Focus on Frailty programme update July 2025
Focus on Frailty programme 2025/26
We support NHS boards and HSCPs to improve access to and experience of person led and coordinated health and social care for older people who are living with frailty.
The programme has a particular focus on:
- setting up hospital front door frailty pathways and
- improving integrated care coordination in primary, community and acute care
It supports delivery of the NHS Scotland Operational Improvement Plan and is grounded in the Ageing and frailty standards (2024)
What we do
We support participating teams to identify, test and spread evidence-based change ideas by:
- Providing one-to-one quality improvement coaching
- Providing places at two in person learning sessions
- Site visits from the Healthcare Improvement Scotland team
- Providing access to clinical expertise on frailty
- Advising on data and measurement, strategic planning and engaging people and families in improvement
- Sharing a change package and measurement framework
- Publishing tools and resources based on the best available evidence
- Deliver a learning system that that enables people working in frailty services to share and learn
Examples of impact so far
Hospital sites with access to specialist staff in frailty teams
40% of hospital sites have access to specialist staff in frailty teams (those with emergency departments and participating in the Focus on Frailty programme)
Evidence shows that identification of frailty at the hospital front door contributes to early identification of frailty, prompt geriatric assessment and timely discharge. British Geriatrics Society, Front door frailty: Advice on setting up services (2023).
Spotlight on
National learning event
Representatives from all 11 teams and Ulster Hospital, Northern Ireland came together to share learning and connect with colleagues. They heard from the Cabinet Secretary for Health and Social Care who acknowledged and supported the improvement work taking place as part of the Focus on Frailty programme. Delegates also heard from Professor Kenneth Rockwood, Dalhousie University, who presented on ‘the golden 72 hours of acute illness for people with frailty’.
91% of respondents rated the learning session extremely or very useful.
This has been achieved by
11 teams are participating in the programme
- NHS Ayrshire & Arran
- Dumfries and Galloway HSCP
- NHS Fife
- NHS Forth Valley
- Glasgow Royal Infirmary
- NHS Highland
- NHS Lanarkshire
- NHS Lothian
- NHS Shetland
- South Ayrshire HSCP
- NHS Western Isles
We are sharing learning from the programme with a team at Ulster Hospital, Northern Ireland through learning sessions and project surgeries.
Recently completed milestones
During April, May and June 2025 we:
- Held one to one coaching calls with all 11 teams
- Delivered an online welcome session. This equipped teams participating in the programme to begin their improvement projects
- Delivered a parallel session on improving person led care for older people living with frailty at the NHS Scotland Event
- Delivered an in person learning session. The session facilitated connections between participating teams. It also demonstrated how quality improvement could support their frailty improvement work
- Facilitated a project surgery on enhancing hospital front door frailty services
- Attended a site visit with NHS Fife and Fife HSCP
Developing aims
Teams are focusing their improvement work on three areas across the frailty pathway:
- Discharge and return to community
- Preadmission and living well in the community
- Hospital care (including setting up front door frailty services)
100% (11/11) teams have developed an aim and a measurement plan.
Testing changes
NHS Dumfries and Galloway and Dumfries and Galloway HSCP are undertaking work to enable health and social care staff in community teams to identify people living with frailty in the community using the clinical frailty scale. The team aim to provide proactive intervention to those identified with frailty.
Sharing learning
We have published:
- Implementation guidance to support the development of
- frailty care pathways in acute hospitals, and
- community-based frailty services
- A quality improvement self-assessment tool for teams in the Focus on Frailty programme to support them to understand their system
- Four insight stories:
Next steps
Between July-September 2025 we will:
- Review the first progress reports, baseline data and measurement plans submitted by teams
- Facilitate a drop in session for teams to discuss challenges and share ideas for improving hospital front-door frailty services
- Deliver a project surgery with a focus on community frailty services to support networking and connection between the teams.
- Attend site visits with:
- NHS Ayrshire & Arran
- NHS Forth Valley
- NHS Highland
- NHS Lothian