- Early identification of frailty and timely support can slow
its progression, helping older people maintain independence and
live healthier lives
- People living with severe frailty are nearly six times more
likely to be admitted to hospital compared to those not living
with frailty
- There are clear failings in how GPs1 assess and
support people living with frailty, with worrying unexplained
variation in practice across England
A new report from the NAO looks at how the NHS identifies and
supports people living with or at risk of frailty before they
reach the point of medical crisis or hospital admission. With the
population aging, the NAO finds GPs are not providing the
required support and follow-up for people diagnosed with frailty.
There are at least 1.5 million people aged 65 or over living with
frailty in England. Frailty is a clinically recognised medical
syndrome related to the ageing process in which multiple body
systems gradually lose their in-built reserves. People living
with frailty get exhausted easily and are more likely to be
housebound.
The GP contract requires GPs to identify any registered patient
aged 65 years or over who is living with moderate to severe
frailty. However, in 2024-25 GPs only assessed one in six
patients aged 65 or over for frailty (1.9 million people). This
is well below the one in four assessed when the requirement
was introduced in 2017-18.
Once they have assessed patients GPs are not providing the
required support and follow-up for people diagnosed as living
with severe frailty. Of the 226,000 patients diagnosed with
severe frailty in 2024-25, only:
- 16% (37,000)
had a medication review;
- 18% (41,000)
had a falls risk assessment; and
- 29% (66,000)
had given consent for an enriched summary care record.
There is significant variation in the proportion of patients who
were assessed for frailty across the country. The report finds a
worrying inconsistency in delivery of the required support and
follow-up for those diagnosed as living with severe frailty.
Support that GPs provide under the Enhanced Health in Care Homes
programme is deteriorating in some important aspects of care. For
example, the percentage of residents who had a personalised care
and support plan agreed or reviewed has fallen sharply, from 76%
in 2022-23 to 44% in 2024-25.
Urgent community response services are meeting targets. The aim
of urgent community response teams is to provide urgent care to
people in their homes which helps to avoid hospital admissions
and enables people to live independently for longer.
The 2025 10 Year Health Plan did not explicitly introduce any
further developments on frailty although it set out the intention
to develop several new service frameworks, with early priority
given to frailty. The more recent planning guidance mentions
frailty as a priority for the new neighbourhood health service
and asks for growth in community health services.
The NAO report makes a number of recommendations, including:
- NHSE should set clear and consistent requirements for GPs to
assess and support people living with frailty
- NHSE should set out a timetable for its work to standardise
community health services and details on how community health
services will align with and support the move to neighbourhood
health services
- DHSC should commission a systematic evaluation to demonstrate
whether its patchwork of frailty initiatives is working together
to provide an effective and holistic approach
, head of the NAO,
said:
“With the need for health and social care services set to
increase in our aging population, it is crucial that people with
frailty are supported effectively and consistently across the
country. Our report shows that many older people are not getting
the support they need.
“The NHS needs to seize the opportunity of the 10-year health
plan to build the more effective and sustainable service that it
recognises older people need.”
ENDS
Notes to editors
Press notices and reports are available from the date of
publication on the NAO website. Hard copies can be obtained by
using the relevant links on our website.
- We use the term ‘GPs' throughout the report as they are the
contracting party, but their work may also be conducted within a
wider general practice team.
