The programme

A coordinated programme of evidence-based improvement interventions delivered in partnership with primary and community care teams with the aim of delivering high quality, person-centred, coordinated care for older people with frailty and their carers. Our Healthy Ageing programme builds on our own electronic Frailty Index (eFI) tool. The eFI represents a major, innovative advance in the care of older people because, for the first time, it enables identification and severity grading of frailty using existing primary care data without the need for a resource-intensive clinical assessment. GPs and CCGs are using the eFI to improve the quality of care for people with frailty through better targeting of evidence-based interventions, improved planning of health service utilisation and the development of more appropriate, proactive, goal-orientated care.


Life expectancy is increasing, the number of people aged 85 years and older is projected to rise from 14 million to 19 million by 2020 and to 40 million by 2050. In 2012, the estimated average life expectancy for females was 79 years, and for males, it was 71 years. Increased life expectancy offers opportunities and challenges as people who live longer are at risk of developing health conditions related to the ageing process that are likely to have a significant impact on individuals, their families and society. Frailty is a condition that is common in old age. It develops because, as we get older, our bodies changes and can lose their inbuilt reserves. These changes mean that older people with frailty can experience sudden, dramatic changes in their health when they have an illness. Major shifts in health, social and economic policies are therefore required to support an ageing population. This programme supports those in health and care settings to provide safe care to people with frailty, better meet the needs of older people with frailty and their carers and reduce health and social care resource use.

How are we helping?

The eFI has been developed in a collaborative partnership between the University of Leeds, TPP (who provide SystmOne, a centralised clinical system used by one third of the UK’s General Practitioners to manage their electronic patient health records), the University of Birmingham, the University of Bradford and Bradford Teaching Hospitals NHS Foundation Trust.  The eFI contains of 36 deficits, including clinical signs (e.g.tremor), symptoms (e.g. breathlessness), diseases (e.g. hypertention) and impairments (e.g. visual impairment). The eFI enables the calculation of a frailty score that can be used to identify older people with mild, moderate and severe frailty. A higher eFI score identifies older people at increased risk of care home admission, hospitalisation and mortality. The eFI was developed and validated using routinely collected UK primary care electronic health record (EHR) data from over 900,000 older people in two large primary care settings (Clegg et al, 2015) and has been implemented in the leading UK primary care EHR systems, which means the eFI is available to GPs across the UK.

eFI engagement has been interactively mapped on a national scale at: and includes examples of new models of care have developed using the eFI. Aligning closely with our Innovation in Primary Care project and local STP plans, this programme uses local learning and case studies, in conjunction with research evidence about what works for people living with frailty, to generate effective approaches at scale.

Our impact to date

Through our Improvement Academy, the eFI has been rolled out and is:

  • Available in the leading UK primary care EHR systems, which means the eFI is available to GPs across the UK
  • At least 72 CCGs are using the eFI to support the development of new, evidence-based models of care for older people with frailty. Examples include: development of integrated community frailty services for older people; identification of older people with frailty for medication reviews and identification of older people with frailty for proactive falles prevention
  • The eFI won the Healthcare IT Product Innovation Category at the EHI Live 2016 Awards
  • The eFI was highlighted in the successful bid that helped the Yorkshire & Humber AHSN receive an international award for healthy ageing initiatives in the region, achieving Reference Site status and a three-star rating for the European Innovation Partnership on Active and Healthy Ageing
  • The eFI has been endorsed by Professor Martin Vernon, the National Clinical Director for Older People and Integrated Care at NHS England

Next Steps

  • We will develop the eFI to be available in Vision.
  • We will support GPs, health and care home staff across the region to deliver evidence-based interventions for people with frailty.
  • We will support members across the region to use the eFI tool to reduce reliance on health and social care resources through better targetting of evidence-based interventions
  • We will help reduce harm associated with inappropriate prescribing
  • A series of case studies will be developed to share best practice and learning from the eFI  implementation and will be disseminated regionally and nationally.
  • A clinical frailty template will be developed for the leading primary care electronic health record systems to support data quality and a comprehensive geriatric assessment approach for people with frailty in primary care
  • Collaboration will continue with health and care organisations, universities and other national representative bodies (including Age UK, the AHSN Network and the British Geriatric Society) to support continuous improvements in the way care is provided for people living with frailty

How to get involved and join the Healthy Ageing Collaborative

If you are a GP, Clinician or an older person who is interested in knowing more about the eFI and/or the Healthy Ageing Collaborative, please contact Sarah.De-Biase.   If you are already using the eFI to inform services for people with frailty but the work is not yet represented on the eFI Engagement Map, please get in touch to share what you are doing with others.

A National Frailty Community of Practice has been established to allow those interested in improving services for older people with frailty to come together to discover what works for people with frailty in primary care through mutual sharing and learning with each other. ‘Please join the Healthy Ageing Collaborative Twitter conversation at #ageingwellnhs.or@sarahdebiase

A selection of resources and further information relating to our Healthy Ageing programme are available on our Improvement Academy website here