Background to the report
Medical professionals use ‘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. The Chief Medical Officer considers that early identification of frailty can slow its progression and delay loss of independence. In 2019, researchers estimated that frailty cost the UK healthcare system around £5.8 billion per year.
Jump to downloadsAs at March 2025, GPs had diagnosed, in total, approximately 1.06 million people as living with moderate frailty and a further 450,000 as living with severe frailty.
The Department of Health & Social Care (DHSC) is responsible for setting and overseeing policy on improving health, including delaying and managing the onset of frailty and supporting people to age well.
At local level, Integrated Care Boards (ICBs) commission primary care services (including GPs) and oversee local delivery, performance and management of the contract. Local primary care networks sit below ICBs and are formed of general practices and other health and care organisations working together to provide integrated services to improve the health and wellbeing of their local population.
Scope of the report
This report examines the effectiveness of the government’s approach to identifying and managing frailty in non-hospital based services in England. The report sets out:
- the growing problem of frailty
- the government’s approach to frailty
- supporting people living with frailty
- frailty and the new neighbourhood health service
Video summary
Conclusion
Early diagnosis of frailty, along with the right support, can slow its progression and delay loss of independence, enabling older people to live longer and healthier lives. Despite DHSC’s and NHS England’s (NHSE) recognition of the importance of earlier identification and care, there are clear failings in how GPs assess and support people living with frailty, with worrying unexplained variation in practice across England.
The absence of a joined-up strategy for addressing frailty is compounded by NHSE’s lack of action on unexplained variation and obscured by limited and unchecked data. While NHSE and DHSC have put in place some positive initiatives that aim to help people living with frailty, these are fragmented and lack holistic evaluation to demonstrate their combined impact.
The scale and impact of our ageing population will only grow in the future. Without effective support and earlier interventions in the community, the NHS risks encountering people living with frailty only when it is too late and independence cannot be recovered. The NHS needs a greater focus on slowing frailty and maintaining independence for the sake of individuals as well as measuring the impact on hospitals.
With the 10 Year Health Plan and the shift to prevention, we can now see the possibility of fundamental change in how healthcare is delivered, with neighbourhood health services and an increasing focus on bringing together the different elements of healthcare. However, if this shift is to gain traction and bring about real improvements, NHSE and DHSC need also to introduce structural changes, including accountability and performance management responsibilities, clear service standards, meaningful budgets and financial incentives and better use of technology.
Downloads
- Report - Primary and community healthcare support for people living with frailty (.pdf — 601 KB)
- Summary - Primary and community healthcare support for people living with frailty (.pdf — 122 KB)
- ePub - Primary and community healthcare support for people living with frailty (.epub — 1 MB)
Publication details
- ISBN: 978-1-78604-646-8 [Buy a hard copy of this report]
- HC: 1518 2025-2026
Press release
View press release (5 Dec 2025)
