Primary and community healthcare support for people living with frailty

GPs are not providing the level of support that people living with frailty need. To improve this, NHSE should set clear and consistent requirements for GPs to assess and support people living with frailty, including the proportion and frequency of assessments and the minimum acceptable care to be provided.

NHSE needs to put in place systematic follow-up for unexplained variations in performance against requirements it has set in the GP contract.

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.

NHSE should assess the added value of collating and quality assuring consistent data from general practices on the numbers of frailty assessments conducted and the support provided as a result.

NHSE needs to establish a direct measure of how well the NHS maintains the independence of the population rather than relying on measures that focus on the perceived burden on the NHS and on hospitals, in particular.

There are many piecemeal initiatives for frailty but no real understanding of the impact they make on people?s health. DHSC should commission a systematic evaluation to demonstrate whether its patchwork of frailty initiatives is working together to provide an effective and holistic approach to supporting people living with frailty. This should include urgent community response, the enhanced Health in Care Homes programme, virtual wards, community health services and neighbourhood health.

To help bring about integration, DHSC and NHSE should create more effective mechanisms to enable service level funding to flow from acute care to community health services.