This is a challenge to conventional wisdom. Meet Rose Oldham, pictured here with her GP Dr Bhatti, and our Practice Manager Lynn at my surgery donneybrook Medical centre.
I met Rose as her Practice nurse a few months ago, when up popped the dreaded tick box on the clinical records system Alert: ‘Frailty’ in front of me. A wonderful 82 year old lady with normal body habitus who bounds energetically into the clinical consultation room, carries a healthy glow, and a smile and proceeds to tell me what keeps her fit and well. Rose has a loving family, and for many years cared for her husband with Parkinson’s. She lives on her own now, and is determined to make the most of life, in the form of living and not just waiting for ‘old age’. Rose has a twinkle in her eye! She has recently fulfilled one of her lifelong ambitions to do a skydive. Not satisfied with this achievement, she tells me to watch this space, as she may yet complete a ‘wind walk’ an experience for her that would count as ‘one of life’s greatest aerial adventures’. Here is Rose pictured in all her glory!
Needless to say, none of this rich information is contained in the electronic records. Time to ask why?
The tapestry of information provided by Rose sets the scene for a truly holistic discussion around well-being. To coin a phrase by my mentor Heather Henry, this discussion leads to an ‘asset based approach to nursing care’. Rose is not a lady without any medical issues that is indeed why she has come to see me today. She has Angina, hypertension, she requires a medication review. However the bio- medical model of care labels her as ‘frail’ and the computer system asks me to initiate a conversation around her needs rather than her strengths.
Here is the official definition of frailty from the British Geriatric Society:
What is frailty? Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. Older people with frailty are at risk of unpredictable deterioration in their health resulting from minor stressor events.
Whilst I do not question the evidence around frailty, and indeed we must look closely at the quality of health and social care provision for vulnerable groups, I want to challenge the application, the assumptions and the deficit based model of care. Are we a health service or just an illness service?
How can we encourage health creating practice, when systems, policies and frameworks are designed purely on people’s deficits? Whilst it is extremely important to prevent unplanned hospital admission, and improve the quality of care we provide for older generations, it is of equal importance that we focus on what keeps people well. We have an array of good quality evidence for this, but we do not universally apply this in practice. Why?
Over the years, multiple frailty screening tools have been developed, refined and utilised for risk assessment and epidemiologic study. I believe the utility of these screening tools in the clinical setting are limited, and as Rose clearly demonstrates old age itself does not define frailty.
This is not a single story. Up and down the land, we meet greet and see people with strengths, gifts and attributes. But do we really see them? Perhaps we are not having the right kind of conversation. As cormac Russell, pioneer of asset based approaches states: we need to focus on what’s strong, not just what’s wrong. This does not mean we ignore problems, or risks. In Rose’s case, I know my GP was genuinely concerned about her safety for a sky dive, given her medical history of angina; however this was stable, and carefully negated through the power of conversation, mutual exchange, and a focus on well-being. Personal values, preferences and goals should trump over policy based practice every time. As a general practice nurse, I learned very quickly to move beyond the security of the tick box, the framework, the guideline… and to see people for who they are, and not what the system dictates they should be.
We must start from a position of strength, moving away from a culture that just deals with needs and problems. In our area, we have an award winning Healthier at home project. This combines the skills of a multidisciplinary team who work collaboratively to enable older people who really need support. This is working well, and takes a health creation focus, that sits side by side the traditional medical model of care.
The ‘Building bridges, breaking barriers’ report looked at existing integration across health and social care and the impact this has had for older people. GP magazine Pulse recently reported their concerns around the unplanned admissions designated enhanced service. ‘’ analysis of official figures showed that GP practices that devise care plans for the majority of their most vulnerable patients have higher rates of unplanned admissions.’’
We need to get this right for our future, and the stability of our beloved National HEALTH SERVICE. Yes, tap into the good, balance the big data with the stories, with what really matters to individuals, communities, families. Age UK’s vision is for a world where everyone can love later life. They achieve this by’ inspiring, supporting and enabling’ – a motto we should all adopt in general practice.
As many will continue to fill in their frailty index… I am off to start a Feisty Folk register, inspired by local people who have amazing strength, have overcome adversity & can teach us professionals a thing or two about life!
This blog was inspired by the all the red devils out there! The young at heart. Rose Oldham, Zulf Bhatti, Jocelyn Ward, Margaret Murphy, Ian Kenworth Heather Henry, john Walsh, and Lynn Wilkinson.
Practice nurse, Clinical Development Lead Practice Nursing, NHS Manchester CCG’s, GPN advisor NHS Alliance, National Executive.