Email your comments

This paper is a short report of a pilot falls prevention programme that took place in an NHS Trust in Wales in 2005-06. The paper includes the epidemiology of falls, the health and social policy framework in Wales, the questions, governance and funding, the setting, patients and methods, a discussion of the findings, and a final summary.

Epidemiology of falls
One in three persons in the UK over 65 years and one in two persons over 85 will fall each year (Health Evidence Network 2004). Of those who fall 20-30% will suffer injury and 14,000 older people will die each year in the UK as a result of hip fracture from a fall (Help the Aged 2004). The county served by the Trust has a population of 79,000 people with approximately 17,500 people over 65 years. If these older people were to fall at national rates, then they would suffer approximately 3,900 falls each year. If those who fell, suffered injury at the national rates, and local Accident and Emergency Department data appeared to support this, then between 780 and 1,170 people would need multi-factorial assessment and risk reduction each year.

Health and social policy framework
The Wales Assembly Government did not adopt the National Service Framework for Older People (Department of Health 2001) with the result that until the publication of NICE Guideline 21, Falls: The Assessment and Prevention of Falls in Older People (NICE 2004), there was no substantive guidance for the prevention of falls in older people in Wales. The Welsh Assembly Government had published the Strategy for Older People in Wales (Welsh Assembly Government 2003), but this did not specifically address the prevention of falls. Within a few months of publication, the NICE guidance had been incorporated into the developing National Service Framework for Older People in Wales (Wales NSF) (Welsh Assembly Government 2006). The Wales NSF standard for Falls and Fractures tasks health providers to work with local authority and voluntary sector partners to produce plans for the provision of integrated falls services by April 2007 and to make the plans operational by April 2008. The Wales NSF Falls and Fractures standard focuses on three areas of activity: falls prevention (primary prevention) care after fall (secondary prevention) and the prevention and management of osteoporosis.

Questions, governance and funding
In 2004, in anticipation of the forthcoming guidance, the Trust formed an 18 member, multi-agency, multi-professional falls prevention group. The group reviewed the literature, and then decided to pilot a secondary falls prevention programme to determine the Trust’s readiness for the Wales NSF. The questions asked were (Q1) do the health, local authority and voluntary sector partners (the partners) in the county have the skills and capacity necessary to meet the anticipated Wales NSF standards for secondary prevention? (Q2) what can the partners learn about the processes of multi-factorial assessment, planning, provision and review? (Q3) what patient outcomes might be possible? The pilot project was approved by the Trust Clinical Governance Committee in May 2004 and allocated £11,000 project funds by the Trust Charitable Funds Committee later that year.

Setting, patients and methods
The pilot programme took place in the Trust day hospital over a 16-month period in 2005-06. The day hospital has a changing population of between 28 and 32 patients who between them make approximately 1,650 attendances each year. During the period of the pilot, 24 older community dwelling people attending the day hospital met the eligibility criteria (Shaw et al 2003) and were offered a place on the programme. Twenty-two accepted a place and 19 completed the programme. There were six men and 16 women with an average age 78.5 years (range 58 to 86 years). The two patients who chose not to join the programme gave no reasons for their choice, the two patients who withdrew each cited fatigue. Each patient who entered the programme underwent (1) physician review by a Consultant Geriatrician or Staff Grade physician (2) medicines review by a staff pharmacist (3) vision testing by an Consultant Ophthalmic Surgeon (4) home safety assessment by Care and Repair (5) Occupational Therapy assessment if indicated (6) assessment for hip protectors (7) assessment for referral to the Osteoporosis Service (8) assessment by a Registered Exercise Professional (REP). The REP assessed (a) falls rate per month (b) confidence using Conf-Bal (c) mood using a Visual Analogue Scale (d) standing functional reach (e) seated shoulder internal and external rotation (f) seated hamstring flexibility (g) three metre Timed Up and Go Test (TUGT) (h) footwear and walking aid assessment and (i) general health using SF36. Once the assessments, medication and other changes were complete, each patient underwent a 13-week strength and balance training programme attending one 90-minute class each week. The classes were conducted as two 45 minute sessions with a 10 minute break for rest and fluids. The assessments, referral to specialist services, drug or other interventions and progress in the classes were logged in a programme protocol. The protocol was attached to the day hospital record and archived in the Trust patient record at the end of the programme.

Findings
Q1. Do the partners have the skills and capacity necessary to meet the anticipated Wales NSF standards for secondary prevention? In assessing the skills available locally, it became clear that partners had all the skills available to meet the Wales NSF standard, with the exception of those necessary to provide strength and balance training. That is not to say that the Trust did not have physiotherapy and occupational therapy staff who regularly assessed and treated older people who had fallen, but none had undertaken the industry-standard falls prevention courses accredited by Skills Active. This level of accreditation was considered essential for the good governance of the programme and an appropriately prepared person was sought to do the work. An REP who had completed the Skills Active Programme was found working independently in the county and was commissioned to run the classes for the duration of the pilot programme. In respect of capacity, if the estimates of falls rates in the county were accurate, then whilst it was possible to absorb the 22 patients on the pilot programme, the day hospital would not be able to absorb a further 780 to 1,170 patients requiring full multi-factorial assessment and risk reduction. This paper does not allow for a detailed examination of the deficits, but it was evident with the volume of referrals indicated above, that there would be a need for additional sessions in most areas of an Integrated Falls Service including coordination of the programme, physician review, medication review, osteoporosis management, to home safety assessment and expert strength and balance training. These costs would need to be made visible in the local commissioning plan.

Q2. What did the partners learn about the processes of multi-factorial assessment, planning, provision and review? The partners learnt two important lessons. The first was that the multi-factorial falls assessments should not sit outside the Unified Assessment Process (Welsh Assembly Government 2002) but be fully integrated as specialist assessments. If patients, many of whom had co-morbidities, were to obtain the full benefit from the programme, then data and information generated in it would need to be accessible to other health and social care professionals who came into contact with the patient during the programme and later. The second was the need to ensure that the data shared was standardised. To those ends, the pilot programme used standardised tools and scales wherever possible. The partners believed that ultimately, data generated in the county could, subject to information sharing protocols being in place, become part of an all-Wales dataset and contribute to research capacity and evidence-based practice across Wales.

Q3. What were the outcomes for patients? The Registered Exercise Professional assessed patients’ functional ability no more than 10 days before the start of the programme and within 10 days of the end of programme. The key patient outcomes were as follows (1) the average falls rate fell from 1.0 fall per patient per month to 0.16 fall per patient per month (2) the average three metre Timed Up and Go Test time fell from 41 seconds to 30 seconds (3) the average standing functional reach increased from 16.5 cm to 24.3 cm (4) average confidence measured by Conf-Bal improved by 30% and (5) average physical functioning measured by SF36 improved by 30%. In addition, 40% of patients underwent further assessment and treatment by the Osteoporosis Services, 50% had urgent home safety works undertaken by Care and Repair and all patients had visual problems requiring further assessment and treatment by the Trust Ophthalmic Services.

Discussion
The limitations of the pilot programme were that it was confined to secondary prevention; that the organisational learning may reflect only local experiences; and that as the patient outcome data were not subject to power calculations they cannot be generalised. The limitations of this paper are that it is only a partial account of the project. With those caveats, the pilot programme caused the Trust to assess its readiness against the Wales NSF standards and to focus on the two factors known to reduce the monthly falls rate: multi-factorial risk assessment and group exercise training (Rubenstein et al 2000: Chang et al 2004). In creating the multi-factorial risk assessment it found that most skills were available within the Trust and that the key challenge was that of marshalling them, and making assessments available to all those with need to access them. To a greater extent the use of the pilot programme protocol was unsatisfactory, because despite it providing a comprehensive record and being accessible to all staff in secondary care, it was not easily accessible to community or primary care staff who probably had the greatest contact with the community dwelling older people who participated in the programme. The partners believe that a wide-area network or web-based application is essential for networking this data. In providing strength and balance training, the Trust had to decide whether to develop its own resources or to contract for them. This decision to contract for them was not subject to the scrutiny of a long-term costing model and will have to be re-visited prior to the establishment of the Integrated Falls Service in April 2008. It could be argued however, that all elements of the programme should be subject to this same economic scrutiny. The outcomes for patients are encouraging. The reduction in the monthly falls rate is probably a greater reduction than it appears, as the data are unadjusted data. When adjusted per 1,000 hours of activity, it is possible that patients achieved an even greater relative reduction in their falls rate, as many of them reported markedly increased levels of activity as a result of increased confidence and well-being. The reduction in TUGT time still leaves the average score well outside the upper range of normal (Whitney, Lord and Close 2005). However this change combined with a 30% increase in functional reach and a 50% improvement in general health probably indicates an improvement in functional ability for most patients. The referral rate to the Osteoporosis Service, Care and Repair and to Ophthalmic Services is likely to have significant cost implications for the development of the Integrated Falls Service. The cost to the Trust of vision testing could be reduced if all patients over 60 years, and other eligible patients, underwent free testing at their local optician. Trust staff could assess those not eligible for free testing.

Summary
In 2004 an NHS Trust in Wales formed a multi-agency, multi-professional planning group for falls prevention. The group commissioned a pilot secondary falls prevention programme to test organisational readiness for the Wales NSF. The pilot took place over a 16-month period in 2005-06. Twenty-two older people completed the programme. The organisational outcomes included better understanding of the process of multi-factorial assessment and falls risk reduction. The patient outcomes included reduced falls rate, increased confidence and improved functional ability and general health.

Correspondence
Dr Hugh Chadderton, School of Health Science, Swansea University, Singleton Park, Swansea SA2 8PP

References

1. Chang J. T., Morton S. C., Rubenstein L. Z., Mojica W. A., Maglione M., Suttorp M. J., Roth E. A. and Sheckelle P. G. (2004) Interventions for the prevention of falls in older people: systematic review and meta-analysis of randomised clinical trials. British Medical Journal 328, 68-687.
2. Department of Health (2001) National Service Framework for Older People. DOH, London.
3. Health Evidence Network (2004) What are the Main Risk Factors for Falls among Older People and what are the Most Effective Interventions to Prevent Falls? How should Interventions to Prevent Falls be Implemented? WHO, Geneva.
4. Help the Aged (2006) (Accessed 17/08/06)
5. National Institute for Clinical Excellence (2004) Falls. The Assessment and Prevention of Falls in Older People. NICE, London.
6. Rubenstein L. Z., Josephson K. R., Trueblood P. R., Loy S., Harker J. O., Pietruszka F. M. and Robbins A. S. (2000) Effects of group exercise program on strength, mobility, and falls among fall-prone elderly men. Journal of Gerontology 55 6, M317-M321.
7. Shaw F. E., Bond D., Richardson D. A., Dawson P., Steen N. I., McKeith I. G. and Kenny R. A. (2003) Multi-factorial intervention after a falls in older people with cognitive impairment and dementia presenting in the accident and emergency department: a randomised controlled trail. British Medical Journal 326,
8. Welsh Assembly Government (2003) Strategy for Older People in Wales. WAG, Cardiff.
9. Welsh Assembly Government (2006) National Service Framework for Older People in Wales. WAG, Cardiff.
10. Whitney J. C., Lord S. R. and Close C. T. (2005) Streamlining assessment and intervention in a falls clinic using the Timed Up and Go Test and Physiological Profile Assessments. Age and Ageing 34, 567-571.