We now move into our second session this afternoon. The way we treat people with frailty is a mark of a civilised society. The NAO estimates that, as of March 2025, just over 1 million people had been diagnosed as living with moderate frailty, and an additional 450,000 with severe frailty. However, the true number of people living with frailty in England is likely to be higher still, as the population ages and the numbers are likely to increase. The harmful effect on people’s health from frailty not only affects individuals but imposes considerable costs on the healthcare system. Today, we are looking to challenge the DHSC and NHS England on why GPs are not adequately identifying and providing the support required by those living with frailty. We will also be examining why there is significant local variation in the proportion of people being assessed for frailty, and determining who is ultimately responsible for whether GPs assess and provide the needed level of support for people living with frailty. To help us with that, we have two of our principal witnesses, who were with us for the earlier session. Permanent secretary, would you reintroduce yourself for the record?

Hello, I am Sam Jones, permanent secretary at the Department of Health and Social Care.

I am Jim Mackey, the chief executive of NHS England.

I am Chris Whitty, the chief medical officer for England.

Welcome back to the Committee.

I am Amanda Doyle, and I am the national director for primary care and community services at NHS England.

I think you have attended the Committee before, haven’t you?

I have.

Welcome to all of you.

Sir Chris, how lovely to see you again. I am looking forward to you visiting Minehead in my constituency as soon as it can be arranged because, as you know, my constituency has one of the largest demographics of elderly and poor people in the country. Given your previous reporting on frailty and an ageing society, how important is identifying and supporting older people in the community before they have a health crisis?

It is absolutely central because frailty drives a lot of the lack of independence and reduction in dignity that people often feel in older age. A lot of it can be headed off early on, and the longer the run-up we have, the better. Preventing frailty should start much earlier in age. Nevertheless, once people have early frailty—if that is identified—first, it is possible to slow down, and in some cases reverse, some of the elements of frailty, at least for a period. Secondly, it means that you can work with them to try and reduce the risks that can come from frailty, for example falls, which can be devastating for people because they lose their confidence in older age once they have reached a period of frailty.

It is funny you should say that because I went to visit my mother in hospital last night. She fell on Saturday and has just had a hip operation today, so it is very pertinent, although she is lucky enough to be well cared for by her family. Thank you; you are so right.

I can understand that is upsetting, and I can see that it is.

I love my mummy.

I hope she gets better soon; I am sure she will receive excellent care.

I want to focus on the role of the GP in supporting people with frailty. Since the contract in 2017-18, it has been a contractual requirement for GPs to identify registered patients over the age of 65 who are living with moderate to severe frailty, and then to put in place a more proactive care plan and make sure that risk is assessed and managed. It is clear from the NAO Report that GPs are not meeting that target and those expectations. Do you know why? I am not sure if this question is for you, Amanda?

It is clear that not enough people are being formally assessed. What happens in practice is that GP practices usually use something like the electronic frailty score, which is not a diagnostic tool for the individual patient, but will risk-stratify and identify the patients who should have a more clinically judged approach to assessment. Then, those patients who are suffering from moderate to severe frailty should be coded as such, so that we can find them and put the proactive interventions in place. We do not have a completely clear idea of the number of people who should have undergone that and been assessed as clinically frail. But we do know that of those who are coded as clinically frail, only a relatively small proportion are actually having the proactive interventions and being coded. That is what we need to address. We are working with ICBs, as commissioners, on how we identify outliers, address variation and increase the proportion of people, and we are putting some things in place to enable greater improvement support to get into practices where that isn’t happening as it should be. A huge proportion of very severely frail patients live in care homes, and as part of the primary care network and enhanced service, we have an expectation that primary care networks put specific interventions for enhanced care in care homes, including weekly ward rounds, multidisciplinary teams and so on. But we recognise that we need to improve those things, and we are working with ICBs to do that.

We might come back to care homes in a minute. Sticking with the core role of the GP in identification and proactive care—and the lack of that—it sounds like you put the responsibility with ICBs to do the contract management and oversight of GPs. Do they have the data to know who is doing it and who is not? What are the consequences for those GPs who are not doing it? There are obviously consequences for those patients: they are more likely to end up in hospital.

The ICBs do have the data. They have access to the range of metrics and measures from individual general practices that we have, such as the GP dashboard. There are no specific consequences other than identification of outliers and improvement support; there are no financial consequences, for example. We took an approach over the past two or three years to try to reduce the number of individual targets that were financially incentivised within the GP contract—

So is this no longer incentivised positively?

It is not positively financially incentivised; it is counted.

Do you think that is a reason why GPs are not doing it, because they are not getting any payment relative to other prospects?

It was not previously financially incentivised very specifically. We have pushed GP practices very hard over the past couple of years to improve access. Unfortunately, when capacity is constrained and demand exceeds capacity, which we know it does across general practice, pushing to improve one aspect of care inevitably causes consequences to appear elsewhere. But it is very important to us—it is in the 10-year plan and is part of the medium-term planning framework—that increasing the focus on proactive care for priority cohorts is a priority.

You may like to come back, but maybe this is one for Jim. I have a local GP who said that their practice was doing really well with same-day urgent appointments, with only one or two-week waits for routine appointments. Since digital access was given greater emphasis, the wait for routine appointments is now about three weeks and they have had to reduce face-to-face appointments. Ministers are saying, “Bring back the family doctor,” and they want more continuity in general practice. For frail older patients, that is vital, so that if they have deterioration, they get in quickly and get continuity. This is reducing those opportunities, so how are you making sure that prioritising one thing, in this case digital access, is not harming the very thing that is in GP contracts, which is proactive care for frail patients?

That is a really good challenge. First, the position that we are in is not acceptable. We have had a lot of discussions over the last couple of weeks about how we use the modern service framework to good effect, and to make sure that there is a clear structure that we expect everybody to comply with. We discussed before how we want to try to incentivise neighbourhoods to do what we want and need them to do. Part of the consideration, when the MSF is being finalised, is whether there are incentivisation options that can make this work. But I completely agree that it is unacceptable. It is central to the neighbourhood plan, so we have to make really big improvements in it. It is a key priority for all of us, so it will have to have a lot of focus. It will have to be tighter in terms of compliance with the framework, transparency of the statistics, and potentially—depending on the overall financial position and other things that we have to decide on—some form of incentivisation.

Okay. Proactive care is three things: medication review, falls risk assessment and an enriched summary care record. The percentages are in the NAO Report: 16%, 18% and 29%. That seems pretty low, so there are pretty poor levels of performance. Clearly, these are not just tasks for GPs. Potentially, pharmacists can do medication reviews. I have even met my local fire and rescue service, who do safe and well checks in people’s homes to try to prevent falls. How will we make sure within teams—whether that is the GP or others—that those with frailty who are recognised as having these risks receive what I understand is the evidence-based care that will really help them? Evidence-based care—that is for you, Chris. How do we make sure that these patients are getting the care that we know they need?

I will start, but I know that Amanda wants to come in as well. You are absolutely right: the first thing we have to do is identify the issues. Let me slightly ride to the defence of my GP colleagues. A lot of people will have identified frailty without having done so formally. That doesn’t mean that they reach the standard, but nevertheless, they will have picked things up and tried to act on them. But you are also completely right that something like, for example, a falls assessment will not necessarily be done by the GP. In fact, many other people are often better equipped to be able to do that. A lot of it is about how particular people move up the ladder of frailty—frailty is not an either/or, it is a continuum—and what they can do in their own homes. That is absolutely critical. It is not an abstract thing; it is about what you can do in the environment in which you live as the individual, as the patient. So you are completely right, but you have to identify the issue first, which is why early identification is important. Clearly, if someone bounds in at 65, having just come off whichever sport they enjoy doing—cycling or whatever—someone is not going to do a frailty assessment. It is a fairly obvious point that those people are quite a long way from that. But the further up you move in age, the more important that is. To pick up an earlier point, particularly in areas of the country that have very large or increasingly large proportions of the elderly population—because this is not even across the country—that becomes even more important. Those tend to be rural and peripheral areas, where it is often more difficult for people to come to their general practice, because of distances, so you have to factor that in as well.

I did not mean, by any means, to criticise GPs, including those in my area, who do a fantastic job. The point I was making is that they were doing a pretty good job of supporting the older, frailer patients, and sometimes, inadvertently, changes that are made can go in the wrong direction, and that this isn’t all for GPs to do. I am glad that you made that point. But the point is that somebody has to take responsibility—if it is not the GP—for making sure that patients who need it, or who are at risk because of increasing frailty, are getting proactive care. To push on that one, who ultimately will be accountable for making sure that those patients get proactive care?

We have established a national frailty dashboard. The data from the first full year, 2026-27, will be experimental data, so it will not be published, but we are collecting it. We will then publish data, and that will take into account the range of interventions that we are asking ICBs to ensure are in place. Part of this is the GPs identifying, coding and putting proactive care in place. Some of it is about asks around what happens at the front door of the emergency department, if you turn up and ask for assessment, and whether appropriate interventions are put in place if that person is moderately ill and severely frail. We are about to write out to ICBs, as part of the framework for neighbourhood health, with the key asks that they need to have in place next year around enabling better, more appropriate care for this population. We have commissioned an NIHR-led evaluation of frailty pathways and interventions, because we need more evidence about which interventions actually make a difference for people, rather than the whole list of things. We have already established a frailty improvement collaborative: seven sites—one in each region—looking at how we develop and scale, what improvement actions are most effective and how we shift care out of hospitals. The commissioners—the ICBs—will be responsible for overseeing all of that happening.

I can see Chris and Sir Jim indicating that they want to come in on this. If you are happy, Chair, I will let them do so.

Yes, briefly. We have a lot of ground to cover.

There are broadly two ways in which frailty tends to be identified. One is, in a sense, the ideal way: it is picked up early in primary care. The other route is that, in quite a lot of cases, it is picked up for the first time when someone goes into hospital with a crisis. Those tend to lead to slightly different immediate approaches. If it is picked up in hospital, geriatricians and others will tend to pick it up and try to reach into the community. Ultimately, it will end up back with the GP, but a lot can be organised from a hospital. If it is identified in the first place by the GP, the GP usually has the point on doing it. This is central to what general practitioners do, and I think all GPs would agree with that.

And they have the tools, with the electronic frailty index. Declaration of conflict: some academics in Bradford were part of the team that developed the electronic frailty index, and they are always very keen for me to publicise that.

I agree with all of that, and I strongly agree that this is a team endeavour. When we have published the MSF, we will hold ICBs to account on commissioning against the MSF.

That is the modern service framework.

Yes. There will be data to support all this, the data will be transparent, and we will try to hold ICBs and their neighbourhoods to account. It will also be at the hospital end. As hospitals are identifying frailty, there will be processes that we expect them to follow. That will be part of our overall oversight framework for them as well.

Thank you. Hopefully colleagues may pick up the point about care homes, which I did not get a chance to come back on.

I am sure we will. I will come back to you, Sir Jim, and take you to paragraph 3.13, page 36, which says, “the percentage of residents who had a personalised care plan agreed or reviewed has fallen sharply, from 76% in 2022-23 to 44% in 2024-25…This fall occurred when payments ceased for these activities, but GPs may still be providing this support and not recording that they are doing so.” I spoke to some of my local medical practitioners on Friday. One very overworked GP said that her practice had a lot of elderly people, and she was really struggling to provide these assessments. Will ICBs specifically target resources to such practices and areas, as Professor Chris has warned about the concentration of the elderly in certain areas of the country? Will resources be tweaked to allow extra frailty assessments to be made in areas where there is a concentration of elderly people?

There are a few things in that question; Amanda will rescue me when I get too far in. In terms of the overall resource distribution, in this year’s financial reset, we had a look at allocation again through the normal mechanisms. We are pretty confident that, according to the mechanisms, it is adequately resourcing our ICBs, and our allocation policy supports the transition towards our target over the next few years. Is the money going to the right place? Broadly, yes, from where we are. On the incentivisation point, we know that primary care is sensitive to financial incentivisation: that is a known factor that we have worked with in the NHS for a long period of time. It is a finite resource, and we are constrained, as every system is, by a limit to the capacity. It has probably been the case in recent years that we have prioritised urgent access, and some other things that have already been mentioned. As part of this next phase, we will consider whether that needs to be rebalanced, especially with supporting neighbourhood development. I cannot guarantee it, but it will absolutely be part of the process we go through to publish the MSF and agree whether it requires any new financial incentivisation. As an aside, I think it is also more likely that we will incentivise neighbourhood teams rather than specific individuals in that process.

There is a big variation between ICBs when it comes to the percentage of elderly people actually assessed for frailty and the percentage assessed for frailty who then actually get support. Why?

There is a big variation. One of the means that we use to improve things overall is tackling variation and looking at outliers. We will particularly ask ICBs in areas with negative outliers or particularly low numbers of people being assessed or offered interventions to tackle that. One of the things we have been doing over the last year—we published an update just last week—is something called standardising community services. There is a range of community services across the country that are not specified or described clearly; people code, measure and count in different ways and often fund through block contracts. What we have done is publish detailed descriptors and coding so that services can be standardised and we can properly compare across the country what is true variation and what are different ways of describing services and interventions; we have now covered about 75% of all community services. That also then gives ICBs the information they need to properly identify local need and commission appropriately to respond to that need. We will then measure it with the frailty dashboard that we are establishing, which I talked about.

So are the ICBs responsible for putting these problems right?

The ICBs are responsible for commissioning services sufficient to meet the needs of their population; obviously, all the service providers have a responsibility to ensure that the services they are commissioned to provide are delivered. Some of this is everybody’s responsibility.

Sometimes everybody’s responsibility becomes nobody’s.

Yes, it does.

I am still not quite certain; we might come back to this. The ICBs are responsible for commissioning the services, but commissioning things and making sure they are done are not the same thing, are they?

This is part of the process of the commissioning cycle. Commissioning the activity includes understanding what is needed but also ensuring that it is delivered by the people who you have contracts with. This is a significant challenge for ICBs because general practice and community services have huge numbers of providers—sometimes at quite a small scale. So it is slightly different from holding a hospital trust to account. Nevertheless, that is the process, and that is what needs to happen.

It is the ICB’s job to rectify the inequalities that exist?

It is the ICB’s job to recognise them and ensure that services understand the needs of their population and that they commission services to meet those needs. It is then the job of the providers commissioned and contracted to deliver those services to ensure that they deliver them. The ICBs will assure themselves of that.

It seems a very divided process. The ICBs out there say, “Oh, we’ll commission what is needed. You get on with it, but it’s not our job to make sure it is happening.”

It is their job also to make sure that it is happening.

The ICB will hold the people it has contracts with to account through its contractual mechanisms. This is a bit of a shift in our oversight frameworks: in our oversight mechanisms, we will hold the providers to account as well. As the CMO mentioned, some of this will rest in hospitals. We will hold them to account in the quality metrics for the delivery of their aspects of the MSF.

As you probably know, in a second I am going to come to the ICBs’ ability actually to do this work, given their reduced staffing and funding. If they are not doing it now, it will be a bigger challenge with 50% fewer staff isn’t it?

It is, but we are doing some work with the ICB primary and community commissioning teams to identify the key actions that we will need them to undertake to ensure that we are getting assurance about the things in the medium-term planning framework. This year, for the first time, we have some numerical targets around community services, as well as expectations about increases in capacity in order to enable both the proactive care that we have talked about for this cohort and the shift away from hospital. ICB allocations include an uplift of about 6% in 2026-27, and 7% the following year, to increase community services’ capacity to start doing some of this work.

In our discussions, we mentioned the whole issue of integrating care at neighbourhood level. Along with MP colleagues, I had a briefing a week last Friday from Sheffield Place, which is part of the ICB that relates to Sheffield. I think what has been developed is an absolutely brilliant integrated health model at local level. Everyone joins in. GPs are the primary providers, and there is public health and social care at the council. Everyone is working together. I said to the acting chief exec of the ICB, “What’s going to happen from April, when you’ve got 50% less resources?” They said, “We won’t be able to do this. This isn’t our job—we are commissioning. We can’t get involved in co-operation and collective working of this type.” I said, “Who’s going to do it then?” They said, “It’ll be over to the council or the hospital trust.”

I think responsibility also sits with the ICB to ensure that they are a part of putting the environment in place to allow providers to work co-operatively.

There are currently more than 40 people at Sheffield Place working in the ICB. There will be one from April. You cannot do with one person what you used to do with 40-odd people.

You raised this last week. We are in the process of picking that up specifically with that ICB. The way you describe it always makes me feel like we have ICBs post-change that are three men and a dog. They are still very large organisations. We have agreed with colleagues that we are reprioritising. They are shrinking, but we are reprioritising some of their activities so that they can do these things. The response you got is completely inadequate, and we are in a process of discussing that with the ICB.

I just cannot believe that it is the only place in the country. If you cut an organisation and suddenly get rid of 50% of the people, the tendency is to say, “We have these people in a local-level place. We will pull them into the centre, because then they can do everything for all the places.” That is what is happening.

They are dealing with it in different ways, so not all are doing that. I accept that a few have been highlighted that have been going that way, but that is not the intention. We will pick it up specifically with that ICB.

Chris Whitty, you came along to the PAC session when we had just had the announcement of the changes. You were saying then that the important thing with the changes—and I asked you the question—was to ensure that there were resources at Sheffield Place, because that is where the real links with social care and public health were going to be. Are you happy that that is working?

At that time, I had the dubious privilege of being the interim permanent secretary, so I was answering those sorts of questions as best I could. So actually—

What is the answer now, Chris?

Broadly, I think all of us here would agree, as all of you would, that having the resources to be able to deliver the services is critical. It is really about how they are best distributed, but that is no longer a CMO job, unfortunately.

Luckily, I have the privilege, as the substantive permanent secretary of the Department of Health and Social Care, to be able to answer the question for the CMO. We recognise—we have talked about this before, and Jim has picked up the specific case that you mentioned—that as we go through the changes, there are some very clear statutory responsibilities that the ICBs need to deliver. There is the oversight framework and the planning framework. ICBs are responsible for being able to demonstrate to NHS England what is happening at all levels, including the outcomes that they are responsible for commissioning through the process. It is the outcomes that make the difference, rather than the input, which goes back to the point that Anna made about the teams. On the numbers of people, notwithstanding the specifics you raised around that ICB, there is the dashboard that Amanda talked about and the dataset around community services. It is about making sure that people are using the dashboard to understand where and how services are being delivered. It goes to the heart of neighbourhood health and care, in terms of how we are ensuring that people are kept as safe as possible in the places that they should be. The answer to your question is that, through any programme of transition, as we are in at the moment with the abolition of NHS England in the Department of Health and Social Care, there is very tight monitoring of what is going on with the statutory responsibilities of the ICBs. Jim has picked up specific cases, such as the one you mentioned.

I think I am getting an assurance that Sir Jim will be coming back to me on those specific issues and concerns. We can all see that this could go in a very wrong direction, and what we want to achieve is integrated care. In Sheffield, we have had really good relationships historically between the NHS and the council; they work together, and it is important that we keep that.

Absolutely. We will come back to you when we have the answers to the questions you have.

And the GPs are all signed up as well.

Yes.

Coming back to the question of care homes, the Report tells us that the number of care home residents with a personalised care plan has fallen from 76% in 2022-23 to only 44%. The Report notes that the fall occurred when specific payments ceased for these activities, so it might be that they were recorded to get the payment and are still going on but no longer being recorded because there is no associated payment. Sir Jim, why has the percentage of care home residents with a personalised care plan fallen and are you concerned about it?

I am concerned about it, but I am sure Amanda will answer the question.

The enhanced care in care homes programme is part of the GP contract through the primary care network DES. Practices are obliged at a network-neighbourhood level to deliver interventions to people who live in care homes, who are the most severely frail group in our population. Part of that is about being part of multidisciplinary teams, weekly care home ward rounds, and moving so that you do not have four or five different GP practices all coming into the same care home so that it is easier for communication, ward rounds and other things to be managed by care homes and the GPs they work with. A range of asks was coded separately and specifically, which originally included care plans, but was narrowed down during the ’23-’24 year as part of a move to have a lot less tick-boxing and more guidance about service provision as part of the GP contract. Associated with that timescale, we have seen a significant reduction in the number of care plans coded. In the 10-year plan, there is a very specific commitment to the people who will most benefit from personalised care plans getting them, so there will be a push to address that.

If, for whatever reason, the data is no longer showing that enough people have care plans, what assurance do you have that GPs are delivering that part of their contract and that care homes and their residents are getting the support they need?

We have assurance that the enhanced care and care home-specific measures, such as ward rounds, are happening. However, as you say, we do not necessarily know whether the care plans are still happening but that nobody is putting the code in because we do not specifically count it any more, or whether they are just not happening. Part of the evaluation of the specific interventions around frailty will help us to understand that. We have a commitment to increase personalised care planning for a whole range of cohorts of the population—for example, people with long term conditions, people at the end of life and the most severely frail people—so we will put processes in place as we develop the 10-year plan delivery to ensure that we can record that it is happening.

Are you saying that you have stopped the incentive to measure it, but you will be bringing it back again?

We stopped the mandating of coding and counting as part of the contract. We never removed the guidance that suggested that it is what should be happening. As we look through 10-year plan delivery to roll out personalised care plans to a much bigger section of the population, we will have to look at how we code and count those. We said earlier that one of the interventions we must offer for severely frail people is an enriched summary care record. Part of what makes it an enriched summary care record is that care plans are available and accessible on that care record through the spine to any clinical area, such as the emergency department or a same-day frailty service that patients might present to. It is really important that we not only code those plans, but have them accessible through the care record.

That is for anyone with frailty. You are not specifically looking at people in care homes at the moment. GPs have the responsibility, and that has not changed, even if the incentive to record that specific care plan has. By definition, if someone is in a care home, they must be frail or at risk of frailty. Could GPs not be doing more to target those residents and ensure that they are being properly looked after?

Those residents are a subset of the cohort with moderate or severe frailty; they are almost all severely frail in one way or another. The enhanced care in care homes services are not just GPs. There is an obligation for GPs to be part of them, but that is within multidisciplinary teams. There is quite a lot of intervention; some of it is community services intervention, for which we have now set targets around waits. If you are already frail, have poor hearing or feet that are not managed, making mobility difficult, or a lack of occupational therapy, that can all contribute to and worsen your frailty. All those things are part of what enhanced care for the frail population, including those in care homes, includes.

It is a good question. Amanda is actually the expert on this and leads on it. Generally, it is a separate contractual negotiation. There is always a lot that colleagues want to achieve through those negotiations, and it is never possible to achieve everything that is wanted or desired. In that, we have to be careful, on the earlier point, not to overcorrect and cause another problem. It is really quite finely balanced how we direct GP resource.

I think that is right. To be fair to general practice, GPs have a wide-ranging contract that includes all the reasonable needs of all their registered population. Obviously, a significant proportion of demand on GPs comes from the sickest people, who are the moderately and severely frail population. However, we ask a whole range of things of them. We have to balance a contract that allows the use of clinical judgment and prioritisation according to the needs of the registered list, versus one where we measure and count every single intervention. We try to balance that. Sometimes we financially incentivise interventions for a period in order to change the way GPs work, and those then become part of the wider expectation. Of course, the main financial incentive in the general practice contract is the quality and outcomes framework, which largely measures specific interventions for specific long-term conditions. The people who are the most severely frail are often the very people who suffer from more than one long-term condition. We are measuring very specific interventions that not only delay the onset of frailty but also prevent and delay deterioration in combination. It is just that we have not put a label of frailty on those measures. We may be looking at blood pressure, diabetes interventions or others.

It is a very complicated answer. We have a GP dashboard—this is just speaking about general practice services rather than all the other contributors to those services. It is a very wide-ranging dashboard that measures a huge range of metrics—everything from the number of staff employed, to the number of appointments offered, access rates, clinical quality outcomes, and the sorts of numbers we have talked about today. What we tend to do is look at practices that are negative outliers across several indicators. There is always going to be one thing that a practice does not do as well as other things, but when you start to look at grouped outliers what you actually get down to is very small numbers of practices. That is how we tend to address those that most need improvement support. We are also taking measures to give commissioners a better ability to ensure that improvement support is accepted and can be put in place in practices.

I will look at it by ICB, identify the ICBs where numbers seem to be low and address those through our regular assurance meetings with ICBs. I would expect each ICB to look at that at an individual practice level and to address those outlier practices. Even within an ICB, we often see quite a huge variation in performance. Some ICBs do that to a greater degree of detail than others. We have a group that are at 10% or lower, and they are the lower end of the performers.

In that scenario, in our regional performance and assurance meetings we would flag that the ICBs in your region look as though their numbers are lower than in comparable ICBs, and we would expect the ICBs in your region to take measures to identify the reasons for that. The reasons will be different in different places. As Chris said, some places have real challenges around a more frail population, or difficulties attracting workforce. In other areas, frailty may not have been focused on as a priority in the way that we would want.

Can I add a note of scepticism? I think that the correlation between GPs who fill in all their forms and GPs who provide an excellent service to their patients is a long way from exact, in both directions. All of us want GPs to do the assessments, whether formally or slightly less formally, and ideally all of us would like them to write them down. That is particularly true because there is much less continuity of care. To go back to a point that the Chair made right at the beginning of the session: when there is continuity of care, you do not need to write things down as much because you know, but if there is a lot of moving around, actually having it written down has clear advantages. Nevertheless, we should not assume that working to the contract equals good care. Unfortunately—or not even unfortunately—that is not the case.

Chris mentioned continuity of care, which is vital—and more vital for this group of patients than it is for most. There is a balance between remaining independent at home and having admissions to hospital that are not actually going to benefit the person. A conversation with a trusted clinician often makes the difference there. One thing that we measure in the monthly HIS surveys that the ONS carries out for us is continuity of care. We measure it by asking, “Do you have a preferred clinician, and were you able to see that clinician?” because that is probably where it is most meaningful for patients. We see that measure slowly but steadily improving. At the last count, about 67% of patients who had had contact with their practice in the previous month were able to see their preferred clinician. That is really important for this cohort. If we have enough data across a wide enough area, we are able to identify whether specific cohorts of patients are able to see their preferred clinician. We can only really get that data at practice level with the annual GP patient survey, which gives us much more granular information.

To add to that, and answer the question in a slightly different and hopefully complementary way, there is a striking statistic in figure 2 of the NAO Report, which shows that at age 90 and above, two thirds of people in the most deprived quintile have frailty and one third of people in the least deprived quintile have frailty. The difference between those is clearly not biologically inevitable. The most important thing, even better than picking up frailty is to prevent it in the first place. That means doing all the things that can be done across the life course to make frailty much less likely. If you take that top quintile of socioeconomic deprivation—the least deprived—that is really what we should be aiming for for everybody. In that case, even in your 90s, the majority would not be living with frailty. That is something we should see as the most central response to this.

Perhaps figure 3 is even more important, Professor Whitty. It shows the projected increase in the number of elderly people, which will make the need for all these frailty services even more acute, will it not?

That is exactly true. However, if you put the two together, what you see is that frailty levels in areas of deprivation appear roughly 10 years earlier than in areas of affluence. If we could get everyone closer to that 10-year difference, we could actually make up the gap between the two. It is really important we do that. There is always an assumption that an older population inevitably means a frailer population. Actually, there is a lot we can do to reduce that, which should be central to our planning here.

Particularly early intervention.

Yes, all the way through. It is not something you wait to do until there is a first crisis in hospital; it has to be done much further upstream than that.

Looking at the constituency statistics we have all been provided with, mine is particularly bad, as always, partly because I have a larger population of deprived elderly people, but also because of a lack of intervention by GPs and, therefore, a poor reflection on the ICB. I wonder whether, rather than just measuring things by metrics and IT, there could be more accountability for ICBs, because I do not see it. For a poorly performing school or a poorly performing local government authority, there would be something called special measures. I am afraid to say that I have had very strong words with Somerset ICB, which is one of the worst performing in the country. Would you be prepared to take on something like special measures for ICBs that are performing so badly?

Shall I make just a quick comment on your constituency? I have had the privilege of being there—

And coming back!

Yes, let me start with that, and then I will turn to Amanda for the second bit. One of the things that was made very clear to me then, and I do not think it has changed since, is the difficulty of attracting GPs to go to work there. It is an amazing place to live, as you know, but in many of the areas where the frailty rates are highest, there are structural reasons why it is difficult to get primary care, nursing, social care and other things that we all need for frailty. Those are issues that, collectively, we need to look at quite seriously.

I take that on. I make absolutely no criticism of my GPs or my nurses. Just to let you know, the very good news is that, because the medical centre in Minehead is now seen to be improving and becoming satisfactory, we have recruited two new GPs in the last six months.

To be clear, the GPs I met were excellent. It is just about getting people in through the front door.

That is right—the better you get, the more you can recruit, and things improve even more. We do have an oversight framework nationally that we monitor, not only for trusts and providers but also for ICBs. We use a range of outcome measures, and there are processes when ICBs are not delivering.

On that, we have started very much at the provider end, within providers, and at the hospital end, where there is more data. This year we will build out the commissioning oversight framework. Chair, it may be worth coming back to this as a specific item and talking about the oversight framework, as it underpins an awful lot of what we are trying to do.

It is particularly acute at the moment, because Somerset is being merged into the broader Wessex ICB. An overview of Somerset as it is now would be useful as it feeds into that wider ICB, not least because the Somerset CEO is being retained for the Wessex ICB.

I have one or two questions. Amanda, I have this sort of vision—I hope I am wrong, and hopefully you will be able to tell me that I am—that there are a lot of moving parts in all of this. There are hospices, hospitals, local care, GPs and a whole range of people involved. When an incident occurs, such as a fall, who co-ordinates that person’s data to make sure it is followed up? It might, for example, happen in a home for elderly people, in an elderly person’s own home, or while they are out on the street. That person may end up in a GP surgery or in hospital. Somebody needs to follow that up and there needs to be a properly kept database so that all the different bits of the system that might interact with that patient are aware of what has happened.

Whatever interventions are carried out in various NHS providers—after a fall, for example—all that information enters the GP electronic patient record. That is the one place where, at the moment, we hold everything. That would include, for example, if an ambulance service went out. Even if they did not take the person to ED, there would still be a record. As part of proactive care for this cohort of patients, you would also expect the GP practice to follow up. We talk about the single patient record in the 10-year plan, and we are developing it. Moderate and severely frail patients are one of the first use cases for the single patient record because it is so important that the information is brought together in a form such that everybody understands what the care plan and the process for that patient are.

Thank you for that. Can we talk about neighbourhood teams and the funding thereof? As you have already said, that funding comes partly from NHSE Ageing Well funding, from ICB funding, from local authority funding and from voluntary and third sector groups. Who makes sure that that funding is really effective at dealing with this problem and at assessing whether people are moderately or severely frail?

The Ageing Well funding is not a specific fund any more. That specific fund was in place from 2019 to 2023-24. It is now part of ICB allocations, in order to mainstream some of the services that it developed. As part of the neighbourhood health implementation programme, we are looking at the integrated neighbourhood teams. We are asking ICBs to start to develop neighbourhood services by focusing on some priority cohorts, one of which is people who are severely frail or at the end of life. We have increased the relative size of the allocation to ICBs for community services compared with acute services, for example, so that they are able to start with those first asks. Alongside that, significant work is being done to look at payment models and financial flows because, ultimately, we need to look after patients in the community and in their own homes. Rather than funding hospitals to look after them, we need to ensure that funding flows into community teams to give them the capacity they need to address that.

The next problem I have in my mind is that a lot of such care is provided by social services. The whole idea of creating ICBs was that the health service would work better with social services and the local authority. I wonder whether, with the shortage of staff in the ICBs, it is one area of work—as Clive has already hinted—that is going to really suffer, not just in Sheffield but throughout the country. A lot of the assessment at home, response to falls and so on needs to be done by social services. If they are not there—and I have only one district nurse in the whole of North Cotswolds—how is it going to be done?

We are encouraging—or creating the environment for—local authority social services to work on a neighbourhood basis to develop those services. Some of that is about assessments, and some is about domiciliary care support to allow people to stay at home while they are less well. I was a GP for about 25 years, and in my experience what made a difference between having to call an ambulance for someone and being able to look after them at home was whether you could rapidly get a domiciliary care package into somebody’s home to enable them to stay at home when they were less mobile, had an infection or had deteriorated. It is absolutely vital that teams do that. We know from the national neighbourhood health implementation programme that those are the things being done by the sites that are testing and developing more quickly in these areas. They are working to identify the interventions that make a difference for priority cohorts, which particularly includes how we work with local authorities’ social care providers to make sure that we keep people independent. Some of that is about discharge processes from hospitals, some of it is about payment flows to enable that to happen and some of it is about single points of contact to enable care co-ordination for care providers and communication.

We have had a real problem with people being discharged from hospitals. It got better, but the lack of domiciliary care packages is a major part of that. As I said, it is quite thin on the ground in Gloucestershire and I suspect, as in Rachel’s area, that these social services are very thin on the ground in rural areas. What do you do in the health service—in your department—to actually help ICBs where there is a real problem with the provision of social care?

One of the challenges that we have—and rural areas are a prime example—is that if there is a greater distance to travel between care visits for domiciliary care providers, you need more staff. It becomes more difficult, and you have less of a pool of people to pull from. It is important that NHS services and local care providers are not all sending people into the same home in an unco-ordinated way. Some of the work that we are doing is looking at which interventions can be offered generically. How do we co-ordinate and share information so that people are getting the best support that they can get? For example, you do not need a nurse to go and check blood pressure. If you have a healthcare support worker going in, they can do that at the same time as they are providing a care package. We have people offering supervision around things like medication in the home, and we need to much better integrate what the NHS is providing with what local authorities do. The Better Care Fund should enable that to happen, and we are looking at how we refresh our approach to using those funds that are in place to commission jointly between health and social care in local places. We cannot sit here in the centre and micromanage that in every individual area, because how you need to approach it in the Cotswolds will be very different from how you do so in Blackpool.

I hear what you say about what should happen. I think it is pretty difficult in North Cotswolds.

We have been hearing about the reform of the Better Care Fund—you mentioned it again: a “refresh”, a reset. When can we expect to see the details of what you are proposing? Or have I missed it?

Very shortly.

It underlines that the whole point of it was to target this population. Generally, obviously, that money has been diverted into providing core adult social care due to the financial straits that local authorities are in. Clearly, how that gets targeted better at this cohort will be very important.

I was not being facetious. It is a very live discussion at the moment. I was responding “very shortly” more seriously than how it came out.

That is fine. We sometimes like short answers, don’t we, Chair?

We do. We like short questions too. Let us finish on a little bit more of a positive note in a rather depressing hearing. I repeat to you all that the mark of a civilised society is how well it assesses frailty. I am not sure that I have come out of this session with terribly bright prospects in that respect, but let us finish on a more positive note. Professor Chris, the Department is putting a lot of emphasis into virtual wards. They look as though they might be able to produce some positive improvements. Do you want to talk about that?

I will give a clinical view. Sir Jim may want to give some views about how it works for the service. For the right patients, a virtual ward, or hospital at home—there are a variety of ways of describing them—can be a much better outcome. They are in a familiar environment. For people with frailty, early dementia and other things, being in a familiar environment is often much better for them. It deals with many of the issues that you hinted at earlier in terms of beds, because they are in their own bed. The thing we always have to remember is that they do require people. If you don’t have enough nurses, doctors or physical or occupational therapists, it does not matter whether it is the hospital or the virtual ward, you will still be unable to provide the full care package you want. For the right people, they can make a remarkable difference. They are not the right thing for everybody. If someone is very unstable medically, you would definitely not want them in that setting; you need them in a setting where you can get to them very quickly. But, for many people, particularly if they are in what, in old-fashioned terms, we would have called convalescing—they have had the acute episode and now have a period of recovery—a virtual ward can be a much better place to be.

Does anyone want to add anything?

I would agree with that. You can see the service finding more and more examples where we can augment people’s care at home and prevent hospitalisation. As Professor Whitty just described, what we saw in Westhoughton last summer is absolutely amazing in that regard. It is scaling that up in a systematic way that is tricky.

Professor Whitty, are we over-medicating elderly patients? If so, is it therefore the case that part of this frailty assessment, the medical review, is really important? There is a statistic, which I can’t find immediately, about the amount that the impact of over-medicating costs. That is why these regular medical reviews are important. What more can we do?

With the slight caveat that I don’t want anybody listening to this to suddenly say, “Okay, I am going to throw away my pills”, there are a lot of things you can usefully do, absolutely. If you ask any dietitian or experienced GP dealing with people in older life, what has happened is that they have acquired one pathway after another, each of which makes sense individually, but in combination gets to the point where the number of side effects is actually causing problems, and the benefit to that individual has passed. One of the most important things you can do in that situation is rationalise down to those drugs that are actually improving quality of life, rather than having a long list of things that are probably very unlikely to achieve that. There are, of course, many people who need to be on many medicines, but there are also many people who need to shrink the amount down quite significantly.

One of the things we are doing about that, to enable us to review the patient’s medication and reduce them where appropriate, is that most primary care networks have pharmacists as part of the team, who are able to go out and see patients and do structured medication reviews. We are looking to step up the clinical service provided by pharmacists, rather than them largely being just a dispensing service. One benefit of that is that, from this year, all graduate pharmacists will graduate as independent prescribers. You have to be a prescriber to start medication, but you also have to be a prescriber to stop it. We hope that pharmacists will now be enabled not only to see the records and have the time to do proper medication reviews with people but stop medication appropriately and monitor the patients afterwards. We hope that the role of community pharmacy and pharmacists in that process will really enable us to make changes. It is one intervention that actually reduces your likelihood of being inappropriately admitted to hospital.

We have had evidence from the pharmacists. They would love to do all of that work, but they say that they are not funded enough to do it. There you are; I leave you with that problem. I thank all our witnesses this afternoon. It has been quite a difficult hearing. It is something I suspect we will come back to, because we need to see it working better. Thank you very much for your time. An uncorrected version of the transcript will be available in the coming days. As you know, we will be producing a Report with recommendations, which I hope you look at seriously. Thank you again for coming.