Frailty Status and Assessment (HP345)

Frailty Status and Assessment (HP345)

HP345 Frailty Status and Assessment

Overview/Purpose

This protocol supports QOF optimisation for 2026/27 by helping users identify patients where frailty coding may affect achievement of blood pressure and diabetes indicators.

Frailty affects blood pressure targets across CD001, CD002, HYP010, HYP011 and DM036. It also affects HbA1c targets for DM020 and DM021, where patients coded as frail may have higher HbA1c thresholds.

What does it do?

The protocol checks whether the patient has outstanding QOF indicators where frailty may affect achievement.

If relevant indicators are outstanding, the alert:

  • tells the user which QOF areas may be affected
  • highlights blood pressure indicators where moderate or severe frailty may remove target requirements
  • highlights diabetes indicators where frailty may affect HbA1c targets
  • identifies where Rockwood frailty coding has been recorded but may not count for QOF
  • shows the latest QOF frailty code
  • shows the latest Rockwood coded frailty entry
  • shows the latest Rockwood frailty score/value
  • links to a template so users can review and update frailty coding where appropriate

Why is it important?

Some patients may have frailty recorded using Rockwood coding, but this may not be the same as a QOF-counting frailty code.

This can affect QOF performance, particularly in harder-to-achieve blood pressure indicators. The alert helps users opportunistically identify patients whose frailty coding may need review, so that the record accurately reflects the patient’s frailty status and QOF logic is applied correctly.

What will the user see?

The alert appears as:

Hovering over it gives more information:



It displays any relevant outstanding QOF areas, including:

  • blood pressure indicators for CHD, hypertension, stroke/TIA or diabetes
  • diabetes indicators affected by frailty
  • frailty coding inconsistencies
  • latest QOF frailty coding
  • latest Rockwood frailty coding
  • latest Rockwood frailty score/value

The alert also explains that Rockwood scores do not count towards QOF frailty and advises the user to review frailty status and record a valid QOF frailty code where appropriate.

Users should:

  • review the frailty information shown in the alert
  • consider whether the patient’s current frailty status is accurately coded
  • check whether Rockwood coding needs to be translated into a valid QOF frailty code
  • use the linked template to update frailty coding where clinically appropriate
  • remember that recording moderate or severe frailty may remove eligibility for relevant QOF blood pressure indicators

System Dependencies

This protocol relies on accurate coding of:

  • QOF frailty codes
  • Rockwood frailty scale codes
  • Rockwood frailty scores/values
  • relevant QOF disease registers and indicator logic
  • blood pressure and HbA1c achievement data

System Triggers

This is an alert protocol which loads on loading the patient record

Change management considerations

Practices should ensure clinical teams understand:

  • the difference between QOF frailty codes and Rockwood frailty coding
  • that Rockwood coding may not count for QOF
  • how frailty affects QOF blood pressure and HbA1c indicators
  • when it is appropriate to update frailty coding
  • that frailty coding should reflect the patient’s clinical status, not just QOF optimisation

How to get it

This protocol is installed as part of the PCIT Handy Protocols set.

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