How do we proactively identify and offer interventions to older adults living with frailty in the community?

National policy is shifting towards proactive, community-based healthcare for older people living with frailty. There is strong evidence for the effectiveness of comprehensive geriatric assessment (CGA) however the practicalities of how to deliver CGA and realise the benefits at a population level are not well-established. We explore several areas - how to identify individuals living with frailty, how frailty should be diagnosed and communicated across sectors, how to prioritise and how to deliver across a system with workforce and financial constraints. Routine clinical data and predictive modelling, including eFI2, offer scalable standardised cohort selection but are not diagnostic of frailty. Screening tools may be helpful but feasibility and access equity needs consideration. Formal diagnosis of frailty remains a clinical responsibility yet consistent language and shared understanding across health, social care and voluntary sectors is variable. The Clinical Frailty Scale offers pragmatic language, supported by evidence across clinical workforces, but requires broader training and evaluation to its utility as a system-wide communication tool. Prioritising moderate/severe frail people for CGA is supported by evidence, but population size means further prioritisation of interventions will be necessary. Delivering at scale will require multidisciplinary models that are flexible and pragmatic, with geriatricians contributing through leadership and education, rather than providing all CGA care directly.