South West Falls, Fractures and

Bone Health Review July – Sept

2009

Overview of Secondary
Fracture Prevention and Falls
services

Dr Karen Harding
A systematic approach to falls and fracture prevention

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Second level
● Third level

● Fourth level

● Fifth level
 Fragility Fractures – Fracture
Liaison
• Secondary fracture prevention will be
optimised by seamless integration of post-
fracture falls risk assessment and
osteoporosis management as
advocated by the British Orthopaedic
Association and British Geriatric Society
Blue Book on care of patients with fragility
fracture.
• The National Institute for Health and Clinical
Excellence guidance on secondary fracture
prevention (TAG 161) can be delivered
through fracture liaison services for patients
presenting to hospital with new fractures
 Fragility Fractures – Fracture
Liaison
Good evidence for fracture liaison services e.g. the
Glasgow model (McLellan, Gallacher) and the cost
effectiveness of these services.
Detailed economic analysis in Department of
Health Prevention Package resources section In
this model, over a 5 year period £290,708 is saved in NHS acute and
community services and local authority social care costs, against an
additional £234,181 revenue costs. This is for an annual patient
cohort of 797 hip, humerus, spine and forearm fractures, anticipated
from a 320,000 population. At a national level, this equates to
approximately £8.5 million saving over 5 years.
 Fracture Liaison Services in the
South West
Some sort of FLS exists in the acute trusts
in Bath, Bristol (UHB and NBT),
Gloucestershire, Yeovil. These are variable
in terms systematic identification of all new
fractures in over 50 year olds, nursing
support and performance on audit.
The majority of acute trusts in our
region have no fracture liaison service
whatsoever.
 Community FLS / Historical Case
Finding
Some Primary Care Trusts have good uptake
of DES and / or LES for Osteoporosis and
these tend to have the best focus on
identifying previous fractures that need
assessment or treatment.
Bournemouth and Poole, Gloucestershire
and Somerset have primary care services
that are innovative or particularly focussed
on this work.
Overall historical case finding is
patchy and inconsistent and in many
areas non-existent
 Falls

The South West Strategic Health Authority

ambition is to reduce emergency
admissions, as a result of a fall, by 30% from
06/07 baseline by March 2010 through
effective falls and bone health prevention
programmes.
The review looked at the approach to
patients presenting with falls, services to
reduce further falls and falls prevention
strategies.
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 Falls Presenting to Emergency
Departments and Ambulance
•
Services
There is lack of data about patients
presenting with falls – in ED they are
usually coded as the injury that
results from the fall and Ambulance
Services are not collecting robust
data about non conveyed fallers
• Most EDs have links with their local
rapid response community therapy
teams and some Fallers presenting
9-5pm were assessed at the time of
presentation (mainly driven by
Only a proportion were assessed and systems
to identify those presenting out of hours or
with no discharge issues were generally poor
Communication with the primary care about
the presentation was not systematic so
opportunities for falls assessment for this high
risk group were frequently missed
Similar picture for non conveyed fallers
although ambulance services are increasingly
using Emergency Care Practitioners to assess
fallers and link to other services
Falls assessment in fracture
•Older patientsclinic
who have suffered a
fracture are the highest risk group
for further falls and fractures
• Most fracture clinics do not assess
falls risk although some are starting
to perform the Falls Risk Assessment
Tool (FRAT) and link patients with
high scores to community falls co-
ordinators
• Trusts with a Fracture Liaison Service
have the best systems for assessing
falls in fracture patients
 Falls – In patients
Most acute trusts have in patient falls
strategy groups and use various tools
to assess falls risk and reduce risk in
high risk patients
The safer patient initiative has driven
some of the improvements for in
patients and root cause analysis is
routinely being done for falls resulting
in serious injury such as hip fracture
 Falls – In patients
There are examples of audit showing reduced
rates of in patient falls when this is a particular
focus within a trust e.g. Yeovil set an internal
performance target to reduce falls by 10% and
has achieved a 6% reduction to date. Their
target for next year is a 15% reduction and
they have invested in falls reduction equipment
such as low beds and falls alarms.
Specialist Falls Prevention Clinics

Most (but not all) trusts provide a

Consultant led clinic for assessment of
patients with multiple / unexplained falls
and investigation of syncope
There are capacity issues for some of
these clinics and investigations
Interventions recommended are not
always actioned e.g. Referral for cataract
surgery, initiation of Ca + vit D
supplements
A systematic approach to falls and fracture prevention

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Second level
● Third level

● Fourth level

● Fifth level
 Community Falls Prevention

This aspect of the great pyramid seems to

have been the area most focussed on by
commissioners with some good partnership
working with local authorities, social care and
third sector organisations.
Wide variations exist, even within PCT areas,
and services were often described as like a
patchwork quilt. Effectiveness of services
often depended on the efforts of a small
number of hard pressed key individuals
 Community Falls Prevention

Some localities had particularly good services:

BaNES was felt to be particularly good at
joining up their approach to falls, fractures and
bone health.
Gloucestershire had made falls services a Local
Area Agreement stretch target and had a
Partnership for Older People’s Project (POPPs)
that addressed preventive schemes in care
homes in relation to falls and bone health.
 Community Falls Prevention
Exercise and balance classes were provided in all
areas but not all were evidence based programmes
and issues with capacity and transport were common
but good examples exist :
In Torbay there is an open referral system to access
exercise, diet, strength and balance classes, and an
Otago exercise programme led by a physiotherapist
with one to one home-based sessions for those unfit
to travel.
Tele-care and Assistive Technology

• Lifeline alarm type services are

available in most areas but some
areas had developed the range of
tele-care services further e.g.
• In Wiltshire this service provides out
of hours contacts and triage. 48% of
people assessed for alarms are
supplied a system with equipment in
addition to the Lifeline and all
patients are followed up and receive
a wellbeing check.
 Where are we now with the
Review?
• All areas have had their individual
report from the review and almost all
have returned action plans in
response to the report
• An overview report for the region will
be presented to the SHA and then be
circulated to localities. This includes
a summary of current performance
against the ambitions, a suggested
dataset and examples of good
practice
• The website is being further
www.southwestfallsandfractures.org.