Introduction

The Medium Term Planning Framework, Neighbourhood health framework and the 10 Year Health Plan for England all identify people living with frailty as a priority cohort and emphasise the need to shift care and resources from hospitals into coordinated, community-based neighbourhood health services. This national direction underscores the importance of proactive, planned, and responsive community-based provision for people living with frailty.

This best practice guide sets out the priorities and related key actions to help ensure people living with frailty and those who support them experience high-quality care and support: co-ordinated, compassionate care that is personalised, consistent, and easy to navigate. Strengthening communication, continuity of care and shared decision‑making is essential to improving outcomes and the lived experience of patients, carers, and families.

Integrated care boards (ICBs) and relevant providers should take these actions now to commission and drive improved performance of frailty pathways, ahead of publication of the modern service framework for frailty and dementia later this year, to plan, deliver and integrate frailty care across health and social care settings, with a specific focus on:

• increasing identification and assessment, including maintaining frailty case lists, recording frailty status in electronic patient records (EPRs) and increasing the use of Comprehensive Geriatric Assessment (CGA), advance care planning and personalised care and support planning.
• improving frailty-attuned hospital care, including the delivery of acute frailty service or same day emergency care (SDEC) and CGA at front door approaches, and understanding local community pathways to streamline neighbourhood enabled discharge.
• using linked data to understand need, commission and plan delivery of services, and track outcomes across systems.
• the modern service framework for frailty and dementia, which will define the frailty pathway and associated enablers further.

Key enablers

These actions are supported by evidence from areas across the country that have implemented them effectively. They are underpinned by the key enablers below that drive improvements in care for people living with frailty:

• Strong organisational and place-based collaborative leadership across clinical, managerial, health and social care teams.
• Consistent use of recognised change methodologies, supported by clear measurement and improvement practices, such as routine use of plan-do-study-act (PDSA) cycles, quality improvement dashboards, local audit templates, and clear improvement goals and trajectories.
• A frailty-attuned, well-supported workforce, including education and training; strong collaboration with social care, voluntary, community, faith and social enterprise (VCSFE) partners, and local communities; and engagement of senior responsible clinicians (GPs, geriatricians, consultant practitioners).
• Clinical safety through adherence to recognised clinical safety standards, including risk management for virtual wards (including hospital at home), robust governance for interoperability of shared care records/EPR interoperability and medication safety processes (for example, polypharmacy review and deprescribing protocols).
• Aligned and supportive financial arrangements across the system.

Their early implementation will help systems prepare for the forthcoming modern service framework and align with the shift in care provision from hospital to the community for this population group.

They should be delivered in conjunction with other national priorities and frameworks, such as:

• NHS England Urgent and emergency care plan 2025/26
• NHS England FRAIL strategy
• NHS England The Model Acute Pathway: standards for care of acutely unwell patients in their first 72 hours in hospital
• Proactive care: providing care and support for people living at home with moderate or severe frailty
• GIRFT guidance on co-ordinated frailty care for better outcomes
• British Geriatrics Society (BGS) Joining the dots: a blueprint for preventing and managing frailty in older people
• BGS Reablement, rehabilitation, recovery: everyone’s business
• BGS Be proactive: proactive care for older people with frailty

Metrics

Each action suggests key metrics for commissioners and providers to collect locally and use to monitor frailty-attuned care (for example, at ICB, provider, neighbourhood, and place level). They are not nationally mandated or collected as part of a single national return. Regional and national metrics for assurance will be set during development of the modern service framework.

The suggested metrics are not exhaustive and should be refined locally to include the outcome and experience measures that matter most to local communities and the quality, safety and outcome measures and patient-reported outcome and experience measures (PROMs/PREMs) that are available locally. PROMs and PREMs are important to understanding whether improvements in services translate into better quality of life, independence and experience for people living with frailty and those who support them.

If you have any queries on this guide, please contact england.frailty.improvement@nhs.net.

Key actions to improve services for people living with frailty

1. Use high-quality linked data to understand current and projected frailty service demand and delivery costs
2. Systematically identify people living with frailty, and maintain active frailty case lists, across all settings using a single frailty risk stratification dataset tool across a system
3. Increase the number and quality of care plans, and home-based assessments, including where appropriate advance care plans
4. Ensure frailty care plans and assessments are visible and actionable by relevant providers and by the patient themselves
5. Develop comprehensive neighbourhood-level frailty plans that align with ICS priorities
6. Provide at least 70 hours a week of acute frailty service/same day emergency care services
7. Provide multi-agency frailty training together across professions including on frailty attuned advance care planning conversations
8. Invest in the expansion of community health services and the primary care workforce

The detail for each action below sets out how best practice in a frailty-attuned system could look like. If resources require prioritisation, a Rockwood Clinical Frailty Scale (CFS) of 5+ is suggested as a target population for frailty intervention and outcomes monitoring. This supports better identification of emergent need and, as local resource allows, means more preventative intervention to slow frailty progression. This should deliver better outcomes for individuals and lower associated healthcare use and cost, with data suggesting that spend on frailty is currently concentrated on those with a CFS score of 6 or more.

Understanding need and resource planning

Action 1

Use high-quality linked data to understand current and projected frailty service demand and delivery costs; track prevalence and outcomes (including functional decline); identify opportunities to shift care from hospital to community; and monitor the impact of neighbourhood-level frailty plans on services.

As a minimum, use the Community Services Data Set, primary care data (including the use of the Electronic Frailty Index) and secondary care data but consider including ambulance, virtual ward, mental health and adult social care data.

This approach will deliver a comprehensive overview of current service provision and prevalence, facilitating informed strategic commissioning and local planning to enhance frailty services in accordance with this guidance and the upcoming modern service framework for frailty and dementia.

Person-centred statement: over time, people living with frailty, their families and carers, will experience more coordinated care, including supported self-management, because services use linked data alongside an individuals’ wishes, preferences and lived experience to understand their needs, ensure continuity and act early to prevent deterioration.

Owner: ICBs through dedicated leads across executive, managerial, and clinical teams with support from primary care, community health services, and acute hospital providers

Case study: South West London Integrated Care System (ICS) has developed a comprehensive health insights dashboard by integrating high-quality linked data from primary, secondary and community care, social care, and ambulance services. This connected dataset demonstrates bold, strong multi-sector leadership, enabling the application of both the hospital frailty risk score (HFRS) and the electronic frailty index (eFI) and allowing accurate identification and mapping of frail patients aged over 65 across the region. The dashboard highlights areas with high prevalence of frailty and tracks service utilisation, revealing that a small cohort with moderate or severe frailty need a disproportionate amount of resources.

Using this data, the ICS models the impact of potential shifts in care – such as moving patients from emergency departments (EDs) to community-based interventions for example proactive care, Home First and virtual wards (including hospital at home) – by analysing cohorts with short hospital stays and estimating avoidable admissions. The Kingston and Richmond proactive anticipatory care model demonstrates significant financial impact and a strong return on investment, strengthening its business case for scaling proactive care across the system. This approach is highly scalable, with clear roles and identified enablers allowing replication across the country, underpinned by multi-sector collaboration and a proven return‑on‑investment‑driven case for change.

Key metrics:

• neighbourhood health services activity per 1,000 people living with frailty and associated cost
• urgent and emergency care services activity per 1,000 people living with frailty and associated cost
• elective and non-elective inpatient admissions per 1,000 people living with frailty and associated cost

Identification, assessment, and care planning

Action 2

Systematically identify people living with frailty and maintain active frailty case lists, across all settings using a single frailty risk stratification dataset tool across a system such as CFS, also referred to as the Rockwood Clinical Frailty Score. Ensure frailty status is recorded in EPR systems and is shared and visible between relevant health, social care and VCFSE providers and other appropriate organisations.

Oversight and co-ordination of this case list should sit with the neighbourhood multidisciplinary team (MDT), who collectively hold responsibility for holistic need identification, proactive case finding and care coordination across organisational boundaries. Using population health management approaches, combining linked datasets, risk segmentation, and predictive analytics will drive proactive case-finding, support earlier recognition of frailty and the targeting of services where they are needed most.

Person-centred statement: people who are at risk of or living with, frailty will receive timely, appropriate support wherever they access, with their priorities, preferences and lived experience captured and recorded. This will shape assessment and follow‑up, allowing people to maintain or maximise their independence at home for as long as possible.

Owner: primary care, community health services, integrated neighbourhood teams and acute hospital providers

Case study: Mid and South Essex ICS developed the Athena Population Health Management (PHM) segmentation model to enable proactive, system wide frailty risk identification using linked datasets from primary care, community services, mental health, acute hospitals, emergency services, and adult social care.

The dynamic PHM model was created collaboratively by clinical experts and business intelligence analysts and is now embedded as business as usual across the ICS to support earlier and more accurate identification of people at risk of frailty, tracks transitions between frailty levels (including towards end of life) and help target timely interventions. This progress has been strengthened by a well-supported workforce and clear resource arrangements that enable teams to work with confidence. To strengthen consistent frailty assessment, the ICS implemented practitioner-validated CFS coding across all provider EPR systems. A shared electronic frailty registry (eFraCCS) provides real-time visibility of frailty populations across providers, enabling unified case management and a single data source for reporting frailty-specific key performance indicators (KPIs) across all teams. In under 2 years, over 20,000 additional people received validated CFS scoring, enabling more coordinated neighbourhood-level proactive care and targeted evidence-based support.

Key metric:

• percentage of the expected frailty population (CFS 5+) with practitioner validated frailty staging recorded across all relevant provider EPR systems (versus PHM modelled prevalence)

Action 3

Increase the number and quality of care plans, and home based assessments, for people living with frailty, using CGA and, when appropriate, advance care plans (ACPs) to ensure more coordinated and responsive care. The care plans should enable delivery against the recommendations and personalised goals detailed in the care plans. They should include multi-factorial falls assessment (MFRA), structured medication reviews (SMRs), structured home-based assessments, and fragility fracture assessments; follow universal principles for advance care planning; involving carers in the care planning as appropriate. CGA should routinely include a discussion with families or carers about their own needs and ability to support the individual. Priority should be given, where required, for people living with moderate or severe frailty, including all care home residents as part of enhanced health in care homes (EHCH).

Care planning conversations should be conducted using clear, respectful, and person-led language that resonates with individuals and those who support them. Systems should be mindful that the term ‘frailty’ can carry negative connotations and ensure that discussions focus on strengths, goals, and access to additional support, rather than limitation or withdrawal of services. The emphasis should be on enabling people to live as well as possible.

Person-centred statement: people living with frailty, and their families and carers will have their needs assessed, preferably at home, and will co-create a personalised care and support plan (PCSP). This plan reflects what matters to them and can be understood and is acted on to help them maintain or maximise their independence at home for as long as possible. Their PCSP will cover falls prevention, medication management, and fracture risk reduction treatment, as well as their preferences and wishes for care at the end of life and integrate with social care services.

Owner: primary care, community health services, integrated neighbourhood teams, and acute hospital providers in collaboration with care homes and hospices.

Case study: Greater Manchester has shown strong system‑wide leadership in developing a digitally enabled approach to anticipatory and personalised care through the Greater Manchester Care Record. This shared record gives all general practices, councils, acute trusts, community, mental health, and emerging social care services access to a single longitudinal record via a single sign-on.

The Electronic Palliative Care Coordination System care plan is being rolled out across Greater Manchester to give clinicians in A&E, urgent care, inpatient wards and discharge planning consistent access to comprehensive end‑of‑life and anticipatory care information, supporting better coordination and reduced unnecessary cost.

The digitally co‑designed frailty care plan was developed as a proof of value piloted in one locality to assess how geriatric assessments, escalation protocols and proactive intervention pathways can be embedded into routine workflows. While the pilot highlighted that further refinement is needed before wider rollout, it has provided valuable insights that are now helping shape future opportunities and next‑stage developments.

Key metrics:

• percentage of people with frailty (CFS 5+) receiving the full CGA intervention bundle (4AT, SMR, MFRA, PCSP and ACP where appropriate)
• percentage of people with frailty (CFS 5+) receiving at least annual review of CGA/care plans
• percentage of people with frailty with same or lower CFS score/band at 6 months
• percentage of people living with frailty (CFS 5+) discharged from acute hospital who receive a post discharge CGA in their usual place of residence within 24–48 hours
• PROMS and PREMS reported experience/outcome measures for people living with frailty and their carers these could be from existing collections such as the GP Survey or Adult Social Care Outcomes Framework

Action 4

Ensure frailty care plans and assessments are visible and actionable by relevant providers (key touchpoints include A&E, urgent care episodes, wards, discharge planning) and by the patient themselves to ensure the recommendations within them are updated and actioned in a timely manner. The care plans, including consistent ACPs, should be digital and all relevant providers should be able to view and edit them, to enable seamless information sharing across appropriate staff within primary care, community health services, acute, mental health, hospices, and social care providers and their EPR platforms.

Person-centred statement: people living with frailty and their families and carers, will only need to share their story once as all professionals involved in their care – and where appropriate, their carers – will have access to up-to-date information such as assessments, PCSPs and medication details and be able to update or change what is in the care plan.

Owner: primary care, community health services, integrated neighbourhood teams and acute hospital providers working with social care and hospices.

Case study: Mid and South Essex ICS developed Fr EDA (Frailty End of Life Dementia Assessment), a digital CGA and ACP tool that standardises frailty-attuned care across primary care, community teams, mental health, hospices, and some acute services. Embedded in shared digital records, Fr EDA supports real time, collaborative working, reducing duplication and improving continuity for people with complex, fluctuating needs.

Through a consistent, system-wide commitment to measurement and improvement, the ICS achieved major gains within 2 years: a 50–75% increase in evidence-based CGA interventions (4AT, MFRA, SMR, ACP), near universal CFS scoring, and widespread CGA completion across frailty virtual wards (including hospital at home). This enabled 20,000 additional people with frailty (CFS > 4) to receive high quality, CGA informed care, with earlier identification of those nearing end of life doubling.

Population outcomes improved: falls rates halved, unplanned admissions from care homes fell by 55% in the proportion of people with over 3 hospitalisations in their last 90 days of life more than halved. More people also received validated CFS scoring, enabling coordinated neighbourhood-level proactive care and targeted evidence-based support.

Key metrics:

• percentage of key services and teams who can access latest CGA and care plans via digital shared record
• percentage of people with frailty CFS 5+ who have their CGA started within 1 hour of being admitted to acute hospital

Integrated, continuous community-based urgent and planned care

Action 5

Develop comprehensive neighbourhood-level frailty plans that are jointly owned and delivered by the NHS and local government and that align with ICS priorities, such as fracture liaison and dementia services, and allocate resource to community based providers. Service design, where possible, should be co-produced with people living with frailty.

Frailty plans should include: 

• System executive-level commitment to shift resources and funding from hospital-based to community-based frailty care, including adult social care, housing‑related support, and prevention services, with clear accountability for outcomes and patient experience. This should include strengthening existing community services with caseloads that already cover people living with frailty, as well as those requiring end‑of‑life care, ensuring capacity, continuity and quality are maintained as neighbourhood‑level models evolve.
• Neighbourhood level integrated frailty MDTs in place (including GPs, community nurses, frailty practitioners, allied health professionals, mental health nurses, pharmacists, social workers, and VCFSE partners), and meeting regularly to deliver care to people living with frailty with specialist input such as rehabilitation and intermediate care, palliative care or housing officers accessed when needed. Where possible, people living with frailty will be supported by familiar professionals who understand their history, preferences, and needs.
• Integrated frailty pathways linking urgent community response (UCR), virtual wards (including hospital-at-home), care homes, diagnostics, fragility fracture prevention, and intermediate care services. Pathways are developed to step patients up, where appropriate, to avoid unnecessary ambulance dispatch and conveyance.
• Expanded UCR services and increased virtual wards (including hospital at home) capacity, with specific capacity for people living with frailty through integrated service delivery. This could be achieved with combined teams, via a single point of access (SPoA), in line with the UCR and virtual ward including hospital-at-home operating frameworks, ensuring safe and effective management of higher‑acuity care in the community. This includes ensuring direct access to diagnostics in the community, such as point of care testing or community diagnostic centres, to enable rapid diagnosis and clinical decision-making and avoid unnecessary hospital admissions.
• Enhanced health in care homes delivery,ensuring regular GP-led rounds, SMRs, consistent advance care planning and neighbourhood MDT input, including from care home matrons and other care home staff. Access to specialist palliative and end‑of‑life care advice should be available to the neighbourhood MDT to support complex needs. Falls prevention and risk reduction is prioritised through consistent, multi-disciplinary assessments and interventions across all settings.
• Mapped and commissioned socially led interventions (for example, VCFSE programmes, exercise classes, befriending), including through digital tools to reduce isolation and support independence, working with local authority public health and adult social care commissioning teams.

Person-centred statement: in time, people living with frailty and those who support them, will be able to access timely co-ordinated help and care either at home or within their local neighbourhood, from a familiar team that understands their needs. This team will help prevent and manage crises allowing people to maintain their independence at home for as long as possible or have the best possible recovery if a crisis does happen. When clinically appropriate, patients with urgent care needs will receive treatment at home and not need to wait in the ED or be admitted.

Owner: ICBs and local authorities, through dedicated leads across executive, managerial, and clinical teams, including in places and neighbourhoods, working with primary care, community health services, integrated neighbourhood teams, and acute hospital providers and in collaboration with hospices, care homes, and social care providers.

Case study: Surrey Downs Health and Care Partnership has pioneered a comprehensive, system-wide model for supporting people living with frailty that aligns neighbourhood delivery with ICS priorities and fosters collaboration across integrated platforms. The approach drives a shift of acute and specialist treatment into communities, embedding proactive population health management and replacing siloed working with shared, place-based accountability through ICB-led governance.

Neighbourhood MDTs unite GPs, embedded geriatricians, community matrons, community health services, social care professionals, pharmacists, mental health practitioners, paramedics, and VCFSE partners to deliver evidence-based CGAs. The embedded geriatrician supports clinical leadership and continuity across settings, joining proactive anticipatory care, responsive care, and urgent reactive care with acute general medical treatment to create a seamless patient journey. Population health intelligence enables early frailty identification, targeted intervention, and flexible resource deployment.

Integrated pathways connect proactive services, such as community CGA and care home support, with reactive elements like UCR and acute hospital at home medical treatment. This ensures patients receive the right care at the right time, avoiding crisis escalation and unnecessary admission.

The key enablers cementing resilient, neighbourhood-based models of integrated frailty care include strong system partnerships and visible clinical leadership, shared outcome frameworks, training, and education.

Key metrics:

• percentage of people living with frailty (CFS 5+) with clinically urgent need who are seen on the same day by any member of the integrated neighbourhood team (including, primary care)
• percentage of people living with frailty (CFS 5+) triaged by SPoA seen by any team in community within < 2 hours and < 24 hours
• proportion of system spend on primary care / community health services.
• proportion of people living with frailty supported by an integrated neighbourhood MDT including named adult social care involvement
• percentage of emergency department (ED) attendances and non‑elective admissions per 1,000 people living with frailty
• percentage of ED attendances and non‑elective admissions arising from care home residents and per 1,000 people living with frailty
• percentage of people living with frailty (CFS 5+) seen by UCR, virtual ward/hospital at home (step up) or Intermediate Care service who avoid ED attendance during their care episode and at 30 days after discharge from the service
• percentage of people living with frailty residing in a non-care home environment

Frailty-attuned hospital care

Action 6

Provide at least 70 hours a week of acute frailty/SDEC services that initiate CGA and provide the CFS at the front door, supported by sufficient Home First capacity and home-based assessments to enable timely same-shift neighbourhood enabled discharge and ensure access to a frailty-focused discharge pathway. For unavoidable admissions, ensure a seamless handover to neighbourhood or community services once hospital care is no longer required. Service models should be proportionate to local frailty demand and designed to avoid unnecessary small standalone units, with a strong preference for embedding frailty‑attuned care across front‑door services where this delivers better access, flow, and value. Providers should adhere to the principles of the FRAIL strategy and standards of The Model Acute Pathway.

Person-centred statement: people living with frailty who need urgent or emergency care will receive rapid assessment and treatment from a skilled MDT on the same day at either at home, or when needed in hospital. They will be given clear communication and have a safe, timely discharge home or to the most appropriate setting, along with prompt follow-up care in the community when needed.

Owner: ICBs with support from primary care, community health services, acute hospital providers, and social care.

Case study: Walsall Healthcare NHS Trust provides at least 70 hours a week of acute frailty or SDEC services for frail patients, anchored in CGA and a front-door frailty scoring system. In parallel, Walsall community services have implemented structured home-based frailty assessments using validated tools such as the CFS, delivered in the person’s home and, where appropriate, involving their family.

Within the acute setting, the service operates during the week with consultant and resident doctors, allied health professionals, advanced clinical practitioners, and senior nurse coverage, and at weekends with senior sisters, occupational therapy, and physiotherapy support, ensuring continuous access to expert decision-making. By contrast, community assessments are delivered by a workforce that ensures consistency and an outcome focus, with oversight from experienced clinicians, with outcomes recorded in shared care records to support continuous monitoring and regular review.

The frailty unit continues to review its operational and workforce design to align staffing with patient demand, enabling timely assessment and discharge. This is complemented in the community by comprehensive holistic geriatric assessments to ensure individual needs are fully understood, with a strong emphasis on prevention, timely escalation, and coordinated responses.

Home First capacity and robust discharge pathways support same-day transitions to community services from the acute setting, while virtual wards (including hospital at home) and strong relationships with domiciliary care providers enable seamless handover for avoidable admissions. In the community, independence is promoted through shared care plans developed with the individual, their family or friends, and the wider MDT, with services including UCR and virtual wards (including hospital at home) providing timely intervention when frailty decompensates.

Both models apply a disciplined approach to monitoring and improvement. The acute service takes a routine approach to ensuring care quality is continuously reviewed, refined, and optimised, while community services operate within a supportive environment that strengthens staff capability and confidence and enables proactive, home-based frailty management.

With a shared focus on maintaining patient independence and ensuring continuity of care across acute and community settings, this integrated approach has significantly reduced avoidable hospital admissions and readmissions, while improving quality of life.

Key metrics:

• number of hours a week of tier 2 and tier3 frailty front door model team covers both EDs and assessment units
• percentage of people living with frailty (CFS 5+) and attending ED who receive the full CGA intervention bundle (4AT, SMR, MFRA and PCSP or ACP)
• percentage of occupied bed days accounted for by people living with frailty (CFS 5+)
• percentage of people living with frailty (CFS 5+) with a length-of-stay of 0-3, >14 and >21 days
• percentage of people living with frailty who have an acute hospital non-elective admission in the last 90 days of life

Workforce and capability

Action 7

Provide multi-agency frailty training together, to enable effective delivery of care for people living with frailty. Training aligned to the Skills for Health Frailty core capabilities framework (tier 1-3) should be provided across professions, particularly in community health, UCR and hospital–at home teams, as well as carers where appropriate. Caring for people living with frailty is a collective responsibility, requiring all professions to work together across organisational boundaries.

Training, where possible, should include the patient voice through patient stories and co-production of modules. This should help staff understand the perspectives of carers and families and how communication and continuity shape their experience.

Providers should increase the number of tier 2 frailty skilled practitioners and ensure they have immediate access to tier 3 senior frailty specialists, 7 days a week for at least 10 hours a day to provide senior clinical advice and support when needed. Training, where possible, should include the patient voice through patient stories and coproduction of modules.

Person-centred statement: people living with frailty and their families and carers, will be supported by staff across all settings who understand frailty, communicate clearly, and provide consistent, personalised care.

Owner: community health services providers working with primary care, acute hospital providers, integrated neighbourhood teams, and social care.

Case study: The Royal Surrey NHS Foundation Trust Frailty Academy has delivered a system-wide frailty training programme that builds capability across health, social care, the voluntary sector, and emergency services to recognise, manage and plan care for people living with frailty. This aligns with the national core capabilities framework and provides tiered education from universal tier 1 for all staff groups, across all organisations in the system, as well as older people with frailty to advanced tier 2 and tier 3 specialist development, supporting early identification, crisis recognition, and multidisciplinary interventions.

A strong focus is strengthening capacity to deliver high-quality CGA, ensuring staff understand their role and feel equipped and empowered to provide a consistent, person-centred approach. Tier 3 development is creating frailty leaders and experts – including advanced clinical practitioners and specialty doctors – who guide MDTs and embed advance care planning n routine CGA.

With over 3,200 staff completing tier 1 training, 2,800 attending tier 2 sessions and frailty experts progressing through tier 3, the programme has significantly enhanced capability and embedded evidence-based, frailty-attuned care across a workforce strengthened by clear leadership and sustained support.

Key metrics:

• percentage of adult inpatient wards delivering frailty-attuned care
• percentage of staff achieving and reporting confidence in delivering tier 2 and tier 3 frailty capability competencies across relevant:
  • acute hospital teams (ED, SDEC and inpatient wards)
  • virtual wards (including hospital at home), UCR, intermediate care and SPoA teams
  • primary care, community health services, mental health, and adult social care

Action 8

Invest in the expansion of community health services and the primary care workforce, informed by comprehensive workforce mapping to identify gaps. Protect capacity for frailty management and continuity of care and consider options to integrate or better coordinate with out of hospital services for people living with frailty, including to rotating staff or providing consultant input across acute and community teams, to offer a safe, admission‑avoiding alternative where clinically appropriate. Minimum workforce numbers should be set based on local frailty demand, capacity, and patient flow, to ensure that subsequent workforce investment and service development are targeted, proportionate and deliver value in the right place at the right time.

Person-centred statement: people living with frailty and their families and carers, will experience continuity and high‑quality care and support from a skilled workforce with the capacity to understand and meet their needs reliably and compassionately, regardless of which healthcare service they use.

Owner: ICBs working with primary care, community health services, and acute hospital providers

Case study: The Royal Surrey NHS Foundation Trust Frailty Academy is working with the Surrey Heartlands Whole System Frailty Network to standardise education, training, and workforce development to support frailty attuned healthcare systems. Driven by strong, clear leadership, the academy promotes a systematic approach to neighbourhood level workforce mapping, benchmarking core capabilities and designing bespoke training needs analyses.

The piloting of this approach with the local UCR service, revealed gaps in frailty capability, induction processes, and role clarity. The audit showed low tier 2 and no tier 3 frailty competence, leading to the creation of a new frailty focused ‘enhanced clinical practitioner’ role and a structured career progression pathway. By investing in a well-supported workforce, staff are equipped with the skills and confidence they need to deliver consistent, high-quality frailty care.

The academy has developed a dedicated training programme to support these roles, ensuring consistent access to frailty trained staff and enabling more reliable CGA delivery and continuity of care across UCR and hospital at home services. This approach strengthens workforce resilience and shows how effective leadership can drive system-wide improvement.

Key metrics:

• community health services and primary care whole time equivalent (WTE) per 100,000 population aged 65+, by role, and associated vacancy rate
• total hours a week of service provision, with access to tier 3 frailty skilled staff, across UCR, virtual wards (including hospital-at-home) and intermediate care services

Publication reference: PRN02404