“Fit for Frailty” is a two-part campaign from The British Geriatrics Society (BGS) in association with the Royal College of General Practitioners (RCGP) and Age UK.

Part 1 was published in June 2014 and provides advice and guidance on the recognition and management of frailty within community and outpatient settings. It is intended for all levels of health and social care professionals working in the community who may encounter older people living with frailty. The guidance is designed to help them to recognise the condition of frailty and to increase understanding of the strategies available for managing it.

The BGS calls for all those working with older people to be aware of, and assess for, frailty.

Recommendations for recognising frailty included:

  • Older people should be assessed for the possible presence of frailty during all encounters with health and social care professionals;
  • Provide training in frailty recognition to all health and social care staff who are likely to encounter older people;
  • Do not offer routine population screening for frailty.

Recommendations for managing frailty included:

  • Carry out a comprehensive and holistic review based on comprehensive geriatric assessment principles in partnership with older people who have frailty, and their carers;
  • Ensure that reversible medical conditions are considered and addressed;
  • Consider onward referral in particularly complex situations (either geriatric medicine or old age psychiatry);
  • Conduct personalised medication reviews;
  • Use clinical judgment and personalised goals when deciding how to apply disease based clinical guidelines;
  • Generate a personalised shared care and support plan (CSP) and establish systems to share the health record information between services, with robust systems to track and review the CSP;
  • Develop local protocols and pathways of care for older people with frailty, ensuring that the pathways build in a timely response to urgent need;
  • Recognise that many older people with frailty in crisis will manage better in their home environment, but only with the support systems that are suitable to fulfill all their health and care needs.

Part 2 was published in January 2015 and provides advice and guidance on the development, commissioning and management of services for people living with frailty n community settings. It is intended for GPs, Geriatricians, Health Services Managers, Social Service Managers and the Commissioners of Services. It sets out a comprehensive framework of clinical development and system management for implementation across local health systems,including:

Identifying Frailty:

    • Older people should be assessed for frailty during all encounters with health and social care personnel;
    • Identifying frailty at practice level using existing health record data is an emerging and attractive possibility.

Managing Frailty:

    • Ensure access to comprehensive geriatric assessments, coordinated care planning and holistic multi-disciplinary interventions to optimise physical, mental and social functioning;
    • Meet complex needs through integrated care pathways;
    • Provide safe, reliable and appropriate alternatives to hospital admission; Avoid delayed transfers of care.

Managing services:

    • Develop training and education packages tailored to local needs to enable multi-professional and cross-organisational delivery of care for frailty;
    • Evaluation must be an integral part of service design and delivery and include patient-centred outcomes and experiences, as well as process and system measures.

Developing and commissioning services: 

    • Develop ‘whole system’ frameworks using new structures and flexible workforce development to overcome traditional boundaries in care;
    • Establish integrated contractual frameworks and collaborative commissioning to support / reinforce provider innovation.


Summary Part 1

Summary part 1

Summary Part 2

Summary part 2

Full Report Part 1

Full report part 1

Full Report Part 2

Full report part 2


Useful links: Visit the campaigns page of the British Geriatric Society website https://www.bgs.org.uk/resources/resource-series/fit-for-frailty