Email your comments

Frailty is a complex multiple system decline characterised by instability in the presence of an environmental stress.

Recent thinking emphasises the advantages of timely comprehensive multidisciplinary assessment, either allowing early intervention, which maintains patients in a community setting or alternatively, reducing length of hospitalisation and expediting discharge. Patients themselves prefer this and while it does sometimes mean greater risk in the community, this should be acceptable if it is based on an informed decision taken by the patient.

It may be opportune to base the method of commissioning health care in this group on care pathways derived from the frailty concept. This will complement contemporary work into chronic conditions management, intermediate care and the co-morbidity syndromes and disability encountered in the elderly.

Potential risks
Work done by Kaiser Permanente in the United States has grouped potential patients into a relatively stable base population at which health maintenance and prevention can be directed. This is overlaid by a more vulnerable group with chronic disease and disability, who are at risk of destabilisation and finally, a smaller group who are defined as frail and who for the most part are either institutionalised or who require high community care input. Frailty is in fact a marker of dependency risk.

The level of assessment and intervention should increase from surveillance of the stable to targeted intervention, treatment and if needed, institutionalisation of the very dependent. This will require simple assessment tools useable by unskilled workers for case finding, which could feed into rapid response assessment and community intervention. Hospitalisation or care home placement would be the final stage and only after all other interventions were exhausted.

An integrated approach
Elderly services in Gwent are developing such a model, which cuts across divisions between health and social services and primary and secondary care. This is supervised by programme organisers and is overseen by a multidisciplinary board with representatives from health, social services and the voluntary sector. The service is jointly run by health and social services and has a joint budget. There is a single point of referral and a rapid response time in hours. There are links with A&E, Medical Admissions Unit and integration with out of hours, intermediate care and 24 hour community nursing services. Input is limited to a maximum of 14 days and is community based. Discharge is to the GP. There is a community hospital facility with inpatients and a virtual hospital of patients in their own homes. This is supported by a daily virtual ward round, multidisciplinary meetings and hot clinics. Future plans will shape the hospital community pathway and elderly medical social care workforce to support this model.

I would like to acknowledge that this paper is based on presentations by Sinead O’Mahony, Ed Wilkins and Pradeep Khanna

Anthony White
Consultant Physician in Elderly Care
North Wales NHS Trust

BGS Newsletter, May 2009
Issue 21 ISSN 1748-6343 21