, and that is an important distinction to make. Instead, it is the marriage of a person’s age-related decline with their physiological reserve. While frailty is not inevitable, its impact cannot be underestimated – 50% of people over the age of 85 will live with frailty, while 10% of those over the age of 65 are already frail. It is, however, potentially reversible, especially in the early stages, which is why it is so important that as clinicians in Scotland we look towards identifying frailty as early as possible, and then work with our patients to prevent it from developing further.
When people become frail there can be a loss of control and a feeling that things often happen ‘to them’ such as care packages or a hospital admission. We need to pay attention to our older adults, giving them a sense of control and dignity in the care they receive. On a recent trip to Sweden I learnt of a term that I think encapsulates this – arsrika – which means ‘rich in years’. This concept represents the richness of experience and knowledge that comes in later life, without the loss of dignity, which is really at the core of what we are hoping to achieve.
What are we doing about it?
We are making great strides in identifying the early signs of frailty, which is essential when it comes to addressing its main causes and working towards early intervention and prevention. As clinicians, we have a selection of tools available to us when it comes to assessing frailty. There is the electronic frailty index, which is used in primary care and which is a great signpost for general practitioners about which of their patients are likely to become frail. This is then further contextualised by the clinical frailty scale, a Canadian tool used in both primary and secondary care, to help identify whether the frailty is mild, moderate or severe. Then of course, there is the Comprehensive Geriatric Assessment (CGA), a holistic and evidence-based assessment of a person’s medical, functional, social and psychological needs. This involves a host of professionals assessing the patient to establish what can be done to help, what their needs are and most of all, which involves the patient and their family in the process. It’s a whole-team approach looking at a range of interventions all of which are aimed at improving a person’s life, often in significant and remarkable ways.
At Healthcare Improvement Scotland we are really excited to draw on the learning from our community and acute care programmes of work – we’ve co-designed an improvement change package, which is integrated in approach, spanning health and social care. This package of best practice will form the basis for the ihub Frailty Improvement and Implementation Programme launching in spring 2023, which will provide an opportunity for teams across acute hospitals, health and social care partnerships and primary care to be part of a national improvement and implementation programme. The aim of this is for people living with, or at risk of, frailty to experience improved access to person-centred, co-ordinated health and social care.
What can we do to improve right now?
If we truly want to make sustainable changes for the better of older people, we need to create an environment where we can continually evolve and improve and I believe that this starts and ends with understanding what is important to our patients. I know from my own experience that people are unique and have their own set of priorities, but the one thing that I see come up again and again is that people want to stay at home and want to be with their families. It is only by being attuned to this and listening to our patient’s needs, will we be able to make interventions that have a positive and significant impact on their lives.
Continuous improvement is like exercise, we know it’s good for us, but we need to commit to making it happen. Given current pressures within the NHS this seems like an almost impossible task especially during the challenges of winter. However, if we value and use the strengths in our talented multi-disciplinary teams we can improve patient care and satisfaction, our culture, staff engagement and service quality. Let’s work together to make healthcare better for our future selves.
Dr Lara Mitchell has been a Consultant in Medicine for the Elderly for 20 years and is the current National Clinical Frailty Lead for Healthcare Improvement Scotland.
We are currently accepting applications to join the Focus on Frailty programme until Friday 28 April 2023 at 17.00.