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Less than one-fifth (16%) of patients with severe frailty in England received a medication review in 2024/2025 against a 100% requirement, a report by the National Audit Office (NAO) has revealed.
The report — ‘Primary and community healthcare support for people living with frailty’, published on 5 December 2025 — showed that 37,000 (16%) out of 226,000 patients diagnosed with severe frailty underwent a medication review in 2024/2025.
It also revealed that 41,000 patients (18%) had a falls risk assessment, while 66,000 (29%) had given consent for an enriched summary care record.
Under the GP contract, GPs are required to undertake an annual medication review of patients diagnosed with severe frailty, as well as a falls risk assessment and a discussion on the benefits of an enriched summary card record, which provides additional information to a standard record, such as significant medical history.
“GPs are not providing the required support and follow-up for people diagnosed as living with severe frailty,” the report said.
It also found that the support GPs and primary care networks provide to patients in care homes is “falling short”.
“For example, the percentage of residents who had a personalised care and support plan agreed or reviewed has fallen sharply, from 76% in 2022/2023 to 44% in 2024/2025,” the report said, adding that there is significant local variation.
The NAO report provided a list of recommendations to the Department of Health and Social Care (DHSC) and NHS England, including that NHS England should “set clear and consistent requirements for GPs to assess and support people living with frailty, including the proportion and frequency of assessments and the minimum acceptable care to be provided”.
It also recommends that NHS England should set out a timetable for its work to standardise community health services and how these services will support the move to neighbourhood health services.
In addition, the report has suggested that the DHSC should commission an evaluation of its frailty initiatives to determine whether these efforts are supporting people living with frailty.
“This should include urgent community response, the ‘Enhanced health in care homes’ programme, virtual wards, community health services and neighbourhood health,” it added.
Heidi Wright, practice and policy lead for England at the Royal Pharmaceutical Society, commented: “Supporting patients who are frail is essential to maintaining their independence for as long as possible — medicine reviews are very much part of the holistic health of this group.
“Pharmacists and pharmacy technicians are uniquely positioned to ensure medicines optimisation, reduce polypharmacy risks and support safer prescribing for frail patients. By embedding pharmacy expertise into primary and community care pathways, we can improve outcomes, reduce avoidable harm and help deliver the personalised care these patients deserve.”
In November 2025, the British Geriatrics Society published guidance that suggested people with moderate frailty may benefit from more lenient therapeutic targets for certain conditions.
