Skip to main content

Our Implementation Projects

The Healthy Ageing Collaborative

Working closely with Improvement Academy, Yorkshire and Humber Academic Health Science Networks (AHSN), our Healthy Ageing Collaborative is implementing the electronic Frailty Index (eFI) tool to help identify older people with frailty in primary care using routinely collected information within a patient’s electronic health record. This is enabling health care professionals to recognise and diagnose frailty earlier, and better address the complex needs for this vulnerable group through individually targeted evidence-based pathways of care.

The Connected Yorkshire programme (part of Connected Health Cities) is supporting the Healthy Ageing Collaborative to:

  • Evaluate evidence based interventions for people with frailty and frailty care pathway changes.
  • Improve public health intelligence by risk stratification and identifying health needs of the population to enable more effective resource allocation
  • Understand patient flow through frailty care pathways and developing quality improvement projects to reduce treatment burden and provide supportive care to those people living with frailty who need it most.

About the Healthy Ageing Collaborative

The Healthy Ageing Collaborative has been actively involved in two Health Foundation funded projects: ‘Supporting self care’ and ‘Safer prescribing for frailty’:

Working in collaboration with Trust Primary Care Limited (TPC Ltd) and Age UK Bradford, this project aims to test the feasibility of a Self-Management Support (SMS) intervention for older people with mild frailty using a before and after cohort design. The project will help determine whether an SMS intervention using the NHS England ‘Practical Guide to Healthy Ageing’ can lead to improvements in self-management ability and reduce healthcare utilisation in a population with mild frailty. A secondary aim is to generate learning about the barriers and enablers to successful implementation of a SMS intervention for this population.


Frailty is synonymous with problematic polypharmacy. 3 million people in the UK have a long term condition managed by polypharmacy. A frail older person on 10 or more medicines has at least 6 times the risk of death than a person with robust health and is 300% more likely to be admitted to hospital. With 50% of medicines not being taken as prescribed and 6% of hospital admissions being related to medicines the impact of problematic polypharmacy on the lives of people with frailty is enormous.

Our polypharmacy programme in General Practice gave 12 GP practice teams the skills, tools and structure they needed to engage frail patients in discussions about their medicines, sharing the goal of reducing medication burden and risk of side effects. We used behavior change psychology, quality improvement methodology and the e-PACT2 polypharmacy metrics to achieve reductions in repeat prescriptions.


The Safer Prescribing for Frailty Health Foundation funded project has been listed as a finalist for the HSJ value award 2018, rewarding efficiency and improvements by the NHS under the ‘Pharmacy and Medicines Optimisation’ category.

The Academic Unit of Elderly Care and Rehabilitation has been collaborating with the Yorkshire & Humber Academic Health Science Network to produce several videos in relations to Safer Prescribing for Frailty, as part of the Healthy Ageing Collaborative:

Achieving Behaviour Change

Reducing inappropriate prescribing

A Quality Improvement Story