Building whole system leadership and culture for frailty improvement: September 2025

NHS Lanarkshire, in collaboration with North and South Lanarkshire Health and Social Care Partnerships (HSCPs), developed an integrated frailty strategy supported by a dedicated frailty network. This approach has strengthened cross-sector relationships and built trust. It aimed to deliver more coordinated, person-led care for people living with frailty. The team were part of the Focus on Frailty programme from May 2023 to December 2024.

Background

The formation of the Lanarkshire frailty network was a key strategic action of the NHS Lanarkshire Strategy for Preventing and Managing Frailty (2024–2029).

The network was established in October 2023. It was coordinated by the frailty nurse consultant and the associate medical director for frailty.

The network provides protected time for the multidisciplinary team to innovate, plan, and coordinate improvements in frailty care. It also supports delivery of the strategy. The strategy sets out a vision to:

  • promote health and well-being
  • reduce inequalities, and
  • deliver sustainable person-led care
Quote / Testimonial:
“There is a definite structure within Lanarkshire now for the frailty work, and I think we have real engagement with the meetings, and they are well attended.”
Frailty Nurse Consultant
NHS Lanarkshire

Creating the conditions for change

The network provides organisational governance, underpinned by the frailty strategy and reports to the Frailty and Ageing Programme Board. This enables the development of co-designed and integrated care pathways. Cultivating whole system leadership and a collaborative culture through the network enhances access to coordinated, person-led care for people living with frailty. Key learning from the network includes:

  • Senior leadership sponsorship accelerates change.
  • Networks enable the delivery of system-level strategies and spreads sustainable improvements.
  • Broad network membership builds trust and supports integrated service development.
  • Improvement projects empower and motivate staff.
  • Advocating for the voices of people living with frailty and their carers informs service improvement.

Impact of the network

The frailty network has representation from across healthcare services, including:

  • primary care
  • HSCPs
  • acute hospitals, and
  • the third sector.

The network has supported key elements of the NHS Lanarkshire frailty work, including:

Improved coordination and access by:

  • Aligning the frailty work and reducing variation across three acute hospitals and associated community services.
  • Improving identification of frailty in both hospital and community settings.
  • Establishing two new frailty assessment units.

Innovative roles and pathways by:

  • Trialling new AHP roles in Emergency Departments to offer alternatives to hospital admission.
  • Piloting consultant geriatrician sessions in the Flow Navigation Centre to support professional-to-professional consultations and alternative care pathways, preventing avoidable hospital admissions.
  • Testing direct admissions to the frailty units from new community pathways.

Medication safety by:

  • Conducting polypharmacy reviews in community hospitals, reducing medication-related harm and length of stay.

Further information

For more information and updates on the Focus on Frailty programme, please visit our webpages.

To find out more about the NHS Lanarkshire’s whole system approach to frailty care pathway improvement, or to join the frailty learning system, please email: his.frailty@nhs.scot.

Further reading: