Title: The dynamics of frailty in older people: modelling impact on health care demand and outcomes to inform service planning and commissioning
Funder: Department of Health and Social Care

Abstract: Older people who have complex health problems are often described as frail. People who are frail are more likely to find it difficult to deal with small changes in their health or circumstances. This means that, when they get ill, the effects are worse than for other people. Until recently, it was difficult to provide care for frail older people because it was hard to identify people who were frail without an assessment by a consultant. This meant that frail older people were not always receiving the care they needed. Better care for frail older people has become a priority for the NHS. It will improve their health and quality of life and it will also help the NHS to use its resources more efficiently. _x000D_ _x000D_ It is now possible to use a tool called the electronic Frailty Index (eFI) to identify all the frail older people in a GP practice from their routine health care information. This will allow GPs to offer services designed for the frail older people in their practice. However, the GPs and local health NHS services need to know more about their frail older patients and what sort of health and care services they need. At the moment, they don’t have enough information about the numbers of frail older people they can expect or the amount and type of health and care services that they use now and will need in the future as the population ages. _x000D_ _x000D_ In this study, we will use routine information from GP practices across England, linked to information about hospital care, from 2004 to 2018 using the Royal College of General Practitioners Research Surveillance Centre (RCGP RSC) database. We will identify the number of frail older people and the severity of their frailty and other health problems. We will examine factors that might increase the level of frailty. We will then look at what happened to those people and what health care they needed over the following 10 years. We will use this information to tell the organisations that purchase (commission) health care and provide health care (including GPs and community health and care services) how much health care and what types of services are needed for frail older people in England. We will test this information against data from a similar database in Leeds (the Leeds Data Model)._x000D_ _x000D_ We will also use this information to build computer models (simulation) that the commissioners can use to work out how many people will become frail in their area in the future. We will use information from the RCGP RSC, Leeds Data Model and other sources of health and social care information to model the health outcomes, health and care service use and costs of frailty in the ageing population. We will develop the computer models and the other information from this study into a toolkit that health and care organisations can use to work out what type of services they will need to look after frail older people in years to come. In the future, the computer models can be developed to look into other conditions, or the type, grade and number of staff needed to look after frail older people in years to come.

Lay abstract: The impact of frailty on demand for and outcomes of care has emerged as a significant issue for the NHS in recent years. The association between frailty and adverse outcomes such as unplanned admission, transfer to residential care and high service use is established. As the population ages, prevalence of frailty and associated demand for health care rise. In the context of reduced resources and rising demand for unplanned care, the delivery of appropriate services to support people with frailty will be key to providing cost-effective, quality care for older people. Recent consensus guidelines have emphasised the importance of identification and clinical management of frailty. Effective interventions for frailty are available, but capacity and resources for delivery are limited. There is recognition that there is an evidence gap in relation to the planning, commissioning and delivery of services for frail older people and that current practice is focused on severe frailty. Questions remain about the incidence and prevalence of the different degrees of frailty and the consequences for service use, costs and health outcomes over time. Addressing these issues requires exploration of population trends in the development and impact of frailty, but this research has previously been limited because of the need for clinical assessment for identification of frailty. The recent introduction of the electronic Frailty Index (eFI) allows routine primary care data to be used to identify frailty across primary care populations. The eFI therefore facilitates the exploration of frailty and its impact at a population level. It stratifies the primary care population into robust, mild, moderate and severe frailty groups, so enabling comparison of trajectories of decline and care use between these groups, which will be key to service development, targeting and commissioning. _x000D_ _x000D_ In this study, we will explore the prevalence, development and impact of frailty using retrospective data from the RGP Research Surveillance Centre database. The eFI tool will be utilised to stratify all people aged 60 and over within the database in 2004-8 into robust, mild, moderate and severe frailty groups. We will extract data on health care use, costs and outcomes for the subsequent 10 years. Outcomes will include mortality, unplanned hospital admission, A&E attendance and residential care use. The RCGP RSC will also provide data on socio-economic factors and practice characteristics. We will calculate incidence and prevalence of the different levels of frailty and explore prevalence over time. We will examine the relationships between population factors such as age, deprivation, location and clinical features of individuals in relation to development and deterioration in frailty status. The influence of frailty on service use, outcomes and costs will be explored. These analyses will inform guidelines for service commissioners, developed with experts in service delivery, commissioning and our PPI representatives in the stakeholder group. The data will also inform the development of a prototype simulation model, which will use a System Dynamics (SD) based approach to explore the development and impact of frailty in the population and likely scenarios over a 10+ year timeframe. The simulation model outputs will be externally validated against retrospective data from the Leeds Data Model dataset and 'what if' scenarios developed with the stakeholder group will be explored.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE