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

Ambition 4. Target more specialist, personalised care and support

The outcomes we want to see

8. People receiving a proportionate response at the time of a fall that minimises harm and enables the best possible recovery.

9. Personalised falls prevention for people at higher risk and with complex needs.

10. Evidence-based and personalised approaches to preventing falls in community settings, in hospitals and in care homes.

11. Evidence-based fragility fracture prevention.

12. Evidence-based and personalised care following hip fracture.

Outcome 9

Personalised falls prevention for people at higher risk and with complex needs.

What we know and where we are now

We want people who use health and social care services to have positive experiences of those services, and have their dignity respected. We believe that our workforce needs to be equipped and enabled to take an outcomes-focused approach, with the person at the centre of decision-making.

Frailty pathways in emergency departments, hospitals, primary care and the community aim to identify people becoming frail or living with frailty to ensure they receive the right holistic care, treatment and support. Many people who fall will benefit from being on these pathways, and we need to ensure falls and fracture prevention is considered as part of their care. We will continue to support frailty initiatives through national improvement programmes led by Healthcare Improvement Scotland.

People with dementia are at increased risk of falls, and the personal consequences of a fall can be significant. Falls are also a serious problem for people with learning disabilities, who are at greater risk than the general population of sustaining an injury, or even dying, from a fall. We need to ensure that people living with dementia and those with learning disabilities receive the same opportunities as any other person for falls and fracture prevention, and the same high standards of care following hip fracture, including accessing bone-density scanning and physical activity programmes to reduce risk of falls.

Outcome 10

Evidence-based and personalised falls prevention in community settings, in hospitals and in care homes.

What we know and where we are now

Community settings

The Prevention and Management of Falls in the Community framework sets out an evidence-based multifactorial approach to falls prevention. It identifies and addresses the causes of falls, including underlying medical problems (see Appendix 2). The aim is falls and fracture prevention, but also rehabilitation, enabling a person to recover well following a fall and return to doing the things that matter to them. This usually needs input from a multidisciplinary team of health and social care professionals.

Emerging models of care show what can be achieved through collaboration involving the NHS, third sector and communities. Many examples exist of physiotherapists working with instructors in leisure services to provide opportunities for individuals to participate in physical activity. Some health professionals promote a universal, targeted and specialist model, such as that used in children and young people's services, to enable physiotherapists, occupational therapists, podiatrists, dieticians, speech and language therapists and others to reach more people at the right time with the right level of information, advice, treatment and support. We believe we need to explore these different ways of working.

Clinical guidelines recommend a multifactorial approach to falls prevention and management. Interventions that continue to have a strong evidence base and which produce personal benefits and cost savings include physical activity programmes carried out at home or in a group, home assessment and modifications carried out by an occupational therapist, and evidence-based strength and balance activities.

We need to explore new approaches to meaningful measurement and evaluation to continue to justify investment in interventions that reduce falls and harm from falls, and to understand better the service-delivery models that are most effective and sustainable. This includes feedback from people who use services and carers. A key component of this work will be investigating the possibility of robustly coding 'fall events' across the system – an important first step in understanding activity related to falls and the impact of falls, and falls prevention, on the system.

Commitment 14

We will work with a range of partners to review the Prevention and Management of Falls in the Community framework. This will include reviewing existing delivery models and exploring more sustainable and collaborative approaches that integrate with ways we are supporting people living with frailty in Scotland and further afield. A key output from this work will be an updated measurement framework to enable better understanding of the impact of different approaches.

Hospitals

Falls remain a common cause of harm to patients in acute hospitals, with as many as 27,000 falls recorded in Scotland every year. Many factors contribute to the risk of falls in hospital. Increased length of stay and after-effects of injury after a fall with harm can impact negatively on patients, a proportion of whom may require ongoing care and support. Falls also contribute to increased costs for healthcare organisations due to increased length of stay and associated care and treatment for patients within hospital and community settings after discharge.

Healthcare Improvement Scotland's Scottish Patient Safety Programme continues to review and update best practice for reducing harm from falls in hospital settings. The programme supports an individualised approach to falls prevention and promotes physical and meaningful activity to prevent people experiencing the negative effects of a hospital stay.

Healthcare Improvement Scotland has also been leading national work since 2012 focusing on two related and critical areas – improving care for older people with frailty and/or delirium. Both frailty and delirium are associated with an increased risk of falls. The results have shown that this approach is making a real difference to the care of older people in Scottish hospitals.

The Chief Nursing Officer, together with senior nursing and midwifery leaders in Scotland, established the Excellence in Care approach to develop and implement an evidence-based national approach to improving and assuring care and support the reduction in harm, variation and waste that reflects the "Once for Scotland" ethos.

One of the many adult areas identified as a key measure of high-quality nursing and midwifery care is inpatient falls rate. The rationale for the measure is aligned to the current approach to reducing falls through the Scottish Patient Safety Programme. Falls that occur in healthcare settings may lead to increased pain, immobility, morbidity and mortality. Efforts to reduce their incidence, including process reliability, are underpinned by measurement of incidence.

The inclusion criteria for the measure is inpatient falls only. The calculation criteria for the measure is the total number of inpatient falls within the last calendar month, against the total number of occupied bed days for the month in the ward within a hospital.

Emergency departments and outpatient and day-case settings currently are excluded, but we are considering including these areas in future.

A Care Assurance and Improvement Resource Dashboard has been developed in partnership with nurses and midwives from across the country. This will enable effective and consistent reporting 'from ward to Board' and will focus on what is needed to improve patient care and show meaningful data that can be understood by all.

Good practice

Healthcare Improvement Scotland carries out a programme of unannounced inspections on behalf of the Scottish Government to provide assurance that the care of older people in acute hospitals is of a high standard. They measure NHS boards against a range of standards, best practice statements and other national documents relevant to the care of older people in acute hospitals, including the Care of Older People in Hospital Standards.^[32]

One of the standards measured is assessment of risk of falls. These assessments should be carried out within 24 hours of the patient's admission and appropriate measures put in place to reduce risk. Examples of evidence of compliance with the standard that inspectors look for include:

• evidence of care plans demonstrating falls-risk assessments and planned outcomes
• policies or strategic plans relating to falls management and prevention, including post-falls protocols
• data and associated action plans relating to number of falls and incident-reporting
• evidence supporting local improvement work relating to falls prevention, such as the Scottish Patient Safety Programme falls bundle^[33] and the Scottish Standards of Care for Hip Fracture Patients^[34]
• evidence of staff training and education on falls prevention and management
• referral pathways for rehabilitation and enablement in community settings.

Excellence in Care will be used to support Older People in Acute Hospitals inspections in the future, particularly by providing easily available access to data on falls and to demonstrate the impact of improvement work to reduce falls.

Care homes

Initiatives in care homes for older people that have resulted in improvements in personalised care and support to reduce harm from falls include the 2014–2015 Up and About in Care Homes improvement collaborative led by the Care Inspectorate in partnership with our Falls Programme, and the refresh of the resource Managing Falls and Fractures in Care Homes for Older People in 2016.^[35]

The Care Inspectorate continues to support the approach to personalised care and support outlined in the resource, and a growing number of care homes are taking action to reduce harm from falls. The Care Inspectorate is also promoting and enabling meaningful physical activity through its Care About Physical Activity Improvement (CAPA) Programme.

Outcome 11

Evidence-based fragility fracture prevention.

What we know and where we are now

An effective fracture prevention pathway needs good joint working between osteoporosis services, fracture liaison services, falls prevention services, primary care, pharmacy and leisure services. As outlined under Ambition 3, a fracture liaison service is central to this approach.

A survey by the Royal Osteoporosis Society suggests services are not consistently meeting the standards set out in their clinical standards for fracture liaison services.^[36] We are aware of the long waiting times for bone-density scans, inconsistent follow-up to monitor treatment, and unwarranted variation in the strength of links to falls prevention services. We need to take steps to ensure we are not missing opportunities to prevent more fragility fractures.

Commitment 15

We will work with stakeholders, including Healthcare Improvement Scotland and the Royal Osteoporosis Society, to explore the application of the clinical standards for fracture liaison services in Scotland to help identify areas for improvement and support NHS boards to improve the care and experience of people experiencing a fragility fracture.

Outcome 12

Evidence-based and personalised care following hip fracture.

What we know and where we are now

A significant number of falls result in serious injury. The acute care of people with severe injury requires a collaborative interdisciplinary approach. The evidence for this is strongest for hip fractures.

Improving the care of older people following hip fracture is one of the five priorities of our Musculoskeletal and Orthopaedic Quality Drive. The Scottish Standards of Care for Hip Fracture Patients were published in 2014.^[37] Since then, the Scottish Hip Fracture Audit^[38] has been monitoring performance against the standards across Scotland and providing NHS boards with data to help target local improvements.

Commitment 16

We will continue to monitor performance and support improvements in the care of people with hip fractures, including care and support following discharge from hospital.