Source · National Audit Office
Primary and community healthcare support for people living with frailty
Published: 5 Dec 2025
Recommendations: 7
Type: Value for Money
Department: Department of Health and Social Care
Tackling frailty is key to the long-term health of our aging population, yet many people are failing to receive a diagnosis or the right care.
Recommendations
Government response pending.
The NAO has not yet recorded a response to these recommendations. This report was published 5 December 2025.
| Rec | Recommendation | Addressee | Acceptance | Implementation |
|---|---|---|---|---|
| 1 |
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.
Ref Page 12, 22a
|
NHS England | Pending | — |
| 2 |
NHSE needs to put in place systematic follow-up for unexplained variations in performance against requirements it has set in the GP contract.
Ref Page 12, 22b
|
NHS England | Pending | — |
| 3 |
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.
Ref Page 12, 22c
|
NHS England | Pending | — |
| 4 |
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.
Ref Page 12, 22d
|
NHS England | Pending | — |
| 5 |
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.
Ref Page 12, 22e
|
NHS England | Pending | — |
| 6 |
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.
Ref Page 12, 22f
|
Department of Health and Social Care | Pending | — |
| 7 |
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.
Ref Page 12, 22g
|
Department of Health and Social Care; NHS England | Pending | — |