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Embedding awareness and identification of frailty in acute & community settings

Working with healthcare staff in two South London acute trusts and their community providers we aim to improve awareness and identification of frailty to improve patient care and experience.

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  • Proposal
  • 2020

Meet the team


  • St Helier Hospital
  • Sutton Health and Care community team
  • St George’s NHS Hospital Trust

What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?

The HIN has been working with South London acute frailty specialists since April 2019. This group identified that system changes arising from the Covid19 pandemic had brought about improved hospital wide and community recognition and awareness of frailty.

The British Geriatric Society explains the COVID-19 pandemic has disproportionately affected older people – around half of diagnoses have been in people aged over 65 and nearly 90% of deaths have been in that age group. We heard overwhelmingly from many clinicians that system changes had enabled “a wider appreciation and recognition of frailty as a long-term condition” with “an increase in frailty score awareness across the Trust”. There had also been “improved awareness of the value of the Clinical Frailty Score, hence broader understanding and collaboration in identifying frailty”.

However, clinicians also believed these positive changes improving patient care would be cut short if their impact could not be measured and evaluated.

What does your project aim to achieve?

Our aims are:

1.      Understanding the system factors that led, under the Covid-19-response, to improved hospital wide and community awareness and identification of frailty.

We will identify what changes took place that led to greater identification of frailty across South London Trusts and community providers, e.g. – whether this was due to frailty teams working in other specialties or the NICE guidelines and improved use of the Clinical Frailty Scale (CFS)

2. Training and education into hospital and community services to embed frailty identification and awareness for non-frailty teams across the acute trusts and community services.

This analysis will enable us to achieve our second objective – appreciating how to embed frailty awareness. Dependent on the findings, this may involve ongoing system improvements, however it will also include use of educational and training resources such as the BGS Frailty Hub.

How will the project be delivered?

The project will have three sequential phases:

1.     Identifying the baseline

We will work with two Trusts and one community team to carry out a short review of frailty identification and awareness– using a modified version of the Wessex AHSN acute frailty audit, using interviews with clinicians to examine changes brought about due to Covid.

2.     Embedding changes and education

Each Trust will use the results of their audit to decide which changes need to be maintained or adapted to embed frailty awareness and use of CFS. We will support a community of practice to help embed positive changes and support the introduction of frailty training and education.

3.     Evaluation to measure improvement

After six months , we will repeat the review to measure progress against the baseline – and collate case studies to capture learning. We will also encourage and support development of routine data reporting mechanisms.

How is your project going to share learning?

The HIN works with regional and national NHS partners including the AHSN Network and NHSE/I as well as a group of South London Frailty specialists and the London Clinical Network on Frailty.

Our learning will be shared locally across South London with our networks of clinicians, commissioners and providers as well as with the AHSN National Healthy Ageing Network and stakeholders though our newsletter.

The HIN will run a national webinar to disseminate the findings, hold a special meeting of the AHSN network on frailty and offer to attend local and regional meetings to share the findings.

The HIN will produce a project report with the findings and recommendations and use opportunities to present at national conferences through posters or opportunities to present such as BGS conference

Finally, post-project, the HIN will then look to spread and adopt this approach in other Trusts.

How you can contribute

  • • Measurement - Can Q members suggest ways to capture data demonstrating the impact of identifying frailty in patients and how this changes care and management?
  • • Education – What resources are Q Members aware of that promote Frailty identification and management for non-specialists
  • • Patient experience – Can Q members help with ways of measuring the quality of the patient experience and how this work has impacted this
  • • Sustainability - How can we increase the likelihood of the changes being long lasting in non-specialist areas
  • • Wider benefits – other than patient experience, what other metrics can we use to demonstrate wider benefits?

Plan timeline

15 Mar 2021 Engagement with Providers-Review of Frailty Identification systems and processes
22 Mar 2021 set up CoP and invite members to 1st session
5 Apr 2021 initiate reviews with providers using adapted version of Wessex audit
3 May 2021 analysis of reviews and QI work with each provider
17 May 2021 CoP meeting to discuss reviews and QI work
17 May 2021 commence provider wide education and training
5 Jul 2021 CoP meeting to review QI work
6 Sep 2021 evaluation of training/education and QI work
20 Sep 2021 evaluation report
18 Oct 2021 sharing event for stakeholders


  1. Hi Fay,

    Myself and my colleague Emma Adams (Health Transformation Partnership) are supporting the Health Foundation this year by fostering conversations between Q members and encouraging collaboration. We were Exchange applicants last year, so we’re hoping that our experience can help others, as their ideas develop.

    It struck me, reading your 'How you can contribute' section, that you have a clear idea of what support you would like. Given your field, you may already be aware of the work of professor Gore on the life curve. I mentioned this because you described non-specialist people tracking frailty: This approach is a key facet of Grampian's care for older people strategy and was greatly championed by their AHPs as an accessible way for the public and clinicians alike to assess people's capabilities (what they can do, rather than what they can't do).

    Also, there's an online group, called Making use of patient experience, that you might wish to connect with: to see if those members have any views around your measuring patient experience question.

    If any other potential connections spring to mind I will of course let you know and in the meantime I'd like to wish you every success with your idea.

    Best wishes,



    1. Guest

      thanks so much for your message, Pete! really helpful!

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