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PREVENTION AND MANAGEMENT OF FALLS PROGRAMME (2007-2009)

Falls prevention and management was identified as a priority topic in 2004 by the Allied Health Professionals ClinicalGovernance network, based at NHS Quality Improvement Scotland (NHS QIS), by NHS Health Scotland andsubsequently the Scottish Executive in 2006.

A Health Department Letter, ‘Delivery Framework for Adult Rehabilitation. Prevention of Falls in Older People.’ (HDL13 2007) was published in 2007. This outlined a number of actions for NHS boards in Scotland, including arequirement for Community Health (and Care) Partnerships to appoint a falls lead. This role has responsibility for co-ordinating falls services in each CH(C)P area.

In order to support these leads, the HDL stated a commitment by NHS QIS to appoint a Programme Manager and, inconjunction with NHS Education for Scotland, to develop a community of practice. In December 2007, Ann Murraywas appointed Prevention and Management of Falls Programme Manager at NHS QIS.

This national, multiagency programme, supported by the Practice Development Unit and led by Ann Murray, aimed toraise the profile of falls and fracture prevention and to support the development of related services in Scotland. Theprogramme focused on older people living in the community. The Programme Manager worked in partnership withFalls Leads from the Community Health (and Care) Partnerships and NHS Board Rehabilitation Co-ordinatorsthroughout the two year programme.

The work achieved in the programme addressed priority topics identified by key stakeholders at the original scopingworkshop held prior to the start of the programme in December 2005, and in other scoping activities at the outset of the programme. It includes a number of work streams (outlined below). A diagram summarising the programme’swork streams and activities can be viewed here.

Throughout the programme it became evident that liaising between many different groups, and acting as a point of information and answering queries, would be a continuing and important part of the Programme Manager’s activity.This illustrates stakeholders’ recognition of the importance of falls and fracture prevention, and the current appetiteto improve related services. In addition, these services vary across Scotland and many agencies are involved; theliaison role of the Programme Manager was identified as very significant early in the programme. This networkingand associated activity absorbed at least twenty percent of the Programme Manager’s time throughout the two years.In addition, the Programme Manager, with administrative support within NHS QIS, was responsible for nurturing theCommunity of Practice among the Falls Leads and acting as a conduit for information. On the diagram of the work,

these two important activities are therefore represented as constant throughout the duration of the programme of work.

The programme at NHS QIS finished in December 2009. The programme will continue, however, for a further twoyears supported by the Scottish Government through the Framework for Adult Rehabilitation in Scotland. TheProgramme Manager, Ann Murray, will continue to support the online community of practice and oversee new workand the completion of the work initiated in the first part of the programme. Ann can be contacted atAnn.Murray3@nhs.net

The development of a Prevention and Management of Falls Community of Practice

NHS QIS, in conjunction with NHS Education for Scotland, launched a Prevention and Management of FallsCommunity of Practice in April 2008. Initially, Community Health (and Care) Partnership Falls Leads in Scotlandformed the core membership, but since then it has expanded. Now the Community comprises a number of activesub-groups with specific interests or purposes, and a wider, online Falls Community(www.fallscommunity.scot.nhs.uk). The online Community aims to enable members to access, exchange and shareknowledge, information, good practice and resources to support the development of services for older people inScotland at risk of falling.

The online Falls Community will continue in 2010. An evaluation of the Community of Practice was undertaken inDecember 2009 by NHS Education for Scotland and the summarising report will soon be available to view.

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Mapping Questionnaire for Falls Services in CH(C)P areas in Scotland

In May 2008, CH(C)P Falls Leads were asked to complete a mapping questionnaire.

The purpose of this questionnaire was threefold:

•  For the CH(C)P Falls Leads to attempt to ‘map’ community-based falls services in their locality. Since themajority of Falls Leads had only recently been appointed to these new posts when the questionnaire was issued,this was a useful exercise for the Falls Leads to consider their locality.

•  For the CH(C)P Falls Leads to use the questionnaire as a stimulus, to reflect and to consider good practicecurrently in place, gaps in service provision and potential areas for future development.

•  To provide baseline information, in order to identify changes in service design, provision or delivery in the future.

The mapping questionnaire also provided information which was subsequently used in further activity. For example itwas used to assist in the identification of outcome measures employed across Scotland, prior to a consensus meetingon measuring outcome, and to identify strategies employed in different Community Health (and Care) Partnerships inScotland to identify older people at risk of falling. This information helped shape the Case Finding workshop. Fromthe mapping questionnaire, it became evident that good practice existed at all stages of the falls pathway in at leastone locality in Scotland and this confirmed that the concept of a Community of Practice, whereby members sharegood practice, was an appropriate tool for improvement in the area of falls services.

Reference Group Meetings for Older People and Carers

Older people and their carers’ experiences of falls and falls prevention services, and their views on the content of ‘Upand About’, a NHS QIS resource under development at the time, were sought in a series of group discussions held inthree NHS board areas of Scotland throughout October 2008. This consultation was organised and delivered inpartnership with NHS Forth Valley, NHS Greater Glasgow and Clyde and NHS Ayrshire & Arran. In total, 31 serviceusers and six carers with recent experience of falls and osteoporosis services attended these events. This attempt tocapture information on the patient experience of falls services provided a useful perspective for the ProgrammeManager to reflect back to the online community and include in the resource, ‘Up and About.’ 

From the discussions, key messages were identified to inform the planning, delivery and development of person-centred services. The messages are presented in Appendix 3 of ‘Up and About’ (see below).

The development of a new resource, ‘Up and About: pathways for the prevention and management of falls andfragility fractures’

This resource focuses attention on the key stages of the journey of care of an older person living in the community.It presents, in one document, an overview of the many aspects of fall and fragility fracture prevention andmanagement, and attempts to demonstrate how they link to provide comprehensive, co-ordinated and person-

centred care. ‘Up and About’ has been produced to assist in identifying and promoting best practice, identifying gaps

in service provision, and planning service improvement. 

This document is underpinned by:•  the best available explicit evidence drawn from recognised guidelines and publications that present

recommendations relevant to this topic•  tacit and organisational knowledge, and•  the views and experiences of older people and their carers.

The pathways featured in the resource have been developed using the model featured in the Delivery Framework forAdult Rehabilitation in Scotland.

Up and About is now available both on this website and via the online Community of Practice, or by clicking here.

Up and About Quick Reference Guide

A Quick Reference Guide for Up and About summarising the key stages of the pathway has been produced and isavailable by clicking here.

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Falls awareness training (with NHS Education for Scotland)

Throughout the various scoping activities undertaken for the NHS QIS programme it was recognised that, with agrowing population of older people, a collective responsibility for falls prevention and management must bepromoted. Health and social care staff working regularly with older people are ideally placed to (a) provide olderpeople and their carers with advice and information about falls prevention to support self management (b) identifyindividuals at high risk of falling, and falling and fracturing, and (c) refer to relevant disciplines or services for furtherintervention. An awareness and understanding of the topic, gained through suitable training, would enable keystakeholders working with older people to have an active role in falls prevention and management.

A working group was established in April 2009 to develop, at a national level, a consistent approach to multi-agencyfalls awareness training. The group comprises professionals with knowledge and experience of delivering fallsawareness training in the workplace, the Falls Programme Manager and a representative of the ScottishQualifications Authority (SQA). The group is chaired by Susan Shandley, Practice Education Co-ordinator with NES,who is leading a national work stream on the accreditation of work-based learning. The group aims to agree a set of national learning outcomes for falls prevention and management training and the underpinning knowledge requiredto achieve them. The group is working with an external verifier from the SQA who will map this information toScottish Vocational Qualifications to enable participants to gain a formal recognition of their learning.

This work stream will continue beyond December 2009.

For further information contact: ahpadmin.qis@nhs.net

Guidance for the use of clinical outcome measures in the management of older people who have fallen

A national survey identified over 30 outcome measures in common use in Scotland as part of the management of anolder person at risk of falling. This work stream aimed to develop advice to assist clinicians and service providers inselecting the best available ‘fit for purpose’ tools to measure the impact of an intervention.

The advice produced aims to:

•  promote the use of outcome measures that are acceptable to older people, valid, reliable, responsive tochange, useful and practical ie measures that are ‘fit for purpose’ 

•  guide service providers and practitioners wishing to start collecting information to evaluate theirinterventions, and

•  promote a common language/currency which will enable the comparison of different populations, practicesand programmes in Scotland.

A consensus development meeting held on Thursday 10 September 2009 contributed to the development of adviceon the selection of outcome measures in clinical practice. Specialist clinicians from across Scotland were invited tocontribute to this process. Five groups discussed outcome measures from the following domains: gait and balance,fear of falling, activities of daily living, environment and quality of life.

This work stream will continue beyond December 2009. When the advice has been finalised it will be disseminatedthrough the CH(C)P Falls Leads and consensus event participants and will be available on this website and atwww.fallscommunity.scot.nhs.uk 

For further information contact: ahpadmin.qis@nhs.net

Case finding: identifying older people at high risk of falling

On Wednesday 9 September 2009, NHS Quality Improvement Scotland (NHS QIS) convened a workshop on fallsprevention and management, focusing on case finding - the identification of older people living in the community whoare at high risk of falling. The event, held at the Beardmore Conference Centre, Clydebank, brought together oversixty participants from a range of professions, services and organisations to discuss effective ways to identify andmanage older people in the community at high risk of falls. Participants included CH(C)P Falls Leads, RehabilitationCoordinators, Long Term Condition Leads and other key stakeholders from across Scotland. The purpose of theworkshop was to promote a common understanding of, and consistent approach to, case finding and falls riskassessment in the community setting.

A report outlines the aims of the day and summarises the presentations and workshop output and is available here.

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The use of telecare within approaches to improve the prevention and management of falls and fractures

Throughout 2009, NHS QIS and the National Telecare Programme (supported by the Joint Improvement Team) havebeen working with three partnership areas (Falkirk/NHS Forth Valley, South Ayrshire/NHS Ayrshire & Arran, andPerth & Kinross/NHS Tayside) to explore the potential role and benefits of using telecare as part of improvements tothe prevention and management of falls and fractures in older people.

It is the stated intention of all the above parties that the experiences and materials developed during this initiativewill be widely shared with other interests and practitioners. This is to promote the exchange of knowledge, ideas andgood practice.

To enable and support this process, the Joint Improvement Team has agreed to:

  facilitate and record the learning/actions from joint workshop sessions  develop a joint monitoring and evaluation methodology for use by all three areas which identifies anticipated

outcomes & measure impacts of approach, and  prepare and publish any good practice materials that may be developed (with clear acknowledgement of all the

parties involved).

Further information can be found by clicking here and by contacting ahpadmin.qis@nhs.net This work stream will continue beyond December 2009.

Data collection

Data collection, from clinical, service and planning perspectives, was identified as a priority throughout the variousscoping activities undertaken for the NHS QIS programme. Stakeholders identified that data relating to falls and theconsequences of falls is not collected consistently on a national or local basis.

At every stage of the older person’s journey of care, the collection of accurate and relevant data would not onlyidentify the impact of falls on the individual and on health and social services, but support direct care and provideinformation for service and resource evaluation, planning and improvement. Baseline data is required to showchanges in trends and demonstrate the impact of improvement work.

Throughout the two year programme, the Programme Manager liaised with Information Services Division, theNational Clinical Dataset Development Programme, the Scottish Government, NHS Ayrshire & Arran and local CH(C)PFalls Leads to explore options for developing consistent and comprehensive data collection for supporting effective,safe and person-centred care for older people who have fallen and/or are at risk of falling.

This work will continue as part of the Framework for Adult Rehabilitation in Scotland work programme.