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

Section Four: Conclusions, Actions and Recommendations

Conclusions

The findings presented in this report represent a snapshot of service organisation in June 2011 (or October 2011 for NHS GGC CH(C)Ps). They indicate that in some areas modest steps forward have been taken since the previous mapping in 2009/10 and that there is much improvement work in progress. Many services are currently in a state of transition. However, the findings also show that unacceptable variation in service provision and quality continues to exist within and across NHS board areas in Scotland, and in some localities services are poorly developed. There are also some examples of NHS boards disinvesting in falls and osteoporosis services.

The measure of success of the service arrangements described in this report will be their impact on older people and their carers, and health and social care services. The findings suggest that the whole system improvements necessary to make a significant impact have still to be achieved. However, steady progress continues to be made in many partnerships and there is much work in progress. It is essential that health and social care services make every effort to reach the population who will benefit most from support to prevent falls and fractures, and then deliver the care and interventions that have been shown to be effective. Primary prevention must also be addressed in partnership with a broad range of stakeholders. These changes will take dedicated time, persistence and close working across all organisations and sectors, with older people and their carers playing a central role.

The findings indicate that Scotland still has much to do to provide older people with equitable, high quality services for fall and fracture prevention. In short, this report outlines a number of inadequacies, and we cannot expect to demonstrate a significant reduction in emergency admissions with falls and fractures if key components of evidence-based care are missing or inadequate in most localities. A systematic and targeted approach, supported by strong leadership at all levels is required.

Actions for the National Falls Programme

The National Falls Programme will take the following four actions to address the consistent shortfalls identified in this report, and progress further improvements.

Action 1

The National Falls Programme will develop, test and report on, the use of four community falls care bundles. This will facilitate the consistent delivery of evidence-based practice and the development of co-ordinated local care pathways for falls and fracture prevention and management.

Four care bundles for secondary falls prevention in the community will be tested in NHS Fife in early 2012. The bundles aim to ensure that clear falls prevention and management pathways exist, and core falls assessments and interventions are delivered consistently and in line with current guidance. The introduction of the bundles, in combination with the Model for Improvement and a measurement framework, will help services to systematically monitor, evaluate and improve the quality and effectiveness of the care they provide. This approach to secondary falls prevention in the community was first developed and introduced in Wales as part of the 1000 Lives Plus Campaign, Reducing Falls in the Community (http://www.wales.nhs.uk/sites3/page.cfm?orgid=781&pid=48636).

Action 2

A Health Economist will carry out an evaluation to quantify the potential clinical benefits gained from implementing the bundles, (at CH(C)P, NHS board and Scotland level) and the resources and associated costs required to do so. This will assess the feasibility of implementing an evidence-based approach across Scotland.

This evaluation will provide each NHS board with the information required to demonstrate the potential costs and benefits to the board of implementing the bundles. It should also assist planning at local and national level, including the implications for the demand for downstream interventions such as falls clinics, DXA scans and pharmacy reviews. The provisional date for completion of the evaluation is April 2012.

Action 3

The National Falls Programme Manager will work with Falls Leads, Osteoporosis Leads, ISD, ehealth services and other partners to develop a national measurement framework. This will facilitate the use of measurement to monitor, evaluate and improve falls prevention and management and fracture prevention.

Action 4

The National Falls Programme Manager will work with the Scottish Centre for Telehealth & Telecare (SCTT) to share learning and explore further opportunities for the appropriate use of telehealthcare technologies.

This will continue to assist with the early identification of people who are at risk of falling, enable effective responses to those who do fall, and will support further shared learning about technology related developments. The expanded use of telehealthcare within care home settings has been identified as an area of joint interest.

Recommendations for NHS boards and partnerships

NHS boards, CH(C)Ps, local authorities and other partners are urged to consider and action the following recommendations.

Recommendation 1

To identify and address any gaps in local service organisation and delivery, CH(C)P Falls Leads, Strategic Falls Leads, Osteoporosis Leads, Unsheduled Care Leads and other relevant colleagues, such as Reshaping Care for Older People leads and local authority partners, should critically review local responses to the questionnaire and recommendations in this report and formulate and deliver a local action plan.

This report will help to signpost partnerships to areas of service organisation and delivery requiring attention. Important areas on which to focus include workforce development in health and social care services, opportunities for the primary prevention of falls and fractures and synergies with the wider active ageing agenda, equity of service provision for residents of care homes in all sectors, and the consistent delivery of person-centred care. In addition to this, the two improvement areas outlined below should be prioritised.

Recommendation 2

To capitalise consistently on opportunities to prevent recurrent falls and fractures, health and social care services should establish:

• Fracture Liaison Services or equivalent, with referral protocols and pathways to multidisciplinary services providing secondary falls prevention.
• Basic falls risk screening in services providing urgent or acute care for older people who have fallen.
• Robust referral pathways from services providing urgent or acute care for older people who have fallen +/- sustained a fracture to multidisciplinary services delivering secondary falls and fracture prevention.

Urgent and acute care services include the Scottish Ambulance Service, Out of Hours Services, Emergency Departments and Minor Injury Units, community alarm/telecare services and secondary care services.

Recommendation 3

To ensure falls prevention programmes are effective, key evidence-based interventions should be available, when required, to older people throughout Scotland.

These interventions include:

• Multifactorial falls risk screening, including an initial basic screen of fracture risk.
• Prescription of a validated strength and balance exercise programme, taught by appropriately trained healthcare or exercise professionals, and necessary support to continue the programme for a sufficient duration.
• Clinic(s) or equivalent facilities to provide focused medical assessment and interventions related to falls prevention. This includes adequate arrangements for the assessment and treatment of transient loss of consciousness.
• Assessment of potential falls hazards within the person's home, using a validated home hazard assessment, by a suitably qualified professional.

Further information on evidence-based interventions can be found in Up and About¹².