Community Connectivity

Community connectivity with access to and involvement of the Voluntary, Community and Social Enterprise sector.

What works

  • Adopt shared decision making to enable choice and engagement to build learning and relationships
  • Focus on and invest in recognised ways of working that embrace ‘relationship and asset-based approaches’ and ‘everyone doing their bit’ to improve the health and wellbeing
  • Enable healthcare professionals to refer patients to non-clinical pathways that are co-designed to improve their health and wellbeing (e.g. social prescribing via link workers in line with PCN contract).

  • Improves the experience of care, health and wellbeing and prevents mental health
  • Reduces crises that lead to unplanned hospital or institutional care admissions.
  • Reduces unnecessary GP/primary care appointments
  • Benefits fitness, activities of daily living and quality of life
  • Improves physical function and  muscle strength
  • Reduces the rate and risk of falling
  • Delays the progression to frailty

Evidence summaries

Public Health England Site. An evaluation in one particular area found that for every £1 invested there was a social return on investment of £1.20; cost-savings for the NHS also come through early intervention that avoids later stage, more expensive treatments – .

Making sense of social prescribing: A review of the evidence assessing impact of social prescribing on healthcare demand and cost implication

(University of Westminster) –

VSCE sector rationale –

NHSE frailty balance and training –

Evidence Review: loneliness in later life, Age UK, 2015

Impact and Measures

We know that frailty has a significant impact on people, populations and health and care systems. Frail older people are highly susceptible to adverse health outcomes, such as falls, disabilities, institutionalisation, hospitalisation and death. However, trying to understand this impact on populations and health and care system is challenging due to poor recording of frailty status and the lack of information sharing and interoperability that exists. The following examples of impact are guestimates based on current intelligence.


  • Potential Impact
    • In the North East and North Cumbria region, mildly frail people are 2.6 times more likely to have fallen in the last 12 months than fit people aged over 65.
  • Potential measures
    • The proportion of people (aged 65+ years) who use services who reported that they had as much social contact as they would like
    • Carer reported quality of life
    • Measurement of loneliness / reduced loneliness
    • Number of people referred into social prescribing schemes


For more information to aid local delivery see what works, resource links, benefits, evidence, local stories and case studies as well as impact/measures in ‘word version of draft frailty toolkit’ page 53.