Healthcare ‘must do better’ for frail patients

Leadership is needed if the provision of healthcare, especially to frail patients, is to change for the better, argues Kenneth Rockwood.

By Kenneth Rockwood

12 Jun 2014

Frailty challenges healthcare and so offers opportunity. As people age they are more likely to die, but not everyone of the same age has the same risk of death. Those at higher risk, compared with others their own age, are frail.

Likewise, people at lower risk are fit. As populations age, more people become frail. It is not clear exactly why. Frail older adults typically have many health problems, and, crucially, as frailty worsens, come daily to depend on others. Frailty can also occur in younger people, such as many with intellectual disabilities or HIV/Aids.

Having a lot wrong, and depending on others, has important policy implications because modern healthcare expects otherwise. It has succeeded largely through greater precision, reflecting ever greater understanding of particular illnesses. Typically this is achieved with greater specialisation, accompanied by more expensive tests and treatments. For many, success is clear, with remarkable results every day.

That is less so for frail patients. Their multiple, interacting medical and social problems leave them ill served when we focus on a ‘most responsible’ diagnosis. Instead, they must be treated as whole persons, whose many problems need attention, and who, to manage, must daily rely on others – chiefly family, usually women. Obliging them to fit narrowly focused care that ignores their dependence is not just ineffective and expensive, it can expose them to high risk, with little chance of benefit.

"We cannot oblige frail people to be better patients. Instead, healthcare systems and providers must change"

Changing how we provide care is difficult. It takes time to recognise that when patients do not fit the system, the system must change. Without leadership, systems are slow to accept that patients get sick the only way they know how. Without leadership, instead of reform we get derision: frail patients are ‘unsuitable’ or ‘social admissions’.

Tragically, the patients being so denigrated have often been harmed by interventions from which they had very little chance to benefit: unable to go home, they become ‘bed blockers’. We cannot oblige frail people to be better patients. Instead, healthcare systems and providers must change. This is not new. It is the same mistake of generals who plan not for the war that they face, but for the war that they know. Healthcare must do better, because, largely, we know what to do. We just can’t do it without leadership.

Getting the incentives right is essential. We must measure patient-centred outcomes. We must evaluate how care changes patients’ function, cognition and social interactions. Declaring surgery successful because the patient hasn’t died after 30 days can no longer be acceptable, especially if it is done in patients at unevaluated, but high risk of catastrophic disability, cognitive impairment and needing a nursing home. Even so, the focus must be effective action, not endless assessment. Likewise, physicians should not be allowed to opt out of dementia care by claiming that there is nothing to be done.

Attitudes must change. Too often we believe that the best care providers should treat only young people with single system problems. In truth, many such patients will survive even indifferent care. Frail older people, however, need highly skilled care to get through. They offer early warning of system inadequacies.

In consequence, any reforms that help them will improve care across the board. This is the opportunity: facing up to frailty can result in better, more cost-effective healthcare for everyone.