Written question WQ91342

Older people and those living with frailty are the largest group who use health and social care services. As the population continues to age, the number of people living with frailty will undoubtedly increase as well. If we do nothing differently, this will increase demand on health and social care services, and more importantly, continue to impact the health and wellbeing outcomes negatively for this population.

This means we must ensure we have a system of health and care that is attuned to the specific needs of this population, transitioning from the traditional medical model of health care to a social model of care that defines, measures and manages health in functional terms (not limiting to the treatment of physiological illness) and enabling the individual to achieve what matters to them.

Through the introduction of quality statements for major conditions such as cancer, diabetes and heart disease, we are encouraging a system-wide focus on secondary prevention. Through the optimal management of chronic conditions, the NHS can work with patients to reduce the risk of secondary complications and as a result further avoidable healthcare demand. If we can support people to manage their condition well then, we will to some extent mitigate the increasing burden on health services that results from an ageing population.

Our longer-term strategy is to develop an effective approach to referral management with clear end-to-end pathways that enable primary and community care to effectively support and manage patients with access to a wider range of care closer to home.

In January 2024 we published Older People and People and People Living with Frailty: An Integrated Quality Statement (IQS). This acknowledges frailty as a long-term condition. It sets out quality-of-life outcomes for this population, and the need for systematic identification and proactive management of frailty as a long-term condition. This is an area where the development of new data will be critical to the attainment of the aims set out in the IQS.

We expect health boards to look at the available data both in terms of healthcare demand and outcomes, to inform their planning and delivery of services. Data availability is continually improving as more parts of the healthcare journey are captured on digital records. We also expect them to work with us and their partners across the health and care landscape to support the development of new data.

In addition, we will continue to publish data on disease registers kept by GPs, broken down by age bands on Stats Wales.

New individual level data on adults with a care and support plan is also being collected for the first time for the reporting year 1 April 2023 to 31 March 2024 and includes information on disability and impairments.