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GMS/PMS core contract data collection


Named GP and the service for the identification and management of patients with frailty are combined in this quality service (QS). It is a contractual requirement for all patients to have an accountable GP. The GP is responsible for the care package the patient receives.

Practices are also contractually required to identify moderate and severe frailty for patients aged 65 years and over on an annual basis.

For the frailty service practices will be required to use an appropriate tool, for example the Electronic Frailty Index (eFI), to identify patients aged 65 and over who are living with moderate and severe frailty.

Changes to the GP contract in 2017/2018 introduced routine frailty identification for patients who are 65 and over. It targets a small number of key interventions (falls assessment, medicines review and promotion of the additional information in the summary care record) at those most at risk of adverse events including hospitalisation, nursing home admission and death.  Early identification coupled with targeted support can help older people living with frailty to stay well and live independently for as long as possible.

Purpose and outline

This quality service supports NHS England to ensure that practices are meeting the requirements agreed as part of the contract. This will also be an important reporting tool to demonstrate that patients are receiving a quality service from their GP practice and identify to commissioners and practices any patient that has not been allocated an accountable GP.

For those patients identified as living with severe frailty, the diagnosis must be recorded in the patient’s record. For those patients identified as living with moderate frailty, clinical judgement will be required to determine whether or not the result should be recorded in the patient record.

For those patients identified as living with severe frailty, practices will be required to:

  • deliver a clinical review, including providing an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12 months, and
  • provide any other clinically relevant interventions, and
  • promote to patients without an enriched Summary Care Record (SCR) the benefits of it, seeking informed patient consent to activate the enriched SCR

How this service is commissioned and provided

NHS England regional teams commission this service from GP practices.

NHS England GP Contract information

Important information about this service

Quality service start date: 1 April 2020

Quality service end date: 31 March 2021

Payment period: N/A - contractual requirement with no funding attached

Collection frequency:  Quarterly

Manual or automatic entry: Automatic

Included in data collection: All system suppliers (TPP, INPS, Microtest and Emis)

Co-commissioning:  No

System type: Core contract. 

Last edited: 16 June 2020 11:25 am