Focus on Frailty programme impact report 2023-24

Background/summary

Our aim is to improve experience of, and access to person centred, coordinated health and social care for people living with, or at risk of frailty.

The number of people over 75 is projected to grow by 340,000 over the next 25 years. This is according to figures from National Registers of Scotland (Projected Population of Scotland: 2022-based, 2025). There is an association between older age and frailty. This means there is a need to plan for an increase in the number of people living with frailty in Scotland.

Six integrated health and social care teams in Scotland took part in our programme. They received multidisciplinary support from us between May 2023 and December 2024.

Hear from the teams who participated in the programme in this video

What we do

We provide practical support for improvement

We do this by supporting NHS boards and health and social care partnerships (HSCPs). We help them test and implement evidence-based changes to integrated frailty services. We codesign and publish resources to support change. This includes a change package and a measurement framework.

We host a national learning system

The system allows colleagues working in frailty services to share and learn from each other.

We raise the profile of frailty

We bring together system leaders. Together they advise on programme delivery and provide national leadership on ageing and frailty

Programme impact

Reduced length of stay

Glasgow Royal Infirmary (NHS Greater Glasgow and Clyde) reduced the average length of stay for older people living with frailty by three days. They did this through:

  • improved frailty identification at the front door,
  • establishing a frailty assessment unit, and
  • hybrid comprehensive geriatric assessment huddles with community partners.

Timely access to the right care

Five new hospital frailty assessment units opened during the programme. Evidence from the Ageing and Frailty Standards, 2024 show that admission to a frailty assessment unit within a hospital can:

  • improve outcomes
  • reduce length of stay, and
  • reduce readmissions

The new frailty assessment units have common features. But each is designed specifically for their local context.

Improved identification of frailty

NHS Lanarkshire improved the identification of older adults living with frailty across three hospitals. Improved identification facilitates timely access to frailty assessment in hospital. During the programme NHS Lanarkshire established two new frailty assessment units.

Improved wellbeing

In South Ayrshire, occupational therapy wellbeing reviews for older people living with mild frailty improved wellbeing for 77% (120/155) of people who received a review. In one GP practice 78% of people (40/51) who had a wellbeing review reduced their GP appointments in the six months following the review. Wellbeing reviews are now being rolled out across all GP practices in South Ayrshire.

Reduced unnecessary medicines

NHS Dumfries and Galloway and Dumfries and Galloway HSCP tested polypharmacy reviews for older people living with frailty. This resulted in 11% of reviewed medicines being deprescribed. 25% of these had a high anticholinergic burden. These are medications associated with:

  • a risk of falls
  • cognitive impairment
  • increased mortality

Strengthened relationships and increased knowledge of frailty

Moray HSCP and NHS Grampian strengthened relationships across primary, community and secondary care. They did this by putting in place operational and strategic multidisciplinary governance groups. These groups supported improvement across community and acute care. These groups supported the development of an integrated frailty pathway in Moray.

Perth and Kinross HSCP and NHS Tayside improved the knowledge of health and social care staff. This was achieved through simulation sessions. These improved self-reported knowledge of identifying and assessing frailty among staff from 5/10 to 8/10.

Enabling improvement

“Without involvement in this programme [Focus on Frailty] we wouldn’t be as far along as we are … Healthcare Improvement Scotland being involved has helped us on the hard days and helped us with the hard stuff”

Advanced practice physiotherapist

This has been achieved by…

Working with six integrated teams

  • NHS Ayrshire and Arran and South Ayrshire HSCP
  • NHS Dumfries and Galloway and Dumfries and Galloway HSCP
  • NHS Grampian and Moray HSCP
  • NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary
  • NHS Lanarkshire and North Lanarkshire HSCP
  • NHS Tayside and Perth and Kinross HSCP

Programme delivery

The programme was co-designed with health and social care professionals. These professionals had expertise in frailty. They worked alongside third sector organisations. This collaboration ensured the views of older people living with frailty, their families and carers were heard.

Through in-person learning sessions, coaching calls and webinars participating teams received support with:

  • quality improvement
  • data and measurement
  • strategic planning
  • storytelling for influence
  • person-centred care approaches

The driver diagram and change package with associated measurement framework are available on our webpages.

Sharing learning

The programme is part of a national frailty learning system. It connects over 1,900 colleagues from across Scotland. Visit our learning system webpage to access resources including webinar recordings and insight stories.

Raising the profile of frailty

A national frailty and dementia advisory group was set up. Its aim is to engage senior system leaders in advising on the work of the programme. Membership is multidisciplinary and multiagency. The group has informed the design of the next phase of the programme.

Next steps

The next phase of the Focus on Frailty programme launches in April 2025. The programme will draw on:

Participating teams will be supported to set up hospital front door frailty pathways and improve integrated care coordination across primary, community and acute care. There will be a focus on the early identification and assessment of frailty. For further information see our webpages.

Find out more

For more detail: Focus on Frailty webpages

Get in touch: his.frailty@nhs.scot