The Kings Fund hosted a full day conference on 15th March 2016, focused on developments by the NHS and other organisations in improving integrated care for those living with frailty.

The day consisted of plenary presentations for all delegates and a choice of smaller breakout sessions, including one about the Nottinghamshire Frailty Toolkit training & education workshops presented by Jane McCombe (Health Education England East Midlands), Elaine Mitchell (Nottingham City Council) and Dr Dawn Moody (Fusion48).

Three of the main presentations are summarised below. The full set of presentations from the day can be accessed here.


  • Presenters from the Yorkshire and Humber Improvement Academy outlined the construct of the eFI which is based on identifying deficits from routine primary care datasets. Thirty-six deficits cover codes for disease states/conditions, symptoms and signs, abnormal pathology results and types of functional disability.

Frailty deficits image

  • Data was presented which defined how the eFI score relates to levels of frailty:
    • 0 to 4 deficits = Well or mostly well (eFI < 0.12)
    • 5 to 8 deficits = Mild frailty (eFI 0.12 to 0.24)
    • 9 to 12 deficits = Moderate Frailty (eFI 0.24 to 0.36)
    • 13 or more deficits = Severe Frailty (eFI > 0.36)
  • Data was presented to illustrate how the degree of severity of frailty (measured through eFI score) affects outcomes. For example, at 5 years after diagnosis, only around 35% of those aged 65 and over with severe frailty (eFI > 0.36) are still alive, compared to around 90% of those aged 65 and over and who are defined as “fit” / “well or mostly well” (eFI score 0 to 0.12).
  • Examples of health & care economies using the eFI to assess people with frailty and to integrate care for them included NHS Hamilton, Richmond & Whitby CCG using practice nurses to assess & co-ordinate and a NHS North West London CCG using the eFI to risk-stratify all those aged 65 and over across the whole CCG in order to match ‘tiered care pathways’ to levels of frailty.
  • Kings Fund presentation is available here


  • Delivered by Caroline Abrahams (Charity Director, Age UK).
  • Emphasised how those living with frailty describe the condition in terms of their ability to perform everyday tasks and how frailty makes them feel.
  • Age UK’s Integrated Care Programme: focus on the person, not the condition; seamlessly connecting health & care services; and needing a step-change in approach as outlined in the ‘Home of care’ model.

Home of Care

  • Triple benefit of the Programme: improves the individual’s wellbeing; reduces hospital admissions; and supports whole system change (e.g. shared single care plans).
  • More information about Age UK’s Personalised Integrated Care programme can be found here.
  • Kings Fund presentation is here


  • Compelling case for change – majority of those living with frailty who attended A&E were admitted, they had the longest length of stay of any group, the highest in-patient complication rate and yet 33% of those admitted met the criteria for home based care.
  • Service in Lincolnshire West has discrete but integrated strands:
    • A community based, multi-professional /multi-organisation service;
    • A transitional care service (bed based but with focus on ‘discharge to home”);
    • A secondary care service which draws on front-door frailty/assertive in-reach teams;
    • An integrated discharge hub.

Levels of care

  • Positive areas of change: integrated MDT approach; specific project management; using a shared case-finding and assessment tools; and GPs with Special Interest in frailty working in primary care.
  • Challenges still present: Workforce, achieving true cultural change, information sharing, GP engagement, consistent care planning, delivering impact at scale.
  • Kings Fund presentation is here.

Link to all the conference presentations is here.