Identification and management of patients with frailty

Practices are required to identify and manage patients living with frailty, as part of routine consultations. This guidance sets out what practices should do to fulfil these requirements.

Location: England
Audience: GPs Practice managers
Updated: Tuesday 4 October 2022
GP practice article illustration

Recognition that a patient has a degree of frailty can prompt a GP to review the care offered to them. Care should be tailored to their needs and take into account the risks of polypharmacy and inappropriate treatment. It can also help in the planning and delivery of services, particularly for older people.


What is frailty?

Frailty is a consequence of a decline in several physiological systems, which collectively results in a vulnerability to sudden health state changes triggered by relatively minor stressor events.
Royal College of Physicians

There is sometimes confusion between three concepts; multi-morbidity, frailty, and disability. This guidance refers to frailty only.

The British Geriatric Society refers to five ‘frailty syndromes’:

  • Falls (eg collapse, legs gave way, ‘found lying on floor’).
  • Immobility (eg sudden change in mobility, ‘gone off legs’ ‘stuck in toilet’).
  • Delirium (eg acute confusion, ’muddledness’, sudden worsening of confusion in someone with previous dementia or known memory loss).
  • Incontinence (eg change in continence – new onset or worsening of urine or faecal incontinence).
  • Susceptibility to side effects of medication (eg confusion with codeine, hypotension with antidepressants).


Identifying frailty

Practices are required to use an appropriate tool, such as the electronic frailty index, to identify patients over the age of 65 who are living with moderate and severe frailty.

Practices should code clinical interventions as appropriate.

These tools should be seen as guides only. The decision to code someone as moderately or severely frail should be made by an experienced clinician guided by the electronic score. It is likely that these patients will be seen on a regular basis and coding can take place over the course of the year.

View NICE guidance on how to assess frailty


Electronic frailty index

The electronic frailty index uses data that is available in the GP electronic health record to identify and severity grade frailty. This enables the identification of older people who are fit, and those with mild, moderate and severe frailty.

It uses a ‘cumulative deficit’ model, which measures frailty on the basis of the accumulation of a range of deficits, which can be clinical signs (eg tremor), symptoms (eg vision problems), diseases, disabilities and abnormal test values and is made up of 36 deficits comprising around 2,000 read codes.

Electronic frailty index


Management of the severely frail

For patients identified as being severely frail, the practice will be required to deliver a clinical review providing an annual medication review and discuss whether the patient has fallen in the last 12 months. Practices should also provide any other clinically relevant interventions and code them.

Where a patient does not already have an enriched SCR (summary care record), the practice should offer this to the patient.

It is up to the clinician whether it is appropriate to code patients who are moderately frail.


Data collection

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.