This project was funded between March 2018 and April 2019.

  • Run by Midlothian Health and Social Care Partnership (HSCP).
  • Used data from the Electronic Frailty Index (eFI) to improve care for people living with frailty in Midlothian.
  • Established a whole-system analytical framework to identify all frail patients in the region, and provided support to general practices to analyse the data and use it to identify improvements that can be made in service provision.

The eFI uses general practice read codes to identify frailty in a practice population. Developed by the NIHR (National Institute for Health Research) CLAHRC (Collaboration for Leadership in Applied Health Research and Care) in Yorkshire and Humber, it is now available to all general practices in Midlothian.

This project by Midlothian HSCP used data analysis and quality improvement (QI) methods to explore how the index can be used to improve care for people with frailty.

A whole-system analytical method was established to identify frail patients, and support was provided to practices on analysing their data and using it to understand how people with frailty are using the care system.

Practice staff were trained on using analytical tools to measure improvement, and funded time allowed GPs to interpret the analysis, discuss the results and perform tests of change.

The project was structured around two learning events, bringing GPs and stakeholders together.

Use of the eFI has led to multiple QI projects within the practices. One practice has transformed its use of anticipatory care plans after data showed improvements were needed. In another practice, prescribing information is being used to develop guidance for realistic prescribing for people with frailty.

The data sharing agreements between the practices and the HSCP have been extended for 12 months, and the data analyst post is now permanently funded.

The project has attracted attention from other areas of the UK, with learning being shared with teams in Leeds and Preston, and NHS England visiting Midlothian to find out about the approach.

Contact information

For more information about this project, please contact Jamie Megaw, Strategic Programme Manager, Midlothian Health and Social Care Partnership.

About this programme


Advancing Applied Analytics

This programme offers £750,000 of funding to support up to 12 project teams aiming to improve analytical capability in suppor...

Opens Nov 2019

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