14 February 2020
Martin qualified in 1988 in Manchester. He trained as a Geriatrician in North West England and London and has been a consultant geriatrician in Manchester since 1999. He has a MA in Medical Ethics and Law from King’s College London which he teaches at Salford University and is a visiting Professor at the University of Chester, with academic interests in frailty and population health. Between 2016 and 2019 Martin was the National Clinical Director (NCD) for Older People at NHS England and Improvement, leading in 2017 on national implementation of routine frailty identification in general practice and in 2019 on developing the national NHS Ageing Well Programme.
Finding the right population ageing narrative to both inform and influence wider NHS and social care policy has until now proven stubbornly difficult. Thankfully all of this is now beginning to change as understanding of clinical frailty grows steadily across the country. Over three years as National Clinical Director for Older People at NHS England I campaigned alongside colleagues across multiple sectors to raise the national profile of frailty as a long-term condition which can be recognised, treated and potentially prevented both among populations and in individuals.
So why is clinical frailty so important? Technically it is characterised as a personal state of increased vulnerability to stressors (such as illness or accident), caused by the accumulation of age and disease related deficits. Put simply, the more that things go wrong with our health and functional abilities, the more likely we are to get into difficulty when physically challenged by something new. In its early stages we might be simply slowing up, but when advanced we will have accumulated greater risk of hospital admission, needing social care or death. Think about an older relative, neighbour or friend, apparently doing well in life, who has suddenly and unexpectedly deteriorated after a relatively minor illness. You get the picture.
Crucially clinical frailty is not an inevitable consequence of ageing, nor is it confined to older people, but with relative ease we can both recognise and manage the condition as it evolves in individuals and populations. Being linked to socioeconomic inequalities is also gives us the best opportunity yet to better understand and address ageing inequality in communities and across the country.
In July 2017 England became the first country in the world to commence routine national frailty identification among people aged 65 and over via a new general practice contract. This deployed the electronic frailty index (eFI) to segment general practice patient populations by risk of frailty and to directly validate frailty status clinically before encoding a diagnosis of either moderate or severe frailty. Within the first year over 2.5 million people aged 65 and over living in England had received a frailty assessment, which led to 950,000 clinically confirmed diagnoses of either moderate or severe frailty. Around two-thirds of the 320,000 people diagnosed with severe frailty had undergone falls risk identification or medications review. Modest achievements for older individuals perhaps, but the policy implications and opportunities created by this work, if fully realised have potential to be game changing.
The attractiveness of frailty as a unifying theme has been striking, none more so than in the work co-ordinated by the Wessex AHSN Healthy Ageing Programme, with frailty experts from across Wessex where colleagues have been working diligently with common purpose to raise standards of care for older people living with frailty. With the fastest growing older population in the UK, Wessex has been one of the most progressive areas in responding positively to the national frailty challenge, creatively using key data to answer important questions focused on identifying how many people living with the condition are being treated in local hospitals, where are they being treated, and to what standards. By drawing attention to the importance of answering these questions, Wessex has sought to reduce unintended variation in care and focus resources where they are needed. Aligned with new NHS policy these approaches will, in due course assist in promoting healthier ageing and raise the quality of care for older people across the region.
There is much to be getting on with. Increasingly we know how best to assess and intervene positively to better support people as they grow older with frailty and need acute or planned health care. But so far much of this work has been undertaken and evaluated only in hospital-based settings. Challenges now lie ahead in ensuring that research, innovation and service quality improvement develop, spread and integrate closely with other sectors and domains of care for older people. This means extending the proven skills and capabilities of clinicians with expertise in the care of older people well beyond their traditional origins in secondary care and into primary, community and social care. This skill set can no longer afford to be siloed in hospitals.
Important health policy changes continue to present opportunities to do this following recent publication of the UK Government Industrial Strategy Grand Challenges, Public Health England Healthy Ageing Consensus Statement and NHS England Long Term Plan in early 2019. As NCD I was privileged to lead the development of Ageing Well, a key new funded national programme set out within the plan, specifically designed to better support older people to live healthier lives in their communities. The programme comprises three main policy areas: 1) supporting older people living with complex conditions including frailty to age well; 2) enhancing healthcare support in care homes; and 3) increasing the capacity and responsiveness of community intermediate care services to deliver into people’s homes, crisis responses within 2 hours and reablement or rehabilitation within 2 days of need being identified.
Soon after publication of the NHS Long Term Plan, NHS England also published a new general practice contract which includes a funded enhanced general practice service element. Through a series of new service specifications this seeks to bring community and primary care services together in England to deliver integrated care within primary care networks . This is very much work in progress but sets important new directions for supporting service integration in communities to better meet the needs of older people with frailty.
We are still in the foothills, but importantly the frailty narrative has, in the last few years, achieved significant NHS policy traction in beginning to tackle the unwarranted impacts of population ageing from a completely new direction. The importance of this should not be underestimated, because it starts to address a phenomenon regarded previously as intractable and inevitable. Until now the absence of a credible plan to address population ageing has rendered policy makers ineffective and more importantly disempowered public services and people living in their communities. At last this is now beginning to change and colleagues in Wessex have much to be proud of, having been in the vanguard of this change.