Health CommitteeSupplementary follow up written evidence from NHS England (LTC0116)

I gave oral evidence to the House of Commons Health Committee hearing on Management of Long Term Conditions on 12 November 2013. During that session I offered to send the committee a note on the definition of frailty in patients. The National Clinical Director for Integration and Frailty, John Young, has kindly drafted a note. That note is attached.

NHS England will be continuing to work to ensure that there is greater understanding of the nature and importance of frailty and ways of addressing it proactively.

Description of Frailty

Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. This means the person is vulnerable to dramatic, sudden changes in health triggered by seemingly small events such as a minor infection or a change in medication. A person with frailty therefore typically presents in crisis with the “classic” frailty syndromes of delirium (acute confusion); sudden immobility (stuck in a chair or in bed); or a fall (and subsequent unsafe walking). There is a strong evidence base that rapid (within two hours) medical assessment, followed by specific treatment and a period of supportive and rehabilitation care, is associated with improved outcomes (lower mortality; greater independence; and reduced need for long-term care). Much of this urgent care response to frailty is currently done in hospitals by Geriatric Medicine departments (Geriatric Medicine is now the largest medical speciality in England). For example, there are over 640,000 hospital admissions for older people with frailty related falls each year. Increasingly, crisis assessment and management of older people with frailty is being done in the person’s home (“admission avoidance”). This requires the provision of dedicated, well led, multi-disciplinary community teams.

Frailty develops slowly over five to 10 years: so could more be done to help older people with frailty before a health crisis occurs? Older people with frailty can be readily identified and are usually well known to local health and social care professionals. They usually have weak muscles and also often have other conditions like arthritis, poor eyesight, deafness and memory problems. This means that frail older people typically walk slowly, get exhausted easily and struggle to get out of a chair or climb stairs. They are therefore more likely to become dependent on others for day-to-day cares and are at higher risk of future admission to a care home. At present, however, we do not formally “diagnose” frailty or identify it with a specific “code”. This means systematic case finding and proactive care is difficult. Slow walking speed is a simple test that could readily help identify people who are frail. Taking more than 5 seconds to walk 4 metres is highly indicative of frailty. The primary care electronic health record contains large amounts of health data from which selected existing items could be readily brought together to form a “Frailty Index” to identify the sub-group of older people who have frailty, and to grade the frailty state. This would allow a structured self-management plan for people with mild/moderate frailty and case management (multi-disciplinary assessment and individualised care planning) for people with moderate/severe frailty.

5 December 2013

Prepared 3rd July 2014