ABSTRACT
This paper explores how the rationing of medical care for older people by frailty score was justified and operationalised in the UK during the COVID-19 pandemic. COVID-19 was expected to overwhelm the National Health Service (NHS) in the UK. In March 2020, the National Institute for Health and Care Excellence (NICE) published the ‘COVID-19 rapid guideline: critical care in adults', which advised that clinicians use the Clinical Frailty Score (CFS) to inform decisions about which patients over the age of 65 should be offered ventilatory support. We present a Foucauldian Critical Discourse Analysis of this guidance and the supporting online resources. Analysis shows how the guidance merchandises the CFS as a quick and easy-to-use technology that reduces social and physical complexity into a clinical score. This stratifies older people by frailty score and permits the allocation of resources along these lines. We show how this is justified through epidemiological discourses of risk, which are merged with the language of individual mortality prediction. We discuss the proceduralisation of the CFS alongside a growing body of research that problematises its application in resource allocation. We argue that the pandemic has increased the use of the concept of frailty and that this effectively obfuscates the concept's limitations and ambiguities;the ageism implicit in the response to COVID-19 in the UK;and the relative resource scarcity facing the UK's NHS.
ABSTRACT
BackgroundPolicymakers anticipated COVID-19 would overwhelm the National Health Service (NHS) in the UK with particular concern about critical care capacity. In March 2020, the National Institute for Health and Care Excellence (NICE) published guidance for clinicians treating people with COVID-19, which used the concept of frailty in its decision-making matrix for the care of people over the age of 65.MethodsThis research paper uses a Foucauldian theoretical approach to explore how the rationing of medical care for older people by frailty score was justified and operationalised in the UK during the COVID-19 pandemic. We present a Critical Discourse Analysis of this guidance and the supporting online resources.ResultsAnalysis shows in the guidance, the Clinical Frailty Score is merchandised as a quick and easy-to-use technology which reduces social and physical complexity into a clinical score. This process makes older people knowable within the biomedical sphere and allows them to be stratified based on frailty score. This is justified through epidemiological discourses of risk, merged with the language of individual mortality prediction. This facilitates the allocation of resources along the lines of CFS score. We discuss this proceduralisation of CFS alongside a growing body of research that problematises its application in resource allocation and frailty studies.DiscussionWe argue that the continuing dominance of frailty effectively obfuscates the concept’s limitations and ambiguities, the ageism implicit in the response to COVID-19 in the UK, and the relative resource scarcity facing the UK’s NHS.
ABSTRACT
This commentary discusses the role and value of qualitative data when undertaking quality improvement (QI) focussing on the care of older adults. To illustrate this, we reflect on our own experiences of planning a QI project to improve the documentation of Clinical Frailty Scale (CFS) scores in the emergency department (ED) during the coronavirus disease of 2019 (COVID-19) pandemic. National clinical guidance for COVID-19 states that all adults over the age of 65 should be given a CFS at the first point of contact during hospital admission. Therefore, there is a need to improve CFS documentation, specifically in acute care settings. We describe how qualitative methods facilitated an understanding of the barriers to CFS documentation in ED. Staff see the CFS as a useful tool for inter-professional communication, though there are tensions between clinical guidance and their beliefs. Staff had moral concerns about how an ED-allocated CFS might limit available treatment options for older adults. Our findings demonstrate how qualitative methods can illuminate the important social and moral dimensions of why improvement does or does not occur.