Perioperative Care of People Living with Frailty

Bringing together the multidisciplinary team to improve care for people living with frailty

The Centre for Perioperative Care, working in collaboration with the British Geriatrics Society, has now published guidance for the care of people living with frailty undergoing elective and emergency surgery that encompasses the whole perioperative pathway

Frailty is a condition characterised by loss of biological reserve, failure of physiological mechanisms and vulnerability to a range of adverse outcomes including increased risk of morbidity, mortality and loss of independence in the perioperative period. With the increasing recognition of the prevalence of frailty in the surgical population and the impact on postoperative outcomes, The Centre for Perioperative Care (CPOC) and the British Geriatrics Society (BGS) have worked together to develop a whole pathway guideline on perioperative care for people living with frailty undergoing elective and emergency surgery.

Delivering whole pathway, quality perioperative care requires multicomponent intervention, with integration across community, primary, secondary and social care. A multidisciplinary ‘one-team’ approach across these sectors is necessary to deliver each component of the pathway:

  • patient and carer involvement, education and empowerment
  • preoperative risk assessment and optimisation of physiological status, comorbidities and geriatric syndromes including frailty
  • lifestyle modification to improve both perioperative and long-term health outcomes
  • shared decision making (SDM)
  • optimal intraoperative surgical and anaesthetic management
  • quality postoperative care in the most appropriate setting to include rehabilitation
  • proactive discharge planning
  • links and referral to relevant community, primary care and follow up services 


 The scope of this guideline covers all aspects of perioperative care relevant to adults living with frailty undergoing elective and emergency surgery. It is written for healthcare professionals involved in delivering care throughout the pathway, as well as for patients and their carers, managers and commissioners. Implementation of the guideline will require collaboration across the four nations of the United Kingdom between all stakeholders, underpinned by an implementation strategy, workforce development with supporting education and training resources and evaluation through refinement of current national audit tools. We believe this is an important step in improving outcomes for our patients and healthcare services.




Structure of the Guidance

Perioperative care for people living with frailty is particularly complex and deficiencies in current perioperative pathways have been well described. Despite published interventions for frailty, an implementation gap between recommended care and routine perioperative practice exists. This may be a consequence of too few geriatricians, silo working and difficulties in embedding complex interventions for frailty in the clinical setting, compounded by unintended consequences of time-based targets (for example the 62 day cancer pathway) and a lack of commissioning incentives to embed a whole pathway perioperative team. To address this challenge, this new guideline has been coordinated by CPOC and the BGS, working with patient representatives and all stakeholders involved in the perioperative care of patients with frailty undergoing surgery.

  • Standards

  • Recommendations for people living with frailty and their carers

  • Recommendations for commissioners and providers of surgical services for people living with frailty

  • Recommendations for primary care teams

  • Recommendations for staff working in surgical outpatients and preoperative assessment services

  • Recommendations for staff working in surgical wards providing care for emergency and/or elective surgical patients

  • Specific considerations in the emergency setting

  • Recommendations for staff in theatre and recovery

  • Recommendations for transfer of care to the community

  • Recommendations for quality improvement and metrics

  • Recommendations for Research

We hope that this jointly produced guideline will empower patients living with frailty to work with health care professionals using shared decision making to ensure they receive the best possible care. This is particularly timely as health care services recover after the COIVD pandemic.

Dr Jugdeep Dhesi
CPOC Deputy Director

Guideline Working Group



Association of Palliative Medicine

Amy Proffitt

Association Surgeons Great Britain and Ireland (ASGBI)

Lyndsay Pearce

British Dietetic Association (Older People Specialist Group)

Vittoria Romano

British Geriatrics Society (BGS)

Jude Partridge

British Geriatrics Society Representative to the Professional Records Standards Body (PRSB)

Emma Vardy

British Geriatrics Society, Wales

Nia Humphry

British Orthopaedic Association  (BOA)

William Eardley

Centre for Perioperative Care (CPOC)

Jugdeep Dhesi

Centre for Perioperative Care (CPOC)

Louise Bates

Centre for Perioperative Care (CPOC)

Scarlett McNally

Chartered Society of Physiotherapy (CSP)

Alison Cowley

College of Operating Department Practitioners (CODP)

Bill Kilvington

Faculty of Intensive Care Medicine (FICM)

Daniele Bryden

Getting it Right First Time (GIRFT)

Adrian Hopper

NHS Elect, Specialised Clinical Frailty Network

Catherine Meilak

NHS Scotland

David McDonald

Patient Representative

Lawrence Mudford

Preoperative Association (POA)

Ali Curtis

Preoperative Association (POA)

Shelley Rose

Royal College of Anaesthetists England (RCoA)

Sarah Hare

Royal College of Anaesthetists Wales (RCoA)

Tessa Bailey

Royal College of Anaesthetists, Northern Ireland (RCoA)

Claire Barker

Royal College of Anaesthetists, Scotland (RCoA)

Laura McGarrity

Royal College of Emergency Medicine (RCEM)

Eleanor Syddall

Royal College of General Practitioners Scotland (RCGP)

David Shackles

Royal College of Nursing (RCN)

Angeline Price

Royal College of Nursing (RCN)

Beck Diedo

Royal College of Occupational Therapy (RCoT)

Catherina Nolan

Royal College of Surgeons of England (RCSEng)

Nicholas Peter Lees

Royal College Physicians (RCP)

Jane Youde

Specialised Clinical Frailty Network (SCFN)

Simon Conroy

Trainee Representative, Clinical Quality Commission (CQC)

Kate Kanga

United Kingdom Clinical Pharmacy Association (UKCPA)

Sarah Carter

United Kingdom Clinical Pharmacy Association (UKCPA)

Sarah Tinsley

United Kingdom Clinical Pharmacy Association (UKCPA)

Derek Taylor

University of Leeds & Bradford Teaching Hospitals NHS Foundation Trust

Andy Clegg

Vascular Society (VASGBI)

Rachel Bell

Dr Jugdeep Dhesi
Centre for Perioperative Care,

Jugdeep Dhesi is a Consultant Geriatrician at Guy’s and St Thomas’ NHS Foundation Trust in London. She is clinical lead for the award winning Perioperative medicine for Older People undergoing Surgery (POPS) service, Vice President at the British Geriatrics Society and President of Age Anaesthesia Association. She has led the development of novel education and training programmes for medical and allied health professionals and established a research programme in perioperative medicine. All of this work focusses on improving quality of care for the high risk surgical population, through fostering a collaborative and proactive approach working with patients, their carers, healthcare professionals, managers and policymakers.

Dr Jude Partridge
British Geriatrics Society

Jude Partridge is a geriatrician working in the Proactive care of Older People undergoing Surgery (POPS) team at Guy’s and St Thomas’ NHS Foundation Trust, London. She has a full time clinical role with one session allowing her to continue her research interests.