New Health Accord should consider ‘frailty’
John Muscedere is scientific director and CEO of Canadian Frailty Network, an interdisciplinary network dedicated to improving care of frail, elderly Canadians. He’s also a critical-care physician at Kingston General Hospital. Samir Sinha is director of geriatrics at Sinai Health System and the University Health Network Hospitals in Toronto, co-chair of the National Institute on Aging’s Advisory Board and a member of the CFN Research Management Committee.
When the previous Health Accord expired in 2014, the Harper government unilaterally established a new funding model for federal health transfer payments to the provinces and territories based on an equal per-capita basis.
Built into the model was a guarantee that no province would receive less than its 2013 transfer amount with a further guaranteed minimum three-per-cent growth rate from 2017 onward. So, what’s not to love?
Plenty. The truth is, in a country as diverse and varied as Canada, such a per-capita funding model creates winners and losers. For provinces with flourishing economies and/or younger populations, the formula may be a welcome one. But for many provinces and territories, this funding formula fails to recognize and accommodate their particular challenges and needs. This is because per-capita models fundamentally ignore the sometimes extreme variations in socio-economic, demographic and health status of regional populations across Canada — a significant oversight.
The good news is that Health Minister Jane Philpott has promised a new Health Accord to be finalized over the coming year. Atlantic premiers have banded together to call for federal health funding based on the needs of their aging populations. Other organizations, such as the Canadian Federation of Nurses Unions have similarly called for an asymmetrical fiscal transfer arrangement based on specific provincial demographic needs such as age.
The health minister could and should craft a new federal arrangement for health funding based on age, but should go one step further and include the more precise and evidence-based concept of “frailty.”
Here’s why. A model based on age alone is attractive because healthcare spending rises overall with increasing age, but not all Canadians age in the same way. Consider an individual in their 60s with multiple medical problems requiring repeated use of the health-care system compared with a healthy octogenarian with few or no health problems.
In a recent review published in the Canadian Journal of Aging, along with our colleagues, we highlight “frailty” as an essential concept that needs more attention in our health system in order to direct our precious health-care dollars efficiently — and to provide the right care at the right time to the right populations.
Frailty is common in our aging population, but it remains highly under-recognized. It’s estimated that over one million Canadians are clinically frail. Clinical frailty can occur at any age and describes individuals who are in precarious health, have significant multiple health impairments and are at higher risk of dying. The hallmark of frailty is that minor illnesses such as infections or minor injuries that would be handled easily by non-frail individuals may trigger major deteriorations in health.
Frailty is a better determinant of outcomes and health-care utilization than age alone.
Our health system came into existence when people generally died younger and more commonly with a “single-system” illness. At that time, many more of us also tended to live in intergenerational households or close to other relatives who could provide help for living independently.
Jump forward several decades and today our health system is scrambling to meet the needs of older individuals with multiple, simultaneous and often inter-related health and social issues that threaten their independence — the essence of frailty.
Simply put, our health system does not respond well to frailty.
Our current health-care structure excels at illness-specific interventions, but many of these may pose higher risks and offer lower potential benefits in frail individuals. In this context, health-care systems may provide those with frailty both too much care and the wrong kind of care. This can be expensive and harmful and also could threaten the overall sustainability of our healthcare system.
So why should the new Health Accord include an understanding of frailty — and base fiscal transfers on the concept — along with other important factors? Because a large and growing proportion of our health-care spending is and will increasingly be focused around frail older Canadians, particularly those nearing the end of life.
Systematically recognizing frailty in Canadians and targeting federal health funding based in part on frailty would both help those provinces and territories who have more significant health and social care needs in this area, but also flag the issue of frailty as one that needs to be urgently addressed across Canada.