The report examines how the NHS identifies and manages frailty, a medically recognised syndrome affecting multiple body systems that leaves people exhausted and often housebound. It concludes that early intervention is falling short despite the growing demands of an ageing population.
Under the GP contract, GPs are required to identify patients aged 65 and over who are living with moderate to severe frailty. However, in 2024-25 only one in six patients aged 65 or over (1.9 million people) were assessed for frailty, far below the one in four assessed when the requirement was introduced in 2017-18.
Once patients were assessed, GPs often failed to provide the required support and follow-up. Of 226,000 patients diagnosed with severe frailty in 2024-25:
- 16% (37,000) had a medication review
- 18% (41,000) had a falls risk assessment
- 29% (66,000) had consented to an enriched summary care record
The report highlights wide regional variation in frailty assessment and significant inconsistencies in care for those diagnosed with severe frailty. Support under the Enhanced Health in Care Homes programme is also declining, with the proportion of residents with a personalised care plan falling from 76% in 2022-23 to 44% in 2024-25.
Urgent community response teams are meeting targets. These teams provide urgent care at home, helping to avoid hospital admissions and allowing people to live independently for longer.
The 2025 10 Year Health Plan set early priority on frailty but did not introduce further developments. Recent planning guidance identifies frailty as a priority for neighbourhood health services and calls for growth in community health services.
The NAO report makes several recommendations, including:
- NHSE should set clear and consistent requirements for GPs to assess and support frail patients
- NHSE should provide a timetable for standardising community health services and align them with neighbourhood health services
- DHSC should commission a systematic evaluation to ensure frailty initiatives work together effectively
Gareth Davies, head of the NAO, said:
“With the need for health and social care services set to increase with our ageing population, it is crucial that people with frailty are supported effectively and consistently. Many older people are not getting the care they need. The NHS must use the 10 year health plan to build the effective and sustainable service that older people require.”
