11 Case Study: NHS North Durham CCG – Care for Frail Patients Scheme

In a nutshell: Older people should be assessed for the presence of frailty during all encounters with health and social care personnel (including reception and clerical staff). The NHS England Direct Enhanced Service (DES) suggests the use of risk-stratification tools or other methods to case find and populate the register of at-risk patients. NHS North Durham CCG has commissioned an enhanced service to specifically improve the care of people living with severe frailty using the NHS England DES as a vehicle to achieve this.


Frailty is an increasingly recognised abnormal health state which signifies increased risk of adverse outcomes including unplanned hospital admission, care home admission and mortality.  There is good evidence that targeted goal orientated interventions can improve the outcomes for people with frailty.  This case study describes how North Durham CCG have developed a frailty model of care across primary, community and secondary care services developed with stakeholders across North Durham.  The primary care component of the scheme was developed with local GP’s and primary care nurses including Dr Gareth Forbes, a GP within NHS North Durham CCG - who played a key role in designing the primary care templates for use as part of the scheme and provided IT support.

The primary care scheme involves using the electronic Frailty Index (eFI) to identify people at risk of frailty to facilitate better care for this population. The CCG is aiming for practices to create a register of, and assess, around 1% on the non-institutionalised population.  An eFI threshold has been set so that 1.5% of a practice’s non-institutionalised population is identified – the eFI threshold is a score >0.36 (this threshold can be lowered to allow greater detection of frail patients). A list of patients who might be frail is generated as a result.

The primary care scheme comprises of three main elements:

  1. Identification of patients at risk of frailty and maintenance of a ‘disease register’ of patients diagnosed as having frailty
  2. Regular assessment of these patients (at least annually)
  3. Creation of a care plan for patients with frailty

Identifying patients at risk of frailty:

Patients at risk of frailty are identified using a combination of approaches. The three main components are:

Dr Forbes built a clinical protocol within SystmOne which generates a patient level eFI score for individual patients within their electronic health record (EHR) which alerts clinicians to patients who are likely to be at risk of frailty i.e. those with an eFI score >0.36. The patient level eFI protocol is modelled on the validated eFI population level report available system wide within SystmOne.

Two patient status alerts (icons) have been created to support the scheme but clinicians can turn these icons off if they do not want these icons to appear.


Diagnosing Frailty

A clinician then needs to confirm whether or not a patient on the ‘at risk of frailty’ register has frailty. Clicking on the ‘stickman’ icon takes the clinician to a clinical template in SystmOne which allows them complete a more detailed frailty assessment. The same template also provides diagnostic tools to help confirm a diagnosis of frailty. For example, the PRISMA 7 or the Timed Up and Go Test.

If a patient is clearly not frail there is a button to click to indicate this. The ‘stickman’ icon will disappear for 5 years if the patient is not frail. For those who are frail, the clinician just needs to add the relevant ‘frailty’ Read code to the clinical template. These patients should have an annual review as a minimum.

Assessment of Frailty

The clinical template for assessing frailty was designed using the British Geriatric Society (BGS) Fit for Frailty (FFF) (2015) recommendations. The key areas that the BGS FFF identified as being of relevance in an assessment are:

Overall aims of the programme:


Outcomes (process measures) being used to measure data quality and impact include:


Publication of a patient level eFI report system wide in SystmOne:

The eFI report published system wide by TPP in SystmOne is a population level report only. Dr Forbes has shared the patient level eFI protocol he built with TPP who have agreed to review the protocol for quality assurance purposes. The plan is then, for TPP and Dr Forbes to collaborate to publish this patient level eFI template system wide which will mean all SystmOne users can then access the patient level eFI report template if so desired.


Sharing the North Durham CCG Care of Frailty Elderly SystmOne clinical template

Dr Forbes as developed and published the clinical template described above within the Derwentside Clinical System; Dr Forbes is happy for the template to be used by others and information on how to access it are available on request. Please also note, as part of the Healthy Ageing Collaborative, a national ‘frailty template’ is under development for both SystmOne and EMISWeb which will draw on the expertise of clinicians including Dr Forbes.

These templates will be published centrally by TPP and EMISHealth in the GP module of their respective systems allowing for the template to be accessed by primary care clinicians across the UK.


Contact: Dr Gareth Forbes, NHS North Durham CCG

Email: gareth.forbes@nhs.net