Recommendation 7

For all patients diagnosed with severe frailty, the GP contract requires GPs to do a clinical review. This includes a review of the patient’s medication, a falls risk assessment and a discussion with the patient of the benefits of having an enriched summary care record that provides healthcare professionals with access to core details about the patient (medications, allergies, bad reactions) plus additional information from GP records to aid care. GPs are not providing the required levels of follow-up support. In 2024–25, 226,000 patients were diagnosed with severe frailty. Of those patients only 16% had a medication review, 18% had a falls risk assessment and 29% had given consent for an enriched summary care record.12 NHSE told us that it did not have a clear idea of how many people had been formally assessed for frailty. It acknowledged that only a small proportion of people who were recorded as being moderately or severely frail, were getting support and that this problem needed addressing.13