SIA/S&B White Papers: Enhancing Care for Frail Older Patients through Specialised Frailty

 

It is essential for every NHS organization supporting cancer patients—whether hospitals, integrated care boards, or other service providers—to leverage the detailed insights from nearly 50% of all cancer patients captured through NHS England’s excellent Cancer Quality of Life initiative. This patient-driven evidence is not only respectful of patients’ voices but critical for delivering high-quality, cost-effective, and truly patient-centred care based on real needs and experiences. By gathering insights directly from patients, the initiative highlights which aspects of services (both during and after treatment) are effective, where improvements are needed, and where strategic investment could yield significant financial savings. This continuous feedback loop allows services to adapt and evolve, aligning more closely with patients’ actual needs rather than assumptions.

 

White Paper: Enhancing Care for Frail Older Patients through Specialised Frailty Services

 

Executive Summary

This paper outlines the compelling case for establishing and expanding specialised frailty services across healthcare settings in the UK. Frailty services, particularly within acute care, have demonstrated significant potential to reduce emergency department (ED) pressures, improve patient outcomes, and reduce healthcare costs. The evidence shows that integrating comprehensive frailty assessments and multidisciplinary team care into emergency settings can reduce emergency admissions and associated costs by 20-30% for patients over 65. This approach aligns with NHS goals outlined in the Long-Term Plan, supporting enhanced, person-centred care that ensures patients receive the right care, in the right place, at the right time.

 NHS England’s Falls Data of people 65+ is reducing over time in Integrated Care Boards where they have initiated pathways prioritising early intervention, same day assessments and management for frail patients creating a potential £14M annual saving. Comparatively, an example ICB  that does not have these focused pathways is seeing an increase in A&E attendance due to falls with an estimated £16M annual increase in costs.

 

Background

As the population ages, the demand for healthcare services tailored to the needs of frail, older patients have become increasingly urgent. According to the UK Office for National Statistics, over 11.1 million people, or 18.6% of the population, were aged 65 or older as of the 2021 census. Projections indicate that this demographic will comprise 25% of the population within 20 years. Frailty is a long-term condition linked to aging, where multiple body systems gradually lose their reserves, reducing resilience and increasing vulnerability. Older adults with frailty struggle to adapt to stressors like illness, injury, or environmental changes, which often lead to health decline and loss of independence. Frailty also complicates care, resulting in higher emergency visits, longer hospital stays, and increased healthcare costs.

 

The Case for Frailty Clinics and Acute Frailty Services

Frailty clinics provide specialised outpatient services focused on proactive, comprehensive care, often resulting in lower admission rates and shorter hospital stays for elderly patients. By offering targeted interventions, these clinics help prevent complications that might otherwise lead to emergency visits. Our research highlighted a hospital that introduced a new frailty unit to improve care for elderly, vulnerable patients. This initiative streamlined specialised assessments and interventions for individuals over 75, resulting in reduced emergency department wait times for all patients.

Acute frailty services, as mandated by the NHS Long-Term Plan, aim to provide assessment and treatment within 30 minutes of a frail patient’s arrival at ED or Same-Day Emergency Care (SDEC) units. This rapid response minimizes unnecessary hospital stays, improves patient flow, and reduces healthcare costs.

 

Key Components of Frailty Services

Same-Day Emergency Care (SDEC) and Early Intervention models exemplify the benefits of rapid assessments, treatment, and discharge processes. By minimising hospital stays, SDEC services help frail patients avoid deconditioning risks associated with prolonged hospitalisation. Additionally, SDEC’s model of care supports continuity in the community, empowering patients to remain in familiar environments while receiving necessary treatment.

Multidisciplinary Teams (MDT): Effective frailty care hinges on a collaborative, multidisciplinary approach. Teams comprising geriatricians, nurses, therapists, and social workers address not only the medical but also the functional and social needs of patients. The ability to provide same-day discharge for many patients through MDT intervention reduces repeat admissions and improves quality of care.

 

The FRAIL Strategy:

The FRAIL framework is a structured, practical approach that guides acute frailty services to address the unique needs of elderly patients in urgent care settings:

• Focus on the Acute Problem: Assess and treat the primary health concern while considering frailty markers.
• Refer: Connect patients with appropriate MDTs and external resources to support same-day discharge.
• Assess: Conduct comprehensive geriatric assessments to guide treatment.
• Identify Needs: Emphasise personalised, patient-centred care planning.
• Leave: Discharge the patient the same day with linked community support for ongoing care.

 

Operationalising Acute Frailty Services: Key Actions

Provider-Level Actions

• Implement SDEC-by-default protocols and enable front door assessments for frail patients.
• Train advanced level practitioners to participate in decision making and support rapid assessment.
• Develop fit-to-sit initiatives at the front door to optimise patient flow and reduce unnecessary admissions.

Integrated Care System (ICS) Actions

• Support community-based frailty assessments that reflect patient needs and settings.
• Facilitate open access to acute frailty services for healthcare professionals, including those in primary, community, and emergency services.
• Build ICS workforce capabilities to support in-home care and community-based SDEC models.

 

Impact of Frailty Services on ED Performance: Case Study

The introduction of virtual wards, including frailty-specific virtual wards has enabled some hospitals to keep frail patients out of ED, preserving independence and improving patient flow. Virtual wards and SDEC units have played a critical role in allowing frail patients to be treated in the comfort of their homes or within targeted frailty units, reducing ED admissions and shortening wait times for other patients.

 

Challenges and Recommendations

Key Challenges

• Limited resources and workforce constraints hinder the expansion of specialised frailty services.
• Fragmented healthcare records and inconsistent access to data impede coordinated care.
• Insufficient community-based infrastructure limits continuity of care post-discharge.
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Strategic Recommendations

• Invest in workforce training to build multidisciplinary teams proficient in frailty care.
• Strengthen and standardise data-sharing protocols between health and social care sectors.
• Develop standardised protocols to guide community-based SDEC models and virtual ward expansions.

Conclusion

Specialised frailty services are essential for the effective, sustainable care of the UK’s ageing population. The expansion of frailty clinics, SDEC models, and virtual wards, combined with multidisciplinary approaches and strategies like FRAIL, can alleviate ED pressures, enhance patient outcomes, and reduce healthcare costs. Addressing current challenges through strategic investments and system wide coordination will position the NHS to better serve its frail, older population, ensuring dignified, efficient and person-centred care across the healthcare continuum.

 

 

Establishing Frailty Services for Cancer Patients Living with Disease and Treatment Consequences

 

Executive Summary

Cancer patients who are also frail face unique challenges, with the dual burden of managing cancer and the long-term effects of cancer treatments, such as chemotherapy and radiation. These patients often experience higher rates of hospital admissions, prolonged recovery times, and complex healthcare needs. A specialised frailty clinic tailored to cancer patients can reduce unnecessary hospitalisations, improve quality of life, and optimise patient outcomes through early interventions, multidisciplinary care, and personalised treatment plans. This paper outlines the critical components, challenges, and recommendations for establishing frailty services specifically for cancer patients, focusing on enhancing patient care, reducing healthcare costs, and supporting long-term survivorship.

 

Introduction

Cancer patients living with frailty are at high risk of complications due to the combined effects of their illness and its treatments. Chemotherapy, radiation therapy, and surgery often lead to frailty-related issues, including fatigue, weakness, cognitive decline, and decreased physical resilience. This vulnerable population requires a targeted approach to healthcare that integrates cancer treatment with specialised frailty management. Given the aging population and the increasing prevalence of cancer survivors, it is essential to establish frailty clinics that address the complex, long-term needs of these patients.

 

 

Key Components of Frailty Services for Cancer Patients

• Early Identification and Screening for Frailty
  • Screening Tools: Tools like the Clinical Frailty Scale (CFS) and Geriatric Assessment should be used to assess frailty in cancer patients at key points in their treatment journey, including diagnosis, during treatment, and post-treatment.
  • Individualised Risk Assessments: These assessments help identify patients at higher risk of treatment-related complications, allowing for early interventions.
• Multidisciplinary Team (MDT) Approach
  • Specialist Oncologists and Geriatricians: Collaboration between oncologists and geriatricians ensures that cancer treatment plans are adjusted to the patient’s frailty status, minimising adverse effects and improving tolerability.
  • Nurses, Physiotherapists, and Dietitians: Provide supportive care, including managing treatment side effects, implementing nutrition plans, and maintaining physical strength and mobility.
  • Social Workers and Palliative Care Teams: Offer psychosocial support, end-of-life care planning, and help address non-medical factors impacting patient well-being.
• Cancer Treatment Adjustments for Frail Patients
  • Personalised Treatment Plans: For frail cancer patients, treatment regimens may need to be adapted to minimise toxicity and side effects. This can include dose adjustments, alternative therapies, or more conservative management approaches.
  • Supportive Therapies: Concurrent treatments like physical therapy, cognitive rehabilitation, and nutritional support help build resilience during and after cancer treatments.
• Comprehensive Discharge Planning and Post-Discharge Support
  • Transitional Care Programs: Frail cancer patients require ongoing monitoring and care coordination following hospital discharges, ensuring that treatment side effects or frailty-related issues are managed effectively.
  • Follow-Up Care: Regular check-ups post-discharge to monitor the long-term effects of both cancer treatment and frailty progression.
• Virtual Wards and Telemedicine for Cancer Survivors
  • Home-Based Care: Cancer patients who are frail may benefit from receiving hospital-equivalent care at home, reducing hospital admissions and supporting recovery in familiar environments.
  • Telemedicine: Allows continuous monitoring of cancer treatment side effects and frailty status, enabling timely interventions without requiring frequent hospital visits.
• Data and Analytics for Continuous Improvement
  • Outcome Tracking: Monitoring outcomes such as quality of life, functional status, and readmission rates allows clinics to adjust care plans and improve service delivery for frail cancer patients.
  • Predictive Analytics: Data on frailty and treatment outcomes can be used to predict which patients are most at risk of complications, allowing for proactive care planning.
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Challenges in Establishing Frailty Services for Cancer Patients

• Resource Constraints
  • Staffing and Expertise: Many oncology clinics lack geriatricians and frailty-trained professionals. Recruiting and retaining multidisciplinary staff with expertise in both oncology and frailty care can be challenging.
  • Funding Limitations: Integrating specialised frailty care into oncology services requires investments in additional personnel, training, and technology, often constrained by limited budgets.
• Care Coordination and Integration
  • Siloed Services: Cancer treatment and frailty management are often handled by different departments, leading to fragmented care and gaps in service continuity.
  • Inconsistent Data Sharing: Without integrated electronic health records, it can be difficult to ensure seamless communication between oncologists, geriatricians, and community care providers.
• Cultural and Operational Barriers
  • Resistance to Change: Oncology departments may be focused on aggressive treatment regimens that are not always suitable for frail patients, leading to resistance in adopting frailty-adjusted care models.
  • Operational Complexity: Developing new workflows, care pathways, and MDT meeting schedules can be resource-intensive and difficult to manage within existing healthcare structures.
• Patient Engagement and Support
  • Complex Needs: Frail cancer patients often struggle with health literacy, fatigue, and cognitive impairments, making it difficult for them to engage actively in their care. Additional support is needed to ensure they understand their treatment options and participate in decision-making.
  • Social and Psychological Barriers: Many patients face social isolation, depression, and anxiety, which can exacerbate frailty and complicate cancer treatment adherence.

Recommendations

1.            Develop Integrated Frailty and Oncology Services

• Establish a collaborative framework where geriatricians, oncologists, and other specialists can co-manage frail cancer patients. This should include shared protocols for screening, treatment modification, and discharge planning.
• Create joint MDT meetings that include cancer care professionals and frailty experts to review cases and develop personalised, holistic care plans.

2.            Invest in Training and Recruitment

• Implement geriatric oncology training programs for staff to enhance their ability to manage frail cancer patients effectively.
• Recruit multidisciplinary teams with expertise in both oncology and frailty, including nurses, therapists, dietitians, and social workers.

3.            Leverage Technology for Remote Monitoring and Virtual Care

• Expand the use of virtual wards and telemedicine platforms to allow cancer patients to receive continuous care at home, reducing hospital visits and providing real-time monitoring of treatment effects and frailty progression.

4.            Prioritise Data-Driven Decision Making

• Use predictive analytics to identify frail cancer patients at high risk of complications, allowing for early interventions and better resource allocation.
• Collect comprehensive data on patient outcomes to evaluate the effectiveness of frailty services and refine care strategies accordingly.

5.            Enhance Patient Support and Engagement

• Offer tailored support programs that address cognitive impairments, depression, and social isolation among frail cancer patients, improving their ability to engage in their care.
• Provide educational resources for patients and caregivers, focusing on health literacy and strategies for managing frailty alongside cancer treatments.

6.            Develop Sustainable Funding Models

• Advocate for targeted funding to support the integration of frailty services into oncology care. Highlight the potential for cost savings through reduced hospital admissions and improved patient outcomes to justify investments.
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Conclusion

Integrating frailty services into oncology care is critical for addressing the complex needs of cancer patients who are frail and dealing with the consequences of both their disease and its treatment. By focusing on early identification, multidisciplinary collaboration, personalised treatment plans, and robust post-discharge support, healthcare systems can improve outcomes for this vulnerable population. Addressing the outlined challenges through strategic investments in training, technology, and data-driven approaches will ensure that frail cancer patients receive the comprehensive, compassionate care they need to manage both their frailty and their cancer effectively.