Abstract Introduction Frailty is a strong prognostic predictor. By incorporation routine frailty scoring as part of routine primary care this can help as guide to clinical teams. Method In 2021 we recognised that our we needed to improve identification of frailty. We undertook whole team training of nurse, GPs and Health Care Assistants, and incorporated scoring the Rockwood Clinical Scale as a routine part of regular chronic disease reviews and template for those over 80. An alert was added on the clinical system to highlight last Rockwood score or where this remained outstanding. Results In May 2020 we have proactively recorded frailty status as mild moderate or severe frailty or a Rockwood score in only 22% patients and 27% patients in May 2021 and 33% in May 2022. With implementation of a systematic approach the completeness of our data has improved from to 66% by May 2023 and has since steadily increased to 81% in May 2024 and 90% in May 2025. Comparison with neighbouring practices in Mendip where this change was not implemented shows a smaller incremental rise in completeness of recording from 33% in 2020 to 47% in May 2025. Conclusion Although in 2021 our proactive coding for frailty lagged behind the performance of other Mendip practices, we have been able to make improvements from coding 24.3% of those over 80 to now having coded 90.1% of this group through a systematic approach. Working as a whole practice team it has been possible to identify those living with frailty using Rockwood scoring. The coding of those at advanced age who are not frail can also help ensure this group continue to have full medical interventions and are not subject to age discrimination.
Kingston et al. (Sun,) studied this question.