Assistiv Ecosystem · Population Intelligence · assistiv.services · assistiv.tools
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.

Live: Thanet 77 · Dartford 55 · Medway 54 · Data refreshed daily
How Assistiv works — data to clinical action
Data signals
Full walkthrough →
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 and updated daily.

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

Assistiv Tools are a voice-first community frailty screen. 12 conversational questions, real-time PRISMA-7 scoring and structured GP referral if needed. Deployable in any community setting.

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

3.5 million people in the Missing Middle nationally. Proprietary intellectual property across the full pathway. 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.
Thanet 77
Highest FEP district in Kent
Frailty Emergence Probability · 21 signals
2
Districts at high or critical FEP risk
Of 13 Kent & Medway districts
40
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
Where this sits alongside the eFI
The eFI tells you where someone is. Assistiv tells you which direction a population is travelling — and how fast.
Every GP system in England runs the Electronic Frailty Index, a validated, clinician-trusted measure of where an individual patient sits in the frailty journey. This platform does a different job: it works at population level, on open data, with no patient identifiers, and it updates daily. Every Primary Care Network in England is contractually required to identify and manage frailty under the PCN Directed Enhanced Service, yet no commissioned tool covers the space between appointments and ahead of presentation. That is the gap this intelligence layer exists to fill — as a complement to the eFI, never a competitor.
Intelligence tools · Live on NHS open data
Nine 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 →
Methodology & rationale →
Scoring engine · Layer 2
Frailty Emergence Probability (FEP) Configurator
21 adjustable signal weights. Commissioner-configurable scoring. Ranked zone results with uncertainty flags. Ada AI explainer built in.
Open scoring engine →
Methodology & rationale →
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 →
Methodology & rationale →
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 →
Methodology & rationale →
Neighbourhood shortlist · Layer 2→3
Reachable Neighbourhoods
Drills below district level to 17 named neighbourhoods of ~7,500 residents, ranked by deprivation, solo living, access and three-month prescribing velocity. Plain-English briefing cards tell outreach teams where to set up first.
Open shortlist →
Methodology & rationale →
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 →
Methodology & rationale →
NHS system pressure · Layer 2
NHS Pressure Intelligence Map
Corridor care, non-elective admissions, SHMI mortality and GP population data mapped to district. Four NHS open data sources. Tells commissioners where system pressure and Missing Middle risk converge — updated monthly.
Open NHS pressure map →
Methodology & rationale →
2026-27 Planning · Live NHS Data
Winter Readiness Intelligence
District-level Winter Vulnerability Index for all 13 Kent districts. Forward-looking risk scoring across five components — frailty load, seasonal amplifiers, prescribing signals, system headroom, and social isolation. Deployment planner with NICE-evidenced intervention windows. PDF commissioner briefing. Ada winter planning mode.
Open winter readiness →
Methodology & rationale →
Community screening · Layer 4
Voice-First Frailty Screen
Twelve conversational questions across six life 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 assistiv.tools ↗
Methodology & rationale →
The pathway
Seven layers. One proactive system.
Each layer feeds the next, from public data through geographic mapping, community identification, precision screening, PCN referral, community services, and clinical triage.
L1Data
Population Data Ingestion
NHS Fingertips outcomes indicators, NHSBSA prescribing exhaust (18 million rows monthly), ONS Census, IMD 2025, 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 — Assistiv Tools ↗
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 · assistiv.tools
L5Refer
PCN Referral Pathway
For people identified through screening who need specialist support: a structured referral into Primary Care Network and Social Care services. Domain scores, screening summary and a CGA preparation brief travel with the person, so the frailty team starts informed rather than from zero. Referral thresholds calibrated by district FEP score.
Prototype · In development
L6Serve
Community Services — Assistiv Services ↗
For people identified through screening who fall below the acute threshold: preventative care, passive home safety monitoring, care coordination, and community connections, delivered through Assistiv Services. Person-led from day one, through a warm onboarding conversation. Technology introduced only in response to what the person says they need, always reversible, always on their terms.
Prototype · In development
L7Close
Clinical Triage & Feedback Loop
Screening and referral outcomes fed back into the geographic model — districts where more frailty is found recalibrate the FEP scoring, and the pathway between screening, PCN referral and community services tightens with every cycle. The dataset becomes the competitive advantage.
Prototype · In development
See how it all connects
An animated walkthrough of the seven-layer pathway — from data ingestion through PCN referral to clinical triage.
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 2025, OHID PHOF, NHSBSA Mar 2026.
RAVI — 5 signals
IMD 2025 Geographic Barriers sub-domain (road distance to GP, pharmacy, food store — rural-enhanced, Oct 2025) · 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 → Per-tool methods → Backtest monitor → View system architecture → View trend history → View source on GitHub ↗
Our platform
Three connected tools. One system of care.

Assistiv operates across three integrated platforms. Each addresses a distinct stage of the journey from invisibility to appropriate support, finding people, understanding their needs, and delivering the right response.

01

Identify

assistiv.cloud

Population-level frailty intelligence. Finds older adults in the Missing Middle before they reach crisis, using open NHS data, geographic signals, and longitudinal risk modelling.

You are here

Refer

02

Screen

assistiv.tools

Community screening for identified populations. Determines the level and urgency of need through structured, validated assessment, sorting those who need acute pathways from those suited to early intervention.

Screening layer

Route

03

Intervene

assistiv.services

Early intervention for those below the acute threshold. Passive home monitoring, warm conversation, and care coordination, delivered on the person's terms before independence is lost.

Early intervention

Acute pathway

Health and Social Care

People approaching or exceeding the acute threshold are referred directly into NHS or local authority care pathways with the longitudinal data needed for rapid, accurate assessment.

Early intervention pathway

Assistiv Services

People below the acute threshold — managing, but at risk — are supported by Assistiv's platform. Proactive, non-intrusive, and designed to extend independence and defer the need for formal care.

Get in touch
Work with us

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

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

Send a message