The programme

A coordinated programme of evidence-based improvement interventions delivered in partnership with primary and community care teams, academics and industry partners with the aim of building improved systems of care for older people living 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, more appropriate, proactive, goal-orientated care and improved planning of health service utilisation.


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 2017, the estimated average UK life expectancy for females was 83.1 years, and for males, it was 79.4 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 improve care for people living 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 each of the leading UK primary care EHR systems, which means the eFI is available to one hundred per cent of GPs across England.

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 each of the leading UK primary care EHR systems, which means the eFI is available to 100 per cent of GPs across England
  • At least 85 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 falls prevention
  • The eFI won the prestigious 2017 RCP Excellence in Patient Care award in the innovation category
  • 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 recommended by NHS England as an appropriate, evidence based tool to identify patients aged 65 and over who may be living with moderate or severe frailty to support routine frailty identification and frailty care through the GMS GP contract 2017-2018

Next Steps

  • We will help drive local improvement in care and outcomes for people living with frailty across the STPs and primary care networks across the Yorkshire and Humber region.
  • We will support members across the region to use the eFI tool to reduce reliance on health and social care resources through better targeting of evidence-based interventions
  • We will help reduce harm associated with inappropriate prescribing.
  • We will pilot a self-management support intervention for people at risk of mild frailty.
  • A series of case studies will be developed to share best practice and learning from the eFI  implementation and these will be disseminated regionally and nationally.
  • A clinical frailty template will be developed for the leading primary care electronic health record systems (SystmOne and EMISWeb) to support multifaceted assessment and care and support planning for people with frailty in primary care based on the principles of comprehensive geriatric assessment.
  • We will work collaboratively with the Connect Yorkshire, part of the Connected Health Cities programme to gain insight as to how routinely collected health information can be linked in order to transform local services, offer more targeted support for people living with frailty and improve frailty care pathways. For example, one project will examine how we can improve triaging of care for people with frailty using urgent care services.
  • Collaboration will continue with health and care organisations, universities and other national representative bodies (including Age UK, the AHSN Network, the British Geriatric Society, NHS England and NHS Digital) to support continuous improvements in the way care is provided for people living with frailty

How to get involved or get more information

If you are a GP, Clinician or an older person who is interested in knowing more about the eFI and/or the Healthy Ageing programme, please contact Sarah.De-Biase or Dr Andrew Clegg.   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 so we can support you to share what you are doing with others.

A Supporting Frailty in Primary Care collaboration platform has been established by NHS England’s Long-Term Conditions team and is facilitated by our Healthy Ageing team. The platform has been designed to build an information frailty network or community that can share and discuss issues and good practice quickly and support the smooth and orderly introduction of changes to the GP contract with regards to the routine identification of frailty, If you would like to join the platform, please contact Megan Humphreys or Iola Shaw.

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