The first challenge in talking about frailty is deciding exactly what it means. This was how one person responded to finding the word on their wife’s notes:
‘A few years ago my wife got discharged from hospital. The report said “a frail old lady of 88”. I said "this is lies"! She’s got more willpower and determination in her body than anybody I ever knew!’
I imagine such a reaction is not unusual.
At the root of caring for older people living with frailty is a question that should be at the core of how care services operate: how can we achieve the best possible quality of life for an individual?
Such a question should seek to bypass the features that typically define healthcare: curing; repairing; treatment. These are all vital processes, but they’re simply a means to an end.
To return someone who has broken their leg to the best possible quality of life, you first need to address the injury. You may then have to give them painkillers and a course of physio. All being well, their leg will once again be strong enough to walk on and they can carry on with their lives.
Now imagine someone living with a combination of conditions and ailments that add up to a frail state. They may have difficulty walking because of arthritis and a fear of falling. They may be under-nourished because they can’t make a meal and because they’re uncertain about what they can eat because of their diabetes.
Imagine someone with COPD who gets out of breath doing basic tasks. They may get a skin ulcer from sitting in a chair all day which then becomes infected and, because a once-a-day carer is their only regular company, they may become increasingly depressed.
In both these cases, the person’s physical reserves would be very low – a crisis now could be catastrophic or, at the very least, would increase their care needs in an instant.
So what does a good response look like? On a basic level, it starts with someone taking a broad overview of their needs. Needs that are properly assessed, understood and communicated to the people involved in their care.
We know health and social care struggles with this kind of approach. A highly siloed approach, dominated by large care settings such as hospitals, does not fit the brief for sustained, coordinated care across multiple disciplines.
There is also a huge divide in professional culture between the NHS and social care services, and massive gaps in training in older people’s care. That older people continue to be the subject of major reports into care failures is, sadly, of little surprise.
Good practice means looking outside of traditional care settings to options such as community-based falls prevention, self-management training, befriending or day care centres.
With these types of intervention, the person is not seen as the recipient of care but the lead partner. Health and social care services work together to plan how they can avoid admissions to hospital, not just for the sake of it, but because admission would typically indicate that the individual has reached an often avoidable crisis point.
And this is not just about older people. Imagine that person earlier with the broken leg is unemployed, also lives with diabetes, has poor living conditions and mental health needs...if we can get it right for older people, we can get it right for everyone.
There is much to indicate that the health sector understands these messages. Just in the last few months, the Department of Health’s vulnerable older people plan and the Royal College of Physicians’ Future Hospital Commission have outlined how the NHS struggles to meet the needs of older people.
In combination, the two publications set some vital challenges for the NHS: strengthening primary care to truly support frail older people at home and then ensuring that if they do need hospital care, it is fit for purpose.
One way Age UK is helping to address some of these issues is through a pilot project in Cornwall that brings together the voluntary sector with multi-disciplinary teams to plan and coordinate care around the individual.
The approach is rooted in establishing goals that are relevant and important to each person. Looking across all of the potential services that could help to meet these goals helps to eliminate the bias towards health care and instead places it in its proper context – as a component of a plan to improve wellbeing.
Because what better achievement could there be from public services than resolving what on paper could be such a bleak existence?
Tom is Chief Executive of Age UK.