Electronic Frailty Index: Identifying People With Mild Frailty And Developing A 3rd Sector Led Response

Midlothian Health and Social Care Partnership

Frailty is an increasing challenge for Midlothian Health and Social Care Partnership (HSCP). Services could be unable to meet growing demand and struggle in the medium to long term if the health and social care system does not change. But there are substantial challenges in identifying people with frailty, particularly mild or moderate (the rising-risk population).

Previously, age and hospital activity was used to identify frailty, which meant our understanding of this population’s needs and services used, was poor.

The Improvement Fund grant from the ihub allowed us to proactively identify this population through GP read codes using the electronic Frailty Index (eFI).

This project aimed to improve person-centred care for people living with (mild) frailty, by:

  • developing a robust process using eFI
  • shifting from being reactive to pro-active
  • building relationships between third sector and primary care 
  • developing referral pathways into community-based support (for example MERRIT, Eat Well Age Well)
  • understanding the needs of this population to help future planning of services


The use of eFI confirmed that over 8000 people are living with frailty across Midlothian, double the number previously thought, with the majority (around 6000) coded as ‘mild’.

eFI also revealed that half of the frail population are aged under 75 (with a strong link to deprivation for the younger frail).

For the mild cohort, there are unmet carer needs, unmet nutrition needs, basic home adaptations required, people not accessing benefits they are entitled to (e.g. attendance allowance, Blue Badge) and a need to link with groups and activities to reduce social isolation and maintain independence

This is important learning for how we forward plan, in terms of growing numbers and challenging our assumptions about age.

  • What was the approach?
  • What was the impact?
  • What was the learning?
  • What are the next steps?

For further information on this project please contact: hcis.inquireseevit@nhs.scot