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 working with Health and social care partnerships and GP clusters through a national collaborative to improve earlier identification, anticipatory care planning and shared decision-making, to ensure that people living with frailty get the support they need, at the right time, at the right place.

By November 2020 the collaborative will:

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

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 November 2020 to improve the identification and support of people with frailty living in the community. Each team includes representation from a GP Cluster and Health and Social Care Partnership.

Collaborative status

The application phase for the collaborative closed on 19 July 2019. Applications are being considered by the ihub with decisions being communicated to those who applied on 16 August 2019.

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 this collaborative?

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


Twitter: @LWiC_QI