How do Primary Care Clinicians manage frailty? A qualitative interview study in England

Context: In 2017 NHS England introduced proactive identification and management of frailty into the GP Contract. GPs were instructed, at a minimum, to conduct a medication review, falls assessment and gain consent to health record sharing for all patients with severe frailty, but no additional funding was provided. Previous research has shown frailty identification in primary care is ad hoc and opportunistic with varying understanding of what frailty is. Little is known as to how this is translated into practical management, particularly within the context of both growing demand and the changing structure of primary care workforce.

Objective: Explore the views of primary care clinicians in England on the management of frailty

Study Design and Analysis: Semi-structured interviews were conducted with primary care staff across England, including General practitioners (GPs), physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 13).

Setting: Primary care staff were interviewed from twenty-seven locations across England. Practices varied in size, location, age distribution, ethnic diversity and socio-economic deprivation.

Results: 31 practitioners participated. Clinicians described how managing frailty was intuitive and governed by patient needs, rather than following a policy directive. Decision-making was often complex, with few clinical guidelines available. Senior clinicians, particularly experienced GPs, were more comfortable with managing risk and had longitudinal relationships with their patients. This helped to prioritise patient wishes and autonomy, for example to remain at home despite deteriorations in health. There was little emphasis placed by interviewees on interventions to delay or prevent decline in frailty, Some healthcare providers had established frailty reviews similar to a complex geriatric assessment (CGA), undertaken by advanced clinical practitioners. This model was viewed as highly successful, particularly for personalised care planning.

Conclusions: There remains a large evidence gap for how frailty is best managed in primary care. Provision of holistic care for those living with frailty in general practice is best done through relational care, with involvement of an experienced clinician who is able to manage complexity in accordance with patient priorities.