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Falls Prevention Strategy
2019 – 2022
‘Working Together to Prevent Falls in people aged 65 and over’
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Contents Pg Executive Summary 3
Introduction 5
What causes a fall? 6
Impact of falls 7
Local issue – why a falls strategy for Barking and Dagenham, Havering and Redbridge? 9 Current BHR wide falls-related services 12
The strategy – what are we going to do? 14
Developing a Local Falls Prevention Service 17
What does success look like? 19
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Executive Summary
Evidence demonstrates that people aged 65 years and older are at an increased risk of falling,
with 30% of people over the age of 65 and 50% of people over the age of 80 falling at least once
a year. The ONS estimates a 20% increase in the size of the 65 and over population between
2014-2024.
The evidence base for falls prevention initiatives is strong and includes guidance from NICE, a
Cochrane review, through to the recent publication of the Falls and Fractures Consensus
statement and resource pack in 2017. The NICE “Falls in Older People” quality standards,
published in March 2015, and updated in January 2017, focuses on the prevention of falls and
assessment after a fall in older people (aged 65 and over) who are living in the community or
staying in hospital.
A review of local falls prevention services has highlighted the presence of significant gaps, as
well as inequitable service delivery across BHR. An analysis of 2017/18 falls activity data
amongst residents showed an increase of 11.6% when compared with the previous year.
Secondary care user service data demonstrates a steadily increasing average in the number of
non-elective admissions associated with falls amongst BHR residents aged 65 years and older
over the last three years, i.e. 2015/16, 2016/17 and 2017/18.
The RightCare pathway for Falls and Fragility Fractures recommends that commissioners responsible for Falls and Fragility Fractures for their population should:
- focus on the three priorities for optimisation:
- work across the system to ensure that schemes to deliver the higher value interventions
are in place
- Use the Falls Prevention Consensus Statement and Resource Pack.
Investing in the development of a holistic falls prevention scheme is expected to support older
residents to live and age well by: (1) improving management of patients who have already
experienced a fall, with or without an injury (2) increasing prevention of a first time fall from
occurring and (3) maintaining risk reduction amongst the target population.
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Vision – Working collaboratively to prevent falls in people aged 65 and over
The Key priorities of the Falls Strategy are:
Priority 1: Increase awareness of falls prevention. Priority 2: Reduce risk of falls amongst population aged 65 and over. Priority 3: Improve collaborative working between all agencies - non- statutory and statutory - involved in falls prevention.
Priority 4: Proactively manage population aged 65 and over to reduce falls risk.
Outcomes
As a result of this strategy there is expected to be:
Greater awareness of falls prevention across the health, social care and community sectors
Increase in identification of older adults at risk of experiencing a first time or recurrent fall
Comprehensive holistic assessment tool that supports falls risk stratification
Proactive management for all levels of risk stratification
Earlier intervention for known falls
Rehabilitation and recovery following fall.
Performance will be measured in a number of ways, including number of people identified at risk of
falling, number of people with their risks reduced and a reduction in injuries as a result of falls. The
key outcome measure is the number of hospital admissions as a result of a fall.
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Introduction Although everyone can be at risk of experiencing a fall, evidence demonstrates that people aged 65
years and older are at an increased risk of falling, with 30% of people over the age of 65 and 50% of
people over the age of 80 falling at least once a year. With 8.7 million people aged 65 years and over,
living in England in 2011, this equates to over 3 million falls annually across the UK (Public Health
England, 2018).1 Falls are a major cause of disability and the leading cause of mortality as the result of
an injury in people over the age of 75 in the UK, with up to 14,000 people dying annually as a result of
an osteoporotic hip fracture.2,3
Population estimates suggest that 30,505 people aged 65 years and older who are resident in Barking
and Dagenham, Havering or Redbridge are likely to fall. The ONS estimates that the size of the
population aged 65 years and over is projected to increase by an average of 20% between mid-2014 and
mid-2024. A 20% increase in the size of the 65 years and older population in BHR equates to around
122,020, therefore indicating that the number of BHR residents aged 65 years and older who fall at least
once per year could increase to 36,606. 4 With the ageing demographics, it is important to identify
actions to reduce both primary and secondary falls.
1 Public Health England: A Return on Investment Tool for the Assessment of Falls Prevention Programmes for Older People Living in the Community. London: 2018. 2 Incidence and costs of unintentional falls in older people in the United Kingdom (J Epidemiol Community Health. Sep
2003; 57(9): 740–744 Scuffham & Chaplin) 3 National Service Framework for Older People (Department of Health 2001) 4 Office for National Statistics. Subnational population projections for England: 2014-based projections. 2016. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/subnationalpopulationprojectionsforengland/2014basedprojections
https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/subnationalpopulationprojectionsforengland/2014basedprojectionshttps://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/subnationalpopulationprojectionsforengland/2014basedprojections
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What causes a fall?
While falls do not have to be an inevitable consequence of ageing, the natural ageing process does place
older adults at an increased risk of experiencing a fall, 5 with the frequency of falls increasing with age
and frailty level. 6 In the UK, falls-related injuries are the most common cause of death in people over
the age of 75. 7
Thomas E. Kennedy, in The Prevention of Falls in Later Life, highlights that falls occur most
frequently as a consequence of an interaction between risk factors, with many of the major risk
factors for falling, both intrinsic and extrinsic, regarded as being modifiable. 8
Listed below are four common intrinsic factors as to why older people are more likely to
experience a fall:
Chronic health conditions such as heart disease, dementia and low blood pressure (hypotension)
which can cause dizziness
Impairments such as poor vision or muscle weakness
Disabilities that can affect balance, e. g., inner ear disturbances
Medication, namely side effects associated with certain medications and polypharmacy, i.e.
medication combinations. 9
The following common extrinsic factors and activities may also increase the likelihood of a fall
occurring:
Floors which are wet or have been recently polished, e. g. in the bathroom
Dim/poorly lit rooms
Rugs or carpets not secured
Reaching for storage areas, such as a cupboard, or walking down the stairs
Rushing to the toilet
Falling from a ladder whilst carrying out maintenance work at home. 10
5 NHS, Falls Prevention. Accessed on 31 November 2018 at: https://www.nhs.uk/conditions/falls/prevention/ 6 World Health Organization. (2008). WHO global report on falls prevention in older age, Geneva: World Health Organization. http://www.who.int/iris/handle/10665/43811 7 NHS, Falls Prevention. 8 Kennedy TE. The Prevention of Falls in Later Life. Dan Med Bull1987;34(Suppl 4):1-24 9 NHS, Falls Prevention. 10 ibid
https://www.nhs.uk/conditions/falls/prevention/http://www.who.int/iris/handle/10665/43811
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Impact of falls
Most falls do not result in serious injury, although 20% of older adults will require medical
attention for a fall and 5% will experience a serious injury such as a broken bone. 11
The average age of a person with a hip fracture is 84 years for men and 83 for women, with 76% of
fractures occurring in women. About 1 in 10 people with a hip fracture die within 1 month and
about 1 in 3 within 12 months (as a result of associated comorbidities). 12
In addition to the immediate health needs and hospital costs associated with falls, a proportion of
people who fall will have to be discharged into residential care, a supported living unit or a nursing
home, unable to permanently or temporarily return to independent living. The fear of falling again
and the loss of independence can often lead to increased inactivity and loss of muscle strength and
mobility, consequently increasing the risk of future falls which will in turn require additional
resources from a range of stakeholders, such as family members, carers, local authority and the
NHS. The financial impact of falls and fractures on the NHS and social care system is significant.
Falls impact on a range of health and social care resources including GP visits, ambulance journeys
and acute and community care. Nationally, falls and fractures take up to 4 million hospital beds
each year in England. 13
11 NICE, 2013. Falls – Assessment and Prevention of falls in older people 12 NICE Clinical Guidelines [CG124], 2011. Hip Fracture Management 13 Public Health England: A Return on Investment Tool for the Assessment of Falls Prevention Programmes for Older People Living in the Community. London: 2018.
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Diagram 1: Department for Work and Pensions – Cause and Effects of a fall14
14 UK Department of Work and Pensions. Falls Factors.
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Local Issue – why a falls strategy for Barking and Dagenham, Havering and Redbridge?
A review of local falls prevention services has highlighted the presence of significant gaps as
well as inequitable service delivery across BHR. In addition to the results of the service review,
local data, as summarised below, suggests the need for a strategy informing a coordinated
approach to reducing falls amongst the target population. This will then contribute to reducing
the frequency of falls for recurrent fallers, thereby minimising the severity of injuries when falls
do occur, improve patient outcomes and reduce health and social care costs associated with
falls.
Data demonstrates that while falls activity for BHR care home patients in 2017/18 decreased
by 6.3% on 2016/17 activity, the falls activity for non-care home patients increased by 11.6%.
Table 1: Falls activity among BHR population aged 65 years & older
BHR CCGs (Average)
Falls Activity 2015/16 2016/17 2017/18
Falls activity for care home patients 79 76 74
Falls activity for non-care home patients 653 632 729
Total number of falls (all patients) 732 708 803
% of falls from care homes 10.8% 10.8% 9.2%
Figures 1 and 2 below provide a summary of activity across BHR CCGs. Figure 1: Falls activity – 3 year average (2015/16, 2016/17, 2017/18)
Data also demonstrates that falls activity (care home and non-care home patients) in Havering
is 47% higher and in Redbridge 4.7% higher than the average falls activity across NCEL. Care
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home falls activity data for Havering must be interpreted with caution, however, as there is a
total capacity of 2748 beds across Havering care and nursing homes, accounting for 30% of the
total number of beds across NEL.
Figure 2: Total falls activity trends (2015/16, 2016/17, 2017/18)
As illustrated in figure 3 below, falls activity in Barking and Dagenham and Redbridge for non-
care home residents has not made significant increases, whilst activity in Havering has
significantly increased from the previous two years.
Figure 3: Total falls activity trends – Non-care home residents
According to the 2015 Mid-Year Estimates of Population, published by the Office for National
Statistics (ONS) on 23 June 2016, the population of Havering aged 65 years and
older is 45,859 (31,855 is accounted for by people aged 65-79 years) which represents 18.5% of
the Havering population. ONS estimates also demonstrate that while the population in
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NHS Barking and Dagenham CCG NHS Havering CCG NHS Redbridge CCG
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Havering has a much older age structure when compared to London, it is similar to the age
structure for England. 15
Table: Hip fractures in people aged 65 years and older (2016/17) 65+
Source: Public
Health Outcomes
Framework16
The figure below illustrates a steadily increasing average in the number of non-elective
admissions associated with falls amongst BHR residents aged 65 years and older over the last
three years.
Figure 4: Non-elective admissions associated with falls
15 Office for National Statistics. Subnational population projections for England: 2014-based projections. 2016. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/subnationalpopulationprojectionsforengland/2014basedprojections.
16 Public Health Outcomes Framework - Hospital Episode Statistics (HES), NHS Digital for the respective financial
year, England. Local Authority estimates of resident population, Office for National Statistics (ONS) unrounded mid-
year population estimates produced by ONS and supplied to Public Health England
Borough Aged 65-79 yrs. Aged 80+ yrs.
Count Value Count Value
Barking & Dagenham 45 336 88 1,475
Havering 73 236 213 1,515
Redbridge 59 234 146 1,388
NCL
https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/subnationalpopulationprojectionsforengland/2014basedprojectionshttps://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/subnationalpopulationprojectionsforengland/2014basedprojections
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Current BHR wide falls-related services
Detailed in the table below is a presentation of current falls prevention service provision across
BHR, set against minimum NICE requirements for falls services.
NICE requirements on Falls Current provision Gaps in service delivery
1. Case/risk identification: ‘Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall(s).
Frailty LIS in place for Redbridge Primary Care which includes identification of patients who have fallen within the last year.
No LIS in place in B&D and Havering, though Primary care is required to utilise e-LfH tool.
2 Use of ‘Get up and go test’ or other tests to assess gait and balance.
NELFT Physiotherapy service utilises standardised assessment tool to assess gait.
Need for GP/practice nurse observation, recording and referral, as appropriate, to be embedded in standard primary care practice, regardless of patients’ primary reason for GP surgery attendance.
3. Multi-factorial falls risk assessments and interventions: ‘Older people who present for medical attention because of a fall, report recurrent falls in the past year or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment’.
Age UK-Redbridge commissioned to conduct falls risk assessments.
Whole Body Therapy conducts falls risk assessments prior to enrolling individuals into programme (not CCG funded).
Electronic Frailty Index scoring utilised in primary care as a frailty assessment tool.
Need for standardised falls risk assessment tool for use by professionals/agencies, as appropriate.
4. Patient engagement: encourage the participation of older people in falls prevention programmes including education and information giving.
The following services encourage and support facilitation of older people in falls prevention programmes: - Age UK – Redbridge - My Life
Need for more coordinated and widespread participation across all three boroughs.
5. Professional education – ‘All healthcare professionals dealing with patients known to be at risk of falling should develop and maintain basic professional competence in falls’.
Age UK - Redbridge commissioned to offer and deliver GP falls prevention awareness sessions and/or material.
No equivalent Age UK service currently available in B&D and Havering. No coordinated falls prevention education programme in place.
6. Strength and balance training: ‘A muscle-strengthening and balance programme should be offered... individually prescribed and monitored by an appropriately trained professional’.
Age UK - Redbridge commissioned to: - deliver individual and group exercise sessions to improve participants’ strength and balance - provide advice and information on reducing falls risks.
NELFT prescribe individual exercise sessions through physiotherapy service.
Whole Body Therapy delivers PSI-led sessions to people aged 65 years and over in B&D and Redbridge who self-refer into the programme. Short term contracts are funded through various streams (not CCG funded).
No equivalent Age UK service currently available in B&D and Havering. Some whole body therapy sessions have to be paid for by participants due to insufficient funding arrangements.
7. Medications: ‘Older people on psychotropic medications should have their medications reviewed… to reduce their risk of falling’. Particular attention should be paid to older persons taking four or more medications.
Medication reviews carried out in primary care and care homes.
No systematic delivery in provision of medication reviews for people over the age of 65 years as appropriate (limited capacity in Community Pharmacy team to deliver medication reviews for care home residents on a 6 monthly basis).
8. Home hazard and safety intervention: is shown to be effective only in conjunction with follow-up and intervention, not in isolation.
Age UK - Redbridge provides information and advice on reducing falls risk, along with a limited number of home hazard and safety checks.
Community Treatment Team, through the OT, conducts home hazard and safety assessments for some patients. NELFT Physiotherapy service conducts home safety assessments through OT for some patients.
Handyperson scheme funded by LBBD.
Home safety assessments across BHR are conducted on an ad hoc basis by service providers.
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Red cross supported discharge service funded by LBBD.
9. Assistive devices: Falls prevention strategies, using tele-care and other devices.
Assistive devices such as telecare, falls detectors, among others, are ordered by CTT, Care City Integrated Service and local authority through social services.
*Need to establish what is available in each borough.
10. Cardiovascular intervention: cardiac pacing should be considered for older people with cardio inhibitory carotid sinus hypersensitivity who have experienced unexplained falls.
BHRUT/other acute service.
AF screening and DOAC initiation in Redbridge primary care. AF screening in B&D and Havering primary care.
BP checks as part of Redbridge frailty LIS.
No DOAC initiation in B&D and Havering primary care. No frailty LIS in B&D and Havering primary care.
11. Visual Intervention: assessment of visual impairment. Studies showed that visual impairment is an independent risk factor for falls and hip fractures.
Ophthalmology (acute) and optometry services. Preventive approaches, e. g. asking patients/clients whether or not they have had their eye check may not be applied routinely.
12. Footwear interventions: although there seems to be no experimental studies relating falls to footwear, AGS/BGS guidelines recommend: ‘Older people should be advised that walking with shoes of low heel height and high surface contact area may reduce the risk of falls’.
None, unless patient has a LTC. Podiatry only commissioned for BHR patients with long-term conditions.
The Strategy – what are we going to do?
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Vision ‘Working Together to Prevent falls in people aged 65 and over’.
The successful implementation of the strategy will be dependent on falls prevention service
providers effectively working in partnership to undertake assessments, make referrals and
deliver intervention(s) in a timely fashion, as appropriate.
The first cog focuses on:
- Raising awareness of falls prevention among the target audience, members of the
wider community and health and social care professionals. - Proactively identifying patients at risk of experiencing a first time or recurrent fall(s)
and undertaking a holistic falls risk assessment. The second cog focuses on ensuring the development and presence of appropriate services
and pathways in community, primary and secondary care and local authority and various
public sector organisations into which suitable patients should be referred in order to
reduce the risk of falls. This will also ensure that these key services and agencies are aware
of their ongoing responsibility in contributing to the delivery of the falls prevention agenda.
The third cog summarises the main outcomes resulting from the implementation of the falls
prevention agenda, namely a reduction in the incidence of falls across BHR.
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This phased roll-out of the Falls Prevention Service is expected to target those at the
highest risk of experiencing a fall first.
As the falls prevention service redesign becomes operational and is fully embedded in the
Older People’s Transformation Programme, the vision is for there to be a reversal of the
current falls-related resource demands so that resources are concentrated on preventing
first time falls, with a decrease in the demand for resources at the more costly end of the
spectrum, on a case-by-case basis, post fracture and post fall without a fracture, i.e. the
falls activity with or without a fracture will decrease as illustrated in the figure below:
Objective 1: Improve outcomes for older adults who have had a fracture and been discharged from the fracture clinic. Respond to 1st fracture, prevent the 2nd.
Objective 4: Prevent frailty, preserve bone health and reduce accidents.
Objective 3: Early intervention to improve independence and mobility while linking primary, community and secondary care services and pathways.
Objective 2: Reduce risk of recurrent falls for those who have fallen in the past.
A systematic approach to falls and fracture prevention Four key objectives:
Identified as being “frail”
At high risk of 1st fragility fracture, i.e. fallen without a fracture
All adults aged 65 and older
Non-hip fragility fracture patients
Stepwise implementation – based on size of impact
Vision for falls related resource demands and investment after three years operation of redesigned falls prevention service
All adults aged 65 and older
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Prevention Proactive management falls risk
Higher needs
Age 55-64yrs 65-74yrs 75-85yrs
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Developing a Local Falls Prevention Service
Falls occur most frequently as a consequence of an interaction between risk factors, with many
of the major risk factors for falling regarded as being modifiable, e. g. balance impairment,
muscle weakness, polypharmacy (i.e. individuals who are taking more than one medication)
and environmental hazards. As the risk of falling appears to increase with the number of risk
factors, multifactorial interventions have been suggested as the most effective strategy to
reduce decline in function and independence. 17 It is therefore important that risk assessments
and interventions are not conducted and developed in isolation of one another, but that both
intrinsic and extrinsic factors are considered – that is, intrinsic factors such as impaired mobility
and gait, sedentary behaviour, age, falls history, medicine and extrinsic factors such as
environmental hazards, footwear/clothing, inappropriate walking aids as well as an individual’s
exposure to the risk factor. 18
The RightCare pathway for Falls and Fragility Fractures recommends that commissioners
responsible for falls and fragility fractures for their population should:
17 Kennedy TE. The prevention of falls in later life. Dan Med Bull1987;34(Suppl 4):1-24 18 Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. In: Cochrane Database of Systematic Reviews [Internet]. John Wiley & Sons, Ltd; 2012 [cited 2016 Nov 24]. Available from: onlinelibrary.wiley.com/doi/10.1002/14651858.CD007146.pub3/abstract
Focus on the three priorities for optimisation:
Falls prevention
Detecting and managing Osteoporosis
Optimal support after a fragility fracture.
Work across the system to ensure that schemes to deliver the higher value interventions are in place:
Targeted case-finding for osteoporosis, frailty and falls risk
Strength and balance training and home hazard assessment and safety interventions for those at low to moderate risk of falls
Multi-factorial intervention for those at higher risk of falls. Common components may include strength and balance training, home hazard assessment and intervention, vision assessment and referral, medication review with modification and withdrawal
Fracture liaison service for those who have had a fragility fracture.
Use the Falls Prevention Consensus Statement and Resource Pack.
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The diagram below summarises the strands of the holistic falls prevention programme which
sets out these recommendations:
Any falls prevention interventions should form part of a whole system approach taking place
right across the patient pathway and include:
Risk factor reduction across the life-course; case finding and risk
assessment; strength and balance exercise programmes; healthy
homes; high-risk care environments; fracture liaison services;
collaborative care for severe injury.19
A Cochrane Collaboration systematic review found that risk assessment followed by
multifactorial interventions for falls prevention reduced the rate of falls by 24%. 20
19 WHO, Europe. What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent? Health Evidence Network, March 2004. 20 Public Health England with the National Falls Prevention Coordination. Falls and fracture consensus statement: Supporting commissioning for prevention - Produced by Group member organisations, January 2017.
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What does success look like?
• Decrease in number of falls in local population
• Decrease in number of non-elective falls-related hospital admissions and A&E
attendances
• Decrease in number of hip fractures in local population
• Falls risk assessment stratification is actively used in local primary care networks.