One of the things I enjoyed most when Executive Director of the Association of Salaried Medical Specialists (ASMS) was its annual conference, A feature was the enrichment provided by many engaging guest speakers on a wide range of pertinent subjects.
At the forefront of these presentations was one on frailty; of itself not a riveting headline, but when linked to health systems and delivered by a quality speaker it led to a riveting session.
The speaker was Dr Tim Frendin, a specialist geriatrician employed by Hawke’s Bay District Health Board. At the time he was also a member of ASMS’s National Executive.
A very thoughtful and ‘thinking-out-of-the box’ Executive member, whenever the opportunity arose, he would remind colleagues and ASMS staff of the increasing challenge of frailty for the health system.
This reminder included that (at least pre-pandemic) two types of patients dominated public hospitals – very young children (including babies) and the frail. This observation alone identifies frailty as something more than a condition; it is a health systems issue.
Dr Frendin’s absorbing presentation was given to ASMS’s 2016 Annual Conference. It was little over half-an-hour. A much recommended watch and listen.
Since becoming a health systems commentator and blogger, Dr Frendin has updated me on further developments, including sharing a presentation on a work-in-progress paper. He has also encouraged me to write on frailty (while suspecting that it was not my thing in terms of writing).
In fact, I was fascinated by the issue, especially after listening to his 2016 presentation, but things like a virus pandemic and botched health restructuring got in the way.
What is frailty
So what is frailty? First of all, it is not a medical condition. The most common definition, according to Dr Google, is that it is an aging-related syndrome of physiological decline, characterised by marked vulnerability to adverse health outcomes.
Perhaps globally about 7% of persons older than 65 years are frail, and that the occurrence of frailty increases with age and may exceed 45% after age 85.
But this description omits much complexity and health system implications. Dr Frendin goes further by identifying frailty as a predictor of surgical outcomes in older patients. He cites research published in Journal of American College of Surgeons(June 2010) which concluded that:
“Frailty independently predicts postoperative complications, length of stay, and discharge to a skilled or assisted-living facility in older surgical patients and enhances conventional risk models. Assessing frailty using a standardised definition can help patients and physicians make more informed decisions.”
The two sentences of the above paragraph say a lot – frailty predicts surgical outcomes and better informed decisions can be made by a better shared understanding of what frailty is.
Clinical frailty scale
Moving on from this Dr Frendin cites a 2005 Canadian study on health and aging. It included a nine-step clinical frailty scale which has been subsequently revised (as below):
- Very Fit – robust, active, energetic and motivated.
- Well – no active disease symptoms but are less fit than above category (either often exercise or very active occasionally).
- Managing well – medical problems well controlled, but not regularly active beyond routine walking.
- Vulnerable – while not dependent on others for daily help, often symptoms limit activities.
- Mildly frail – often have more evident slowing, and need help in high order help including finances, transportation, heavy housework and medications).
- Moderately frail – need help with all outside activities and with keeping house, including problems with stairs and help with bathing.
- Severely frail – completely dependent for personal care from whatever cause (physical or cognitive) but not high risk of dying within six months.
- Very severely frail – completely dependent, approaching the end of life. Typically could not recover even from a minor illness.
- Terminally ill – approaching the end of life (a life expectancy of up to six months, even if not otherwise evidently frail.
What stands out in is the broad scope and complexity of differentiation of frailty. It is a continuum from being very fit and well to deteriorating degrees of frailty ending with being very severely frail to terminally ill.
Each step on this scale involves different interactions with the health system from independence to increasing levels of dependency (ending with complete dependency). The further a frail person deteriorates the greater the demand for and cost of healthcare increases.
In his linkage of frailty to dependency Dr Frendin also draws upon an article published in British Journal of Preventive and Social Medicine (June 1976) on the needs of old people and the ‘interval’ as a method of measurement. This included an ‘interval dependency’ scale of five stages – independent; care but less than daily; daily care; residential care; and death.
Behind frailty dependency
What is especially significant for health systems is Dr Frendin’s consideration of what sits behind people becoming frail. Rather than age, as what one might intuitively think, the biggest contributing factor is social determinants (external to the health system) such as poverty, employment, connectedness, ethnicity and education. Sitting behind them are comorbidities (additional health conditions) and age. Further back are genetics and gender.
This leads to his five recommendations:
- As frailty is a clinical problem, clinicians must guide the health system.
- Outcomes relating to frailty must be incorporated into decision-making both at individual level and at systems level to inform and predict healthcare demand.
- Recognise that inability to predict demand compromises all of the health system.
- Priority to be given to adopting measures of dependency for planning.
- Conversations must start now on the above.
Political leadership is needed; we can’t wait for ardernity
I agree with these recommendations but would add the following three observations. Unfortunately the Government’s fetish for restructuring has led it to be distracted from the imperative of addressing what sits behind them.
First, given the significance of social determinants to frailty, including increasing dependence, the government has a responsibility to take the lead. These determinants are external drivers of healthcare demand which the health system has no control over apart from some mitigation.
To date, Jacinda Ardern’s government has been itsy-bitsy. Some useful measures here and there but overall, like candles that can’t light a path for an ant. This must change with a strategic approach able to be operationalised.
Second, in respect of the health system, the severe workforce shortages must be addressed. It must be recognised that frailty is a significant driver of health demand and cost (in 2019-20 the healthcare costs of frailty were estimated to be close to the over half a billion dollars operational deficits of all DHBs).
This requires investment to address but what makes good clinical sense also makes good financial sense. Frailty and dependency don’t necessarily have to go hand-in-hand. Reduce the linkage will reduce the cost.
This means that we need a workforce strategy that includes recruiting and retaining the right capacity with the right capabilities to both prevent frailty leading to dependency and better coping with the dependencies that presently exist. This is across the health system from community to hospital.
To give effect to this requires a political u-turn by Government which so far has treating workforce shortages with indifference. It has been the opposite of wellbeing.
Third, to get this right, the health system needs to be led by an engagement culture based on leadership that is distributed throughout the workforce in community and hospital care, especially the clinical workforce.
Unfortunately the Government’s health restructuring will lead to increasing bureaucratic centralism (ill-informed and distant top-down decision-making) which is the antithesis of distributed clinical leadership.
Tim Frendin is a health professional who helps keep the health system honest. Government needs to match this honesty. If frailty as a driver of health demand and cost is to be addressed, then the Ardern government will need to make a major cultural shift in its approach to the health system.
Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion