Identifying Frailty Early: It's more than just a CQUIN.

In acute healthcare, every minute matters. It matters for clinical staff who need more time to deliver the care they want. It matters for patients, with every minute waited an extra minute in pain or an extra minute uncertain about the future. And it matters for health systems, with every minute waited unnecessarily increasing cost, reducing performance and adding no value.

In A&E, time is more critical than in most other places in a health system. Wasted time increases queues, and longer queues increase clinical risk. As A&E queues increase, so do the number of undifferentiated patients waiting to be seen. So do the number of patients needing treatments and medications in A&E, and patients to monitor, and patients waiting to handover, and patients waiting in the community. The list goes on.  

But sometimes, slowing down is the only way to speed up.

The biggest challenge to well-functioning A&Es is poor flow. In most organisations, flow is driven by non-elective bed occupancy, and as older adults occupy most non-elective beds, identifying Frailty in older adults as early as possible is critical. Doing it right will cost minutes in A&E, but it can save days or weeks elsewhere in the system. NHSE pushed early frailty identification in A&E in the 2023/24 Frailty CQUIN, which was a good start. But on our travels, the Frailty teams often needed help to get early identification and scoring in place. The most common pushback came from A&E, with the most common reason being they have too much to do, and this is an extra task that adds no value for them.

But identifying and managing Frailty early and proactively will benefit A&E. There's no doubt about that. Managing Frailty well benefits everyone. It starts with the person, and the benefits flow to their family and friends, and all the way to the finance ledgers. But the benefit won't be seen straight away. And it's this lack of instant benefit against immediate performance monitoring and the visible queue out the door that can make behavioural change so difficult.

The impact of Frailty on people's lives and health systems' performance, finance, and safety can't be understated. You only need to glance at population demographics and acute trust utilisation by age to see the tsunami heading toward Health and Social Care in the next ten years.

Hopefully, you're beginning to see the opportunity as we do. But if you need more convincing, let's explore some areas in slightly more detail.

Patient Outcomes

We have the 'golden hour' in many parts of health, from sepsis care and early discharge to theatre lists, and early Frailty identification is no different. Identifying Frail patients early in their acute episode creates a window of opportunity for targeted interventions. A study in the Journal of the American Geriatrics Society found that early identification of Frailty led to significantly better outcomes, including reduced mortality and fewer complications (Smith et al., 2019). By recognising Frailty at the first point of contact – be it with paramedics or in A&E – we can:

• Make better and more informed admission and discharge decisions.

• Tailor treatment plans more accurately.

• Implement preventive measures against common complications like delirium or falls, or at least, take a holistic view of the person's current delirium or history of falls.

• Adjust medication and provide support and equipment to reduce the likelihood of future acute episodes resulting from their progression of Frailty.

Operational Efficiency

The NHS is overwhelmed almost everywhere, almost every day. Early Frailty identification can help Trusts and systems triage admissions and allocate resources more effectively, increasing the impact and effectiveness of staff. A 2020 study showed that hospitals using early frailty screening reduced the average length of stay by 2.5 days (Jones et al., 2020). That's not a bad return on investment. We think focussing on people and doing the right thing for patients is the best (and only) way to approach operational productivity and cost reduction.

Financial Impact

The financial implications of early frailty identification are hard to ignore. We've mentioned some short-term savings above in reduced length of stay. And considering what the population demographics and the NHS will look like in the next 5-10 years, those 2.5 days will quickly mount up.

But the real story isn't the short-term in-hospital savings. Early Frailty intervention can significantly reduce long-term health and social care needs and costs. By identifying this cohort early and case managing them through your system, the opportunity to reduce long-term health and social care needs is staggering. Keeping people at home for longer is the right thing to do for almost every person and every part of your health system. And it will probably have the biggest overall impact on system flow and finance too. 

Delivering the change

Making these changes and moving to person-centred and outcomes-focused care can be challenging. At the start of this blog, we highlighted one of the biggest changes needed when we talked about the A&E teams being too busy to adopt Frailty scoring on patient arrival.

Most organisations still look at performance in siloes, looking at departmental targets and driving for local optimisation. The regulatory and political landscape drive these behaviours, but that's only part of the story. Most people naturally think in 'either/or' terms. We either focus on A&E performance or we take a holistic system view. But the opportunity for health systems is in the 'and'. Local A&E performance and system flow can be looked at together. We might see fringe benefits in the department by focusing on optimising individual departmental performance. But at best, the system won't improve, and at worst, the local optimisation will lead to system dysfunction and lower departmental performance in the long run.

But to be clear, the answer isn't to tell people in A&E to work harder and just get on with it. It's about understanding how things work in their most granular detail to identify and remove waste and ensure the whole picture is communicated to everyone involved.

The Future is Frailty-Aware

As our population ages, the importance of frailty-aware healthcare will only grow. Early frailty identification isn't just a nice-to-have – it's a must-have for any system aiming for excellence in non-elective care.

If you're struggling to get to grips with anything discussed in this blog, from population health management or Frailty processes to in-hospital flow or culture, get in touch with Nexus for a confidential chat.