Kent & Medway · Population Frailty Intelligence

Finding older adults at risk
before the system has to respond

Assistiv Systems builds intelligence tools for the NHS — identifying the Missing Middle: people with emerging frailty who are invisible to existing care pathways, living at home, not yet in crisis, but heading there.

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How Assistiv works — data to clinical action
Data signals
Full walkthrough →
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For commissioners
I need to understand risk in my patch right now

Open the live Frailty Heat Map, download a PDF commissioner briefing, and see the economic cost of inaction — district by district, updated daily.

Open the intelligence tools →
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For clinicians & PCN leads
I want to identify frail patients before crisis

RESILIENCE is a voice-first community frailty screen — 12 conversational questions, real-time PRISMA-7 scoring, structured GP referral. Deployable in any community setting.

Explore the screening pathway →
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For academics & researchers
I want to understand the methodology

21-signal composite scoring, LSOA-level Rural Access Vulnerability Index, Carer Burden Index — all built on open NHS data with full signal weights, sources, and uncertainty bounds documented.

Explore the methodology →
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For investors & partners
I want to understand the opportunity

3.5 million people in the Missing Middle nationally. Three granted patents. Working tools on live NHS data. A validated pathway from geographic intelligence to clinical screening in one system.

Request a briefing →
Live from kent-fep-data.json · Updated daily
Real NHS data. Real Kent districts. Right now.
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Highest FEP district in Kent
Frailty Emergence Probability · 21 signals
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Districts at high or critical FEP risk
Of 13 Kent & Medway districts
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Rural LSOAs with critical isolation risk
Rural Access Vulnerability Index · 1,065 LSOAs
185
Patients delayed daily at East Kent Hospitals
NHS England Discharge Sitrep · Apr 2026
Intelligence tools · Live on NHS open data
Six tools. One intelligence layer.
All built on open NHS data. No login. No procurement. Open in a browser now.
Primary tool · Layer 2
Frailty Heat Map
Live ONS district boundaries, FEP colour tiers, economic cost of inaction, discharge intelligence, 111 demand, prescribing signals. One-click PDF commissioner briefing.
Open map →
Scoring engine · Layer 2
FEP Configurator
21 adjustable signal weights. Commissioner-configurable scoring. Ranked zone results with uncertainty flags. Ada AI explainer built in.
Open scoring engine →
LSOA hotspot map · Layer 2
Rural Access Vulnerability
1,065 LSOA-level hotspots revealing hidden frailty in Challock, Hever, Appledore and 53 unnamed rural settlements — invisible to district-level FEP scores.
Open RAVI map →
Dual intelligence · Layer 2
FEP × Carer Burden Quadrant
Frailty risk and carer burden overlaid. Identifies districts where both patient and carer systems face simultaneous pressure — the most urgent intervention targets.
Open CBI map →
Outreach planning · Layer 3
Community Touchpoints
GP surgeries, pharmacies, libraries, faith communities and VCSE organisations within priority zones — mapped by district for outreach planning. NHS API and OpenStreetMap.
Open touchpoints →
Community screening · Layer 4
RESILIENCE — Voice-First Frailty Screen
12 conversational questions across six clinical domains. PRISMA-7 and FRAIL Scale scored in real time. Structured GP referral output. Carer pathway integrated. Deployable in any community setting with no clinical training required.
Open resiliencetools.xyz ↗
The pathway
Five layers. One proactive system.
Each layer feeds the next — from public data through geographic mapping, community identification, precision screening, and clinical triage.
L1Data
Population Data Ingestion
NHS Fingertips outcomes indicators, NHSBSA prescribing exhaust (18 million rows monthly), ONS Census, IMD 2019, Rural Urban Classification. 21 signals normalised against England averages and updated daily via GitHub Actions.
Live · Daily refresh
L2Map
Geographic Frailty Intelligence ↗
FEP composite score for 13 Kent districts. Rural Access Vulnerability Index for 1,065 LSOAs. Carer Burden Index. Discharge delay intelligence. NHS 111 demand. Economic cost of inaction. All in one commissioner-facing map.
Live · Six tools deployed
L3Reach
Community Touchpoint Identification ↗
GP surgeries, pharmacies, libraries, faith communities, and VCSE organisations mapped within priority zones using NHS API and OpenStreetMap. Routes outreach to where the Missing Middle already is.
Live · NHS API + OpenStreetMap
L4Screen
Precision Community Screening — RESILIENCE ↗
Voice-first frailty assessment. 12 conversational questions. PRISMA-7 and FRAIL Scale scored in real time. Structured clinical referral output. District FEP score injected as context — higher-risk zones trigger lower referral thresholds.
Live · resiliencetools.xyz
L5Close
Clinical Triage & Feedback Loop
Structured referral to GP, community matron, or social prescriber. Screening outcomes fed back into the geographic model — districts where more frailty is found recalibrate the FEP scoring. The dataset becomes the competitive advantage.
Phase 2 · In development
See how it all connects
An animated walkthrough of the five-layer pathway — from data ingestion to clinical referral.
Watch the animated explainer →
Methodology & data provenance
Open data. Defensible methodology. Transparent signals.
FEP — 21 signals
10 NHS Fingertips outcomes indicators · 11 NHSBSA EPD prescribing signals · 3 ONS synthetic signals. Weights documented and adjustable. England averages as comparators. Uncertainty bounds at ±30%. Source: MHCLG IMD 2019, OHID PHOF, NHSBSA Mar 2026.
RAVI — 5 signals
IMD 2019 Geographic Barriers sub-domain (road distance to GP, pharmacy, food store) · ONS 2021 Rural Urban Classification · Population 65+ · Car access · Limiting long-term illness. All at LSOA level. Source: MHCLG, ONS, Census 2021 via Nomis.
Economic model
Falls cost: NHS Improvement £2,600 CPI-uplifted. Hip fracture cost: £14,642 (Lancet Healthy Longevity 2023, n=178,757). Preventability: BGS Fit for Frailty & NICE QS86. Bed day cost: £562 NHS England 2025/26. All sources cited in-tool.
Read the full methodology → View system architecture → View trend history → View source on GitHub ↗
Get in touch
Work with us

Whether you're a commissioner looking for a briefing, a clinician interested in deploying RESILIENCE, an academic exploring collaboration, or an investor evaluating the opportunity — we want to hear from you.

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Commissioner briefing
A 30-minute live demonstration of the FEP intelligence layer for your patch.
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Academic collaboration
Methodology review, co-authorship, or validation study design.
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Investment & partnership
Pre-seed conversation, strategic partnership, or clinical trial funding.

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