Preventative care for older people living with frailty in the community: May 2025

South Ayrshire HSCP and NHS Ayrshire and Arran were part of the Focus on Frailty programme. The programme ran from May 2023 to December 2024.

Spotlight

South Ayrshire HSCP and NHS Ayrshire and Arran have improved the wellbeing of older people living with frailty and reduced GP appointments.

Impact data:

  • 77% of people (120/155) who received a wellbeing review from an occupational therapist or occupational therapy assistant reported an improvement in their wellbeing.
  • Occupational therapy wellbeing reviews for older people living with mild frailty improved wellbeing for 77% of people (120/155) who received a review.
  • In one GP practice, there was a 37% reduction in demand for GP appointments in the six months following the wellbeing review. This is equivalent to freeing up three days of GP time for the 51 people who received a wellbeing review.

The team did this by proactively identifying older people living with mild to moderate frailty. They used the electronic frailty index in primary care. This was followed up by an offer of an occupational therapy wellbeing review. Evidence shows that proactive approaches to frailty identification coupled with preventative measures can reduce:

As part of this work, the team tested and implemented changes including:

  • frailty identification in primary care through the electronic frailty index
  • an ageing well check-in form for the public
  • occupational therapy wellbeing reviews, and
  • referrals to services and support around healthy ageing.

This work is part of the Stay Ahead of the Curve service in South Ayrshire and is supported by an Ageing Well strategy. The service was developed in Troon and is being spread to the whole of South Ayrshire.

Changes for impact

Frailty identification using a reliable tool

Multiple approaches were used to identify people living with frailty and those who might benefit from an ageing well review. This included:

  • using the electronic frailty index in primary care
  • proactively engaging with the public around healthy ageing, and
  • providing a route for people to self-refer.

Wellbeing reviews and frailty assessments

Part of the pathway for people who may be living with mild or moderate frailty is a wellbeing review carried out by an occupational therapist, or occupational therapy assistant. This involves a person-centred discussion about a person’s health and wellbeing needs. Where appropriate a full frailty assessment is carried out by an occupational therapist.

Integrated care coordination

Following a wellbeing review, person-centered advice on a range of issues including nutrition, physical activity and hydration is offered. This is done alongside referrals to appropriate services or community supports.

Transferable learning

  • Utilise multiple approaches to identify frailty and those at risk of frailty including risk stratification tools, enabling self-referral and proactively engaging the public in healthy ageing.
  • It can be challenging to gather data on frailty prevention. In this context it is useful to collect a wide range of impact data. This includes data on people’s wellbeing, demand on other services such as GP appointments and patient stories.
  • Strategic support from senior leadership within a health and social care partnership or NHS board enables spread.

Further information

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

To find out more about South Ayrshire HSCP and NHS Ayrshire and Arran’s approach, or to join the frailty learning system, please email: his.frailty@nhs.scot.

Further reading