A new report found clear failings with how GPs assess and support people living with frailty with ‘worrying unexplained variation' in practice.
Gareth Davies, head of the NAO, said: ‘With the need for health and social care services set to increase in our aging population, it is crucial that people with frailty are supported effectively and consistently across the country. Our report shows that many older people are not getting the support they need.'
The report found GPs assessed only one in six people aged 65 or over for frailty (1.9m people) in 2024-25 compared with one in four when the assessment requirement was introduced in 2017-18.
In addition, of 226,000 patients diagnosed with severe frailty in 2024-25, 16% (37,000) had a medication review; 18% (41,000) had a falls risk assessment; and 29% (66,000) had given consent for an enriched summary care record.
Furthermore, the percentage of residents who had a personalised care and support plan agreed or reviewed has fallen sharply, from 76% in 2022-23 to 44% in 2024-25.
The report recommended that NHSE sets clear and consistent requirements for GPs to assess and support people living with frailty along with 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.
In addition, it says DHSC should commission a systematic evaluation to demonstrate whether its patchwork of frailty initiatives is working together to provide an effective and holistic approach.
Reaction
Professor Victoria Tzortziou Brown, chair of the Royal College of General Practitioners, said: ‘The Government has ambitious aspirations to provide more care in the community, but funding must follow if we are going to be able to deliver more care close to home. The forthcoming NHS 10-Year Workforce Plan needs to set out a clear road map for recruiting and retaining the GPs we need to provide the level of care our older, frail patients deserve.'
Liberal Democrat spokesperson for primary care Helen Maguire said: ‘Elderly and frail people deserve so much better. The Liberal Democrats are calling for everyone over 70 or with a long-term condition to have a named GP, with thousands of extra doctors so that people get the time they need during an appointment.'
An NHS spokesperson said: ‘While we know GP teams are already delivering millions more appointments a year compared to before the pandemic, it is vital that GPs fulfil their contractual requirements to ensure that frail patients over the age of 65 have the support they need.
‘We will use this report's findings to help ensure that we can provide care for an ageing population in a sustainable way, alongside the rollout of neighbourhood health hubs across the country which will bring more joined up care closer to home as part of the 10-Year Health Plan.'
A Department of Health and Social Care spokesperson said: ‘Our 10-Year Health Plan will fundamentally reform how care is delivered, shifting more healthcare out of hospitals and into the community. This includes rolling out 250 new neighbourhood health centres to provide more personalised care closer to where people live.
‘We are taking immediate action to improve early diagnosis and treatment, including investing in 13 high-tech DEXA scanners in 2025/26, which are expected to provide an extra 29,000 scans a year once fully operational - helping people with bone conditions such as osteoporosis get diagnosed earlier.'
