The 2017/2018 GP contract introduced routine frailty identification for patients who are 65 and over from 1 October 2017.

The three steps are:

  1. Identify potential frailty.  For all patients over 65 use Electronic Frailty Index (eFI ) or appropriate validated tool to identify patients who may be living with severe or moderate frailty.
  2. Apply clinical judgement.  For patients that may be living with moderate or severe frailty apply clinical judgement to confirm people living with severe frailty.  Take into account an individual’s complete clinical picture; use tools such as PRISMA-7Timed Up and Go test, Gait Speed Test  or the Clincal Frailty Scale (CFS) as appropriate.
  3. Take action.  For patients diagnosed as living with severe frailty:
    1. Clinical review – annual medication review and falls risk assessment (if indicated) and any other clinically relevant interventions.
    2. Seek informed patient consent to activate the enriched SCR, where the patient does not already have one
    3. Code the clinical interventions appropriately
    4. For other patients consider appropriate interventions and coding as normal.

NHS England have released guidance to provide GPs and Primary Care with a summary of the core contract requirements in relation to frailty within the contract and includes signposting to further support.  This includes NHS England’s Older People’s webpage which contains information, support and resources on improving care for older people.

An extensive set of Frequently Asked Questions is available and there is also a series of webinars hosted by national leaders covering a variety of relevant topics which can be accessed here.


NHS England Guidance

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Toolkit for general practice in supporting older people living with frailty

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