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Supporting older people across the frailty pathway

3 Jul 2025

How can each of us in our individual roles support older people across the Frailty Pathway?

A consultant nurse perspective

As a consultant nurse, I find myself at the intersection of clinical expertise, system leadership, and compassionate care. One of the most pressing challenges we face today is how we support older people living with frailty—especially as we anticipate a significant demographic shift.

The urgency for change

In England, the population aged over 75 is projected to rise dramatically over the next 20 years. While this increase is a testament to advances in medicine and public health, it also brings a sobering reality: many people spend the last decade of life in poor health and with disability. Life expectancy has outpaced healthy life expectancy, and this gap demands urgent attention.

The NHS Long Term Plan outlines a clear direction—shifting care from hospitals into communities, with a strong emphasis on neighbourhood health services and integrated care. This is not just a logistical shift; it’s a cultural one, requiring collaboration across primary care, social care, mental health, and the voluntary sector.

A blueprint for frailty care

The British Geriatrics Society’s 2023 report, Joining the Dots: A Blueprint for Preventing and Managing Frailty in Older People, provides a comprehensive framework for commissioners and practitioners alike. It encourages us to:

  • enable independence and promote wellbeing
  • deliver population-based, proactive anticipatory care
  • provide integrated urgent community response, reablement, and intermediate care
  • ensure frailty-attuned acute hospital care
  • enhance healthcare support at home and in care homes
  • reimagine outpatient and ambulatory care
  • offer coordinated, compassionate end-of-life care

System-wide integration in action

Key enablers include to a system wide approach to frailty include:

  • joined-up communication supported by digital tools for seamless handovers across health, care, and voluntary sectors
  • consistent identification of frailty and access to Comprehensive Geriatric Assessment (CGA), shared via integrated care records
  • ongoing involvement of carers and families, ensuring continuity and compassion throughout the pathway.

Putting people at the centre

At the heart of this approach is a simple but powerful question: “What matters to you?”

This question underpins personalised care planning and ensures that older people are not just passive recipients of care, but active participants in shaping it.

As a consultant nurse, I see my role as a bridge—connecting clinical insight with system-level strategy and always advocating for people living with frailty. Whether it’s leading on frailty identification, embedding CGA into routine practice, or mentoring colleagues in holistic care approaches, we each have a part to play.

A call to action

So, I leave you with this question:

What one thing will you do to make a difference to people living with frailty as part of a system-wide approach?

Let’s continue to challenge ourselves, collaborate across boundaries, and champion the dignity and wellbeing of older people at every stage of the frailty pathway.

Page last updated - 03/07/2025