1 in 10. That’s the number of adults over 65 that are estimated to be frail in England, equivalent to nearly 1.1 million people. That’s over 30,000 people in Essex alone. What’s astonishing is that, for the most part, the severity of frailty can be mitigated.
1,098,109 over 65s could be affected by frailty in England – 32,586 are likely to live in Essex
As outlined in our previous blog, the North East Essex Alliance have been working on rolling out their Frailty Toolkit which aims to identify the presence and severity of frailty within a population to inform proactive care planning. The Data and Analytics team at Essex County Council have worked hard to support those efforts by using linked health and care records to identify when patients receive a Rockwood Clinical Frailty Score. The Rockwood Clinical Frailty Score is a nine-point scale used to evaluate an individual's health status through clinical assessment, designed to determine their degree of frailty. The higher a patient’s score, the more severe their frailty is. The Frailty Toolkit outlines what a GP or health professional should do when they conduct these assessments.
Our initial analysis suggested that 78% of patients were not being referred on to services after receiving a frailty score. To be clear, not all patients need referring following a frailty score, especially if they receive low scores (indicating that they are among the least frail) or high scores (indicating that they are extremely frail or end of life). For that reason, most referrals are for patients in the middle of the frailty scale. The Alliance has established several frailty clinics across Colchester and Tendring that conduct more comprehensive assessments and provide a holistic plan to support patients with their ongoing health needs. However, we found that referrals into this service were low, suggesting that the preventative service was not being used to its full potential.
This is particularly necessary given that frail patients over 65 are nearly four times as likely to have an emergency hospital admission due to a fall compared to non-frail patients in the same age group. That also extends to GP practice visits due to falls, with frail patients aged over 65 a third more likely to attend than non-frail patients. These proactive and preventative services are therefore vital for reducing demand on stretched A&E and GP services. As such, work to identify frail patients and proactively intervene is of the utmost importance for preventing, reducing, and delaying escalations in their health needs.
Since our initial insight was delivered in November 2024, the Alliance has made considerable progress. We sought to return to the data six months after our initial project delivery to understand if the Alliance’s efforts are leading to improved patient experiences. We were pleased to find that the number of frailty score assessments tripled in the period of November 2024 to May 2025, compared to the same time the previous year. That increase is reflected across the whole frailty scale, with greatest increases in the least frail categories. That’s great news because it tells us two things. First, that use of the Frailty Toolkit is increasing drastically. Second, that frailty assessments are being done earlier in the patient journey, providing opportunities for implementing preventative measures.
Frailty score assessments have tripled in just one year
This has mainly been driven by the rollout of the Proactive Care programme and a concerted communications campaign with Primary Care Networks. These efforts have contributed to a reduction in primary care attendances among individuals with recorded frailty scores over the past six months, generating cost savings that can be reinvested in services. Results aren’t just monetary either. Patients receiving a frailty score are now 8% more likely to be referred following their frailty assessment, suggesting a considerable improvement on the 78% who did not receive a referral in November 2024. These referrals are spread across a multitude of different services, ensuring patients are directed to the appropriate support they need to slow their journey along the frailty scale. Notably, dedicated frailty clinics are now seeing more patients than ever before.
Returning to the original work we delivered last year has demonstrated that concerted efforts to prevent, reduce, and delay poor health outcomes for patients can be achieved through collaborative partnership working driven by decisive evidence-based action. With that in mind, older patients in North East Essex can be confident that now, more than ever, they can receive quality wrap-around care that will enable them to live independently for longer.
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