As the population ages and health problems become more complicated, we need to make sure more people can benefit from better joined-up care.
The NHS in mid and south Essex is leading the way in digitally enabled, person-centred care – delivering real results in frailty and end-of-life care.
Three powerful tools ensure everyone involved in a person’s care has the same, current information — reducing duplication, preventing avoidable admissions, and helping people stay well and independent at home for longer
Find out more below:
WHAT is FrEDA?: an award winning tool that provides a rich source of detailed information on a person’s health and care needs, including their views and wishes to inform conversations and decisions. It is essentially a digital Comprehensive Geriatric Assessment tool for personalised support and planning – digitally enabled to support a whole person view and effective advance care planning.
WHO is it for?: For all professionals supporting adults with frailty, dementia, or end-of-life needs across health, social care, and voluntary sectors.
HOW does it work?: Accessible via SystmOne. You don’t have to complete every section, just complete, read, or use what matters for your patient. It’s designed to fit around your practice, not the other way round.
WHY use FrEDA?: FrEDA helps you see the full picture — enabling joined-up care, reducing duplication, and improving outcomes for people living with frailty, dementia, or nearing the end of life. It connects the dots — through one shared record that everyone can access and contribute to – bringing the most important information together in one place, so teams can make faster, better-informed decisions.
By working together, we can make personalised, compassionate care the standard for everyone across Essex.
WHAT is ePaCCs?: The electronic Palliative Care Coordination System (ePaCCS) register provides a shared digital record for people in the last year(s) of life, ensuring that all professionals can access up-to-date information about their care preferences, treatment plans, and key decisions.
Designed for people in their last year(s) of life with severe, life-limiting conditions, EPaCCS ensures key information—such as palliative medication, preferred place of care, and resuscitation decisions—is accessible to all professionals involved, from GPs and community services to care homes and emergency responders.
WHO is it for?: For professionals supporting people with severe, life-limiting conditions, including (but not limited to) GPs, community teams, care homes, hospices, and emergency services.
HOW does it work?: All professionals/staff across all providers in mid and south Essex can add a person to an EPaCCS register via a direct referral in SystmOne to the specific EPaCCS register based on where the person is currently living (please see health professional guide) or
by email:
- South East Essex (EPUT): – [email protected]
- Basildon, Brentwood, and Thurrock (St Luke’s): – [email protected]
- Mid Essex (Provide): – [email protected]
WHY use ePaCCs?: This coordinated approach helps deliver care aligned with patients’ wishes, prevents unwanted hospital admissions, avoids care delays and allows preferences to be updated as conditions change, ensuring person-centered care throughout the patient journey.
WHAT is eFraCCS?: A digital frailty register that enables us to see who our adults living with frailty and dementia are, supporting early identification and coordinated care of people living with frailty and with dementia across our whole system. It also supports population health planning, helping our system to allocate resources and design services around real community frailty needs.
WHO is it for?: All healthcare professionals supporting adults with frailty and all aged adults with dementia.
HOW does it work?:
- Accessible via SystmOne and FrEDA
- Live updates across organisational boundaries
- Everyone sees the same, current information
WHY use eFraCCS?:
- Helps all teams and providers to see adults with frailty quickly
- Helps all teams and providers to prioritise people with frailty
- Enables early identification & proactive intervention
- Safer, joined-up care
- Reduces duplication reducing reactive demand on all teams and providers across the system
- Prevents avoidable admissions/avoidable crisis
- Helps people stay independent at home
- Improves communication between teams
- Supports population health management
- Helps us see how well we are delivering best practice evidence-based interventions
- Captures the evidence of all our efforts – so we can view our system wide performance to drive continuous improvements