Frailty JSNA

What is being done and why

Nationally

NHS England: Transforming the Frailty Pathway 3

NHS England is implementing a nationwide shift from hospital‑centred to community-based care, delivered through the Neighbourhood Health Service. Key components include:

  • Managing increasing frailty demand by shifting more care into the community.
  • Integrated working across primary care, social care, community health, mental health, acute services and VCSE partners.
  • Improving patient flow, reducing non-elective admissions and reliance on temporary care beds.

NHS Long Term Plan11

NHS policy requires all major A&E departments to implement Acute Frailty Services and provide rapid assessment for older adults.

NICE Guidance & Frailty Model (FRAIL Framework)11

NICE provides nationally endorsed standards supporting:

  • Frailty identification
  • Multidisciplinary frailty assessment (CGA)
  • Falls risk assessment
  • Intervention planning and medication review

NHS England Frailty Resources12

Nationally available, these include:

  • NHS RightCare Frailty Toolkit
  • Frailty Framework of Core Capabilities
  • BGS Comprehensive Geriatric Assessment toolkit
  • National falls prevention resources

Proactive Care Framework (2023‑present)13

Supports consistent nationwide delivery of proactive frailty care, including:

  • Case identification (using eFI)
  • Holistic assessment
  • Personalised care and MDT working
  • Continuity of care

Regionally

North East & North Cumbria Ageing Well Network14

The NENC ICS has a dedicated Ageing Well Network, with professionals contributing to regional frailty planning and service transformation. This includes clinical leads, frailty nurses, geriatricians and community specialists.
 

NIHR‑Funded Frailty Pathways Toolkit (North East & North Cumbria) 14

Regionally significant, this toolkit provides a standardised framework for:

  • Planning frailty pathways
  • Operational delivery
  • Evaluation of frailty services across settings
    Developed with North East & North Cumbria expert contributors, it strengthens frailty integration across the ICS.

Integrated Frailty Pathway (FrailtyPath.co.uk)

Widely used across the region, offering:

  • Guidance on identifying causes of deterioration
  • Comprehensive assessment pathways
  • Support for integrated, personalised, compassionate care

Falls & Fragility Pathways

The North East region uses NHS England’s national falls resources, which highlight:

  • Over one‑third of people aged 65+ fall annually
  • High-cost hip fracture burden
  • Need for community-based falls prevention and reconditioning approaches

Locally

Community Frailty Pathways

Delivered via NENC ICS and local Primary Care Networks:

  • Frailty identification using electronic Frailty Index
  • Proactive, MDT frailty assessments
  • Falls risk assessments and medication reviews
    These services form part of the national neighbourhood care model described by NHS England.

Local Falls Prevention Services

  • Home/environmental risk assessment
  • Strength, balance, and reconditioning programmes
  • Referrals to community therapy (OT/physio).

Aligned with national falls-prevention guidance and ICS implementation practice.