How Mid & South Essex Is Transforming End-of-Life and Frailty Care using SystmOne
We’re excited to share how Mid and South Essex is leading the way in digitally enabled, person-centred care – delivering real results in frailty and end-of-life care through three powerful tools: FrEDA (Frailty, End-of-Life & Dementia Assessment), ePaCCS (Electronic Palliative Care Coordination System), and the eFraCCS (Electronic Frailty Care Coordination System).
FrEDA, ePaCCS, and the ICS-wide eFraCCS are fully embedded in the SystmOne environment. That means:
- Real-time sharing of Advance Care Plans, palliative needs, and holistic assessments (CGA)
- Real-time sharing of Frailty scores and functional assessments, including falls risk assessments
- Joined-up care across all settings – no matter who’s involved
- Earlier identification of people with complex needs
- Greater autonomy for patients, and faster action by staff
- More care delivered at home, fewer avoidable hospital admissions
Because GP practices, community services, hospices, community hospitals, frailty and dementia teams, virtual wards, and UCR teams are all on SystmOne, Mid and South Essex was uniquely positioned to scale FrEDA, ePaCCS, and eFraCCS across the entire ICS in order to gain maximum benefit.
We are one of the first areas in the country to have an electronic Frailty Register (eFraCCS) that all providers across Primary Care, Community Teams, Hospices, Dementia Teams, and more can use – enabling proactive, personalised care at scale.
FrEDA was designed from the ground up to support the NHS 10-Year Plan’s neighbourhood model. It enables any professional across the neighbourhood to:
- Identify those at risk earlier using frailty and illness indicators
- Create and update holistic assessments and ACPs
- Share those insights instantly with any team, anywhere in the ICS
- Coordinate and deliver care without duplication or delays
Results in just two years: - 20,000 more people identified for personalised, proactive care (up from 18,000 just six weeks ago!)
- 50% increase in Advance Care Plans
- 40% increase in ePaCCS usage
- 50% drop in multiple emergency admissions in the final 90 days of life
- 45% reduction in non-elective admissions from care home residents
- 90% of people in high-adoption areas dying in their preferred place of care
- 15% fewer population deaths in hospital vs national average
- 50% fewer A&E attendances for older adults after falls
What Staff Are Saying:
“FrEDA helps us work as one team. We don’t waste time chasing information – we can just focus on what matters to the person” – Community Nurse
“Now everyone has a good plan, and we know how to manage our residents well.” – Care Home Provider
“It’s so easy to use FrEDA to connect to other teams in seconds… to help me support a patient at home” – UCR Paramedic
“We hear thank-you much more than we did before.” – Virtual Ward Nurse
What’s Next? Scaling Across Every Neighbourhood
Mid and South Essex ICB is now embedding FrEDA, ePaCCS, and eFraCCS across all neighbourhoods, hospital teams, and urgent care services – using the foundation of a fully unified SystmOne platform.
This is digitally connected care in action.
This is what the NHS 10-Year Plan envisions.
Ready to unlock this in your area?
Get in touch to find out how SystmOne can help your system deliver joined-up, person-led care for those who need it most.