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

Ambition 2. Build resilience at population level

The outcomes we want to see

2. A culture where behaviours to prevent falls and maintain bone health are the norm.

3. More people participating in regular movement and physical activity to maintain their strength, balance and bone health.

4. More older people living in homes and communities that are safe, promote independent living and allow them to flourish as part of their community.

5. More people taking measures to maintain and improve their health and wellbeing and avoid harm from falls.

Outcome 2

A culture where behaviours to prevent falls and maintain bone health are the norm.

What we know and where we are now

We have to promote and support healthy ageing and the prevention of frailty, falls and fractures in ways that resonate with people across socioeconomic groups and throughout the span of older age.

People's living environments can determine the extent to which they have a physically active lifestyle and interact with others – two important factors that can reduce harmful falls and fear of falling. The Place Standard tool,^[7] which was developed in partnership by NHS Health Scotland and Architecture & Design Scotland, allows communities to work together to assess the quality of their place and prioritise areas for action.

It is important that all stakeholders talk about falls and bone health in ways that don't reinforce negative assumptions about old age, or gender. Focusing on actions to keep well and preserve or restore functional ability and independence is positive and enabling. Over-emphasising risks and focusing only on safety can inadvertently stigmatise falls or cause people to restrict their activities.

Older people often view 'a problem with falls' as happening to those who are older and in poorer health than themselves, even if they have a history of falls.^[8] Men often think they are not at risk of falling or sustaining fractures and often don't think they would benefit from interventions. Using the medical term 'frailty' can provoke a strongly negative reaction from older people because of its associations with loss of independence and end of life. Language is very important, and the emphasis should be on the benefits of active and healthy ageing rather than avoiding risk.

Enabling people to look after and improve their own health and wellbeing and live in good health for longer requires that they have access to the right information, advice and support, at the right time. People expect information to be available through many channels, and in a range of formats. Internet use in people in later life is increasing, but using the internet is not always their first choice to find information about health and wellbeing.

Many older people like to get information materials from their GP practice. It is important for people to know that information comes from a trustworthy source – a reliable individual with the right knowledge and skills talking people through the information is highly valued. It is also important for carers and families to be able to access good information – they have a vital role in supporting falls prevention. If carers receive the right kind of information and support, the health and wellbeing outcomes for the cared-for person are often much better. This is relevant for those who are risk of falls.

Commitment 2

We will work with Public Health Scotland, NHS Inform and other partners to build on and improve the availability of information on healthy ageing, falls prevention and bone health in a range of formats.

The workforce across the system has a pivotal role to play in promoting key messages about healthy ageing generally and falls prevention and bone health specifically.

Commitment 3

We will commission NHS Education for Scotland and other partners to develop learning resources for our workforce, and work with higher education institutions to build healthy ageing, falls prevention and bone health into curricula.

Outcome 3

More people participating in regular movement and physical activity to maintain their strength, balance and bone health.

What we know and where we are now

There is good evidence that people can reduce their risk of falls and harm from falls by being physically active and moving regularly to counteract the effect of ageing on muscle strength, bone and balance.

The Scottish Government published its Active Scotland Delivery Plan^[9] in summer 2018. The plan includes 90 actions that aim to cut physical inactivity in adults and teenagers by 15% by 2030 using wide-ranging approaches, including active travel funding, support for formal sports and informal movement and physical activity, and partnership-working across the transport, education, health and planning sectors. The World Health Organization supports the plans.

We recognise that it would be helpful if people had more opportunities to participate in activities which are proven to improve strength and balance. It is also clear that options need to be enjoyable, accessible, affordable and wide-ranging to appeal to everyone. Many older people prefer to participate in activity at a group or club they already attend, in a class with a qualified instructor, or in their local gym. It would be helpful if activity opportunities that include measures to improve strength and balance were clearly labelled by providers to help people choose well.

Barriers to participation include fear of falling and lack of transport, especially for people with limited mobility, social isolation, perceived cost and time constraints. Opportunities can be limited for some groups in the population, including people with dementia, multiple long-term conditions, learning disabilities and sensory impairment.

Good practice

The Care Inspectorate's Care about Physical Activity (CAPA) Improvement Programme^[10] has been working with care homes, care at home, housing support and other support services for older people to equip staff to promote 'moving more' every day in ways that are meaningful to the person. Outcomes have been extremely positive; as well as becoming more active, evaluation of the Programme showed many participants' risk of falling had reduced.

As an example, Bob, a resident in a care home in Perth and Kinross, needed assistance from two carers to walk and would regularly have between eight to 12 falls a month, resulting in continuous trips to hospital. Staff supported Bob to do more small day-to-day movements and leg-strengthening exercises. Over five months, he reduced his number of falls by roughly 90%. This resulted in reduced time at the doctor's surgery, fewer hospital visits and less assistance needed from care staff. Bob now enjoys increased independence.

On average, individuals who participated in CAPA reported spending 80 more minutes per day moving than at baseline, with significant improvements recorded in balance tests, grip strength, lower leg strength and flexibility. The Programme also worked with Glasgow Caledonian University to develop an undergraduate module for those who will work with frailer older adults.

Commitment 4

We will work with partners, including the Care about Physical Activity (CAPA) Improvement Programme and Sport Scotland, to explore how better labelling of physical activity options can help people to make the right choices for them, and support the further development of a local information system for Scotland.

Our workforce across the system has a vital role in promoting the benefits of physical activity and supporting people to participate. This requires an understanding of key messages from the new UK Physical Activity Guideline, which is expected to be published later in 2019, and awareness of online resources that can support people self-managing their health and falls risk.

The Active Scotland Delivery Plan includes actions to ensure that health and social care professionals have the resources and opportunities to support people to be more active. This includes integrating learning around physical activity into undergraduate and continuing professional development curricula for health professionals, providing a package of practitioner resources to support the delivery of the National Physical Activity Pathway,^[11] and raising awareness of recommended levels of physical activity as set out in the Chief Medical Officer's Physical Activity Guidelines for Adults and Older Adults (Appendix 1).^[12] In addition, health and social care professionals should be aware of online resources that can support people to self-manage their health and falls risk, such as the NHS-approved Falls Assistant online resource.^[13]

Promoting and enabling physical activity is also important while in hospital. Evidence suggests that many patients spend more than 80% of their time in bed, with even those who are able to walk in hospital hardly taking any steps.^[14] Loss of muscle strength can begin very quickly. The Scottish Patient Safety and Excellence in Care programmes will continue to promote the importance of supporting people to keep active and engage in meaningful activity during a hospital stay.

Commitment 5

We will continue to take action through our Active Scotland Delivery Plan to encourage and support more people to be more active more often.

Outcome 4

More older people living in homes and communities that are safe, promote independent living and allow them to flourish as part of their community.

What we know and where we are now

The right home environment can maintain a person's physical and mental health, wellbeing and social connections, enable them to carry out everyday activities safely and comfortably, and help them to do the things that are important to them.

Simple, low-cost pieces of equipment and adaptations (such as grabrails, bannisters and toilet frames) prevent falls and injuries and improve the performance of everyday activities. Minor adaptations are particularly effective when combined with repairs and home improvements, such as improving lighting and removing trip and fall hazards. The Age, Home and Community: the next phase strategy^[15] commits to continuing to support the service provided by Care and Repair to older homeowners as a trusted source of advice and handyperson services, as well as using the opportunity to further develop beneficial partnerships with the Scottish Fire and Rescue Service and Home Energy Scotland.

We recognise the importance of the timely provision of equipment and adaptations, which we highlighted in our guidance on the provision of equipment and adaptations, published in 2009.^[16] The guidance aims to give professionals, service users and carers a better understanding of local health and social care services' responsibilities, and to create a more consistent approach across Scotland.

Many people at risk of falls are not in a position to organise their own health and social care, so carers often take this responsibility on their behalf. For example, it may be carers who arrange for home aids and adaptations such as grab rails to be installed. It's therefore important that health and social care professionals meet the duty under the Carers (Scotland) Act 2016 to include carers in conversations about the cared-for person's care, as they are often very knowledgeable about the situation and associated risks for the people they care for.

The Public Bodies (Joint Working) (Scotland) Act 2014 established a legal framework for the integration of health and social care services in Scotland. The Act requires each NHS board and local authority to delegate some of their statutory functions, and associated budgets, to their Integration Authority. The Integration Authority is then responsible for the planning and delivery of related services. The provision of equipment and adaptations are services that must be delegated to the Integration Authority.

The Public Bodies Act 2014 introduced national health and wellbeing outcomes that apply equally across health and social care services in Scotland. These outcomes aim to enable service users and carers to have a clear understanding of what they can expect in terms of improvements in their health and wellbeing. Outcome 2 acknowledges the important role housing plays in people's lives, stating: "People, including those with disabilities, long-term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community."

Commitment 6

We will work with Integration Authorities and other key stakeholders to review and update the current guidance relating to the provision of equipment and adaptations in people's homes.

Early intervention and preventative approaches by Care and Repair services, occupational therapists and others are highly valued. But there is variation across the country in terms of provision of equipment, adaptations and technology-enabled care solutions, and sometimes opportunities to respond to 'lower-level' needs that would promote continued independence and help prevent loss of function and falls are being missed. Potential exists for more health, housing, social care and third sector services to have a role in home-safety checks and in provision of straightforward equipment, technology-enabled care and adaptations.

Good practice

In some areas, the Scottish Fire and Rescue Service has included elements of falls prevention in their Home Fire Safety Visits.^[17] This can include the provision of basic information and advice on falls prevention in the home, and link with Integration Authorities, rehabilitation services and others to offer further assessment and support when required.

The Scottish Fire and Rescue Service currently is working on a project to expand the scope of visits to include other safety and wellbeing risks within the home. In developing this holistic approach, the service reflects the inclusion of early information about falls prevention and considerations about social inclusion and ageing safely. Carried out by dedicated prevention staff and, if agreed by representative bodies, firefighters across Scotland, this will add huge value and positive outcomes to communities, with the service delivering thousands of risk-based visits every year.

Commitment 7

We will support the Scottish Fire and Rescue Service to design and deliver their new Safe and Well visits and promote greater collaboration between blue-light services to identify people who would benefit from support to make their home safe and enabling. We will also establish local partnerships where they are able to refer people identified into non-statutory community-based supports, including Care and Repair services.

A familiar home environment is particularly important for people with dementia, especially as their symptoms develop. Early consideration of the role of equipment, adaptations and technology is an essential part of enabling people with dementia and their carers to live safely at home. We will continue to take action through Scotland's National Dementia Strategy 2017–2020^[18] and the Connecting People, Connecting Support^[19] framework for allied health professionals working with people with dementia and their carers to ensure people diagnosed with dementia have access to the right housing and support to enable them to live in their home independently for as long as possible.

We published Age, Home and Community: the next phase in 2018.^[20] It sets out a range of actions to achieve our vision of older people in Scotland enjoying full and positive lives in homes that meet their needs. We are focusing on three key areas – Right Advice, Right Home and Right Support – to enable our growing population of older people to live safely and independently at home for as long as they choose to do so.

Commitment 8

We will continue to take action through our strategy, Age, Home and Community: the next phase, to ensure we have a housing system that works for older people.

We continue to work with partners to reduce unintentional harm and injury, including those caused by falls. We know that older people are one of the key groups who are disproportionally affected by unintentional harm in Scotland. Over the last five years, we have provided the Royal Society for the Prevention of Accidents with almost £600,000 to undertake work around home and community safety, including developing and delivering bespoke courses on older people's safety and running the 'Be Aware' campaign to increase awareness of carbon monoxide poisoning.

Through our ambition to Build Safer Communities, we are developing a co-ordinated and strategic approach to reducing unintentional harm in Scotland, including falls, by building links with wider community safety activities. A key step in this work was the development and publication of a Strategic Assessment of Unintentional Harm in April 2017,^[21] which sets out the key groups who are disproportionally affected in Scotland (children and young people, older people and those living in areas of increased deprivation). This work is being driven forward by a partnership Executive Working Group chaired by the Scottish Fire and Rescue Service, with membership from the Scottish Community Safety Network, the Royal Society for the Prevention of Accidents and the Scottish Public Health Network. The Executive Group is focused on collaboratively supporting implementation of recommendations from the strategic assessment.

The work acknowledges the impact the wider environment in which we live can have on how we live our lives and the activities in which we engage. Community safety, both in and outside the home, can influence decisions we make; living in a safe environment and being informed about how to keep safe has a direct impact on the falls agenda.

Good practice

As part of the Building Safer Communities Unintentional Harm work, an online tool, known as the Hub, is being developed to gather and share initiatives across Scotland that support the reduction of unintentional harm, and to provide advice and guidance that will drive forward best practice. The information is for practitioners, professionals and community groups at local and national levels. The Hub will go live in early summer 2019 and will act as a key route to co-ordinating and supporting learning from existing practice relating to unintentional harm prevention.

We have worked with local practitioners throughout Scotland to develop practice exemplars for the Hub. These form the main content of the Hub and describe existing good practice and promising practice covering a range of themes – home safety, fire safety, water safety, road safety and outdoor safety, including falls. Other relevant documents, strategies and publications will be available on the Hub, as well as a recently developed evaluation framework for practitioners.

Issues in the physical environment, such as gritting of pavements in the winter, maintenance and lighting of pavements and paths, handrails and accessible facilities and amenities, including public toilets, are important in enabling people to remain independent and engage safely with their communities. We are developing a strategy and updated guidance on clear pathways to reduce obstruction and street barriers that can lead to falls through lack of dropped kerbs and street obstacles.

Accessible public and community transport is vital for people to stay socially active. We continue to take forward a collaborative review of our National Transport Strategy, with accessibility identified as an important theme.

We are committed to providing free bus travel to older and disabled people, helping them to lead more connected, healthier and happier lives. Since the scheme began in 2006–2007, we have provided over £2 billion to fund concessionary travel. The average benefit per year is about £260 for a person eligible to use the Scotland-wide Free Bus Travel Scheme for Older and Disabled People. There are close to 1.4 million cardholders in Scotland, of whom 90% hold a pass on the basis of age. The scheme as a whole was responsible for around 141.8 million journeys in 2017–2018.

Good practice

Going Further: Scotland's accessible travel framework (launched in 2016)^[22] is about improving journeys for disabled people and working to remove the barriers that prevent them travelling. The 10-year framework has been shaped by people with disabilities and organisations that represent them. The vision is that all people with disabilities can travel with the same freedom, choice, dignity and opportunity as other citizens.

Fear of falling when using buses is common, as statistics from Police Scotland confirm. We are taking forward the national roll out of the Thistle Assistance Card,^[23] which allows passengers discreetly to inform transport staff of any extra assistance required through use of recognised symbols. This includes signalling the need for extra time to sit down before the vehicle moves, which will assist in the reduction of falls on public transport.

Good practice

While a bus journey is one of the safest ways to travel on our roads, a bump on the bus that might be brushed off by most of us could lead to a loss of confidence and independence or a serious injury for an older person. Now police, bus companies and other partners have teamed up to make bus travel even safer for some of the most vulnerable members of our communities.

Since May 2018, Police Scotland has issued social media messages outlining the steps to take to get on, ride and then get off the bus safely. This is complemented by a leaflet that is available on buses aimed at those who have a concessionary card, and a police-led training message delivered to drivers in the Edinburgh, Lothians and Forth Valley areas.

Early indications from the first six months of the project in Edinburgh and Forth Valley on bus passenger casualties aged 60+ are looking favourable, particularly in relation to 'killed and seriously injured' collisions against the five-year average.

Source: Police Scotland (2018). Initiative helps older bus passengers travel with confidence. https://www.scotland.police.uk/whats-happening/news/2018/may/new-initiative-help-older-bus-passengers-travel-confidence

Commitment 9

We will ensure that Scotland's revised National Transport Strategy will include recommendations on accessible safe transport schemes for frailer, visually impaired and disabled passengers.

Social contact opportunities are vitally important – isolation and loneliness are commonly experienced by older people, particularly among those who lose their spouse or live alone. We know from research that as social interaction decreases, risk of falls increases, and that fear of falling is increased by isolation and depression triggered by lack of social participation, and vice versa.

We published A Connected Scotland: our strategy for tackling social isolation and loneliness and building stronger social connections in 2018.^[24] The strategy sets out a wide range of actions to create opportunities for people to connect, and to support an infrastructure that fosters connections.

We need to explore how we can work with community groups and organisations to take opportunities to include learning about ageing well, falls prevention and bone health in the work they already do.

Commitment 10

We will continue to take action through our strategy, A Connected Scotland, to recognise the psychological, emotional and social circumstances that can lead to older people becoming increasingly sedentary and at higher risk of falls and frailty.

Outcome 5

More people taking measures to maintain and improve their health and wellbeing and avoid harm from falls

What we know and where we are now

A wide range of positive behaviours and actions can lower a person's chances of experiencing harm from falls, as well as contributing to keeping active and well for longer. These include:

• managing health conditions well: a number of conditions are associated with an increased risk of falls (including arthritis, dementia, Parkinson's disease and stroke) and fragility fractures (such as rheumatoid arthritis and inflammatory bowel disease)
• managing medicines: taking five or more medicines is associated with an increased rate of falls, and the use of certain high-risk medicines can contribute to risk of falls and osteoporotic fractures
• good personal foot care: good foot care can increase independence and participation in physical and social activities
• good nutrition and keeping hydrated: calcium and vitamin D are particularly important for bone health and inadequate nutrition contributes to frailty and loss of muscle mass
• regular eye checks and choosing the right spectacles
• safe alcohol consumption: our threshold for alcohol can change as we age, and the falls rate is higher among older people receiving support for alcohol issues
• not smoking
• managing bladder and bowel problems: these are associated with increased falls risk
• keeping physically active.

Public and service providers don't always recognise the link between falls and fragility fractures and the health and wellbeing topics listed above; key positive and enabling messages about falls prevention and bone health need to be threaded through information advice, treatment and support in all of these areas.

An important part of keeping physically active is continuing to carry out daily tasks for as long as it's possible and safe to do so. Doing things for older people when they are still able to do things safely themselves can hasten a decline in strength, balance and mobility. Actions, often motivated by kindness, can increase the risk of falls due to physical deconditioning and people losing confidence and belief that they can continue to undertake activities themselves.

'Keeping active to keep independent' is an important message for families, carers and professionals in the health and care sectors. Risk aversion is a significant barrier to people being more active, and positive risk-taking is key to having a less sedentary older population.

Positive risk-taking involves a person weighing up the potential benefits and harms of carrying out activities and making choices that are right for them – sometimes the risk to health and wellbeing from being sedentary outweighs the risk of harm from falls. For meaningful and successful falls prevention, we need to enable people, families, carers and our workforce to practice positive risk-taking.

Good practice

Organisations such as Roar: Connections for Life^[25] encourage self-management by reaching, understanding and supporting people to value wellbeing and social connections, offering a varied menu of social opportunities to laugh and learn. The organisation also takes a whole-systems approach to dispelling the myth that falls are an inevitable part of ageing.

Commitment 11

We will work with third sector partners to co-produce resources and opportunities to support community groups and organisations to embed learning about healthy ageing and preventing harm from falls in their core work.