Partnered byIBM Logo


Mid and South Essex ICS, Essex Partnership University Trust and Arden and Gem CSU

Electronic Frailty Care Co-Ordination System (Efraccs) And Frailty End-Of-Life Dementia Assessment (FrEDA)

The project’s aim was to create capability to capture data never measured or shared before at scale across all their providers. Data-driven innovation supports delivery of an effective Population Health Management framework integrated care system-wide, to improve identification and quality of care for people with frailty/dementia/PEOLC needs. The comprehensive all-provider data tool has created a performance dashboard with the capability to measure performance of best practice quality metrics at PHM level by all major providers across the system to effectively drive quality improvement.

Capturing the right data is reducing inequalities to this population, improving outcomes, experience and reducing system pressures, say organisers. The judging panel felt this was a great example of strong data analytics combined with an engaging approach.

To read this entry in full visit HSJ Solutions.

Highly commended: North West London ICS, South East London ICS, Imperial College Health Partners and Vizify -  London Asthma Decision Support Tool (LADS)


  • Cambridgeshire and Peterborough ICB, Greater Peterborough Network, East of England Ambulance Service: Call Before Convey
  • Gloucestershire ICB and Gloucestershire Hospitals FT: Caring For Communities And People And Home Group - One Gloucestershire - High Intensity Use Patients
  • NHS South, Central and West, Peninsula Cancer Alliance and Somerset, Wiltshire, Avon and Gloucestershire Cancer Alliance: South West Prostate Cancer Dashboard
  • NHS Sussex: Data-Driven Transformation Improving Population Health Outcomes And Health Inequalities Across NHS Sussex Community Musculoskeletal Services
  • North of England Care System Support: Optica - Optimising Patient Flow And Hospital Discharge Processes
  • University Hospitals of North Midlands Trust: Automated Weight Management Programme Referrals
  • West Suffolk FT: Stroke Service: Using Data To Drive And Improve Patient Care & Outcomes