NHS England has published a best practice guide for NHS frailty pathways, intended to inform ICBs and providers on the actions that should be taken to commission and drive improvements in performance, ahead of the publication of the modern service framework for frailty and dementia later in 2026.
Key enablers include strong organisational and place-based leadership, education and training, strong collaboration with the VCSFE sector, and clinical safety including risk management for virtual wards, and governance for interoperability of shared care records and EPR.
A number of actions are set out around improving frailty services, covering the use of high quality data to understand demand and delivery costs, the use of a single frailty risk stratification dataset tool across systems to identify those living with frailty, increasing the number of care plans or home-based assessments, and making these visible to relevant providers as well as patients themselves.
A comprehensive neighbourhood-level frailty plan should be developed to align with ICS priorities, NHSE continues, multi-agency frailty training should be offered around things like advanced care planning conversations, and investment should be made in the expansion of community health services and the primary care workforce.
In the guide, NHSE also offers further insight into each of the key actions identified, including the use of linked data to understand demand and delivery costs, where it recommends at a minimum the use of the Community Services Data Set, primary care data, and secondary care data. Considerations should also be given to the use of ambulance, virtual ward, mental health, and adult social care data, it adds. The owner for this action should be ICBs, NHSE outlines, through dedicated leads across executive, managerial, and clinical teams, with support from primary care, community health services, and acute providers.
A case study from South West London ICB is included, where a dashboard has been developed integrating data from primary, secondary, and community care, along with ambulance services and social care. The connected dataset allows the application of the hospital frailty risk score and electronic frailty index, mapping frail patients across the region, NHSE notes, adding: “The dashboard highlights areas with high prevalence of frailty and tracks service utilisation, revealing that a small cohort with moderate or severe frailty need a disproportionate amount of resources.” The dashboard also reportedly allows the ICB to model the impact of shifts in care such as virtual wards.
Similarly, NHSE turns to the use of a single frailty risk stratification dataset tool, recommending that frailty status should be recorded in EPR systems and shared between relevant health and care organisations, with oversight from neighbourhood MDTs. Population health management approaches will facilitate proactive case finding, support earlier recognition of frailty, and promote the targeting of services where they are needed most. Ownership for this action will lie with primary care and community health services, along with integrated neighbourhood teams and acute providers, NHSE outlines.
In Mid and South Essex ICS, a segmentation model has been developed to proactively identify frailty risk across the system using linked datasets, NHSE shares, created by clinical experts and business intelligence analysts. Practitioner-validated CFS coding across provider EPR systems is promoting consistency in assessment, and a shared electronic registry offers real-time visibility of frailty populations. “In under 2 years, over 20,000 additional people received validated CFS scoring, enabling more coordinated neighbourhood-level proactive care and targeted evidence-based support,” it reports.
The guide also makes provision for the inclusion of integrated frailty pathways linking virtual wards and hospital at home in neighbourhood-level frailty plans, designed to support the stepping-up of patients where appropriate.
Wider trend: The role of digital and data in patient pathways
For a recent HTN Now session exploring what good looks like for a digital patient journey, HTN was joined by a panel of experts from across the health sector. Panellists included Shanker Vijayadeva, GP lead – digital transformation in primary care, London Region, NHS England; Amanda Jackson, associate CCIO and digital inclusion lead, Leeds Community Healthcare NHS Trust; Tom Stocker, CHCIO and EPR adviser; Simon McNair, head of digital business development, Restore Information Management; and Tom Baldock, MD at Synertec, part of Restore Information Management.
A pilot of the Connected Health Network model at Northern Lincolnshire and Goole NHS Foundation Trust is using video call functionality to bring specialist rheumatology input into primary care, with the ambition of reducing “unnecessary referrals to secondary care”. The model includes a GP with a special interest in rheumatology and dermatology triaging patients; a lead consultant joining the last part of the clinic by video call to discuss and advise on investigations, management and referrals; and direct access for patients to physiotherapy, weight loss programmes, social prescribing, and mental health support. According to the trust, the service currently receives around 200 new patients per year, receiving referrals from GPs and physios as well as supporting existing patients in secondary care.
East of England Adult Critical Care Network is partnering with Mela Solutions on a shared analytics project to deepen data-driven understanding of the region’s critical care services which has already, according to the company, helped to highlight a “significant improvement in admission delay” from the 2024 to 2025 time period. The ambitions of the project include harnessing data insights to inform decision-making, improve coordination across the system, identify areas for improvement, and enhance outcomes for critically ill patients.
