What needs to be done and why?
Strategic Issue 1
What needs to be done
Robust preventative services and prevention engagement within at-risk age groups through community interventions and supporting multi-agency identification and support of high-risk individuals.
This requires proactive, community-based, multidisciplinary approach that prioritises early identification, holistic assessment, personalised care and coordinated support. Neighbourhood-level services (rather than hospital) ensure frailty is identified earlier through systematic use of tools like the electronic Frailty index.
Effective pathways must integrate falls prevention.
With increasing demand, frailty pathways need to be competent with flexible delivery approaches to ensure equity across underserved groups.
Low educational attainment and health literacy create barriers to self-management, prevention and early help requiring accessible, tailored, community-based and non-digital interventions therefore this must be considered at each level of service and support.
Why
With more people living alone and increasing health needs the demand for unpaid care will rise. Housing suitability, accessibility and insulation become major determinants of frailty and healthy ageing. Without action there will be pressures on informal caregiving and age-appropriate housing.
Strategic Issue 2
What needs to be done
Addressing modifiable risk factors requires a targeted, preventative approach that identifies and intervenes early on the key contributors to decline (muscle weakness, poor balance, visual impairment, environment hazards and polypharmacy).
Services must actively prioritise those living with socioeconomic disadvantage, multimorbidity and limited engagement with primary care by embedding proactive screening in community settings and expanding outreach through neighbourhood health teams and tailoring support to cultural, social and environmental needs.
Why
This combined approach can help close inequality gaps and prevent avoidable deterioration among those at risk. Particularly for women as there is higher risk among women. 53.7% of adults aged 65+ are women and 67.1% of older people living alone are women. National evidence shows women are more likely to progress into frailty at any level.
Strategic Issue 3
What needs to be done
Improving data for frailty and falls requires building a complete picture of risk and incidence by collecting data on non-hospital falls, functional decline and early deterioration within community and primary care settings.
Integrating frailty and falls recording into routine community contacts, enhancing the use of tools such as the electronic Frailty Index and shared care records allows simple, accessible reporting.
Strengthening data requires linking information across services and pathways so that early warning signs are recognised before they escalate.
Why
Integrating frailty and falls recording into routine community contacts, enhancing the use of tools and shared care records allows simple, accessible reporting.