Facing Frailty: Exploring the Implementation of Frailty Identification and Management in Primary Care

Abstract

Frailty is a multidimensional syndrome that places individuals at increased risk of adverse health outcomes. Longer lifespans are resulting in increasing numbers of frail older people with associated increased healthcare costs. In response, a suggested long term strategy is to better support frail people in the primary care setting. In particular, since 2017 GPs in England have been contractually required to identify and code all their frail elderly patients and to provide appropriate management interventions. However, the concept of frailty and its use to help structure care is relatively new in primary care with little relevant evidence available. The aim of this thesis was to develop greater clarity on how the concept of frailty is currently being implemented in English primary care and how it is used (or not) to inform and target appropriate care. To this end three related studies, as research papers published or intended for publication, were undertaken. Paper 1 used qualitative interviews to explore the views of professionals on the implementation of the frailty contract. Paper 2 analysed the 2018/19 national contract dataset to examine implementation coverage in English general practices and relationships between GP practice and clinical commissioning group (CCG) factors and implementation outcomes. Paper 3 entailed a rapid realist review to identify factors that enable or constrain the implementation of frailty management interventions in primary care. Key findings were: first, access to necessary resources is a key factor in enabling professionals to authentically implement contractual requirements. Second, practices vary widely in the implementation of frailty coding and the delivery of the mandated interventions, with CCGs the main drivers of practice-level implementation. Third, current case-finding strategies miss the majority of moderately frail patients – those who might benefit most from early interventions. Fourth, successful interventions tend to be those with explicit resourcing of a professional skill-set designed to target specific needs. Finally, social interaction appears to be a key factor in encouraging older people to adhere to and participate in interventions. Accordingly, frailty interventions in primary care need to be supported by a system fully resourced to link older people to effective interventions tailored to their needs and perspectives. To this end, research is needed to ascertain the long-term costs and benefits of managing frail individuals in primary care and to better establish the roles of older people and CCGs in supporting general practices to deliver care for frail individuals.