NHS RightCare - Frailty toolkit, do we need one?

14 August 2019

Beverley Marriott is a Frailty and Dementia Matron working in the Birmingham community healthcare foundation trust. She is also a King’s College Older Person Fellow. She tweets @bevbighair

A toolkit has been developed by NHS RightCare in collaboration with NHS England’s National Clinical Director for Older People, Age UK, Getting It Right First Time and The National Institute for Health and Care Excellence (NICE).

Why do we need a toolkit?

Increasing numbers of people are at risk of developing frailty and a person living with mild frailty has twice the mortality risk of a fit older person. Unfortunately more people living with mild, moderate or severe frailty are attending emergency departments, with over 4000 admissions daily for people living with frailty.

Older people living with mild, moderate or severe frailty are more likely to have delayed transfers of care. 45% of people experiencing delayed transfers of care are over 85 (approximately 50% of people aged 85 and over will encounter frailty). Severe frailty brings over four times the costs of non-frailty.

Often people living with frailty could have their needs met within the community setting, outside acute hospital care.

What does the NHS Rightcare toolkit offer?

This NHS RightCare toolkit supports the delivery of the NHS Long Term Plan for frailty, an evidence-based framework of care for older people with frailty to be delivered through the national Ageing Well programme. This highlights the focus on delivering integrated personalised care in communities. It also aims to support the delivery of care to meet the needs of older people with three inter-related service models centred on identified patient groups.

Community multidisciplinary teams

Community multidisciplinary teams will target the moderate frailty population, moderately frail people whose annual risk of urgent care utilisation, death and care home admission is 3 times that of an older person of the same age who is fit. This identified patient group needs targeted proactive interventions to reduce frailty progression and unwarranted secondary care attendances.

Urgent Community Response

Urgent Community Response is designed for older people who are at risk of unwarranted stays in hospital, as these people can have their needs met more effectively in a community setting.

Enhanced health in care homes

Enhanced health in care homes will enable consistent health care support across England. Care home beds outnumber NHS hospital beds by 3:1 and can be an important place for end of life care. The Ageing Well programme and framework aim to support commissioners, acute and community health services providers, social care and the voluntary sector to work together, turning what is currently urgent care into planned care for key groups of vulnerable older people.

The Frailty Toolkit highlights system improvement priorities as delirium, dementia and cognitive disorders. It seeks to highlight that people living with frailty will often live with or experience dementia and delirium and that there are specific conditions that require attention across systems to support prevention, identification, support and management. Recognition of the signs of delirium and dementia is essential.

Although delirium is treatable, and preventable if dealt with urgently, unfortunately it is associated with increased length of hospital stay, hospital acquired complications and higher mortality rates. From experience, people who have falls are more at risk of developing delirium.

Dementia and cognitive disorders are progressive, and experience of dementia will vary, meaning that care and support must be person-centred and that families and healthcare professionals must have access to screening, appropriate training and support to improve the care they receive.

Moving forward, the toolkit aims to support clinicians in understanding how to identify frailty, care planning and outcomes, and provides an opportunity to assess and benchmark current systems to find opportunities for improvement.



Anything we can do to improve the quality of life and independence has to be fully researched and implimented if found to be beneficial.

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