There are “clear failings” in how GPs assess and support older people living with frailty, with unexplained variation in practice across England, according to the National Audit Office (NAO). 

The report described frailty as “one of the greatest challenges facing the NHS.” Improvements could be “a massive gamechanger,” boosting care quality and freeing up hospital capacity.

Frailty occurs when the ageing process causes multiple physiologic systems to lose resilience. It affects an estimated 1.5 million people aged 65 or over in England and costs the NHS £5.8 billion a year. People with frailty may become housebound and have higher risk for disability, falls, and long-term care needs. They have nearly a sixfold increase in risk for hospital admission.

Early identification and timely support can help slow progression and maintain independence.

GP Assessments Below Target

GPs must identify registered patients aged 65 years or over who have moderate-to-severe frailty. However, the NAO said GPs assessed only 17% of eligible patients in 2024-2025, well below the 25% target.

Support after diagnosis was also limited. Of the 226,000 patients diagnosed with severe frailty in 2024-2025, only 16% received a medication review and 18% underwent a falls risk assessment, despite both being mandatory. Just 29% had consented to the enriched summary care record.

The NAO reported “significant variation” in assessment rates and “worrying inconsistency” in the delivery of support. 

Declining Support for Care Home Residents

Support for care home residents under the Enhanced Health in Care Homes framework has also deteriorated.

Only 44% of residents received a personalised care and support plan within 7 working days of admission or readmission in 2024-2025, down from 76% in 2022-2023.

Care England said the findings showed a crisis demanding urgent action, investment, and a prevention-focused national strategy. Structured movement, stability programmes, and personalised activity could delay, reduce, or even reverse frailty, it said. 

Care England's chief executive, Professor Martin Green, said care homes were “ready and willing” to deliver preventive, rehabilitative support but the national framework was “incomplete.” Primary care, community services, and social care must be “properly aligned” so older people receive proactive support, he added.

NAO Recommendations

The NAO recommended that:

• NHS England set clear requirements for GPs assessing and supporting people living with frailty
• It publish a timetable for standardising community health services and for aligning them with neighbourhood health services
• The Department of Health and Social Care commission an evaluation to determine whether its “patchwork of frailty initiatives” delivers an effective, holistic approach

Gareth Davies, head of the NAO, said, “With the need for health and social care services set to increase in our ageing population, it is crucial that people with frailty are supported effectively and consistently across the country.” 

Rapid-Access Policies ‘Deprioritising Elder Care’

Professor Victoria Tzortziou Brown, chair of the Royal College of General Practitioners, said the findings were “disappointing” and must be taken seriously. Barriers to delivering consistent, proactive care for frail patients must be addressed, she said.

She warned that the GP workforce had not kept pace with rising demand and complexity. Political priorities “focused overwhelmingly on rapid access” had deprioritised interventions such as structured medication reviews, often “at the expense of the long-term, continuous care that older people with complex health needs require.”

Professor Mumtaz Patel, president of the Royal College of Physicians, said frail older people’s needs were not being met. Many could be well supported in the community “but only with sufficient investment in primary and community care.” The shift from hospital to community care must involve physicians, particularly community geriatricians, playing a more proactive role early in managing complex cases, she said.

Daniel Elkeles, chief executive of NHS Providers, said the report should prompt action to address a longstanding challenge. “There are far too many older people being admitted to hospital who could have better care in a place they’d prefer, at or close to home,” he said.

“We can and must tackle this with a new model of care,” he said, pointing to integrated health organisations, multi-neighbourhood contracts, and payment reform. “That would be a massive gamechanger, improving care for older people and unlocking much-needed capacity in hospitals.”

Dr Sheena Meredith is an established medical writer, editor, and consultant in healthcare communications, with extensive experience writing for medical professionals and the general public. She is qualified in medicine and in law and medical ethics.