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Identifying patients living with frailty

Since July 2017 there has been a new contractual requirement for practices to focus on the identification and management of patients living with frailty.

Practices are required to use appropriate tools, such as the Electronic Frailty Index (eFI), to identify patients over the age of 65 who are living with moderate or severe frailty. It is likely that these patients will already be seen on a regular basis and coding can take place as and when required throughout the year.

NHS England is aware that some practices have batch-coded a read code diagnosis of frailty. It is recommended that this should not be done for the following reasons:

• eFI is not a clinical diagnostic tool: it is a population risk stratification tool
• automated diagnostic coding without clinical judgement will lead to inappropriate diagnosis of frailty with direct consequences for patient care

For those patients identified as being severely frail, practices will be required to deliver a clinical review providing an annual medication review and, where clinically appropriate, discuss whether the patient has fallen in the last 12 months.

Where a patient does not already have an enriched Summary Care Record (SCR) practices should offer this to the patient and, after receiving informed consent, activate the enriched SCR.

Under these provisions, data will be collected on:

• the number of patients recorded with a diagnosis of moderate frailty
• the number of patients with severe frailty
• the number of patients with severe frailty with an annual medication review
• the number of patients with severe frailty who are recorded as having had a fall in the preceding 12 months
• the number of severely frail patients who provided explicit consent to activate their enriched SCR

This information will be used by NHS England to understand the prevalence of frailty and guide future commissioning arrangements. It will not be used for performance management.

Last updated : 25 Oct 2017

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