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

The Pathfields Tool was validated as a Frailty Casefinding Tool in the last year (link: In adddition to diagnosing frailty severity (mild, moderate, and severe), it subsegmented the population by residential status (not housebound, housebound, and in a care home).

The Pathfields Tool also showed its worth as a population health management tool in the pandemic where entire population segments could be referred to partner organisations to offer targeted care (see case study one, link:

Delivering this required partnership working between primary care, community services, City Council, VCSO, and carehome providers.

What does your project aim to achieve?

During the time of the pandemic, we also conducted an in-house one year followup of patients from the time of frailty diagnosis. The one year mortality data was  stark with the outcomes as below:

1. Mild frailty ~25%

2. Moderate frailty ~50%

3. Severe frailty ~90%

What surprised us most was the mild frailty mortality data. This patient are generally living in their own homes and are independent but showing signs of slowing up and are beginning to struggle with higher order activities of daily living.

We would like to conduct a more in-dept analysis of this group to ascertain:

1. Cause of death

2. Whether upstream intervention can prevent death

How will the project be delivered?

This project will be delivered in two phases:

1. Analysis of deaths from mild frailty in Pathfields Medical group to determine the main causes of death. This will be written up and published as no one knows the causes of death in this group.

2. The next phase will be largely determined by the outcomes of the first phase. Depending on the disease, upstream interventions will take place to see if it possible to reduce these adverse health outcomes. For example if stroke is the leading cause of death, patients with mild frailty could be screened for atrial fibrillation and be brought in for blood pressure monitoring.

The team will involve colleagues in the Q community and the Centre for Better Ageging to ensure analysis is robust.

How is your project going to share learning?

This data has never before been discovered but has potentially massive ramification on how frailty is managed in the community. We would hope to publish this data and share it in international conferences such as the British Geriatrics Society Autumn meeting.

We would also hope to publish it in a leading journal and use organisations such as the South West Academic Health Science Network to support with webinars and dissemination.

How you can contribute

  • 1. Support with design of the project and analysis in phase 1
  • 2. In phase 2: appraising options for upstream intervention and analysis of health outcomes.
  • It is difficult to say what sort of help we require as no one has ever done this work before. However, frailty is the one condition that accounts for the majority of NHS non-elective spend and if intervention upstream can prevent mortality or progression, this will be a massive win for the NHS

Plan timeline

1 Mar 2021 Assuming we are a winner, start analysing mortality data
7 Aug 2021 Write up and publish mortality data
7 Sep 2021 Phase 2 - Plan services for upstream intervention
7 Jan 2022 Initiate services for upstream intervention
7 Sep 2022 Complete 9 months of service
12 Jan 2023 Complete write up and publication and onward dissemation of phase 2


  1. Frailty is such a key area of work and impacts on multiple specialities. It will be really interesting to see the data and understand if it has uses in other areas such as Community Hospitals where Frailty Units seem to be evolving currently.

  2. Hi David. Good to see your bid to support further understanding of frailty - such a huge area of interest across health and social care.

    My colleague, Pete Dudgeon, and I are working with the Health Foundation to support conversations and collaboration among Q members during this Q Exchange round. We were successful as Q Exchange bidders last year, with Improving Improvement, so we're hoping that our experience will help others' ideas to develop and take shape.

    Couple of questions on your proposal:

    - any ideas yet who will be your Q exchange "team"? - it would be great to see input from different partners as well as some patient involvement

    - do you already have thoughts about interventions you might apply? if so are they being tried elsewhere already - this might help with linking you up to other Q members

    - and do you have any wider thoughts about sharing the learning with the Q community and others in a more informal way, outside of publication?

    Good luck with your bid. We'll look out for any connections that might be helpful to you.

    Best wishes, Emma


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