Frailty Matters

IFIC Scotland’s end of year blog mentioned our ‘Frailty Matters’ project, funded by the Burdett Trust for Nursing. I am pleased to share some more detail about this innovative collaboration between the ALLIANCE, NHS Ayrshire & Arran, the University of the West of Scotland (UWS), IFIC Scotland and the Queens Nursing Institute Scotland (QNIS).

Frailty affects around 1 in 10 people over the age of 65 and around half of people aged over 85. It is  increasingly recognised as a public health priority due to the associated demand for acute and longer term health and social care support, and the impact on the lives of individuals, caregivers and families. Comprehensive assessment and integrated care are at the heart of a Frailty Prevention Approach in Europe as described by the European Joint Action on Frailty and by the SUSTAIN consortium.

District Nurses have a vital role in coordinating the care and support that older people need to stay well at home. They are ideally placed to identify frailty and prompt early intervention. This project aims to improve their knowledge, skills and confidence in leading person centred integrated care for older people living with frailty.  It set out to co-produce and deliver a combined coaching and education programme with nine community nurses from Ayrshire, West Central Scotland, and two co-coaches who have experience of living with frailty.  The programme began in October with face to face education on key topics and person centred coaching sessions supported by an online teaching resource. Unfortunately, the arrival of COVID-19 and the first UK lockdown in March 2020 meant the face to face programme had to cease.  An amended plan allowed completion of the content wholly online from October to December 2020.  The final evaluative phase underway aims to understand the views of community nurses on the programme and educational materials.

Along the way everyone involved has contributed to co-creating a ‘House of Frailty’ Model to describe and help participants reflect on what is being learned within the programme. We aligned the ‘House of Frailty’ to Scotland’s House of Carean established person centred framework for collaborative care and support planning for people with long term conditions. The ‘House of Frailty’ highlights the knowledge base needed to deal with frailty in the community effectively and the person centred coaching and leadership skills required. The model presents these in a way that we hope is accessible, intuitive and meets their educational needs.

The team would like to thank the community nurses for their participation despite the challenges of Covid-19 and are grateful to our co-coaches for sharing valuable insights and lived experience in the interactive sessions.  It has been great to work with the Health and Care Alliance Scotland who have much expertise in co-production and person centred coaching. Thanks also to members of IFICs Ageing and Frailty Special Interest Group for their constructive feedback.

As we head into the final phase of the project, we are keen to hear from organisations who may consider testing our ‘House of Frailty’ approach. Please contact me at


Dr. Raymond Duffy
University of the West of Scotland
Frailty Matters Principal Investigator