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

Ambition 1. Build an integrated approach

The outcomes we want to see

1. A whole-system approach that is joined-up, collaborative and co-designed with communities.

Outcome 1

A whole-system approach that is joined-up, collaborative and co-designed with communities.

What we know and where we are now

A joined-up approach at care-delivery level

Activities to reduce harm from falls are often fragmented. We believe a more integrated approach is needed, with services, organisations and sectors working together more closely in planning and providing information, advice, treatment, care and support.

Supporting a person to prevent harm from falls can involve a number of professions, teams and services from different parts of the system – from the response at the time of a fall, to providing rehabilitation and reablement to restore independence.

Links between falls and osteoporosis services could be improved. Care at the time of transitions can be a challenge – particularly transitions between hospital and the community. We need to ensure people receive the right support on returning home from hospital, to stay safe, but also to enable a good recovery and return to independent living.

Services being unable to share information easily throughout a person's episode of care presents a barrier to taking a more joined-up approach. This is due, in part, to incompatible IT platforms and data-sharing governance issues (both perceived and real).

Healthcare Improvement Scotland's Living Well in Communities programmes^[6] have been working with health and social care services to increase the quality and quantity of anticipatory care plans shared in the Key Information Summary for access by unscheduled care services. This has resulted in a 12% increase in the use of anticipatory care plans over 2017–2018 and an improvement in the quality of plans in the Key Information Summary, enabling unscheduled care services to respond to a crisis in accordance with an individual's wishes and achieve their best possible outcome. Examples include use of the Electronic Frailty Index to identify people with frailty who are at risk of falls-related unplanned admissions.

Good examples exist of health and social care services linking closely with leisure services and third and independent sector organisations to provide the right support at the right time, but there are many more opportunities for joint working to support self-management and identify risk to optimise recovery following a fall or fracture.

A joined-up approach to planning, funding and governance

Nationally and locally, we need to share leadership, intelligence, ownership and resources to ensure a joined-up whole-system approach to preventing harm from falls. Authorities need to see this as a cross-policy issue that requires collaboration across the system and is reflected in planning, funding and governance. Building relationships, along with meaningful engagement with staff and communities to plan and implement support and care, is central.

There are 32 community planning partnerships across Scotland. All are working collaboratively with key partners, including Integration Authorities and community safety/justice partnerships, to reduce inequality and deliver on local outcome improvement plans.

Commitment 1

We will establish a National Preventing Harm from Falls Collaborative made up of organisations involved in the prevention of falls, care of falls-related injuries and promotion of healthy ageing. The aim of the multi-agency Collaborative will be to co-ordinate and support national falls and fragility fracture prevention activity across Scotland during the lifetime of the strategy.