GP views on the routine identification and management of frailty in primary care

Problem

The 2017/18 General Medical Services (GMS) contract requires primary care providers to use electronic tools to risk-stratify for frailty all patients over 65 years of age. Those patients flagged as moderately or severely frail should be clinically reviewed and if severe frailty is confirmed, providers have been asked to offer relevant interventions. These include an annual medication review, sharing of the summary care record and if applicable referral to a falls prevention scheme. However, little is known about how this is being operationalised. The aim of this study was to improve our understanding of the ways in which the frailty contractual requirement is being implemented in primary care and the barriers and facilitators GPs encounter when routinely identifying, risk-stratifying and providing interventions for people living with frailty in primary care.

Approach

This was a 2-part study- a survey via online questionnaire to recruit participants, selected by maximum variation sampling, for a follow-up semi-structured telephone interview. All GPs working in the East Midlands region (Derbyshire, Leicestershire, Lincolnshire Nottinghamshire, Northamptonshire) were eligible to take part. A written invitation to participate in the survey was circulated electronically through primary care newsletters and direct GP email. The questionnaire and interview schedule were developed following a review of the literature, peer-reviewed by an expert advisory group from NHS England’s Older People team and piloted with 8 and 3 GPs respectively. The questionnaire collected demographic information, responses to a series of Likert-type statements assessing GPs' knowledge and attitudes and provided an opportunity for the GP to volunteer for a follow-up interview. The interview schedule consisted of 3 stem questions exploring practice systems to identify patients living with frailty, subsequent actions and how it was implemented. The online questionnaire was analysed using descriptive statistics. Interview recordings were transcribed verbatim and transcripts were analysed using framework analysis.

Findings

188 GPs responded to the survey from a possible 3,058 GPs (response rate 6%) and 18 GPs were interviewed. GPs held mixed attitudes towards stratification and pro-active identification of people living with frailty, underpinned by a lack of understanding about frailty and frailty stratification. GPs found an increase in workload from both undertaking reviews and uncovering unmet need. Many GPs found the usefulness of electronic tools hampered by a lack of sensitivity and specificity.

Consequences

The study has highlighted a range of factors which influence the ability of primary care services to proactively identify and manage older people living with frailty. The findings will inform the ongoing development of NHS England policy on the GMS frailty contractual requirement for primary care providers, development of frailty educational interventions for primary care healthcare professionals and further research about appropriate service configuration.