Small steps become giant leaps for frailty care

NHS England’s National Clinical Director for Older People and Person Centred Integrated Care reflects on recent regional frailty meetings:

One of the real privileges of being a National Clinical Director is having the opportunity to get out, meet new colleagues and hear first-hand what is going on all around the country.

I am pleased to report that in its 70th Year, our NHS and its partners are going strong and doing what they do best, with huge enthusiasm, creativity and commitment to respond to the rapidly emerging challenges of our ageing population.

During a recent run of five regional frailty meetings together with colleagues from NHS Right Care and Getting it Right First Time (GIRFT) we toured the whole country.

For the first time in England these meetings brought together regional teams including commissioners, system leaders, service providers, innovators and, importantly, older people and carers from across the regions to exchange knowledge, learn from good practice and hear about the local challenges. I was particularly struck by how much great work is going on everywhere.

With high profile support from the Regional Medical Directors, their teams and the Academic Health Science Networks, the events were over-subscribed and hugely successful. Importantly they achieved our objective of bringing greater clarity of purpose focused on healthy ageing while responding to the needs of older people with frailty.

We have been encouraged by the enthusiasm of all participants in working together to develop shared priorities focused on sustainably addressing the needs of older people living with frailty. I am equally impressed by the collective enthusiasm expressed for provoking positive change towards ageing well in local populations.

Among the many themes which emerged from the meetings I would especially pick out the following as noteworthy actions for the forthcoming year:

  • Raising the profiles of fitness and frailty prevention as a positive opportunity to promote ageing well
  • Developing and sharing strategic plans for frailty care across integrated care systems
  • Actively sharing existing good practice examples within and between care systems
  • Ensuring that routine frailty identification is embedded throughout care systems
  • Moving from exclusively reactive care to proactive care approaches
  • Focusing on falls risk identification and prevention
  • Engaging proactively with and supporting care homes
  • Smoothing complex patient pathways and creating single access points
  • Working in partnership with academic teams and innovators on active ageing
  • Working productively with community assets and partner organisations including fire and rescue services to promote home safety and wellbeing

Alongside these we consistently heard about a number of key challenges:

  • The desire for cultural change towards closer organisational planning and working facilitated by positive risk taking
  • The requirement for shared narratives which cut across professional and organisational boundaries, and focus on the dual aims of both achieving active ageing and meeting the needs of those living with frailty
  • The need for meaningful and consistent communication between organisations, professionals, patients and carers to build productive relationships

None of this is going to happen overnight and reassuringly I believe we are all clear that this nationally important work requires careful, diligent and sustained effort. That said we are making tremendous progress. For the first time anywhere in the world we are as a country collecting systematic data on frailty and have established frailty registers in general practice in a very short time scale.

I strongly recommend you take a look at the data we have already amassed and which has been analysed.

So what next? The NHS England offer developed from the regional events is designed to keep up the momentum:

  1. Supporting effective population sub-segmentation using the electronic frailty index
  2. Using this information to guide planning and share learning
  3. Supporting best use of effective information using linked data
  4. Promoting peer to peer networking through providing access to the Kahootz forum for frailty (joining details can be provided from
  5. Supporting local work on agreeing care standards and ambitions for frailty
  6. Supporting effective care planning for older people living with frailty
  7. Promoting workforce development with the Core Capabilities Framework for frailty
  8. Supporting effective local commissioning through integrated health and care systems to support older people to stay healthy, independent and live safely in their home or community.
  9. Develop and refine over time NHS Right Care and GIRFT Frailty pathways and data packs.

And in July we invite you to join a series of regionally focused follow up webinars to keep the conversations going:

Regional Event follow up Webinar time table and links


Date: Monday 9 July 2018
Time: 12:30pm to 13:30pm




Date: Tuesday 10 July 2018
Time: 12:30pm to 13:30pm



South West

Date: Tuesday 17 July 2018
Time: 12:00pm to 13:00pm




Date: Monday 23 July 2018
Time: 12:00pm to 13:00pm


Register – Password is: 993 264 304

Martin Vernon

Professor Martin Vernon was appointed National Clinical Director for Older People and Person Centred Integrated Care at NHS England in 2016.

He qualified in 1988 in Manchester and following training in the North West he moved to East London to train in Geriatric Medicine where he also acquired an MA in Medical Ethics and Law from King’s College. He returned to Manchester in 1999 to take up post as Consultant Geriatrician building community geriatrics services in South Manchester.

Martin was Associate Medical Director for NHS Manchester in 2010 and more recently Clinical Champion for frail older people and integrated care In Greater Manchester. He has been the British Geriatrics Society Champion for End of Life Care for five years and was a standing member of the NICE Indicators Committee.

In 2015 Martin moved to Central Manchester where he is Consultant Geriatrician and Associate Head of Division for Medicine and Community Services. He also holds Honorary Academic Posts at Manchester and Salford Universities and was appointed as Visiting Professor at the University of Chester in 2016.

In 2017 he became Chair of the NHS England Hospital to Home Programme Board and is working on National Frailty Care with NHS Improvement.

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  1. Jody says:

    I was wondering if you could point me in the right direction regarding a visual representation of the integrated care pathway for frail older adults?

  2. beverley marriott says:

    will there be any regional frailty meetings in 2019 and if so will the details be shared eg twitter

    • NHS England says:

      Hi Beverley

      Thank you for enquiry, the regional frailty events delivered in 2018 were a follow up to the successful National Frailty event held in Leeds in 2017. The aim was to bring together National Programmes and Regional Stakeholders to exchange knowledge, learn from good practice, discuss the local challenges and consider how they could support STPs in improving the quality of care for people with frailty. There are no further regional frailty event planned for 2019. I would suggest you make contact with the appropriate regional event lead identified within this blog to see if there any local regional frailty event planned.

      Kind Regards
      NHS England