National falls and fracture prevention strategy 2019-2024 draft: consultation

Introduction

Harm from falls and fear of falling affect large numbers of people both directly and indirectly, have a significant impact on wellbeing, and prevent many people from experiencing healthy ageing.

When we^[1] talk about harm from falls, we don't only mean the physical and psychological harms (such as hip and other fractures, head injuries and soft tissue injuries, and fear of falling, anxiety and depression), but also the negative impacts a fall can have on a person's life. These include being unable to continue doing the things that are important to them, losing independence and/or becoming isolated or lonely.

Falls and frailty

Frailty is the inability to withstand illness without loss of function. Frailty can be physical or psychological, or a combination of the two, and exists on a spectrum ranging from vulnerable to severe. A fragility fracture is a broken bone that has occurred after a minor bump or fall (a fall from standing height or less, for example).

Not everyone who experiences harm from a fall is frail, but there is a strong relationship between falls and frailty. Frailty can contribute to falls and result in a person making a slower or poorer recovery following a fall. Conversely, a fall can trigger or accelerate the progression of frailty.

Some actions and approaches to prevent falls will also help prevent or slow the progression of frailty. These include being physically active and less sedentary, improving muscle strength and balance, promoting continence, and ensuring good medicines management and adequate nutrition.

An important part of reducing harm from falls is reducing fracture risk by preventing, detecting and managing osteoporosis, a condition that weakens bones, making them fragile and more likely to break. Although osteoporosis has a genetic link, lifestyle factors such as physical activity and nutrition are important in prevention and need to be considered both at a young age, when bone strength is first built, and later in life, when good nutrition and activity help maintain bone health.

People with advanced dementia symptoms can also be at greater risk of frailty and falling.

Around 10% of falls result in a fragility fracture and 2% in a hip fracture.

Work to reduce falls and harm from falls

The factors that contribute to risk of falls and fragility fractures are many and wide-ranging. Risk of harm from falls are shaped by life circumstances, and health, wellbeing and lifestyle choices in early and adult life through into older age. Prevention requires a life-course approach; behaviours such as being physically active, eating well and avoiding smoking should be promoted across the lifespan.

It is five years since we published The Prevention and Management of Falls in the Community. A Framework for Action for Scotland.^[2] The Framework focused on acting on every opportunity to prevent people experiencing recurrent falls and the associated decline in independence and quality of life. It set out key actions to move away from an ad hoc approach to preventing recurrent falls towards a systematic approach based on the best available evidence and tailored to the needs of the individual. Health and social care partnerships and a wide range of cross-sector partners have been working to implement the Framework, supported by our Active and Independent Living Programme's Falls Programme.^[3]

Since 2011, Scotland has been an active participant in the Falls Prevention Action Group of the European Innovation Partnership in Active and Healthy Ageing.^[4] Through involvement in this European Union initiative and the Action Group, we have had the opportunity to work with and learn from European partners to advance falls prevention, and to share our progress in Scotland.

Considerable work has been done nationally and locally over the last 10 years to reduce harm from falls in community and hospital settings. This work has been informed by evidence-based clinical guidance produced by a range of organisations and professional bodies. Falls in acute hospitals, for instance, has been a key focus of the Scottish Patient Safety Programme since 2013, and the Programme continues to use a variety of approaches to support NHS boards to reduce harm from falls.

The result of all this is that we have seen reductions in:

• the rate of hip fractures in Scotland
• emergency admissions due to falls in a number of Integration Authorities.

With an ageing population and more people living longer with complex health needs, these are promising signs. But falls present an important challenge. In 2017–2018, over 37,000 people – 22,400 of whom were over the age of 65 – were admitted to hospital because of a fall. We need to do more and offer opportunities earlier in the lifespan to help older people age healthily to avoid or postpone the time at which they may fall or sustain a fracture.

The strategy

Although anyone can experience harm from a fall throughout life, some groups of people are more likely to fall and more likely to experience harm.

For this reason, the strategy focuses on falls related to:

• the ageing process, which for some people, such as those with learning disabilities, may begin to have an impact earlier in life
• underlying long-term conditions (such as dementia or stroke), visual impairment or frailty
• deconditioning caused by physical inactivity and/or being sedentary
• osteoporosis, with affected adults being at higher risk of harm through fragility fractures.

The strategy does not include specific measures to reduce harm from falls:

• in childhood
• in the workplace
• as a result of high-impact mechanisms, such as falls from a height.

The process

We spoke to a wide range of people in developing the strategy, including the general public, people who had experienced falls and fragility fractures, and people involved in planning, delivering, researching and improving care and support to prevent and manage harm from falls. We wanted to hear from them what has been working well, what we need to do differently and ideas for things we need to start doing.

We also looked at published evidence and the learning we've gained from delivering our Falls Programme and working over a number of years with UK and international partners.

Through this process, we identified four central ambitions we want the strategy to achieve and 12 outcomes people want to see through taking forward this strategy. The ambitions comprise the main chapters of the strategy, with the outcomes being dispersed throughout.

The outcomes span the Up and About Pathway,^[5] which describes a person's journey through prevention, self-management, risk identification and co-ordinated care and support. The 2019 version of Up and About reflects that falls and fracture prevention is underpinned by healthy ageing and building and maintaining resilience.

The strategy also presents 16 commitments that aim to deliver on the strategy's vision, ambitions and outcomes.

Policy and strategic context

Preventing and managing falls and fractures cuts across a number of our policy areas. We make reference throughout to related strategies, delivery plans and documents to show connections and signpost to further information.