Supporting routine frailty identification and frailty through the GP contract 2017/2018

The 2017/2018 GP contract introduces routine frailty identification for patients who are aged ≥ 65 years from 1 July 2017. This guidance provides GPs and Primary Care with a summary of the core contract requirements in relation to frailty within the contract and includes signposting to further support.

The six step contact process asks GPs to:

    1. Identify patients at risk of frailty using the Electronic Frailty Index (eFI) or other validated tool or clinical judgement
    2. Undertake secondary check using Clinical Frailty Scale (CFS), clinical knowledge of patient or information available
    3. Code the patient
    4. Complete a Summary Care Record (SCR)
    5. For those with severe frailty, undertake falls assessment and medications review
    6. Use clinical judgement for other relevant and appropriate interventions

Read more on the NHS England website.

NHS RightCare: Falls and Fragility Fractures Pathway

The Falls and Fragility Fractures Pathway defines the core components of an optimal service for people who have suffered a fall or are at risk of falls and fragility fractures. It has been developed in collaboration with the National Clinical Director for Musculoskeletal Services, Peter Kay, Public Health England (PHE), the NOS and a range of other stakeholders from across the health and care system. 

The Pathway contains a number of key messages for commissioners who are responsible for Falls and Fragility Fractures for their population. 

Local health economies, with support from their NHS RightCare Delivery Partner, can use the Falls and Fragility Fractures Pathway resource as a framework for their local improvement discussions. 



Clinical Commissioning Group (CCG) indicators relevant for the field of osteoporosis

The CCG indicators are designed to provide evidence-based area of practice to:

  • measure against to demonstrate improvement;
  • form the basis of payment tariffs.

NHS England and other organisations can use the NICE menu of indicators for national and local frameworks incentive schemes and they can be used to support measurement of the new Sustainability and Transformation Plans work programmes.

A full set of the indicators can be found on the NICE website via the 'Single menu of indicators' which can be filtered by indicator type and by subject. 

Indicators relevant to osteoporosis and hip fracture as published in August 2017:

The proportion of people with hip fracture, who receive a formal hip fracture programme from admission.

View indicator details     NICE id code: CCG20CCG


The proportion of people with hip fracture, who receive surgery on the day of, or the day after, admission.

View indicator details     NICE id code: CCG21CCG


The proportion of people with hip fracture, who receive a multifactorial risk assessment of future falls risk.

View indicator details    NICE id code: CCG22CCG


The proportion of people in the national hip fracture database who have received all nine care processes performed.

View indicator details     NICE id code: CCG23CCG


The rate of people admitted with a primary diagnosis of hip fracture per 100,000 CCG population.

View indicator details     NICE id code: CCG24CCG

Fracture Liaison Service Implementation Toolkit

The FLS Implementation Toolkit has been developed by the NOS, with support from relevant professional bodies, to support health professionals and commissioners to set up or improve an FLS. It includes a template business case which you can adapt to put forward a case for the development of an FLS in your area. Use our FLS benefits calculator to support your business case and learn from case studies of existing FLS services across the UK. Our dedicated Service Delivery Team can also provide bespoke support to help you develop a new service or improve an existing service. More information is available in the FLS section of this website. 


FREE osteoporosis module CPD accredited by RCGP

Consolidate your learning and gain CPD accreditation by completing this half-hour module developed by the National Osteoporosis Society and RCGP. 

RCGP osteoporosis module

Practice Nurses

To go to the Osteoporosis and the Practice Nurse resource area, click on the link below. 

Practice Nurse resources