Guidance to support acute teams to deliver optimal care for older people living with frailty – in the face of increasing demand – has been developed by GIRFT.
Office for National Statistics (ONS) figures show that the number of people aged 85 and over is expected to double in the next 20 years. This growth is already seen in an increase in demand for acute care of older people living with frailty – as highlighted in the NHS England Urgent and emergency care plan 2025/26. This population group are the highest users of health and social care services and have the highest levels of emergency hospital admissions.
GIRFT’s new guidance ‘Co-ordinated frailty care for better outcomes’ – co-badged by the British Geriatrics Society (BGS) – offers key tools, actions, practical advice and checklists to support an optimal system-wide approach ensuring older people with frailty receive timely access to care in the right setting.
The guidance features a set of actions for key areas; identifying frailty, preventing deconditioning, delirium, falls and bone health, end of life care and advance care planning, community-based care and working with care homes. In addition to optimising hospital care, its overarching principles are:
- Early identification of the severity of frailty.
- Adopting a ‘home first’ approach to avoid unnecessary emergency department (ED) attendance or hospital admission.
- Delivering care outside of hospital at an appropriate scale, to meet local demand and avoiding long waits in EDs which cause delay-related harm.
- Early discharge planning using a ‘home first’ principle.
This latest guide builds on GIRFT’s 2023 collaboration with the BGS and the Royal College of Physicians (RCP) to produce the Hospital Acute Care Frailty Pathway and the linked Six Steps to Better Care. It should also be used in conjunction with BGS resource: Joining the dots: A blueprint for preventing and managing frailty in older people
In addition, the guide can support the move towards developing neighbourhood teams as outlined in NHS England’s Neighbourhood health guidelines 2025/26, through its focus on delivering an integrated response, improving independence and reducing reliance on hospital care.
"The demographic changes we are already seeing means all healthcare professionals, regardless of their specialty, need the knowledge and skills to deliver effective care to older people. Now is the time to tackle variation in care we have seen across the country – issues like older people with frailty being conveyed to hospital disproportionately or deteriorating in hospital – and to adopt system-wide best practice. We hope that integrated care systems review their existing services against this GIRFT guide and will work with their partners to embed an approach that will help us to deliver optimal care for older people living with frailty, now and into the future.”
