“Frailty can now be identified and diagnosed with comparative ease using the validated electronic frailty index. It can enable us to distinguish those with severe frailty from those who remain fit. We can find populations who are at greater risk of adverse events including hospital and nursing home admission.”
Dr Martin Vernon, NHS England’s National Clinical Director for Older People and Integrated Care

One in 10 people over 65 are likely to be living with frailty, rising to up to half the population aged over 85 years.

Early diagnosis of frailty in primary care and proactive interventions can potentially keep people living independently, reducing reliance on health and social care resources.

The electronic Frailty Index (eFI) is an innovative tool that uses routine GP data to identify older people with mild, moderate and severe frailty. The Yorkshire & Humber AHSN is supporting its rollout.

The eFI is available in SystmOne, EMIS Web and Vision electronic health record systems making it accessible to around 100 per cent of GP practices nationally. Around 90% of Clinical Commissioning Groups (CCGs) in Yorkshire and Humber use the eFI to identify frailty and establish new care models. Examples include: practice nurse-led holistic assessment, care and support planning; medication reviews; proactive falls prevention interventions and self-management support.

July 2017 sees the launch of a new BMA and NHS England GP contract in which the eFI is recommended as a support tool for primary care to identify patients with frailty and meet the contract’s requirements.

The eFI is also recommended for use within the NICE Multimorbidity guideline.









Winner in the Innovation Category at the RCP Patient Care Awards 2017 

Challenge / problem identified

Frailty is a distinctive abnormal health state in which a minor event, such as a urinary tract infection, can trigger major consequences. The person living with frailty may not fully recover, leaving them at risk of losing independence and increasing reliance on health and social care resources.

People living with frailty are more likely to be greater users of health and social care services and frequently people move between services and organisations. This can result in care that is poorly coordinated, fragmented and not person-centred.

The growing pressures on NHS and social care services mean it is increasingly important for people living with frailty to be supported in managing their health and wellbeing.

Early identification and diagnosis of frailty in primary care and tailored proactive interventions have the potential to keep people living at home independently, improving their quality of life and reducing reliance on health and social care resources.

Actions taken

The eFI was developed in a collaborative partnership between Leeds, Bradford and Birmingham Universities, TPP and Bradford Teaching Hospitals NHS Foundation Trust. It was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Yorkshire and Humber.

The Yorkshire & Humber AHSNs Improvement Academy is supporting the roll out of the eFI through its Healthy Ageing Collaborative.

An example of eFI implementation is with the CCGs across Leeds. The Leeds Intelligence Hub is using the eFI alongside other linked data sets to the population of Leeds and identify different groups likely to benefit from varying degrees of care and support. Evidence based care pathways are being implemented for the populations identified including those at risk (obese, smoking excessive alcohol, asthma) and suitable for public health interventions – single long term condition (LTC) pathway, multimorbidity (two or more LTCs) and frailty (excluding those with multimorbidity).

Impacts / outcomes

The Yorkshire & Humber AHSN has engaged with 86 CCGs across the UK to support eFI implementation and/or replication locally.

Examples of how it is being used include:

  • Identifying people with severe frailty for inclusion on practice frailty registers and offering GP-led assessment and care and support planning (NHS North Durham CCG)Yorkshire & Humber
  • Medication reviews for people with severe frailty and care home residents (NHS Vale of York CCG, NHS Harrogate and Rural Districts CCG)
  • Falls prevention interventions (NHS Leeds South & East CCG, Birmingham Public Health Falls & Fracture Pathway)
  • Nurse-led frailty assessments (NHS Scarborough and Ryedale CCG, NHS Hambleton, Richmondshire & Whitby CCG)
  • Adding people with severe frailty to palliative care registers and offering advance care planning (NHS Airedale, Wharfedale & Craven CCG)
  • Offering people with mild frailty self-management support using the Age UK and NHS England co-produced Practical Guide to Healthy Ageing (NHS Bradford Districts CCG)
  • The eFI is recommended as an appropriate tool in the new BMA and NHS England GP contract that requires GP practices to identify and manage patients with moderate and severe frailty. The eFI is recommended in the NICE Multimorbidity guideline.An EIP-AHA Symposium was hosted by the NHSA on 6 June 2017 with the aim of co-producing a North of England collaborative frailty strategy.

“As a GP it will be useful to find out the frailty level of every patient I see in the consulting room. Linking the tool to appropriate interventions then this would be even better and would act as a trigger for interventions to consider.”

Dr Lesley Freeman, GP & CCG Dementia Lead, NHS Leeds South & East CCG

Plans for the future

In collaboration with Yorkshire Health Economic Consortium (YHEC), evaluations have been undertaken to assess the economic impact of using the eFI in medication reviews for care home residents with severe frailty and practice nurse-led frailty assessments.

An analysis of a large primary care research dataset is underway in the Connected Bradford project, part of the Connected Health Cities programme, to inform understanding of the care costs associated with different grades of frailty.

Both these reports are due later this year. It is anticipated the cost consequence analyses will identify the value added by the eFI and the interventions that warrant being scaled up. The findings will be shared regionally and nationally.

Manchester University researchers, in collaboration with the Academic Unit of Elderly Care and Rehabilitation, University of Leeds, are reviewing the eFI Read codes and plan to increase the number of deficits from 36 to 55 including mental health. The team is also reviewing the codes from a GP perspective.

Which national clinical or policy priorities does this example address?
  • Care and Quality
  • Funding and Efficiency
  • Health and Wellbeing.
Start and end dates


Contact for help and advice

Sarah De Biase
Improvement Programme Manager
E: Sarah.de-biase@yhahsn.nhs.uk
T: 01274 383407

Esme Crabtree
Head of Marketing & Communications
T: 01924 664720