Up and About or Falling Short? - A Report of the Findings of a Mapping of Services for Falls Prevention in Older People

Section One: Introduction

Well-organised services, based on recommended practice and evidence-based guidelines can prevent many falls and fractures in older people in the community. A national mapping exercise benchmarked service provision in Scotland against these criteria.

As part of the National Falls Programme, between May and October 2011, CH(C)P Falls Leads completed a self-assessment of arrangements in their locality for falls prevention and management and fracture prevention for older people. The findings therefore are based on the Falls Leads' knowledge of current service provision. The purpose of the mapping was three-fold:

1. To identify the extent to which recommended practices to prevent and manage falls and fragility fractures are built-in to the wider systems of care for older people in Scotland.

2. To capture good and promising practice as well as common gaps in service organisation and provision, and where possible, identify developments and changes since a previous mapping in 2009/10.

3. To inform recommendations for the improvement of services in Scotland.

A 100% response rate was achieved, with all 35 CH(C)Ps in Scotland participating (including the three sectors within Glasgow CHP), demonstrating the CH(C)P Falls Leads' commitment to service improvement. The Programme team would like to thank everyone who was involved in providing a response.

The findings represent a snapshot of service arrangements in June 2011 (or October 2011 for NHS GGC CH(C)Ps). Responses indicate that there is much improvement work in progress, and in some cases there will have been significant steps forward since the mapping was carried out.

This report outlines the reasons why the prevention of falls and fractures should be a priority for all health economies, reports and discusses the main findings of the 2011 mapping exercise and presents recommendations to improve falls and fracture prevention services in Scotland and reduce unwanted variation.

Why focus on falls and fractures?

With an ageing population, falls and the consequences of falls are a major and growing concern for older people and health and social care providers. Recurrent falls are associated with increased mortality, increased rates of hospitalisation, curtailment of daily living activities and higher rates of institutionalisation¹. Falls are the leading cause of accident related death in older people². Falls are a common problem amongst older people with long term conditions, including dementia.

Falls and fractures, in people aged 65 and over, account for over 18,000 unscheduled admissions and 390,500 bed days each year in Scotland. Average lengths of stay for falls and hip fracture admissions exceed those for other emergency admissions in the same age groups: average lengths of stay for falls and hip fractures in the 75+ population are 25 days and 36 days respectively (compared to an average stay of 13 days for a COPD admission in the same age group) (2010/11 data provided by ISD Scotland).

Around 1% of falls result in hip fracture³; although the percentage is low, this amounts to over six thousand hip fractures in Scotland each year. The acute management of hip fracture alone costs NHSScotland in excess of £73 million each year. Twenty percent of older people who sustain a hip fracture die within six months⁴; approximately half will never be 'functional' walkers again².

In addition, in the over 65 population, falls cases are the largest single presentation to the Scottish Ambulance Service (over 35,000 presentation each year)⁵, one of the leading causes of Emergency Department attendance, and are implicated in over 40% of Care Home admissions⁶. Post - fall syndrome, a combination of fear of falling, anxiety, loss of confidence and depression is prevalent, leading in many to an inability to carry out day to day activities and social withdrawal and isolation.

Despite these statistics, falls are not an inevitable consequence of old age. An individual's risk of falling or fracturing is determined by a complex interaction of multiple risk factors relating to the ageing process, the presence of long term conditions, lifestyle choices, risk-taking behaviours and the surrounding environment. Well-organised services delivering evidence-based care can help to prevent future falls. Recognising and modifying an individual's risk factors is crucial in preventing falls and injuries, including fractures. In many cases early identification of risk and timely intervention can prevent falls and fractures and improve outcomes for older people, retaining or restoring independence and reducing health and social care needs.

Services in Scotland

In most NHS boards in Scotland, falls prevention and management is not provided by dedicated, specialist falls services, but by generalist assessment and rehabilitation services for older people, such as community multidisciplinary teams and day hospitals for older people. Even in NHS boards where dedicated falls services exist, other members of the health and social care team will have a role to play in falls and fracture prevention and management. As this is the case, it is essential that service providers are aware of, and implement, the key components of falls prevention and management and fracture prevention identified in this mapping.

The National Falls Programme and the wider policy context

Co-ordinated, Integrated and Fit for Purpose: the Delivery Framework for Adult Rehabilitation in Scotland⁷, published in February 2007, gives strategic direction and support to health and social care services and practitioners who deliver rehabilitation or enablement services to individuals and communities. The vision underpinning the framework is the creation of modern, effective, multi-disciplinary, multi-agency rehabilitation services, which are flexible and responsive in meeting the needs of individuals and communities in Scotland. Rehabilitation co-ordinators were appointed to board areas to facilitate these re-designs. Specific high impact changes were outlined around improving access to rehabilitation services, promoting self management, developing integrated rehabilitation / enablement services, and developing vocational rehabilitation programmes. Three specific high impact areas were identified: musculoskeletal redesign, vocational rehabilitation and older peoples' services with an emphasis on falls prevention and management. The National Falls Programme is part of the Delivery Framework for Adult Rehabilitation, and is led by the Scottish Government's Directorate of the Chief Nursing Officer, Patients, Public and Health Professions.

Reshaping Care for Older People; A Programme for Change 2010-2021⁸, sets out the Scottish Government's headline ambitions for improving quality and outcomes of care for older people, against a background of demographic and funding pressures. Falls prevention and management is closely aligned with the aim, themes, outcomes and commitments outlined in the Programme for Change; effective falls care pathways can help avoid unnecessary admissions to hospital, optimise an older person's independence and well-being and enable him or her to remain at home. The Change Fund has provided an opportunity for partnerships to build on existing work to develop a co-ordinated, integrated approach to falls and fracture prevention. At the time of the mapping (June/October 2011) 13 partnerships had allocated a proportion of the Change Fund to directly support the prevention and management of falls in the community. A further eight partnerships had developed proposals and were waiting to hear whether funds would be allocated. The findings of this report will help to identify potential improvement areas for partnerships, and can inform future Change Fund expenditure.

Maximising Recovery and Promoting Independence: Intermediate Care's contribution to Reshaping Care⁹ provides a framework for local health and social care partnerships to review and further develop Intermediate Care within their area. Intermediate Care services provide a set of 'bridges' at key points of transition in a person's life, in particular from hospital to home and from illness or injury to recovery and independence. Intermediate Care services can play a vital role at a point of crisis, such as in the event of serious fall, providing timely care and support, and beginning the process of optimising a person's recovery and restoring independence post fall.

Caring Together: The Carers Strategy for Scotland 2010-2011¹⁰ acknowledges the vital contribution carers make to the health and social care system. In many situations, carers will have a critical role in falls prevention and management, and as such, must be fully involved along the care pathway. In addition, services providing effective falls prevention and management can support carers in their role and enable older people to continuing living safely in their own homes.

Start Active, Stay Active: A report on physical activity for health from the four home countries' Chief Medical Officers (2011)¹¹ delivers the key public health message that physical activity has a vital contribution to make to achieving good health and well-being in later life. It presents the evidence that physical activity programmes, which emphasise balance training, limb co-ordination and muscle strengthening activity are safe and effective in reducing the risk of falls. Providing older people with opportunities for regular appropriate physical activity contributes to preventing both a first fall and recurrent falls.

The National Falls Programme (2009-2012) supports partnerships to implement the co-ordinated, evidence-based and person-centred approach to falls and fracture prevention referred to in HDL (13) 2007¹² (see below) and described in the 2010 NHSQIS resource, Up and About¹³. A Programme Manager works with a network of CH(C)P Falls Leads, Rehabilitation Co-ordinators, AHP Directors/Leads and other key stakeholders to support the development of local falls and fracture prevention care pathways in the community setting. Partners in this work have included the Long Term Conditions Collaborative, the Care Inspectorate, the Scottish Ambulance Service, the Joint Improvement Team, the National Telecare Development Programme, NHS Education for Scotland, Healthcare Improvement Scotland, local authorities and the third sector.

Successful falls prevention and management contributes to the achievement of both HEAT targets and Community Care Outcomes relating to reductions in emergency inpatient bed days rates for people aged 75 and over.

The vision and aspirations of the National Falls Programme are consistent with the three Quality Ambitions of the Healthcare Quality Strategy for NHS Scotland¹⁴: mutually beneficial partnerships between the NHS and patients and their families; care that is reliably safe; and appropriate, timely and efficient care and treatment.