What is frailty?

Frailty is the term used for people at high risk of bad health outcomes after an illness, including even apparently minor conditions like a simple cold. Another way to think of frailty is the reduced ability of the body to fight off challenges. This is not about how old someone is – young people can be frail – but, in general, we are all likely to become more frail as we get older. However, it is important to realise that most older people living in the community are not frail.

Why is it important to understand frailty?

By understanding when people are frail, healthcare professionals can identify and support those at highest risk of coming to harm. For example: we can review medications to help reduce the risk of older people falling and breaking bones; we can arrange rehabilitation services like physiotherapy to keep people active, while checking what additional support is provided if needed; and we can identify and support people who develop memory problems earlier than usual. 

The aim is always to keep people living as independently as possible and for as long as possible in their own homes. So knowing who is frail can help healthcare professionals target care and support to ensure people can live independently. This is called proactive care. Too often in our health system, we provide only reactive care, responding when harm has already happened (e.g. admitting people to hospital).

Knowing whether someone is at risk can help to develop a proactive care plan: this is a clear statement of what a person wants (and does not want) to happen to them if their health deteriorates. This is crucial for healthcare professionals in the event of a sudden health crisis, to make sure that the care given best reflects a person’s wishes. 

How can health and care data help?

The most common way of measuring frailty comes from looking at a person’s health conditions, day-to-day symptoms, and blood test results. A lot of this information is held within separate medical records, for example in GP practices or hospitals. By putting these multiple sources of data together, we can understand when people are living with frailty as soon as their records trigger enough measures of concern. These people can then be reviewed by their doctor to confirm if any proactive care measures are required.

What has DataLoch done in this project?

The DataLoch team has been working with a group of GPs in North-East Edinburgh to design an automated report, which captures when people are considered frail and helps to understand what proactive assessments have been completed for these patients. 

This project has been supported by the Scottish Funding Council and involves the Edinburgh Health & Social Care Partnership alongside NHS Lothian. In the design phase, this work has focussed on medication reviews, where GPs check the appropriateness of prescriptions for frail patients to see if some medications started earlier in life may now be causing more harm than benefit. The automated report has been designed to track performance over time, to show where progress is being made and where more work is needed. It also allows GP surgeries to compare their performance against other practices, to try and make sure frail patients receive the same quality of care across the area. This design uses combined (known as “aggregated”) data rather than individual-level data, which means there is no risk of a single patient being identified. 

What is next for this project?

Once GPs working with the DataLoch team finalise the design of the automated report, the project will move to NHS Lothian so that the report can be set up as a live service. While DataLoch enables the design of the report, the team is not involved in the live deployment within the NHS. At this point, the NHS Lothian Analytical Services team can set up the automated report for any local GP on request. The report's outputs can assist GPs to explore how to improve support for any frail patients cared for within their own practices and ensure that the care given best reflects a person’s wishes.