Acute care of older people: Reflections on Acute Frailty Network impact

08 September 2023

In July 2023, Street et al published a paper in BMJ Quality and Safety1 analysing the impact of the Acute Frailty Network (AFN). There has been much discussion within our specialty about the findings of this paper and what this means for older people’s care. In light of this, the following statement sets out the BGS’s position on the paper, addressing why we think that focusing on older people’s healthcare is more important than ever.

The AFN was a scheme run in England by NHS Elect, using an approach called Quality Improvement Collaboratives (QICs), to help Trusts implement principles of Comprehensive Geriatric Assessment (CGA) as part of their acute pathway. The analysis compared data from 105,292 patients seen at 66 participating Trusts, with data for 1,305,135 patients from 248 Trusts which did not participate in AFN, or were not yet participating in AFN when the patients were seen.

The paper concluded that there was no difference in length of hospital stay, in-hospital mortality, institutionalisation and hospital readmission between organisations that took part in AFN and those that did not.

These findings are important, and have the potential to impact the field substantially, but they must be interpreted with caution. There are compelling data from systematic reviews that CGA for older people with frailty outperforms routine care in the acute setting.2-5 Current models of care – which do not fully incorporate components of CGA – are failing older people with frailty. The results from this analysis of engagement with the Acute Frailty Network most likely represent a failure of implementation, rather than a failure of intervention.

QICs are complex interventions which need to deliver changes in policies, procedures and behaviours in order to implement the intended intervention – in this case CGA. The study, although well designed, was not designed in such a way that the researchers could be sure that CGA had happened. The paper’s authors highlight a number of reasons these desired changes may not have been implemented – including shortage of appropriately trained staff, poor availability of age-attuned environments and inability to access early supported discharge services.

With this in mind, we need to ensure that these findings are not used as a reason to abandon efforts to improve acute frailty care. Rather, they should be seen as a call to redouble our efforts to identify and overcome the barriers to delivering CGA in acute settings.

The winter of 2022/23 saw unprecedented delays in ambulance services, emergency departments, acute medical units and for inpatients awaiting a care package or rehabilitation on discharge from hospital. In each instance it was older people with frailty who were most adversely affected. This highlights that we need to focus our attention on this group even more than previously.

Professor Adam Gordon, President of the British Geriatrics Society said:

Despite the best efforts of frontline healthcare staff, older people often receive inadequate care and experience dreadful outcomes when they become acutely unwell. It is essential that we work as a health and social care system to ensure that older people can receive rapid assessment from a specialist multidisciplinary team when they become acutely unwell, in order to support rapid institution of care and speedy return to home. The paper from Street et al shows us that even carefully designed and expertly-led quality improvement collaboratives can fail to improve outcomes for older people when they are faced with a system where resources for frailty care are deprioritised. It is essential that government and policymakers remain focussed on removing the barriers to effective care of older people if such initiatives are to fall on more fertile ground in future.”

References

  1. Street, A., Maynou, L., & Conroy, S. (2023). Did the Acute Frailty Network improve outcomes for older people living with frailty? A staggered difference-in-difference panel event study. BMJ Quality & Safety. https://doi.org/10.1136/BMJQS-2022-015832
  2. BANERJEE, J., CONROY, S. P. & OTHERS 2012. The Silver Book: quality care for older people with urgent & emergency care needs. http://www.bgs.org.uk/index.php/bgscampaigns-715/silverbook.
  3. BERTFIELD, D. & CONROY, S. 2020. Acute care for older people living with frailty. London: Royal College of Physicians.
  4. NHS BENCHMARKING NETWORK 2016a. Older people's care in acute settings Benchmarking Report [internet] accessible from http://www.nhsbenchmarking.nhs.uk/CubeCore/.uploads/Marketing/201617%20p....
  5. GETTING IT RIGHT FIRST TIME (GIRFT). 2017. GIRFT national report on geriatric medicine [Online]. London. Available: https://www.gettingitrightfirsttime.co.uk/medical-specialties/geriatric-... [Accessed 31/8/22].
  6. BLEIJENBERG, N., DRUBBEL, I., SCHUURMANS, M. J., DAM, H. T., ZUITHOFF, N. P. A., NUMANS, M. E. & DE WIT, N. J. 2016. Effectiveness of a Proactive Primary Care Program on Preserving Daily Functioning of Older People: A Cluster Randomized Controlled Trial. Journal of the American Geriatrics Society, 64, 1779-1788.
  7. BLOM, J. W., VAN DEN HOUT, W. B., DEN ELZEN, W. P. J., DREWES, Y. M., BLEIJENBERG, N., FABBRICOTTI, I. N., JANSEN, A. P. D., KEMPEN, G. I. J. M., KOOPMANS, R., LOOMAN, W. M., MELIS, R. J. F., METZELTHIN, S. F., MOLL VAN CHARANTE, E. P., MUNTINGA, M. E., NUMANS, M. E., RUIKES, F. G. H., SPOORENBERG, S. L. W., STIJNEN, T., SUIJKER, J. J., DE WIT, N. J., WYNIA, K., WIND, A. W., GUSSEKLOO, J. & CONSORTIUM, T.-M. R. 2018. Effectiveness and cost-effectiveness of proactive and multidisciplinary integrated care for older people with complex problems in general practice: an individual participant data meta-analysis. Age and Ageing, 47, 705-714.
  8. CARE, N. R. 2019. NHS RightCare: Frailty Toolkit. London: NHS England.
  9. CONROY, S. P., BARDSLEY, M., SMITH, P., NEUBURGER, J., KEEBLE, E., ARORA, S., KRAINDLER, J., ARITI, C., SHERLAW-JOHNSON, C., STREET, A., ROBERTS, H., KENNEDY, S., MARTIN, G., PHELPS, K., REGEN, E., KOCMAN, D., MCCUE, P., FISHER, E. & PARKER, S. 2019. Health Services and Delivery Research. Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study. Southampton (UK): NIHR Journals Library