Supporting more personalised care for people with heart failure and frailty

Summary

The Frailty‑First and End of Life Practical Management Pathway for Heart Failure supports clinicians to recognise and respond to frailty when assessing and managing people living with heart failure. The pathway brings together evidence‑based, practical guidance to support management planning that reflects an individual’s overall health, risks and wishes.

Challenge

Frailty is common among people living with heart failure across all adult age groups. However, early identification and staging of frailty are not always embedded within routine heart failure assessment. As a result, care planning may not fully reflect a person’s complexity, risks or priorities.

During the development of the NHS Surrey and Sussex Heart Failure Pathway, this gap was identified. This reconfirmed the need for a dedicated frailty‑first approach to support more appropriate and person‑centred decision‑making [1].

Approach

The pathway was developed through collaborative working across multiple health systems and professional groups, including our Sussex colleagues from NHS Surrey and Sussex, NHS Mid and South Essex, NHS County Durham and Darlington and Primary Care Cardiovascular Society. Health Innovation Kent Surrey Sussex (Health Innovation KSS) project‑managed the conception, development, communications and dissemination of the pathway.

Health Innovation KSS facilitated a multidisciplinary group of healthcare professionals with expertise in heart failure, frailty, pharmacy and dementia. This included coordinating virtual and in‑person meetings, supporting shared discussions and drafting pathway content for iterative review. This facilitation helped ensure that development work did not add pressure to already stretched clinical capacity.

Health Innovation KSS also led on the production of a final published pathway and a coordinated launch. This included a news article, social media activity and publication on the CVD Central resource website.

Impact

By using this pathway, clinicians can make decisions on patient treatment and plan for future care needs with patient wishes entrenched in those decisions. The impact of this change in treatment planning has the potential to lead to fewer hospitalisations due to exacerbated frailty or episodes related to heart failure.

The pathway launched in early February 2026 and as of June, has been downloaded 132 times from the CVD Central resources webpage across the United Kingdom and beyond, by colleagues in primary, secondary and community care.

The pathway has been included in the Health Innovation National Heart Failure Blueprint, developed with AstraZeneca, as the named resource for frailty and end of life care in heart failure.

Other local Health Innovation Networks have adopted the toolkit, with Health Innovation West Midlands citing the pathway within its heart failure toolkit and Health Innovation Wessex also exploring local adoption.

Health Innovation KSS are gathering feedback from users to understand where and how the pathway is being implemented and to capture learning for future pathway transformation work. Examples of current feedback from early users include:

• Covers a big gap in care and empowers clinicians to stop treatment that although may be useful to treat heart failure, exacerbates frailty and doesn’t consider the overall needs of the patient
• We have an aged population and feel this tool would be beneficial regarding management tools and conversations with patients
• Symptoms remain, but they may be more comfortable or empowered
• The one pager for every day and the longer for my information and referencing

This feedback highlights that the pathway is proving to be useful and is empowering clinicians and patients alike to ensure that there is balance in care across patients with both frailty and heart failure. Impact will continue to be captured.

Dr Sarah Zaidi – NHS England East Regional Clinical Lead Frailty & Home First said:  “Addressing frailty first for adults living with cardiovascular conditions, including heart failure, is vital if we are to deliver higher-quality care that reflects the realities of today’s increasingly complex and vulnerable populations.

 

“It was a privilege to work alongside colleagues from Health Innovation KSS who recognised the urgency of this challenge, brought together a wide range of clinical and professional experts, to develop practical guidance that can support frontline staff across hospital, community, and primary care settings.

 

“Enabling front line clinicians to navigate the realities and challenges of today’s real-world population living with heart failure- and deliver higher quality care, with better outcomes for all.

 

“This work exemplifies the ambitions of the NHS 10-year plan: enabling more holistic, personalised, proactive, and higher-value care that better meets the true needs of increasingly frail and multi-morbid populations, helping to reduce inequities, inequalities and avoidable harms.”

Spread and scalability

The pathway was shared through multiple channels to support early spread. These included Health Innovation KSS social media platforms, a dedicated news article and circulation to the CVD Central mailing list of over 1,000 healthcare professionals. The pathway was also shared nationally through circulation to Health Innovation Network heart failure leads.

Early interest from other regions, including Derby and Derbyshire, Thames Valley and Hampshire and Isle of Wight, suggests that the pathway is transferable beyond Kent and Medway, Surrey and Sussex. While evaluation is ongoing, there is potential for the frailty‑first principles used within this pathway to be applied to other disease areas where frailty significantly influences treatment decisions and outcomes.

Find out more

Healthcare professionals can download the Frailty‑First and End of Life Practical Management Pathway for Heart Failure and explore options for local implementation. Teams can contact Health Innovation KSS for further information or implementation support.

References

[1] The burden of frailty in heart failure: Prevalence, impacts on clinical outcomes and the role of heart failure medications – PMC