Overloaded GPs’ capacity to support older people reduced by NHS digital access push, says new PAC report

- PAC report warns of failure to deliver preventative care for people with frailty, highlights unacceptable postcode lottery in support  

NHS England (NHSE) has overloaded GPs with new and expanding priorities, with consequences for their ability to support older people. In a new report on support for people with, or at risk of, frailty*, the Public Accounts Committee (PAC) voices concern that GPs might not be prioritising care for this group, with limited capacity taken up with delivering NHS England's priorities on improving patients' access and digital access to general practice.

GPs are contractually required by NHSE to identify, assess and support people living with frailty. The PAC's report makes clear that many GPs are not currently able to deliver on these requirements. The GP contract requires the identification of any registered patient aged 65 years or over who is living with moderate or severe frailty – but just 17% of patients aged 65 or over were assessed for frailty in '24-'25. Of the 226k people diagnosed with severe frailty in the same year, only 16% had a medication review, and 18% had a falls risk assessment. This is not acceptable care, where the GP contract sets out that 100% of this group should receive these follow-up actions.

In evidence to the PAC's inquiry, NHSE recognised that it had pushed GP practices very hard over the past couple of years to improve access, and that pushing to improve one aspect of care inevitably causes consequences to appear elsewhere – in this case, support for people with frailty. It told the PAC that it is looking at other healthcare professionals sharing the service, such as community pharmacists undertaking medication reviews – but the inquiry received evidence from pharmacists keen to do this work who told the PAC it is not adequately funded.

The PAC is calling on NHSE to set out the basis on which it considers GPs have the capacity to deliver the full range of services and responsibilities expected from them.

The report further highlights significant and unexplained regional variation in support for people with frailty. In '24-'25, 32 of 106 local NHS areas assessed less than 10% of their registered patients aged 65 or over. Better performance is clearly possible with existing resources, as nine of these areas assessed 90% or more of this group.

While NHSE accepted that the position with regard to frailty is “not acceptable,” the PAC's report warns that it is not clear exactly who is responsible for improving performance between local health boards who commission services, and those, including GPs, who deliver these services. The PAC warns that this divided system could lead to no-one being responsible.

The report comes in the context of NHSE's planned 50% cuts to local health boards, announced in April 2025. Boards will be planning large-scale redundancies to achieve these, with some current functions to be transferred away from them. The PAC has deep concerns that the government's planned cuts to local health boards are insufficiently thought-through, and will harm their ability and capacity to carry out their important work. Further, it risks undermining well-performing boards, while limiting the ability of poorly-performing ones to improve. The PAC expects to return to this issue during the current Parliament.

Sir Geoffrey Clifton-Brown MP, Chair of the Public Accounts Committee, said: “Those at risk of frailty need preventative and follow-up care – indeed, the value of this kind of care is so well-established that it is a requirement in GPs' contracts. Yet our report shows that in too many parts of the country GPs are simply unable to do this important work, overloaded as they have been with new and expanding priorities from NHS England. NHSE needs to take a long hard look at what it expects from both the wider health system and from GPs, who are only human beings, running already complicated operations, and with limited resources.

“NHSE and government must also closely assess the impacts of changes they wish to make, including the cuts to local health boards, the concerns around which we have raised since they were announced and to which we will keep returning until we secure true reassurance.  NHS England has been hyper-focused on ensuring people's access, and digital access, to general practice. Given the well-established challenges in these areas, this is of course understandable. However, we have an ageing population in this country, with millions of people at risk of frailty. Our report must act as a warning that any success in ensuring such access must not be built by a system turning its face away from older people as it prioritises other things.”

*Notes to editors

Medical professionals use the term ‘frailty' to identify the group of older people who have the highest risk of adverse outcomes such as disability, falls, hospital admission and the need for long-term care. It is a medical syndrome linked to ageing, in which the body gradually loses its reserves, making people more vulnerable and dependent on care.

PAC report conclusions

GPs are not doing enough to identify and support people living with frailty. It is clear that GPs are not delivering their contractual requirements, with only 17% of their patients aged 65 or over recorded as assessed in 2024-25. There is also poor performance on follow-up support for people with severe frailty, the most vulnerable group, where 100% of people should receive the key follow-up actions. In practice, only 16% had a medication review, 18% a falls risk assessment, and 29% gave consent for an enriched summary care record. NHSE accepts frailty assessment rates and follow-up support need to improve but has not provided convincing evidence how this will be achieved.

Recommendation 1. NHS England and the Department of Health & Social Care should set out, by the end of 2026, how they will ensure GPs assess more people with frailty and provide the severely frail with adequate support.

NHS England is not reducing the unacceptable variation in support for people with frailty across and within Integrated Care Boards (ICBs). There is significant and unexplained regional variation between areas – 32 out of 106 local NHS areas assessed less than 10% of patients aged 65 and over. The NICE's guidelines specify that any patient living with frailty who has fallen in the past year should be offered a comprehensive falls risk assessment and comprehensive falls management. However, in 2024-25, only 30% of local NHS areas could have followed NICE guidelines. NHSE acknowledges that there is variation and told the Committee that it is asking ICBs, particularly those who stand out as poorly performing or with low numbers of people assessed and supported, to tackle this under-performance.

Recommendation 2. NHS England should seek to reduce variation in support for people with frailty by establishing a threshold for intervening in areas of poor performance. Alongside its response to this report, it should write to the Committee to set out the nature of that intervention.

NHS England's existing oversight arrangements are not improving GPs' assessment and support of people with frailty. It is not clear exactly who is responsible for improving performance. NHSE considers that ICBs are responsible for commissioning services to meet the needs of their population; and that the service providers must ensure that the services they are commissioned to provide are delivered. We are concerned that this divided system could lead to no-one being responsible. NHSE is aware that this system of accountability is challenging for ICBs given the large numbers of providers in general practice and community services. In the future, NHSE intends to hold ICBs to account for commissioning against the promised modern service framework, and expects there will be data from a national frailty dashboard to support the framework. However, it is still finalising details of how this will work.

Recommendation 3. The Department of Health & Social Care and NHS England should set out how new accountability arrangements will improve how GPs assess and support people living with, or at risk of, frailty.

NHS England has overloaded GPs, who have limited capacity, with new and expanding priorities. NHSE has prioritised improving patients' access and digital access to general practice. It recognises that pushing to improve one aspect of care inevitably causes consequences to appear elsewhere, in this case, support for people with frailty. NHSE is looking at interventions that could be done by other healthcare professionals in primary care. For example, NHSE is looking to step up the clinical service provided by community pharmacists including undertaking medication reviews for people with frailty, rather than being just a dispensing service. If this is to be case, community pharmacists must be properly funded to do this work. The Committee is reporting separately on the New Hospital Programme which makes assumptions about the level of work that will be shifted to primary care and which is heavily dependent on more care being delivered in the community. We expect the Department to demonstrate joined-up thinking on capacity and patient flows for primary, community and acute services.

Recommendation 4.

1. a) NHS England should set out the basis on which it considers GPs and general practice have the capacity to deliver the full ranges of services and responsibilities expected from them.
2. b) Alongside this, NHS England should write to the Committee with details on what they have done to assess of the expected impact of new and expanding priorities on continuity of care for patients with frailty and for digitally excluded patients with frailty.
3. c) NHS England and the Department of Health & Social Care should also set out how neighbourhood health teams will share responsibilities and balance the load of assessing and supporting people with frailty.

The frailty policy landscape is confusing and fragmented. NHSE and the Department are planning and developing several frailty specific initiatives, such as a national frailty dashboard, and a Modern Service Framework for frailty and dementia. There are also a number of broader developments which may affect service provision for frailty, such as neighbourhood health, new funding models for ICBs and a refresh of the Better Care Fund. It is unclear whether or how these different initiatives will overlap and interact. It is encouraging that NHSE has commissioned a National Institute for Health and Care Research-led evaluation of frailty pathways and interventions, because it understands that it needs more evidence about which interventions work best. However, it is also concerning that NHSE does not have a clear idea as to whether the range of frailty interventions currently available actually work.

Recommendation 5. The Department of Health & Social Care should write to the Committee within six months with an update setting out  how all frameworks, policy initiatives and dashboards relevant to frailty provision interact and support one another.

We remain deeply concerned that cuts to ICBs are insufficiently thought-through and will undermine their ability and capacity to carry out their functions. It is unclear what oversight roles ICBs will retain under NHSE's plans to make them into strategic commissioners. On 1 April 2025, NHSE announced that ICBs had to make 50% cost reductions. To achieve this, ICBs are planning large scale redundancies and NHSE will transfer some of ICB's current functions away from ICBs. The planned reduction in resource across all ICBs risks undermining well-performing ICBs while limiting the ability of poorly-performing ICBs to improve. This is a matter that we expect to return to during the course of this Parliament.

Recommendation 6. NHS England and the Department of Health and Social Care should set out what further reassurances they can provide to the Committee that ICBs' cost reductions will not impact on ICBs' ability and capacity to carry out their functions effectively.