- 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
“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.”
Gareth Davies, head of the NAO
Read the full report
Primary and community healthcare support for people living with frailty
Notes for editors
- 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.