• There is a disparity in the numbers of individuals who call an ambulance as a result of a fall, those who are admitted to hospital and those who are referred to the specialist services.
• The number of fallers being admitted to hospital continues to rise year on year.
• The number of people aged 85 and over living in the city will increase and this is the most at risk group.
• The number of older people ( mainly age 80+) entering residential care has risen in 09 after two years of falling admissions, the reasons for this needs to be understood and preventative and early intervention services put in place to re-establish a reduction in admissions. Falls are a major risk factor for entering residential care.
• A wide range of health and social care staff come into contact with older people who have fallen or at risk of falling presenting an opportunity to intervene.
• There continues to be a lack of intelligence available regarding falls in BME communities.
• In order to prevent admissions as a result of falls an increase in specialist services will be required and improved identification, prevention and management of falls by health and social care teams. The service has been expanded through service redesign and waiting times reduced. This will need reviewing over time to see whether the new service is sufficient.
• However given the ongoing increase in falls, the awareness raising amongst health staff of the referral route, and the aging population, it is likely that referrals will increase over time and the need for the service will expand over time. This will continue to be monitored.

• Improve identification of at risk individuals, prevention and treatment of falls by health and social care professionals including GP’s, District Nurses and Home Care staff
• Review referral pathways in line with Rehabilitation Service redesign to ensure high-risk individuals are accessing appropriate services including the Falls Prevention Service

• City Central PBC cluster has prioritised falls within its business plan, promoted the Guide to Action tool and produced the GP guide to patient information. The PBC cluster will also be organising training for GPs. The PCT should consider encouraging the other PBC clusters to follow this strong lead.

• Continue to monitor the referrals to the PCT Falls Prevention Service, in light of the increase in hospital admissions from falls and the increase in the proportion of over 85s in Nottingham city, both of these factors may lead to an increase in referrals and insufficient capacity within the falls prevention service.

• Continue to focus on falls risk in care homes which will include medicines reviews of residents.

The risk of falling increases with age, particularly in those 65 and over (APHO 2008). 35% of over 65s are at risk of falling each year, rising to 45% of people aged 80 and over. Between 10- 25% of these fallers will sustain a serious injury. 22% and 60% of older people suffer injuries from falls, 10-15% suffer serious injuries from falls, 2-6% suffer fractures and 0.2 – 1.5% suffer hip fractures (Masud et al 2001).

Regardless of the outcome, falls are associated with a loss of confidence, and a subsequent restriction in physical activity which leads to a further loss of capacity and bone density. This increases the risk of another fall and also the likelihood of entering residential care. (DH 2009a)

Falling rates are higher in older women than older men and higher in Care Homes, where there is increased likelihood of co-morbidity. This has been calculated to be as high as 1.5 falls per bed with as many as 75% of nursing home residents falling annually, twice the rate of older people living in the community. (Rubenstein et al1994) Evidence suggests that the tendency to fall is higher in the White British population than in the BME population. White British females are more likely to experience fracture in relation to falls because of their increased risk of osteoporosis (Todd et al 2006).

Nationally the number of people aged over 65 is due to rise by a third by 2025, which is associated with increased incidence of falls of 2% per year (DH 2009b). In Nottingham City the number of people aged 85 plus is projected to increase, and this is the most vulnerable group.

Older people and Dementia are considered elsewhere in the JSNA.

Regardless of which definition of falls is used, all numbers of events and Directly age and sex standardised admission rates are increasing, year on year. This is with the exception of ambulance call-outs for which trend data has not yet been made available to the PCT.

The number of older people ( mainly age 80+) entering residential care in Nottingham City (Source: ASH) has risen in 2009 after two years of falling admissions, the reasons for this needs to be understood and preventative and early intervention services put in place to re-establish a reduction in admissions. Falls are a major risk factor for entering residential care.
A recent audit carried out by NHS Nottingham City in 2009 in 80 care homes across the city identified significant variation in the frequency and quality of medication reviews, a lack of formal communication links between care home staff, GPs and community pharmacists and other services, high levels of ‘waste’ medicines, a lack of formal training and policies around essential medicines management activities e.g.: Administration of medicines and controlled drugs management which are increasing risk of harm to both patients and staff, a lack of coordination of the prescribing of other agencies including OOH providers, secondary care providers, community psychiatric teams and dieticians in order to minimise conflict and duplication, and a need to improve systems for the safer management of controlled drugs.

Assuming that 35% of over 65s are at risk of the fall, then relating this to the Nottingham City population of over 65s gives almost 12, 000 at risk (11,839). A high proportion of these (9430) are estimated using the ‘Poppi’ tool to actually fall in a year.

There are several different ways of defining a fall and data has been given on all of these where available. Numbers given below relate to a one year period, which will be the most recent year of data available, for City PCT residents, aged 65 plus.

Population at risk:11,839 (Source: ONS mid year population estimates applied to 35% risk in over 65s reported in Masud et al 2001).
Numbers aged 65+ estimated to fall: 9430 (Source: Poppi)
Fallers attended by East Midlands Ambulance Service: 2942, 1254 of these were transferred to hospital (EMAS, 2006) More up-to-date data is currently being sourced from EMAS.
Fallers who are admitted to hospital, but may or may not have broken anything in 2008:1565 (Source: NHS Nottingham City Information team)
People who are admitted to hospital with an avoidable injury (previous LAA target) in 2008: 1383 (Source: NHS Nottingham City Information team)
People who are admitted to hospital with an avoidable injury which is serious 2007/08 (Length of Stay >3 days): 790 (Source: NCHOD)
Fallers who were admitted to hospital with an injury in 2008: 766 (Source: NHS Nottingham City Information team)
People admitted with fractured neck of femur in 2007/08: 253 (Source: NCHOD)

Figure 1: Chart showing Avoidable injuries (also referred to as ‘injury and poisoning’ because of the ICD 10 chapters which are included in this definition) in Nottingham City residents aged 65 plus, with comparison of Nottinghamshire County districts. (Source: NHS Nottingham City Information team).

This broad definition of falls which was previously the LAA HCOP 9 target, has increased year on year since 2004.  These are increasing over time, in common with the other districts but with a more pronounced pattern.

Figure 2: Serious accidental injury (defined as length of stay in hospital 3 days or greater) admission rate to hospital, 65 plus
 
Figure 2 shows that our admission rate to hospital with a serious accidental injury (defined as length of stay in hospital 3 days or greater) is significantly worse than the England average and worse than our peer local authorities.

Figure 3: Emergency hospital admissions: fractured proximal femur

Figure 3 shows that our admission rate to hospital with fractured proximal femur is quite low compared to our peer local authorities, and is not significantly different to the England average.

Within City variation
Due to the relatively small number of hospital admissions from falls, it is difficult to compare the areas within the City in a statistically significant way.  Any significant variations at ward level between specific wards and the average for Nottingham City have been described below. The admission rates are all DSRs (Directly Age and Sex Standardised) so any differences in the age structure of the wards have been accounted for in the calculation, meaning observed differences are over and above the effect of age and sex.

Falls with injury, Nottingham City residents, 2008, people aged 65 plus
Wards with the highest rates were Bilborough, Dales and Dunkirk and Lenton, although due to low numbers many of the wards of the city do not have a statistically significantly higher or lower rate than the city average. Only Wollaton West and Bulwell were significantly lower in terms of falls admissions than the average for Nottingham City.

Falls (may or may not have had an injury, Nottingham City residents, 2008, people aged 65 plus
Wollaton East, St Ann’s, Bilborough and Bulwell wards had significantly higher admission rates the average for the City, Bulwell Forest, Wollaton West were significantly lower.

All injuries and poisonings (former LAA HCOP9 target definition, Nottingham City residents, 2008, people aged 65 plus
Bridge and St Ann’s wards have significantly worse admission rates than the average for the City, whereas Bulwell Forest, Wollaton West and Arboretum were significantly lower than the City average.

Falls with injury from care home residents
Over a three year period (2006-2008) Area 4 was found to have the highest number of falls per care home compared to other care homes in the City. This agrees with previous data from 2003-2005 which showed area 4 to be the highest area for numbers of falls from care homes.

There is inadequate recording of ethnicity in hospital data therefore it is not possible to analyse falls admissions by ethnicity.

Notable changes in need since JSNA April 09
Numbers of admissions to hospital with a fall in older people have increased in the City, regardless of which definition of falls is examined, with the exception of fractured neck of femur (has only increased slightly)
Further needs assessment needs to be carried out to establish whether this a real increase in people actually falling, whether we are witnessing already the effects of our aging population or whether there has been a change in hospital admission/ discharge policies which would explain the increase.

Primary Prevention

Partnerships and Training
Working to prevent falls in the community requires a partnership, co-ordinated approach. The Home Safety for Older People group (HSOP); has been providing training and a referral pathway for over 9 years in the city. This enables frontline staff from all agencies to refer older people for services which can promote and maintain independence in the home and ultimately reduce the need for people to move into residential care.
In 2010, the City Council, along with all of the key partners from HSOP- will be launching the new ‘City Signposting Service’. This will build on the success of HSOP, and will provide 10 pathways on one simple to use form. The Falls Prevention Service is one of the pathways – along with;
Age Concern Nottingham & Nott’s, Pension Service, PAD, Telecare, Nottinghamshire Fire & Rescue Service, Safer Homes Team, NCC Adaptations Agency, NCH Housing Options Team, NCC Active Communities Team and Greater Nottingham Healthy Housing Service. Again, frontline staff will be trained to use the pathway. The service has funding for 2 years and will be hosted by Age Concern.

Falls Prevention Training (foundation and advanced levels)
During the previous 2 years, the FPS have delivered training on falls prevention to 893 staff in health, social care, the voluntary sector and other key frontline staff. The aim of this training and awareness raising at both a public and professional level is to have an overall effect on the reduction of falls in the community.

Community Falls Forum
This group has been recently set up to form an ‘interface’ between health and social care. The relationships which were formed during the previous LAA under HCOP9 and 10 were very successful, so it is hoped that this group will enable those relationships to be maintained and developed further.

Community Events
Over the last 2 years, the FPS has been represented at community events/talks/awareness days throughout the city to engage the public and raise awareness of the services provided, and those of partners. Health Promotion and FPS have organised an event in the Market Square for the last 3 years to mark National Falls Awareness Day in June. These have been very well attended, and well supported by partner organisations. The service also give talks to smaller groups.

Specialist Services

The Falls Prevention Service (FPS)
This service is provided by CitiHealth. The Falls Prevention Service will provide a service to adults with urgent, complex rehabilitation needs to falls patients. The Domiciliary Rehabilitation Teams will provide a service to patients with non urgent basic rehabilitation needs to include Falls patients (see separate service specification)

An expected 1550 referrals per year will be screened per year, 60% of non-urgent referrals will be seen and assessed by the domiciliary team and 40% of urgent referrals will be seen by the FPS (Falls Prevention Service) The falls prevention service assessed and treated 854 people in 2009, 850 in 2008 and 750 people in 2007. Referrals are generated from hospital admissions and from health and social care professionals. Additional short term funding has enabled the current waiting list to be reduced to 2 weeks. The service is designed to reduce the number and impact of falls in the elderly alongside the promotion of independence and healthy bones. The specialist assessment by the service involves: identification of falls history, assessment of balance, mobility and muscle weakness, osteoporosis risk, home hazard, health assessment and medicine review.

The work of the falls prevention service in Nottingham City was praised at national level. A local audit from a small sample of patients who accessed the service showed a considerable reduction in the numbers of falls (32 to 2). This audit is being repeated to assess current service delivery.

The expected outcomes from the service are:

• An improvement in support, advice and information available to older people who fall and their carers
• The promotion of effective medicines management
• A reduction in the pressure on the Emergency Care Pathway by a reduction in:
• unplanned hospital admissions and emergency bed days due to falls
• attendances at the Emergency Department due to falls
• A reduction in hospital admissions from care homes precipitated by falls
• A reduction in hip fractures resulting from falls

The service aims to provide an advanced level of clinical expertise in the assessment, diagnosis and management of highly complex patients, using specialist knowledge and skills within the area of falls prevention and bone health. To include:

• Anxiety management
• Vestibular rehabilitation
• One to one exercise programmes
• Provision of equipment
• Chair based exercise programmes
• Home hazard assessments
• Postural stability groups, intermediate and advanced
• Fracture risk assessment

Figure 4: The patient pathway for the service is given below. :

Universal Health and Social Care Services

A large range of services come into contact with people who fall including GPs and health and social care teams. A recent audit found that nearly a third of clients present to the Nottingham Emergency Home Care Service with a fall. Over 6000 people in the 65 and over age group were seen by a District Nurse in 2006. Assuming that this population would be at 30% risk of a fall. Up to 1800 of these individuals have the potential to fall annually.

East Midlands Ambulance Service

The East Midlands Ambulance Service (EMAS) were called to 2942 falls, in the 65 and over age group in 2006. 1254 of these were transferred to hospital. More up-to-date data is currently being sourced from EMAS.

Telecare
This is a service commissioned by the Adult Support and Health directorate of the City Council. The term “Telecare” describes several levels of remote monitoring for vulnerable people. These range from well-established community alarm systems, motion-monitoring systems, to monitoring symptoms of specific medical conditions.
Nottingham on Call is the care alarm call centre for Nottingham City Homes (Telecare Services Association accredited). They monitor and respond to approximately 13,000 alarms and triggers and act as the Telecare monitoring centre for Nottingham City. Nottingham on Call operates a pool of Mobile Support Officers who provide an installation and response service for service users where appropriate.

The Telecare Service went live in July 2007. As at November 2009 there have been 1314 Telecare packages installed, 620 packages have been installed in the first 6 months of 2009/10, double the whole of last year. Installations are carried out within 7 days of a referral being made, with emergencies installed within 48 hours. Approximately 20% of installations are for falls detectors. The system works by alerting named key holders in the event of an emergency. It aims to reduce fear of falling in vulnerable older people which may increase the likelihood of them remaining independent in their own home.

Limited Supporting People funding which was originally agreed to fund 400 users is no longer available which means all users are liable to pay the £2.85 weekly charge. It would be useful to analyse the referrals data by characteristics such as age and deprivation to see whether this is disproportionately affecting vulnerable groups.

Practice Based Commissioning activity
Falls and Osteoporosis had been included on the City Central PBC cluster business plan within Nottingham City PCT for 09/10 and 10/11 and work has included producing a GP guide to patient information (Novak et al 2009) and arranging awareness sessions for GPs and practices nurses to cover the new referral pathway following the redesign of the rehabilitation services commissioned by the PCT. During 2010 this will involve organising training for GPs on Falls Prevention and Osteoporosis and entering into a partnership with the pharmaceutical industry similar to the INFORCE and Happy Hearts projects. This guide and the associated training could be rolled out to all GP practices across the City.

Medicines management activity
The PCT medicines management continues to undertake medication reviews with care home residents in Nottingham City, which will help to reduce falls risk. The aim is to carry out 500 in depth reviews in 2009/2010.

Notable changes in services since JSNA April 09

• Increased capacity of specialist Falls Prevention Service to enable requisite training and development to be carried out to support Rehabilitation Service redesign objectives. This has reduced the waiting list considerably. The target in the service specification is for
• Falls Prevention Specialist role expanded to substantive F/T post
• Health Promotion Specialist (Older People's Avoidable Injuries) confirmed as a substantive post
• Clinical Specialist for Falls now  in post with Nottingham CitiHealth (August 09)
• Community Geriatrician with special interest in falls in post in Nottingham CitiHealth (September09)
• Reviewed referral pathways in line with Rehabilitation Service redesign to ensure high-risk individuals are accessing appropriate services including the Falls Prevention Service
• Local research due to be published by Logan et al at Nottingham University has confirmed the effectiveness of the Falls Prevention Service in reducing repeat fallers. The abstract of this research is available.
• Limited Supporting People funding which was originally agreed to fund 400 users of the Telecare service is no longer available which means all users are liable to pay the £2.85 weekly charge.

Local population projections indicate little change in the 65 and over age group overall, however the number of people aged 85 plus is predicted to increase, and given that this is the most vulnerable group this will lead to an increased number of falls.

Figure 5: People aged 65 and over predicted to be admitted to hospital as a result of falls, by age group (65-69, 70-74 and 75 and over), projected to 2030

	2009	2015	2020	2025	2030
People aged 65-69 predicted to be admitted to hospital as a result of falls	46	54	50	57	64
People aged 70-74 predicted to be admitted to hospital as a result of falls	75	72	84	80	89
People aged 75 and over admitted to hospital as a result of falls	655	640	659	729	780
Total population aged 65 and over predicted to be admitted to hospital as a result of falls	776	766	793	865	934

Source: Poppi (2009)

Figure 6: Population aged 65+ living in Nottingham City predicted to have a fall

	2009	2015	2020	2025	2030
People aged 65-69 predicted to have a fall	1,809	2,109	2,014	2,224	2,547
People aged 70-74 predicted to have a fall	1,955	1,847	2,142	2,055	2,297
People aged 75-79 predicted to have a fall	1,669	1,569	1,534	1,802	1,718
People aged 80-84 predicted to have a fall	1,804	1,733	1,699	1,730	2,052
People aged 85 and over predicted to have a fall	2,193	2,408	2,666	2,881	3,225
Total people aged 65 and over predicted to have a fall	9,430	9,666	10,055	10,692	11,839

Source: Poppi (2009)

NICE (2004) Falls: The assessment and prevention of falls in older people.
This recommends that all those hospitalised following a fall or with abnormalities of gait and balance are seen by a specialist falls service.
DH (2009) Prevention for older people resources http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_103146
This brings new guidance on data sources for needs assessment and cost effectiveness of interventions together in a new pack of resources.

Local research due to be published by Logan et al at Nottingham University has confirmed the effectiveness of the Falls Prevention Service in reducing repeat fallers. The abstract of this research is available.

It has now been written into the PCT service specification of the falls service and the domiciliary rehab service that 10% of the users of the service will be surveyed on their level of satisfaction. This information will be reviewed at the yearly contract review, and will be included in future JSNA updates.
Feedback has been received from service users and carers on their experiences of the Telecare service, this has been very positive with 90% of service users stating that the equipment had given them more confidence/ peace of mind. This is available on the City Council website.
Research by Help the Aged (2005) has provided feedback from older people participating in falls prevention focus groups, and has identifed 3 key messages to maximise impact:

• focus on improving strength and balance, not falls
• encourage people to personally choose the advice and activities that suit them
• don’t focus on avoiding ‘hazards’ or physical restriction such as wearing hip protectors – this is perceived as overbearing.

EIAs are planned for the specialist falls service and domiciliary rehab service.

• There is a disparity in the numbers of individuals who call an ambulance as a result of a fall, those who are admitted to hospital and those who are referred to the specialist services.
• The number of fallers being admitted to hospital continues to rise year on year.
• The number of people aged 85 and over living in the city will increase and this is the most at risk group.
• The number of older people ( mainly age 80+) entering residential care has risen in 09 after two years of falling admissions, the reasons for this needs to be understood and preventative and early intervention services put in place to re-establish a reduction in admissions. Falls are a major risk factor for entering residential care.
• A wide range of health and social care staff come into contact with older people who have fallen or at risk of falling presenting an opportunity to intervene.
• There continues to be a lack of intelligence available regarding falls in BME communities.
• In order to prevent admissions as a result of falls an increase in specialist services will be required and improved identification, prevention and management of falls by health and social care teams. The service has been expanded through service redesign and waiting times reduced. This will need reviewing over time to see whether the new service is sufficient.
• However given the ongoing increase in falls, the awareness raising amongst health staff of the referral route, and the aging population, it is likely that referrals will increase over time and the need for the service will expand over time. This will continue to be monitored.

• Improve identification of at risk individuals, prevention and treatment of falls by health and social care professionals including GP’s, District Nurses and Home Care staff
• Review referral pathways in line with Rehabilitation Service redesign to ensure high-risk individuals are accessing appropriate services including the Falls Prevention Service

• City Central PBC cluster has prioritised falls within its business plan, promoted the Guide to Action tool and produced the GP guide to patient information. The PBC cluster will also be organising training for GPs. The PCT should consider encouraging the other PBC clusters to follow this strong lead.

• Continue to monitor the referrals to the PCT Falls Prevention Service, in light of the increase in hospital admissions from falls and the increase in the proportion of over 85s in Nottingham city, both of these factors may lead to an increase in referrals and insufficient capacity within the falls prevention service.

• Continue to focus on falls risk in care homes which will include medicines reviews of residents.

Notable changes since JSNA 2009
The following recommendations have been removed as they have either been implemented or are in the process of being implemented:

• Increase capacity of specialist falls prevention service to enable requisite training and development to be carried out to support Rehabilitation Service redesign objectives.
• Falls Prevention Specialist role expanded to substantive F/T post.
• Health Promotion Specialist (Older People's Avoidable Injuries) to be confirmed as a substantive post to support this agenda.

Further needs assessment needs to be carried out to establish whether there is a real increase in people actually falling, whether we are witnessing already the effects of our aging population or whether there has been a change in hospital admission/ discharge policies which would explain the increase.
Updating of the Interim Falls paper (2007) and identification of number of ‘individual’ fallers admitted to hospital. It would also be useful to include in this update an analysis of referrals to the falls prevention service, by referral source- to identify those staff groups or GP practices where awareness of the service needs raising.

Updating of figures from EMAS regarding ambulance call outs to those who have fallen.

Identify whether there is a fall in the rate if increased referrals to the Telecare service following removal of the Supporting People funding (which means service users now have to pay weekly fee of £2.85). Identify through Health Equity Audit whether there is inequity of access to the service, for example whether those in more deprived areas are now being referred less.

Helen McCloughry, Head of Rehabilitation and Intermediate care, Nottingham City PCT
helen.mccloughry@nottinghamcity-pct.nhs.uk

Elaine Yardley, Director of Adult Services, Housing and Health, Nottingham City Council
elaine.yardley@nottinghamcity.gov.uk

Shirley Smith, Assistant Director for Community Services and Older People Commissioning, Nottingham City PCT

shirley.smith@nottinghamcity-pct.nhs.uk

APHO (2008) Indications of Public Health: Older People 2008. Available at http://www.wmpho.org.uk/resources/APHO_OP.pdf [Accessed 15 March 2010]
CSED (Care Services Efficiency Delivery Programme) (2009) Projecting Older People Population Information System. Available at www.poppi.org.uk [Accessed 25 January 2010]

DH (2009) Prevention for older people resources http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_103146 [Accessed 25 January 2010]
DH (2009a) Impact assessment for fracture prevention interventions. Available at: http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_106379.pdf [Accessed 25 January 2010]

DH (2009b) Falls and fractures: effective interventions in health and social care. Available at:  http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/@pg/documents/digitalasset/dh_109122.pdf [Accessed 25 January 2010]

Help the Aged (2005) Don’t mention the F word! http://www.helptheaged.org.uk/NR/rdonlyres/727A83F3-6579-452F-96AE-0478593DCC38/0/dont_mention_the_f_word.pdf [Accessed 25 January 2010]

Logan et al (2009) Community Falls: A randomised control trial. Nottingham University. (Not yet published) Abstract available at http://www.controlled-trials.com/ISRCTN67535605/

Masud, T. & Morris, R. (2001) Epidemiology of falls. Age and Aging 30-54:3-7

NICE (2004) Falls: The assessment and prevention of falls in older people. Available at http://www.nice.org.uk/Guidance/CG21/Guidance/pdf/English [Accessed 25 January 2010]

NHS Nottingham City Information team (2009). Hospital activity data, Secondary Users Service.

Novak, C., Garlick, S., Ward, M. & Dicks, S. (2009) A GP Guide to Patient Information on Falls Prevention and Osteoporosis. NHS Nottingham City and CitiHealth.

Rubenstein, L.Z., Josephson K.R. & Robbins A.S. (1994) Falls in the nursing home. Annals of Internal Medicine.1994; 121: 442–51.

Todd, C., Ballinger, C. & Whitehead, S. (2006) Reviews of the socio-demographic factors related to falls and environmental interventions to prevent falls amongst older people living in the community. WHO. Available at http://www.who.int/ageing/projects/3.Environmental%20and%20socioeceonomic%20risk%20factors%20on%fallspdf [Accessed 15 March 2010]