Living and Dying Well with Frailty

Helping community teams to improve how they identify and support people aged 65 and over to live and die well with frailty in their community

We are seeking interest from Health and Social Care Partnerships and GP Clusters to join the new Living and Dying Well with Frailty Collaborative.

The collaborative aims to improve earlier identification, anticipatory care planning and shared decision-making, and support a multidisciplinary/agency approach so that people living with frailty get the support they need, at the right time, at the right place.

By October 2020 the collaborative will:

  • reduce hospital bed days for people aged 65 and over by 10%, per 1,000 population
  • reduce unscheduled GP home visits for people aged 65 and over by 10%, per 1,000 population, and
  • increase percentage of anticipatory care plans in the Key Information Summary (KIS) for people living with frailty by 20% per 1,000 population.

During the collaborative, GP practices and community teams will:

  • use the eFrailty Index through SPIRE to identify people aged 65 and over living with frailty
  • engage in anticipatory care planning conversations with these individuals and record the information in the Key Information Summary (KIS)
  • work within a multi-disciplinary team to consider the holistic needs of the person, and
  • use quality improvement methods to structure the work, including using data to learn how changes are being implemented and the impact they make.

Teams will be invited to work with us between August 2019 and October 2020 to improve the identification and support of people with frailty living in the community. Each team should include representation from a GP Cluster and Health and Social Care Partnership.

How to apply

The Living and Dying Well with Frailty Collaborative is open to accept applications between 17 June 2019 and 19 July 2019. Applications can be submitted at any time between these dates and we are happy to discuss any queries at this time. Please contact us at should you have any questions.

To apply please review the guidance document and download an application form from the key documents section on the right hand side of this page.

Key dates:

  • Applications open between 17 June 2019 and 19 July 2019.
  • Applications will be assessed between 20 July 2019 and 16 August 2019. During that time we will be in touch with applicants to discuss their applications and seek any clarification needed.
  • Successful applicants will be notified by the 16 August 2019 and a Memorandum of Understanding issued to confirm the teams place on the collaborative.


Please see our pages on the Electronic Frailty Index (eFI), People with Frailty, People nearing the end of their lives and Anticipatory Care Planning for key information and resources related to Living and Dying Well with Frailty.

Related programmes

Frailty at the Front Door is a further programme within the ihub that aims to address the needs of people living with frailty across their pathway of care. The aim of the Frailty collaborative is to improve the process of identification of frailty and the coordination of care to deliver better experiences and outcomes for people living with frailty who present to unscheduled care. This collaborative is currently open for applications from new acute sites, please contact the Acute Care team for further information.

Interested in being part of the collaborative?

Contact the Living Well in Communities team to find out more.

Tel: 0131 314 1232


Twitter: @LWiC_QI