As part of the 2017/18 contract agreement the Avoiding Unplanned Admissions DES was ended. There will now be a contractual requirement to focus on the identification and management of patients living with frailty. This guidance sets out what practices should do to fulfil these requirements.
A recognition that a patient has a degree of frailty can prompt a clinician to review the care offered to their patient, to make sure that it is tailored to their needs, and to be mindful of the risks of polypharmacy and inappropriate treatment. It can also help in the planning and delivery of services, particularly for older people.
Many of the studies showing benefits from preventive interventions, particularly with drugs, excluded those with frailty from their study group. Thoughtful use of exception reporting for QOF domains should be encouraged.
There is sometimes confusion between three concepts; multi-morbidity, frailty, and disability. Patients may have any combination of these states, and this guidance refers to frailty only. The Royal College of Physicians talks about the phenotype of frailty as being a ‘consequence of a decline in several physiological systems which collectively results in a vulnerability to sudden health state changes triggered by relatively minor stressor events’.
The British Geriatric Society refers to five ‘frailty syndromes’:
- Falls (e.g. collapse, legs gave way, ‘found lying on floor’).
- Immobility (e.g. sudden change in mobility, ‘gone off legs’ ‘stuck in toilet’).
- Delirium (e.g. acute confusion, ’muddledness’, sudden worsening of confusion in someone with previous dementia or known memory loss).
- Incontinence (e.g. change in continence – new onset or worsening of urine or faecal incontinence).
- Susceptibility to side effects of medication (e.g. confusion with codeine, hypotension with antidepressants).
From July 2017, practices are required to use an appropriate tool, such as the Electronic Frailty Index (eFI), to identify patients over the age of 65 who are living with moderate and severe frailty. Practices should code clinical interventions as appropriate. It is likely that GPs will choose the tool that is integrated with their clinical IT system.
It is important to note that these tools should be seen as guides only, and the decision to code someone as moderately or severely frail should be made by an experienced clinician guided by, but not restricted by, the electronic score. It is likely that these patients will be seen on a regular basis and coding can take place on an opportunistic basis over the course of the year.
NICE recognises many ways to identify frailty, including:
- an informal assessment of gait speed (for example, time taken to answer the door, time taken to walk from the waiting room)
- self-reported health status (that is, 'how would you rate your health status on a scale from 0 to 10?', with scores of 6 or less indicating frailty)
- a formal assessment of gait speed, with more than 5 seconds to walk 4 metres indicating frailty
- the PRISMA-7 questionnaire, with scores of 3 and above indicating frailty.
Read further information from the British Geriatric Society
The electronic frailty index
Under the 2017/18 contract agreement practices are able to use any appropriate tools for identifying frailty. One of the most common of these tools is the electronic Frailty Index (eFI).
How was the eFI developed
The eFI was developed by at Leeds University and uses data and was tested using data from around one million UK patients aged 65-95 in two large research databases (ResearchOne and THIN).
The study identified and validated patients in the following proportions:
||eFI development cohort
| Internal validation cohort
| External validation cohort
How do these tools work?
The eFI uses data that is available in the GP electronic health record to identify and severity grade frailty, enabling the identification of older people who are fit, and those with mild, moderate and severe frailty. It uses a ‘cumulative deficit’ model, which measures frailty on the basis of the accumulation of a range of deficits, which can be clinical signs (e.g. tremor), symptoms (e.g. vision problems), diseases, disabilities and abnormal test values and is made up of 36 deficits comprising around 2,000 Read codes.
The conditions used in defining frailty by the eFI are listed below:
36 deficits used in the eFI
| Activity limitation
|| Ischaemic heart disease
| Anaemia and haematinic deficiency
|| Memory and cognitive problems
|| Mobility and transfer problems
| Atrial fibrillation
| Cerebrovascular disease
|| Parkinsonism and tremor
| Chronic kidney disease
|| Peptic ulcer
|| Peripheral vascular disease
|| Requirement for care
|| Respiratory disease
| Foot problems
|| Skin ulcer
| Fragility fracture
|| Sleep disturbance
| Hearing impairment
|| Social vulnerability
| Heart failure
|| Thyroid disease
| Heart valve disease
|| Urinary incontinence
|| Urinary system disease
|| Visual impairment
|| Weight loss and anorexia
Read detailed information on how the tool was developed
Read guidance notes on the eFI
Management of the severely frail
For those patients identified as being severely frail the practice will be required to deliver a clinical review providing an annual medication review and, where clinically appropriate, discuss whether the patient has fallen in the last 12 months. Practices should also provide any other clinically relevant interventions. All clinical interventions should be coded appropriately.
Where a patient does not already have an enriched Summary Care Record (SCR) the practice should offer this to the patient and, after receiving informed consent, activate the enriched SCR.
It is for individual clinicians to determine whether it is clinically appropriate to code patients who have been identified as being moderately frail.
Enriched Summary Care Record
Further information on enriched Summary Care Records can be found on the NHS Digital website.
Under these provisions data will be collected on:
- the number of patients recorded with a diagnosis of moderate frailty
- the number of patients with severe frailty
- the number of patients with severe frailty with an annual medication review
- the number of patients with severe frailty who are recorded as having had a fall in the preceding 12 months
- the number of severely frail patients who provided explicit consent to activate their enriched SCR
This information will be used by NHS England to understand the prevalence of frailty among practice populations and nationally and guide future commissioning arrangements. It will not be used for performance management.
Do we still have to do any of the additional care planning that was included in the AUA DES?
The only actions required are those outlined above. The various elements necessary to fulfil the AUA enhanced service are no longer contractually required after 31 March 2017.
Do we need to review all patients over 65 or just those we think are frail?
A frailty tool within electronic clinical record systems will automatically identify patients of any age with varying degrees of frailty. Clinicians should use this information as clinically appropriate during consultations with patients. When patients aged 65 and over have been identified as having moderate or severe frailty consideration should be given to coding this information as part of the consultation.
Do we need to call in patients to undertake this?
No. This should be undertaken within the context of routine consultations or regular contacts with patients.
What if patients don’t want this information to be recorded?
There is no obligation on the practice to code information relating to frailty that a patient does not want recording.
What happened to the funding for the AUA DES?
The £156.7 million funding for the AUA DES has been recycled into Global Sum.