Identification and assessment of frailty in general practice – event resource: September 2025

These are the resources discussed in the frailty in general practice – a team approach session held on 30 September 2025.

If you have any questions or would like to speak to a member of the Healthcare Improvement Scotland Focus on Frailty team please email us at his.frailty@nhs.scot

Useful resources

To meet the requirements of the Scottish Government 2025–26 Directed Enhanced Service (DES) practice frailty leads should:

The following resources provide greater detail about frailty and why it is a priority area within general practice in Scotland. They can support General Practitioners (GPs) and the wider Multidisciplinary Team (MDT) in general practice to make improvements to care for older people living with or at risk of frailty.

Identification of frailty: tools and resources

The Clinical Frailty Scale

The Clinical Frailty Scale (CFS) is a judgement-based frailty tool that assesses the person’s illnesses, function and cognition (thinking and understanding) to generate a frailty score ranging from 1 (very fit) to 9 (terminally ill).

View the The Clinical Frailty Scale

Healthcare Improvement Scotland Ageing and Frailty standards (2024)

Healthcare Improvement Scotland have developed standards for ageing and frailty in Scotland. The standards draw on current evidence from:

  • improvement work
  • lived experience
  • best practice
  • stakeholder recommendations

They cover older people who may experience frailty as they age and apply in all settings.

Read the Healthcare Improvement Scotland Ageing and Frailty standards (2024)

NHS Lothian frailty toolkit: scaling up quality improvement in primary care

This toolkit produced by NHS Lothian is designed to provide a structured approach to planning and testing improvements in older people’s frailty identification, diagnosis, and evidence-based management in primary care.

Read the NHS Lothian frailty toolkit: scaling up quality improvement in primary care

Webinar: Early identification and assessment of frailty

South Ayrshire Health and Social Care Partnership (HSCP) share an example of how early identification and assessment supports improved outcomes for people living with frailty in the community and reduced GP appointments.

Watch Webinar: early identification and assessment of frailty

Webinar: the golden 72 hours of acute illness in people who live with frailty

Professor Kenneth Rockwood shared his insights and experience of interventions which can improve outcomes for older people with frailty.

Watch Webinar: the golden 72 hours of acute illness in people who live with frailty

Case study: improving frailty identification and management

Dr Stephen Carty, Clinical Frailty Primary Care Lead, Edinburgh HSCP improved the quality of care for people living with frailty by introducing a proactive approach to frailty coding, identification and management.

Read Case study: improving frailty identification and management

Coding frailty in general practice: read codes

Approved ‘read’ codes for EMIS and Vision

  • Mild frailty (CFS 4-5) – 2Jd0 
  • Moderate frailty (CFS 6) – 2Jd1 
  • Severe frailty (CFS 7-9) – 2Jd2 

Frailty care planning and coordination: tools and resources

British Geriatric Society: Comprehensive Geriatric Assessment hub

The British Geriatric Society: Comprehensive Geriatric Assessment (CGA) hub is a powerful, evidence-based approach to improving care for older people. By ensuring holistic assessment and coordinated intervention, CGA supports better outcomes across acute, primary, and community settings.

The CGA hub aims to:

  • offer a definition for CGA
  • explain how CGA works as a clinical intervention at a practical level
  • outline the key evidence base for CGA across various health and care settings
  • provide an intricate guide for each domain of CGA, to help clinicians and teams understand the detail behind these interventions

Read the British Geriatric Society: Comprehensive Geriatric Assessment Hub

Future Care Planning toolkit

The Healthcare Improvement Scotland Future Care Planning (FCP) toolkit pulls together guidance and resources on all aspects of FCP to support health and social care professionals throughout the care planning process.

Visit the Future Care Planning toolkit

Delirium toolkit

The Healthcare Improvement Scotland delirium toolkit provides tools and resources developed to support delirium identification and treatment.

Visit the Delirium toolkit.

Improving person led care for older people living with frailty

This presentation by Healthcare Improvement Scotland at the NHS Scotland Event, June 2025 highlighted the importance of taking an integrated, system-wide approach to improving care for older people living with frailty and shared practical insights for those seeking to improve services for an ageing population.

Watch Improving person led care for older people living with frailty

Case study: how one clinic in Hull cut emergency admissions for frail people by 50 %

This article describes how the Jean Bishop Centre, City Health Care Partnership, cut emergency admissions for the most severely frail people by 50 %.

Read the Case study: how one clinic in Hull cut emergency admissions for frail people by 50 %

Frailty: research shows how to improve care

This article from the National Institute for Health and Care Research (NIHR) brings together evidence from the NIHR and elsewhere to help improve the quality of care in hospitals and the community for people with frailty.

Read Frailty: research shows how to improve care

Effectiveness-matters: recognising frailty in primary care (May 2017)

This article produced in collaboration with the Yorkshire and Humber AHSN Improvement Academy and Connected Yorkshire summarises research evidence into frailty and shares key actions for the recognition and management of frailty in primary care.

Read Effectiveness-matters: recognising frailty in primary care (May-2017)

Medication reviews: tools and resources

Polypharmacy guidance toolkit

This guideline developed by the Scottish Government Effective Prescribing and Therapeutics Division aims to provide resources, expertise and insight for all involved with polypharmacy management. Please note that this guidance is under review.

Visit the Polypharmacy guidance toolkit

Webinar: medication reviews for older people living with frailty

Moray HSCP and NHS Dumfries and Galloway share learning from improvement work they have been undertaking with Healthcare Improvement Scotland’s Focus on Frailty programme. They share how they have reduced the number of medications for older people living with frailty through polypharmacy reviews.

Watch Webinar: medication reviews for older people living with frailty

Further learning modules: tools and resources

TURAS module: evidence-based polypharmacy reviews and the 7-step process

This training equips pharmacists, doctors and other healthcare professionals to undertake an in-depth review of prescribed medications.

It focuses on highlighting the public health challenge of polypharmacy, and the urgency to address it to prevent medication related harm and hospital admissions. The process is a person centred approach to review appropriate use of medication using the “7 step process” where shared decision making is paramount and centred around “what matters to the patient?” and the effective use of medicines. 

Note – it is a requirement of the 2025–26 DES for frailty practice leads to engage with this module.

Complete the TURAS module: evidence-based polypharmacy reviews and the 7-step process

PBSGL Module: Diagnosis and Management of Frailty (August 2024)

This is a Practice Based Short Group Learning (PBSGL) module which is available from NES for members of the PBSGL scheme. The module aims to:

  • offer some definitions of frailty,
  • present tests for identifying individuals with frailty,
  • review measures to reverse or stabilise frailty in susceptible individuals,
  • consider management of pre-existing conditions in frailty, including “tipping points” and crisis management in frail adults, and
  • recognise the need to change disease management targets for hypertension and diabetes.

Visit the PBSGL Module: Diagnosis and Management of Frailty (August 2024)