Improving care and support for people with frailty

How NICE resources can support local priorities

Making the case for action

People with frailty are at risk of falls. They're also at risk of developing conditions such as anxiety and depression, and are more likely to have unplanned hospital admissions. Identifying people with frailty and improving their care and support are therefore priorities for the health and care system.

The NHS Long Term Plan includes an aim for all major A&E departments to set up an acute frailty service to ensure people with frailty receive the most appropriate care quickly. Three areas of the Five Year Forward View relate to frailty:

  • urgent and emergency care – freeing up hospital beds, and reducing unnecessary hospital attendances and admissions
  • prevention – helping frail older people stay healthy and independent
  • efficiency– medicines optimisation.

NHS England describes frailty as a loss of resilience that means people don't bounce back quickly after a physical or mental illness, an accident or other stressful event. The National Clinical Director for Older People, Professor Martin Vernon, has based NHS England's advice on the British Geriatric Society’s Fit for Frailty model. This involves the following steps, which together spell FRAIL:

  • Find.
  • Recognise frailty in a person.
  • Assess – a multidisciplinary assessment involving a geriatrician, allied health professionals, specialist nurses, and mental health and social work teams. The aim is to identify and manage long-term health conditions, identify goals and develop a personalised care and support plan.
  • Intervene – for example, a falls risk assessment and a multimorbidity review.
  • Long-term.


Finding the right information

The easiest way of finding our products on frailty is to go to our topic pages on older people and multiple long-term conditions.

Our guidelines on multimorbidity: clinical assessment and management and older people with social care needs and multiple long-term conditions are particularly relevant. They include recommendations covering the ‘Assess’ and ‘Intervene’ steps in the frailty model.

The main NICE Pathways for this area are:

The following video explains how to use NICE Pathways.

Using quality standards to make an impact on care and support

Care and support

The main focus for frailty is on improving care and support. Our quality standards help you identify areas to make high impact improvements for people with frailty or at risk of frailty, in line with the British Geriatric Society model. Quality standards contain a list of quality statements, each describing a priority area for quality improvement. They include metrics that can be a useful source of key performance indicators or performance metrics for system-wide performance dashboards. See how to use quality standards for more details.

For example, the quality standard on social care for older people with multiple long-term conditions highlights the importance of integrated health and social care plans. The development sources section of the quality standard shows the guidance underpinning it and the national policies that it fits with.

The main quality standards that help with improving care and support for people with frailty are:

Reducing the risk of increasing frailty

Risk factors that can be reduced include excessive alcohol use, dementia and mood disorders, falls, social isolation and polypharmacy. Interventions such as good foot care and preparing for winter and helping people keep warm can be targeted for people most at risk of becoming increasingly frail.

The quality standards listed above can help with this, and the following ones can help with specific risk factors:

Support for quality improvement

Illustration showing three cogs that fit together.

We publish a range of tools and resources to help with putting our guidance into practice.

You can find these on the ‘Tools and resources’ tab for any guidance (such as multimorbidity: clinical assessment and management).

We also list any tools produced by other organisations that we've endorsed as supporting our guidance. For example, we've endorsed several tools relevant to preventing falls. They include a toolkit produced by Keele University in collaboration with NHS Walsall Clinical Commissioning Group.

Shared learning case studies show how organisations have used our guidance and standards to improve the quality of services around the UK.

There are some useful examples relevant to frailty, including some on medicines optimisation for older people:

Other case studies cover work to improve mental well being:

Organisations have also written about how they are preventing risk of falls:

And other organisations have used our guidance to improve services for people with dementia:

Shared learning case studies

Improving frail older people’s health and wellbeing using pharmacist-led medication reviews

Ensuring frail older people have the most effective combination of medicines has improved their health and wellbeing and reduced unnecessary hospital admissions. It's also saved money and improved staff satisfaction at Guy’s & St Thomas’ NHS Foundation Trust (Community Health Services) and other NHS organisations that have adopted their approach.

Integrated care clinical pharmacists agree a joint plan with those at risk of medicines-related problems, coordinating this aspect of their care with other health practitioners and carers.

Patients surveyed had a better understanding of their medicines and almost half felt their health had improved. Benefits for staff included more effective joint working and increased knowledge of medicines issues.

A hand holding a box of medicine in front of shelves of medicines in a pharmacy.

Meaningful activities in care settings improve older people’s general wellbeing

Older people in day care centres and 450 care homes in the south and south-west of England are benefiting from meaningful activities that improve their mental health and general wellbeing.

The dementia-friendly activities were developed by Alive! working with more than 10,000 older people. They include music, poetry, art, dance and gentle movement, and using iPads for reminiscence exercises. Many social care staff have been trained to use the tools and techniques.

After an Alive! session, 95% of older people say their mood has improved. Care staff say that people who do not normally interact at all thoroughly enjoy the sessions - and that the effect can last days.

An elderly man with a beard playing a guitar in a lounge setting.