Rethinking Frailty PHA & AgeNI April 2018

‘The most problematic expression of human ageing facing the NHS today’ (Clegg)

NI Issues No agreed definition for frailty No ‘road map’ – do we know what good looks like? Tend to operate from a medical model We focus on conditions, rather than the ‘whole’ person Service users views not captured until this year Need to shift to public health, preventative model that is evidence based and has population health focus and measurable outcomes.

We all age, but not always in the same way.. FRAIL FIT Not all older people are frail, and not all people with frailty are old

Current Landscape

Paradigm shift THEN NOW ‘The frail Elderly’ ‘An Older Person living with frailty’ A long-term condition Late Crisis presentation Fall, delirium, immobility Timely identification preventative, proactive care supported self management & personalised care planning Community based person centred & coordinated Health + Social +Voluntary+ Mental Health Hospital-based episodic care Disruptive & disjointed

Frailty Fulcrum

Profile of Older Adults in Northern Ireland

Demographics- Changing NI population 2017 2027 2047 2064

Mortality- What do older people die from in NI Mortality- What do older people die from in NI? (Registrar General Annual Report 2015) Big cause of death (65 to 84 years) Cancer Circulatory disease Big cause of death (85 and over years) Circulatory disease Alzheimer’s and dementia

Frailty prevention through active ageing Lack of physical activity is costing the UK an estimated £7.4 billion/year Including £0.9 billion to the NHS alone. Long term conditions such as diabetes, cardiovascular and respiratory disease lead to greater dependency on home, residential and ultimately nursing care. This drain on resources is avoidable, as is the personal strain it puts on families and individuals.

Preventing frailty progression: Potential Cost impact Adjusting for age, gender and deprivation, in a 254K 65+ population: If 10% of the severely frail had remained moderately frail the gross savings in Kent would be £1.6m over 10 months If 10% of the mildly frail had remained fit, gross savings would be nearly £9m (owing to higher patient numbers) NB: Gross estimates- these figures do not account for the costs of interventions to prevent frailty progression Kent Integrated Dataset economic model 2017-18 NHS England

Bending the fitness curve Also, consider inequalities carefully: Lowest economic quartile frailty commences earlier in the life course and progresses more rapidly, contributing to reduced life expectancy

‘As a population, we are living longer lives and many In essence Ageing population, Cancer, circulatory disease, Alzheimer’s & dementia, Lifestyle & mental wellbeing focus, Wider determinants, In a digital world. Implications for HSC the working group needs to put on the agenda Vision, ‘As a population, we are living longer lives and many older adults enjoy good health and make significant contributions to their families, their friends, and to society.’ (The Public Health Agency, Corporate Plan 2017-2021)

Electronic Frailty Index (eFI) Clegg et al: Age Ageing2016: 45:353-360

Direct Clinical Verification

Suggested priority areas to think about Frailty syndromes Falls Medicines Cognitive disorder Mental Health Continence Service approaches Acute frailty care Community frailty care Specialist services Frailty coordinators Frailty networks Key enablers Data linkage with local IG agreements (system and individual) Population risk stratification: understand demand/supply Benchmarking to understand and manage outcome variation ‘Real time’ data pathways to drive quality improvement Workforce core capabilities and skills

Ambition for frailty.. ‘Everybody should know what to do next when presented with a person living with frailty and/or cognitive disorder’

Rethinking Frailty: What matters to older people

Rethinking Frailty: What really matters to older people

ExpertAge and Peer Facilitators “I would like to feel like I was still a part of the world, not just waiting to die” Model includes: Bespoke recruitment, training and briefings Multi-channel approach to reach older people across NI.

A snapshot of demographics Sexuality Heterosexual 89% Bisexual 0.5% Gay 1% None 7.6% Prefer not to say 1.9% 98% White 23% Carers Gender   Male 21% Female 78% Other 1 % 51% Report difficulty walking 62% LT health condition

Characteristics of frailty

Perceptions of frailty 85% reported that they were not frail. 95% stated a professional had not described them as frail. ‘doesn’t look like me’. 77% of older people are not comfortable with the term frail. 56% believed that the possibility of being categorised as frail may deter people from seeking help. 40% related frailty with a loss of independence.

What makes a good life? 25% of people thought frailty was only physical. 25% believed frailty was irreversible.

What would help?

Conclusions Co-design of services is key to shaping future health and social care services. Peer facilitator model has been designed with older people and works to reach, engage and involve older people. What really matters to older people is wellbeing and independence and approaches to frailty can reflect this ‘Personal health is basic to everything’ ‘Independence gives you encouragement day by day’

Why is frailty so important right now? Timely identification of people at risk with complex care needs It permits sub-stratification by needs, not age It provides opportunity to standardise care for people with similar needs It crosses health & social care, so can drive integration It’s predictive: finding those who benefit from active and healthy ageing It will guide & track commissioning, design & service delivery It directs towards key outcomes: maintained functional ability & wellbeing

Top priorities moving forward We want to make NI the best place to age well Use language that matters to people Public conversation on frailty – focus on independence, maintaining good health Develop a vision/guiding principles Better identification Know what works well and build on that Agree what good looks like

Thank You