Focus on Frailty programme update November 2025
Focus on Frailty programme 2025 – 2026
We support NHS boards and Health and Social Care Partnerships (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
- 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.
- by providing places at in person learning sessions.
- with site visits from the Healthcare Improvement Scotland team.
- by providing access to clinical expertise on frailty.
- by advising on data and measurement, strategic planning and engaging people and families in improvement.
- by sharing a change package and measurement framework.
- by publishing tools and resources based on the best available evidence.
- by delivering a learning system that that enables people working in frailty services to share and learn.
Examples of impact so far
Access to specialist frailty teams
87% (13/15) of hospital sites that accept emergency admissions and are participating in the programme have access to specialist staff in frailty teams.
Reduction in length of stay in hospital for people living with frailty
The implementation of a frailty unit in Glasgow Royal Infirmary has led to a four-day reduction in median length of stay for people identified as frail with an estimated cost avoidance of £4.1m over 12 months.
Spotlight on
We have published a report outlining hospital and community services for older people living with frailty in Scotland. The aims of the report are to:
- provide an overview of frailty services in Scotland in community and hospital settings
- highlight areas of good practice
- raise awareness of challenges to improvement and what might help
You can read the report by clicking on this link to our website.
Achievements
11 teams participating in the programme
- NHS Ayrshire & Arran
- NHS Dumfries and Galloway
- 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
Between July and September we:
- held a webinar on frailty in general practice – a team approach with a total of 484 attendees
- visited the following teams: NHS Lothian, NHS Shetland, NHS Highland and NHS Ayrshire & Arran
- published the ‘Think Frailty’ tool on the Right Decision Service
- published an insight story: building whole system leadership and culture for frailty improvement in Lanarkshire
- published an identification and assessment of frailty in general practice toolkit
- reviewed and provided feedback on the data and progress reports submitted by teams in July
Testing changes
Admission avoidance
NHS Highland tested functional criteria for discharge in the emergency department. During the test, occupational therapy and physiotherapy led a needs-based assessment to enable discharge with proportionate care being delivered at home.
This led to avoided admissions and reduced length of stay for those who were admitted. Over a five-week period this avoided 1,100 bed days equating to approximately £300,000 in costs avoided.
Multi-professional meetings
South Ayrshire HSCP are testing weekly multi disciplinary team meetings in one locality that bring together professionals including allied health professionals, social workers, pharmacists, nurses and GPs. They have now started testing this approach in another locality. These focus on:
- improving identification and management of frailty.
- enhancing care co-ordination, shared responsibility and relationships across health and social care.
Sharing learning
On 29 July 2025 we facilitated a project surgery: enhancing hospital front door frailty services for teams participating in the programme with 97 attendees.
Attendees heard from Professor Simon Conroy Consultant Geriatrician, Royal London Hospital who presented on ‘urgent care for older people living with frailty’ and Drs Lesley Anderton and Kat Allen who shared examples of good practice from the Queen Elizabeth University Hospital, Glasgow.
85% of respondents found the session extremely or very useful.
Next steps
In the next quarter we will:
- review the data and progress reports submitted by teams.
- deliver a second in person learning event where teams will have the opportunity to share and learn from each other.
- visit the following teams;
- NHS Western Isles
- NHS Dumfries & Galloway
- NHS Forth Valley
- NHS Lothian
- South Ayrshire HSCP
Email us at his.frailty@nhs.scot if you have a question about the improvement programme or would like a PDF copy of the progress update.