Falls

Falls and related injuries are a common and serious problem for older people. In the UK. 30% of people older than 65 and 50% of people older than 80 fall at least once a year; those who fall once are two to three times more likely to fall again within the year (Source: National Institute for Health and Care Excellence). Falls are the most frequent type of accident in people over 65. The number of injuries caused by falls increases with age. Most injuries resulting from falls are minor, however, 10% of falls result in fractures which are a major cause of mortality and morbidity amongst those aged over 65 years. For those over 75, falls are also the most common cause of death from injury (Source: Age UK).  

Falls have a large impact on quality of life as well as physical health. A fall can damage confidence, reduce independence and increase social isolation. An older person who has fallen has a 50% probability of significantly impaired mobility and a 10% probability of dying within a year (Source: Age UK). Falls can cause individuals to feel less confident or able to leave the house or attend activities that they previously engaged with. This can lead to a decline in social relationships, therefore effecting loneliness and isolation, as well as physical and emotional wellbeing. Research suggests that individuals with poor social connectedness are less likely to engage in preventative services (Source: Lancet Public Health). 

The impact of falls on healthcare costs is significant. In the UK, falls are estimated to cost the NHS more than £2.3 billion per year (Source: NICE). In England alone, over 200,000 people aged 65 and over are admitted into hospital per year because of a fall, and nearly 60,000 people are admitted because of hip fractures (Source: BMJ).  The causes of having a fall are multifactorial but many can be prevented. Key risk factors increasing the risk of suffering a fall include: a history of falls, muscle weakness, poor balance, visual impairment, polypharmacy, the use of certain medicines, and environmental hazards. 

The most common places for older people to fall are: in their home, in hospitals, or at a place of residential care. The risk of falls can be mitigated by a number of interventions including: strength and balance exercise programmes, home hazard assessments and interventions, vision assessment and referral, or a medication review with modification/withdrawal of medicines (Source PHE). 

• NICE Clinical Guideline CG161 (Falls: assessment and prevention of falls in older people) notes the preventable nature of some falls, and the physical and psychological benefits of modifying falls risk. CG161 specifically recommends falls prevention strategies with components of exercise, strength and balance training. 
• The NHS Right Care The Falls and Fragility Fractures Pathway defines the core components of an optimal service for people who have suffered a fall or are at risk of falls and fragility fractures. 
• Falls and fractures consensus statement was written to support commissioners by outlining approaches to interventions and activities helping prevent falls and fractures and so improve health outcomes for older people. 
• The Chief Medical Officer’s Physical Activity Guidelines underline the importance of all age groups participating in a range of physical activities, recognising that, for older adults, activity helps maintain strength whilst delaying the natural decline of muscle mass and bone density. 
• The Return on Investment Tool: Assessment of Falls Prevention Programmes for Older People Living in the Community can be used to estimate the cost, effectiveness and potential return on investment (ROI) for falls prevention programmes aimed at elderly people based in the community. 
• Embedding prevention into all pathways across health and care forms one of several cross-cutting themes within the Lincolnshire Joint Health & Wellbeing Strategy. Physical activity is one of 7 key priorities within the strategy. 

The estimated resident population of Lincolnshire in 2020 was around 766,333.  Based on this, it is expected around 53,000 people in Lincolnshire will suffer a fall each year, creating a significant strain on health and care services. 

Key national indicators (e.g. emergency hospital admissions for falls or hip fractures) indicate that outcomes across Lincolnshire, and in the Districts, were similar, or better, in comparison to national and regional averages over the last decade (Source: OHID). Such indicators are adjusted for the older age profile of the Lincolnshire population to be an accurate representation of cases. Hip fractures were significantly higher than the national average in South Kesteven in some years (e.g. 2021/22), with no obvious explanation for this geographical variation. The crude numbers of falls are highest in East Lindsey reflecting the population profile of the costal and rural areas of the district. The impact of falls is projected to increase in the future as the population ages (Source: POPPI). 

People living in more deprived areas are more likely to have multiple long term conditions, a lower level of physical activity, and poorer housing conditions, all of which contribute to an increased risk of falls (Source OHID). Risk factors such as: visual impairment; cognitive impairment; sedentary lifestyle, or multiple medications; are more likely to be present in people with learning difficulties than the general population of similar age, placing this group at increased risk of experiencing a fall (Source: Public Health England). 

Within the Lincolnshire Integrated Care System (ICS), falls prevention is considered as part of the ‘Ageing Well’ agenda and is a subset of both the Enhanced Health in Care Homes (EHCH) and the Anticipatory Care (AC) work programme. The EHCH model, of proactive care delivery, is centred on the needs of the individual, their family, and care home staff. In principle, people living in care homes should expect the same level of support as people living in their own home. Of the five clinical elements of EHCH, “Falls prevention, reablement, and rehabilitation (including strength and balance)” is care element three. Anticipatory care is focused on ensuring proactive, holistic care matched to patient health and social care need, which addresses health inequalities and variation.  

There are a range of organisations providing services contributing to falls response and prevention. 

Prevention 

The integrated lifestyle service, ‘One You – Lincolnshire‘ (OYL), provides adults in Lincolnshire with information, advice and direct support focussing on the four lifestyle behaviours with the greatest impact on health and wellbeing: smoking, physical activity, excess weight and alcohol consumption. Staying healthier and more active throughout life diminishes many risk factors associated with falls and frailty. OYL also offers a ‘Healthy aging pathway’, 12-week physical activity groups catering for older adults. The programme consists of chair based and standing exercises to improve strength as well as 20 minutes coffee/tea social time. The digital resource, Gloji Gym provides access to live and pre-recorded online classes. 

Connect to Support Lincolnshire provides people with a range of options on how healthcare, support, and community services can be accessed. The site includes an online directory of providers and services (like local exercise classes) alongside information and advice to support prevention and self-care. 

ULHT Bone Densitometry and Fracture Liaison Service provides secondary prevention for fragility fractures by offering bone health assessments and “gold standard” bone mineral density scans. 

Response 

East Midlands Ambulance Service (EMAS) is the primary emergency medical provider delivering emergency 999 care and clinical assessment telephone services in Lincolnshire. There are several additional partnership services and projects responding to people who may have experienced a fall in the county. 

The Falls Response Service, provided by the local charity, Lincolnshire Integrated Voluntary Emergency Service (LIVES), assists people who have called an emergency number following a fall. Three falls teams operate across Lincolnshire. These comprise two responders operating from specially equipped vans. They are able to perform diagnostics, lift patients after a fall and can initiate emergency and temporising treatment where necessary. The Community Emergency Medicine Service (CEMS) is supported by qualified medical specialists and experienced clinicians, doctors, paramedics, and nurses who can further assist with medication reviews and enable access to specialist support pathways. 

A Wellbeing Response service, linked to the provision of Telecare, sends a responder to service users who have had non-injury falls, assisting them to mobilise. Fees apply to some service elements. 

Staff at care homes are offered support through the dedicated phone number to Clinical Assessment Service (Enhanced CAS) in unpredictable circumstances like falls (when a patient is no longer on the floor). CAS teams can provide advice to staff, issue remote prescriptions, refer to GP or A&E department, or contact the ambulance service, if required.  

From October 2021, Lincolnshire Community Health Service has offered two-hour urgent community response to adults who are at immediate risk of hospital admission, this is in line with the NHS national standards. Falls with no apparent injury, but where care support is required within two hours to prevent hospital admission, are named among the common clinical conditions that may lead to a patient requiring this service. The multi-disciplinary team consists of Nurses, Physiotherapists, Occupational Therapists, assistant practitioners and therapy assistants, and covers the whole of Lincolnshire, operating between 8am-8pm, 7 days a week. 

Ongoing support 

The Wellbeing Service provides a range of interventions and community based support to promote confidence in living independently e.g. providing small aids for daily living and minor adaptations. 

LCC Adult Care provides support for people with ongoing, long lasting health issues or disabilities, with the aim to maintain or increase independence. The Occupational therapy service can advise of actions to take in order to make a home safer by installation of minor adaptations like handrails or ramps. Depending on individual financial circumstances, funding may be available for major adaptations through the Disabled Facilities Grants. 

Community Physiotherapy and Occupational Therapy provide assessment, diagnosis and treatment for those with complex needs that are best met within their home environment. Interventions include falls assessment, exercise programmes, home risk assessment and the provision of equipment. The Musculoskeletal Physiotherapy Service supports recovery after an accident or surgery. 

Vision assessment is a key intervention in falls prevention and can be offered by a wide range of community opticians (NHS). The Lincolnshire Sensory Service provides specialist information, guidance, and support for anyone in Lincolnshire living with sight and/or hearing loss. The ophthalmology department at United Lincolnshire Hospitals NHS Trust diagnoses and treats a wide range of eye conditions. The Trust employs Eye Clinic Liaison Officers (ECLO) across the Lincolnshire sites to provide advice and support for anyone affected by sight loss. 

Urinary incontinence is associated with increased risk of falls. In Lincolnshire, the continence service is provided by the Lincolnshire Community Health Service. 

The complexity of falls requires a joint response and a coordinated effort from partners including primary, secondary and community healthcare settings, residential care providers, the leisure industry and those working with older people and their carers. The development of Primary Care Networks creates many opportunities for access to a wide range of specialists within primary care settings (e.g. physiotherapists, community pharmacists, or specialist nurses). This should enable collaborate working to better meet the needs of individuals. 

The findings of a recent community engagement exercise, to inform the development of a Strength and Balance Service, will shape the specification of the service currently being commissioned for Lincolnshire.  

Individual services routinely gather feedback from service users to ensure continued improvement and to report on the impact interventions have made for the health and wellbeing of the population. 

Research shows that physical activity levels have decreased across all older adult age groups during the COVID 19 pandemic with the greatest change observed in the 70 to 74 age group. The observed decrease in strength and balance activity is projected to result in a significant increase in falls, requiring urgent action from local systems. 

Large proportions of older populations in Lincolnshire live in coastal and rural areas where provision of services may be impacted by limited infrastructure, transport or staffing issues. 

Services and resources relevant to falls prevention are increasingly delivered digitally (online). While this makes them more accessible, digital skills of some population segments need to be considered, especially in areas of deprivation (Source: Centre for Aging Better). 

Considering that falls affect people with learning disabilities disproportionally more than the rest of the population, services need to apply reasonable adjustments to meet their needs. Adjustments could include information in an accessible format, longer appointment times, or having a support person present (Source: PHE). 

• Lincolnshire County Council will commission a new Strength and Balance Service to support falls prevention. The new service will be based on the FaME model and is planned to go live in late 2022. Funding has been secured for 2 years initially, with a planned evaluation to inform future commissioning. 
• Staff training is currently being rolled out across PCNs with funding allocated by Lincolnshire CCG. Intended to embed best practice in prevention and falls response/treatment, the training will include content to enable risk stratification and the identification of other frailty syndromes. 
• The local NHS has secured funding to introduce ‘Proactive Groups’ to support frail adults to improve their wellbeing and maintain independence. This provision will be a series of face to face and virtual workshops based in community venues and delivered by integrated community teams within PCNs. This provision is already ongoing in Grantham and Sleaford areas. 
• Falls Prevention in Care Homes through use of sensor-based technology is supported by NHS Digital Transformation fund. The national targets assume reaching at least 10% of care home residents by March 2023 and by 2024. 
• There is a recognised need to arrange services and support into a seamless pathway ensuring ongoing personalised care that address wide range of patients’ needs in an integrated way. 
• With a number of new projects in development, evaluation of the effectiveness of each new initiative will be important to inform future service commissioning and delivery.  
• There will be significant learning from the Population Health Management programme to be applied across the system to inform future work to prevent falls. 
• Digital resources with information and advice for both professionals and public will continue to be developed in the county.