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GMS/PMS core contract data collection


Named GP and the service for the Identification and Management of Patients with Frailty have been combined into this quality service. From April 2014 it became a contractual requirement for all patients to have an accountable GP. The GP is responsible for the care package the patient receives.  

This forms an integral part of transforming primary care and the drive to deliver a personalised care package for patients identified as most vulnerable. 

From 1 October 2017, the General Medical Services (GMS) contract required practices to routinely identify moderate and severe frailty for patients aged 65 years and over.

The first paragraph of the 5 Year Forward View notes that support for older people living with frailty, along with mental health and cancer, is one of three areas where the NHS faces particular challenges. Frailty has been described as the most problematic expression of population ageing, in part because it can be difficult to distinguish those living with frailty from those without frailty. The introduction of routine identification of frailty can help practices address this and provide an opportunity to target and tailor appropriate care and support for older people with the greatest need and enhance the proactive care GPs are providing for this patient group.

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 who achieve the age of 75, they will also be entitled to a health check, should they request one.

The requirement for patients over 75 to receive a health check is not a new initiative - this has formed part of core general practice service requirements for some time. This data collection programme will help inform commissioners if this service is being taken up by patients, and whether there is a requirement to raise awareness of patients that this service is available.

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.

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
  • provide any other clinically relevant interventions
  • 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 service specifications.

Guidance and technical requirements for NHS Employers.

Important information about this service

Quality service start date: 1 April 2019

Quality service end date: 31 March 2020

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: 17 June 2019 12:06 pm