Supporting routine frailty identification and frailty through the GP Contract 2017/2018

The 2017/18, GP contract aims to respond positively to frailty and the challenges it poses through routine frailty identification for patients who are 65 and over and targeting a small number of key interventions (falls assessment and medicines review) at those most at risk of adverse events including hospitalisation, nursing home admission and death.  This creates an opportunity to reduce the likelihood and/or impact of these events for people living with frailty.

View Supporting routine frailty identification and frailty through the GP Contract 2017/2018

Supporting information:

Frailty awareness

Distinguishing older people living with frailty from those who remain fit is of key importance to ensure that fit people are supported to remain fit while those living with established frailty are supported on the basis of their needs.

It is important that patients, carers and health and social care  professionals  have a shared understanding of frailty and what interventions are appropriate for those living with frailty.

It is also important that we understand what is important to those living with frailty.

Older people prefer to describe their needs in more straightforward terms: they see themselves as starting to struggle with things, or being worried about their health, but not specifically as ‘frail’.


Early identification aids targeted support for older people living with frailty to help them stay well for as long as possible. We suggest using the Electronic Frailty Index (eFI )(or other validated tool such as PRISMA-7, gait speed or clinical judgement) to establish the presence of frailty for all patients aged 65 and over.


For people at risk of developing frailty who remain fit there are potentially  preventable or modifiable risk factors or conditions which include: Alcohol excess; Cognitive impairment; Falls; Functional impairment; Hearing problems; Mood problems; Nutritional compromise; Physical inactivity; Polypharmacy; Smoking; Social isolation and loneliness; Vision problems.

Promoting healthy ageing in older people who are not living with frailty offers the potential avoid or postpone the onset of the condition.


For people living with early frailty the focus should be upon helping individuals and their carers to acknowledge, understand and address the condition, ensuring that they are aware of the support available to them. This is intended to empower them to self manage their condition and enable them to access appropriate support when they need and choose to do so. This may be from families, carers, community and voluntary sector organisations, as well as, from health and care services if needed.


In addition to the approaches described for mild frailty, people living with moderate frailty will benefit from further focused assessment, aligned to the principles of ‘comprehensive geriatric assessment’.  Key elements of this process include falls risk assessment, medicines optimisation and cognitive assessment, with consideration of modifiable wider psychosocial and environmental factors also being important. This aligns strongly with the tailored approach to care recommended for people with multimorbidity.

By focusing upon what it is important to each person and by understanding each individual’s sources of resilience and vulnerability, a person-centred and holistic care and support plan can be developed. This will support individuals to maintain choice and control over the further interventions and support offered to maintain health and wellbeing, as well as reducing the risk of adverse outcomes commonly associated with frailty.


Care for people living with severe frailty builds upon the principles and processes described for moderate frailty, with continued needs focused care review, assessment and care planning.

It supports a continued focus upon personal goals and the available support required to achieve them.

This approach focuses on timely recognition of advancing frailty and thus enables appropriate steps to be taken to identify and meet an individual’s needs and wishes during the last stages of their life.

People living in care homes are likely to be living with higher levels of frailty and therefore merit particular attention to their care needs using the approaches outlined. The delivery of comprehensive, consistent and structured enhanced support to people living in care homes will ensure that their needs continue to be identified and met proactively.

Sharing information

Having access to appropriate patient information is vital. SCRs enriched  with additional information offer the opportunity to:

  • Increase patient safety by providing timely access to information such as significant diagnoses
  • Empower patients and increase satisfaction as patients can make their preferences, including end of life care, known
  • Empower health professionals by providing consistent, accurate, accessible information
  • Increase efficiency and effectiveness through more integrated care and reduced time/effort.

SCRs can also flag the existence of an advance care plan, resuscitation status and Lasting Power of Attorney and compliment other record sharing solutions such as electronic palliative care co-ordination systems (EPaCCS).

EPaCCS provide a shared locality record for health and social care professionals; It allows rapid access across care boundaries, to key information about an individual approaching the end of life, including expressed preferences for care. EPaCCS are a powerful enabler; supporting people to achieve preferred place of care and death.

  • A simple and more efficient way to update SCRs with additional information from a patient’s GP record is available to GP practices.
  • Additional Information is added with explicit patient consent and supporting guidance is available here (including optional patient leaflets to support conversations with patients).
  • EPaCCS implementation guidance is available as well as an EPaCCS case for change.
  • NHS England’s quick guide: Sharing patient information


Both multimorbidity and frailty are associated with ageing. They are closely linked, both have an adverse impact upon individual quality of life and are associated with higher mortality, adverse drug events and greater use of unplanned care. In line with NICE Guideline NG56, we are encouraging a tailored approach to care coupled with skilled clinical judgement and good communication – to provide high quality and efficient care for people with multimorbidity and frailty.