• Run by Midlothian Health and Social Care Partnership (HSCP).
  • Used data from the Electronic Frailty Index (eFI) to improve care for people living with frailty in Midlothian.
  • Established a whole-system analytical framework to identify all frail patients in the region, and provided support to general practices to analyse the data and use it to identify improvements that can be made in service provision.

The eFI uses general practice read codes to identify frailty in a practice population. Developed by the NIHR CLAHRC in Yorkshire and Humber, it is now available to all general practices in Midlothian.

This project by Midlothian HSCP used data analysis and quality improvement (QI) methods to explore how the index can be used to improve care for people with frailty.

A whole-system analytical method was established to identify frail patients, and support was provided to practices on analysing their data and using it to understand how people with frailty are using the care system.

Practice staff were trained on using analytical tools to measure improvement, and funded time allowed GPs to interpret the analysis, discuss the results and perform tests of change.

The project was structured around two learning events, bringing GPs and stakeholders together.

Use of the eFI has led to multiple QI projects within the practices. One practice has transformed its use of anticipatory care plans after data showed improvements were needed. In another practice, prescribing information is being used to develop guidance for realistic prescribing for people with frailty.

There are common themes within the projects: professionals need more time with people in their own home; continuity of care is fundamental; teams need to work differently to improve coordination of care; the system needs to shift from being reactive with insufficient time to care, to proactive with time to care.

The understanding of opportunities to improve quality of care and how services are currently utilised by people with frailty demonstrates that current capacity and organisation of services across Midlothian is insufficient, but also identifies opportunities to improve the frailty system of care.

Contact information

For more information about this project, please contact Jamie Megaw, Strategic Programme Manager, Midlothian Health and Social Care Partnership.

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