02/09/2015 07:20 BST | Updated 01/09/2016 06:59 BST

Frailty Care: Home Is Where the Health Is

Just a few weeks ago, news broke that Gill Pharaoh - a healthy 75 year old retired nurse - had chosen to end her own life at a Swiss suicide clinic. Whatever your stance on euthanasia or assisted suicide, for me the story raised another very important question. Can our health service truly support an aging population?

I don't just mean in terms of resources - monetary or medical. I also mean in terms of attitudes and approaches.

Gill had no long term conditions; no life threatening illness. She did have "a few aches and pains", minor ailments and a feeling that her life was complete. Deteriorating with old age was not a future she wanted, nor did she intend to become "an old lady blocking beds in a hospital ward". Her decision to end her life at 75, she felt, would "save the NHS a fortune". Her words should be our worry.

Are we now faced with a generation whose fear of becoming burdensome to our health service is so great that it becomes an illness itself?

If so, things really need to change. Nobody should have this concern as they grow older.

But how can we change things? NHS Trusts have a deficit in excess of £800m, there is a national GP shortage, a population where 17.7% are over the age of 65 and A&E departments are stretched to (and in many cases beyond) capacity. It's little wonder that 'contributory fear' is setting in among those who need help most.

Many older people don't have conditions that need urgent medical attention or immediately life-threatening illnesses; yet they do end up in A&E. What's needed to help this group is adequate care for what are often multiple long-term conditions - long before admission to hospital is even a consideration.

The answer is simple: treat patients as people first, by assessing what factors might have a negative impact on their health as frail and elderly individuals, and then implementing a proactive support mechanism. Help people to stay at home with the right kind of support and you'll help them to stay healthy.

How do I know this? Not just because I'm a son of a frail father, it's also because, through my role at EMIS Group, I'm in the fortunate position of seeing the numerous real-world benefits of this kind of frailty care.

In Camden, for example, there are multidisciplinary teams - spanning primary, secondary, community and social care - who coordinate care plans for the borough's vulnerable elderly patients.

Rather than being sent for episodes of care from different health providers who may not necessarily talk to each other, 'at risk' patients get a bespoke and holistic plan.

This approach utilises a shared IT system to ensure healthcare providers across the borough, including community nurses, social workers, GPs and hospital teams, are aware of real-time care and treatment updates. The aim is to ensure that people avoid hospital admission through "early intervention, prevention and recovery".

It is proving highly effective. In just one year there was a reduction in 'emergency bed days' of 51%, and 47% fewer A&E visits.

In Gateshead, an award-winning GP practice pilot is managing frailty in the community with the same sort of personalised care planning.

Oxford Terrace and Rawling Road Medical Group (OTMG-RR) identified elderly patients who did not necessarily need care from community matrons but who were at risk of hospital admission because of broader health or social issues associated with age and frailty.

South Tyneside NHS Foundation Trust recruited an older persons specialist nurse (a post now substantive in the practice) to co-ordinate and implement care plans as part of an 'extended family' of healthcare providers, including practice GPs, nurses, primary care navigator, a practice-based Occupational Therapist and community matrons. A shared IT system ensures all healthcare staff collaborate on care plans.

In just nine months, A&E attendances and admissions were down by 54% and the number of GP house call requests had dropped by 81%.

Both these projects have demonstrated that change is possible without radical disruption. We don't need a new healthcare system; we need to follow examples like these.

The reductions that were achieved in hospital visits and admissions shows how the NHS can benefit from this strategy - co-ordinated, proactive care is the sustainable future of our health system. I'm also convinced that projects like Camden and Gateshead have more far-reaching implications for our communities and for the relationships between generations.

Positive frailty care that favours early intervention over necessary treatment means that older people are much less likely to fear becoming a burden on society. That's an outcome that's as good for humanity as it is for healthcare.