Lack of GP targets resulting in too few frailty assessments, says Government watchdog

The public spending watchdog has strongly criticised the level of support for patients living with frailty by primary and community care.

The National Audit Office (NAO) report found that not enough patients aged 65 and over are assessed by GPs for frailty, and of those who are diagnosed, the level of follow-up support is often insufficient.  

It cited the lack of assessment targets from NHS England as an issue, as well as missed opportunities to use GP data on frailty to identify national-level trends. 

However, in response, the RCGP said the Government’s focus on rapid patient access had diminished GP opportunities for care continuity.

Last year, GPs assessed around 1.9 million registered patients aged 65 or over for frailty – 17% of the eligible population in England. When the requirement to identify frailty was introduced in the GMS contract in 2017/18, that figure was 26%. 

The report also said ‘GPs are failing to provide the required levels of follow‑up support’ for the 226,000 patients diagnosed with severe frailty last year.  

It pointed out that just 16% of those had a medication review, 18% had a falls risk assessment, and 29% had given consent for an enriched summary care record. 

The watchdog said the fact ‘NHS England has not set any standards or expectations’ for GPs ‘for the numbers of people to be assessed’ could explain the figures. 

It cited the ‘absence of a joined-up strategy for addressing frailty’ as a contributing factor, ‘compounded by NHS England’s lack of action on unexplained variation and obscured by limited and unchecked data’. 

The report continued: ‘GP contract data show the numbers of people who GPs assess for frailty and some of the follow-up services that they receive, such as falls risk assessments. 

‘However, NHS England neither validates nor quality assures these data. NHS England mainly uses these data to support contractual payments and for management information, but not as a formal tool for assessing individual GP performance nor to identify national trends or local variations in performance.’ 

The watchdog recommended a ‘single clear joined-up strategy for dealing with frailty’ more in line with a ‘national frailty service’ than the current ‘patchwork’ of offerings such as the Enhanced Health in Care Homes programme. 

It said support through this programme was ‘deteriorating’ in ‘important aspects of care’ – citing the fact the proportion of residents with personalised care and support plans has fallen from 76% in 2022/23 to 44% in 2024/25. 

Responding to the report’s findings, an NHS England spokesperson told Pulse: ‘While we know GP teams are already delivering millions more appointments a year compared to before the pandemic, it is vital that GPs fulfil their contractual requirements to ensure that frail patients over the age of 65 have the support they need.  

‘We will use this report’s findings to help ensure that we can provide care for an ageing population in a sustainable way, alongside the rollout of neighbourhood health hubs across the country which will bring more joined up care closer to home as part of the 10 Year Health Plan.’ 

Professor Azeem Majeed, a GP and professor of primary care and public health at Imperial College London, told Pulse eligible patients themselves, along with their carers, could ‘play an active role by seeking early support’ if they notice early symptoms indicating frailty, and by ‘attending routine reviews offered by their GP practice’. 

He told Pulse that GPs ‘should strengthen frailty identification and follow-up by ensuring routine assessment of patients aged 65+, clinically validating frailty findings, and consistently delivering core interventions such as structured medication reviews, falls-risk assessment, enriched summary care records and personalised care planning, while integrating with community and social care teams to provide proactive support’.

Meanwhile, NHS England should take from the report the need to ‘provide clearer national standards, better data and accountability frameworks, and ensure sufficient workforce capacity and funding’, Professor Majeed said. 

RCGP chair Professor Victoria Tzortziou Brown said the report’s findings showed an over-focus on access at all costs – at the expense of factors like workload considerations and continuity of care. 

Professor Tzortziou Brown said: ‘The reality is that GPs and our teams are working under intense and increasing pressures. Workload has risen consistently over recent years – both in terms of volume and complexity as we have an ageing population, with patients who often live with more than one serious condition – but workforce has not kept pace.’ 

She pointed to figures that showed a 15% increase in patients per fully qualified, full-time GP in England over the past decade – currently at 2,241 patients per GP. 

‘For too long, political priorities have focused overwhelmingly on rapid access, with important interventions such as structured medication reviews deprioritised. This often, unfortunately, comes at the expense of the long-term, continuous care that older people with complex health needs require.

‘Effective frailty management needs both time and access to well-resourced multi-disciplinary and community services working alongside general practice.’, she said.

To address the issues raised, Professor Tzortziou Brown again called on the Government to include a ‘clear road map for recruiting and retaining the GPs’ within the expected update to the 10-year NHS workforce plan.

Meanwhile, membership organisation NHS Providers said new neighbourhood provider structures were an opportunity to improve care for people living with frailty. 

Chief executive Daniel Elkeles said: ‘There are far too many older people being admitted to hospital who could have better care in a place they’d prefer – at or close to home. 

‘This report should be a spur to tackle one of the greatest challenges facing the NHS – one that has too often been overlooked. 

‘We can and must tackle this with a new model of care – using Integrated Health Organisations, multi-neighbourhood contracts and payment reform to make it happen.’ 

Earlier this year, a study found that an update to the widely-used electronic frailty index – which predicts risk of needing home care, hospital admission for fall or fracture, care home admission or death – helps GPs more accurately identify patients at risk.