Box 1.

Over-arching principles to consider for older people living with frailty who have specialised needs

  • Establish a mechanism for early identification of people with frailty

  • Deliver personalised care and improve patient experience

  • Communicate shared decision making across services, settings and systems, making frailty everyone's business

  • Use a holistic approach early in the pathway to inform subsequent care planning

  • Decide upon tailored interventions, personalised to the patient

  • Develop a measurement / quality improvement mindset

  • Adopt clinical professional standards to reduce unnecessary variation

  • Identify clinical change champions

  • Put in place appropriate education and training to develop a highly capable workforce

  • Identify an executive sponsor and underpin with a robust project management structure