Source · National Audit Office

Primary and community healthcare support for people living with frailty

Tackling frailty is key to the long-term health of our ageing population, yet many people are failing to receive a diagnosis or the right care.

Published: 5 Dec 2025 Recommendations: 7 Type: Value for Money Department: Department of Health and Social Care
Dept: Department of Health and Social Care Topics: Health and social careNHSPublic healthSocial care nao.org.uk →

Recommendations

7 items
No response position recorded.

The indexed recommendations do not yet have a recorded response position. This is separate from evidence of implementation. This report was published 5 December 2025.

Recommendation 1

Addressee: NHS England · Source location: Page 12, 22a

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.

Response position: No response position recorded

Delivery: No implementation status recorded

Recommendation 2

Addressee: NHS England · Source location: Page 12, 22b

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

Response position: No response position recorded

Delivery: No implementation status recorded

Recommendation 3

Addressee: NHS England · Source location: Page 12, 22c

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.

Response position: No response position recorded

Delivery: No implementation status recorded

Recommendation 4

Addressee: NHS England · Source location: Page 12, 22d

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.

Response position: No response position recorded

Delivery: No implementation status recorded

Recommendation 5

Addressee: NHS England · Source location: Page 12, 22e

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.

Response position: No response position recorded

Delivery: No implementation status recorded

Recommendation 6

Addressee: Department of Health and Social Care · Source location: Page 12, 22f

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.

Response position: No response position recorded

Delivery: No implementation status recorded

Recommendation 7

Addressee: Department of Health and Social Care · Source location: Page 12, 22g

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.

Response position: No response position recorded

Delivery: No implementation status recorded