Why personalised approaches are transforming frailty care

Frailty is often misunderstood, reduced to a label or an image rather than recognised as a clinical condition that requires thoughtful, compassionate, and personalised support.

In July 2021, Alison from the It’s All About People team sat down for a chat with Clare Credland and Dr Sadie Aubrey about all things ‘frailty’. 

Clare is Head of Integrated Community Partnerships, leading on frailty, at Lincolnshire Community Health Services NHS Trust (LCHS). Sadie is a GP, Clinical Director of South Lincoln Healthcare Primary Care Network, and Clinical Lead for Frailty for Lincolnshire. 

Together, they shared their passionate belief that recognising frailty is not about defining someone by their condition - it’s about understanding what really matters to each individual, and shaping care and support around that.

Understanding frailty beyond the label

What does ‘frailty’ actually mean?

Sadie explained that frailty is not simply “looking frail” or a vague descriptor; it is a clinical diagnosis that helps the system respond appropriately.

“Frailty means where your physical and mental abilities and reserves gradually decline... and if something stresses your body… you’re at risk of deteriorating.”

That deterioration may be triggered by illness, bereavement, moving house, or other factors. Crucially, the diagnosis enables earlier, more tailored support:

“If we can diagnose people with frailty, then we know what we can do to help them.”

Understanding frailty through this clinical lens reframes it not as an inevitable stage of ageing but as something that can be better managed - and even slowed - through proactive, personalised care.

Why a system-wide shift was needed

The Lincolnshire system reached a collective realisation: support for people with frailty could be better. This sparked collaborative work across community services, hospitals, social care, voluntary sector partners and Primary Care Networks (PCNs).

Clare: “We recognised, actually, that as a system, we can do better… from a person with lived experience point of view, what it's actually like to be on the receiving end of how we are supported.”

The result was a bold five-year frailty strategy with prevention and proactive care at its centre. Rather than responding when a crisis occurs, the system aims to identify people earlier, build resilience, and ensure they retain choice and control.

“We wanted to be really brave and be really different… intervene early, have really good conversations, and empower people.”

Neighbourhood working: Support rooted in the community

The “neighbourhood pillar” is a standout part of the strategy. It brings together PCNs, community health services, therapists, district nurses, social prescribers, voluntary groups, and local residents to design support that reflects local needs.

Sadie: “What can we do for our frail population in our neighbourhoods? It's about bringing it all together… preventing frailty or identifying it, and then knowing what we can do to slow down the progression.”

Localising this work matters because frailty does not exist in isolation. People’s social connections, access to community resources, living conditions, and sense of belonging all influence their wellbeing.

And across the county, these neighbourhood teams are already seeing change: shared decision-making, better understanding of people’s circumstances, and more timely, appropriate support.

Personalisation: The golden thread

Perhaps the strongest theme woven through our conversation with Sadie and Claire was personalisation - not as a “nice to have,” but as the foundation of effective frailty care.

Sadie: “It won’t surprise you to know that the vast majority of what works is centred around personalisation… what’s right for that person.”  

Whether through personalised care and support planning, strength-based conversations, or simply asking the right questions, the shift is clear: professionals are moving away from doing to people and toward working with them.

One social care worker’s story illustrates the impact. After completing a routine assessment, she added one simple question: “When you have a good day, what makes it good? And when you have a bad day, what makes it bad?” The answer - about the person’s love of crime novels - opened the door to new social connections, enriched daily life, and deepened trust.

Alison: “That relationship then opens up more conversations… people feel more comfortable to share other things as well.”

Personalisation is not a task; it’s a mindset.

Co-production: Designing support with communities

Co-production has become a powerful driver of change across PCNs. Instead of professionals assuming what people want, communities are shaping solutions themselves.

The impact has been profound. In one neighbourhood, residents redesigned an entire local event, reframing the content, timing, and even the language used to make it accessible and engaging.

Clare: “One of the ladies said to me, ‘If you say it like that, people won't get what you're talking about.’… It really made me think.”

The process hasn’t just improved individual projects, it has shifted culture. Ideas that professionals brought into the room were often transformed once community voices were heard.

Sadie: “It just really opened our eyes to what people really want and really need.”

And these insights are now being shared across neighbourhoods, ensuring learning spreads rather than sitting in silos.

Building trust takes time – but it’s worth it

A recurring challenge for clinicians is the belief that personalised conversations require more times - something that’s in short supply. But as Sadie argued, that investment is essential:

“If the person doesn’t believe in the plan… you're no further down the line. Putting that extra time in up front actually pays dividends later.”

Clare shares a story that illustrates this deeply. A man in significant ill health refused hospital care. Many might have labelled him “non-compliant.” But personalised conversations revealed the truth: he simply wouldn’t leave his dog.

Clare: “None of the options were any more important than his dog.”

With patience and trust-building, the team supported him in a way that respected both his health needs and his personal priorities. Without that relational approach, his story might have ended very differently.

A proactive, data-driven outreach

The work is not only relational but also analytical. Neighbourhoods are using population health data to identify people who may be at risk but are not yet known to services.

Sadie: “We’re proactively reaching out… and that wouldn’t have happened if we weren’t doing this work.”

By identifying early indicators of frailty, such as moderate frailty scores coupled with social vulnerability, teams can intervene before a crisis develops, supporting independence and quality of life.

Conclusion: Changing frailty care by having different conversations

Across Lincolnshire, a quiet transformation is underway. It is not driven by new buildings, expensive technology, or complex structures. It is driven by people listening differently, working differently, and seeing the whole person rather than a set of symptoms.

Personalisation isn’t an add-on to frailty care; it is frailty care. As Sadie, Clare, and Alison make clear, when we build trust, involve communities, and take the time to understand what matters most, better outcomes follow, for individuals, families, and the system as a whole.

Alison: “It’s really lovely to see… people thinking differently about how we can help people live their best lives in the way they want to.”

And that, ultimately, is what good care is all about.