1

Falls Prevention Strategy

2019 – 2022

‘Working Together to Prevent Falls in people aged 65 and over’

2

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

3

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.

4

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.

5

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

6

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

7

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.

8

Diagram 1: Department for Work and Pensions – Cause and Effects of a fall14

14 UK Department of Work and Pensions. Falls Factors.

9

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

12180

28

934

703

377

0

100

200

300

400

500

600

700

800

900

1000

Havering Redbridge B&D

Falls

act

ivit

y

Care Homes Non-Care Homes

NCEL avg Care Homes NCEL avg Non-Care Homes

10

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

0

200

400

600

800

1000

1200

1400

2015/16 2016/17 2017/18

Falls

act

ivit

y

B&D Havering Redbridge NCEL average

0

20

40

60

80

100

120

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

emb

er

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

emb

er

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

emb

er

Jan

uar

y

Feb

ruar

y

Mar

ch

2015/16 2016/17 2017/18

NHS Barking and Dagenham CCG NHS Havering CCG NHS Redbridge CCG

11

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

12

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.

13

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?

14

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.

15

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

16

Prevention Proactive management falls risk

Higher needs

Age 55-64yrs 65-74yrs 75-85yrs

De

cre

asin

g fi

nan

cial

inve

stm

en

t an

d r

eso

urc

e d

em

and

17

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.

18

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.

19

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.