Developing reliable frailty care pathways: September 2025

Improvement work undertaken by Glasgow Royal Infirmary as part of the Focus on Frailty programme between September 2023 and August 2025.

Spotlight

Glasgow Royal Infirmary (GRI) in NHS Greater Glasgow and Clyde has reduced the average length of stay for people identified as frail by four days (reduction from 13 to nine days) with no increase in readmissions. This would result in £4.2 million of costs avoided if sustained for a year at a 85% occupancy rate. This is the equivalent of freeing up hospital capacity for an additional 1,400 admissions a year.

They did this through:

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

GRI demonstrated that developing person-centred frailty pathways can increase how quickly older people living with frailty return to live at home or in a homely setting. Reducing the amount of time people spend in hospital can release capacity in the system. It can also prevent deterioration in the health of patients due to hospital related harms.

Quote / Testimonial:

“Having a comprehensive geriatric assessment huddle involving community rehab teams meant that patients could be flagged at an earlier point for discharge. They [community team] were …prepared and able to support a patient centred discharge home.“

Focus on Frailty programme member

Changes for impact

Changes for impact include:

Reliable frailty identification

  • Using a reliable frailty screening tool at the front door.
  • Using an electronic icon to make it easier for people to benefit from a frailty pathway.

Early multidisciplinary CGA

  • Establishing dedicated frailty assessment beds.
  • Developing frailty specialist roles across the multi-disciplinary team.

Integrated person centred care coordination

  • Collaborating with community teams to deliver integrated CGA huddles.
  • Using existing outpatient services as alternative options to admission.

Transferable learning

  • Senior leader sponsorship of frailty improvement work accelerates the pace of change.
  • Using local data over time to demonstrate the impact of changes supports momentum and buy in.
  • Including the voice of the person, their family and carers is a powerful lever for keeping focused on what matters most.
  • Interdisciplinary integrated teams create the conditions for innovation.

Further information

More information and updates on the Focus on Frailty programme are available on our webpages.   

To find out more about Glasgow Royal Infirmary’s approach, or to join the frailty learning system, please email: his.frailty@nhs.scot.

Further reading