Developing effective services for falls and fracture patients

1. Developing effective services for falls and fracture patients Presented by member of Older People & Dementia Branch, Department of Health

2. Why are we here today? • 68,000 fell and fractured hip in England in 2008/9 • largest occupier of trauma bed days • high mortality, morbidity, and cost • 200,000 + other fragility fractures: wrist, pelvis, shoulder • Total costs of fragility fracture care is < £2 billion yearly • Falls affect 30% of people over 65 and 50% over 80yrs • - major reason for hospital attendance and admission • - ambulance call out and admission to long term care • We have guidelines and standards, but………… • The NHS is NOT delivering adequate care • Care and outcomes show massive variation

3. Oxfordshire PCT Commissioning 2008/9

4. Falls and Fractures – the growing epidemic of our ageing population Why we need to get it right for older people Why we need to get it right for the NHS and Social Care Understanding fragility fractures as a long-term condition How are we doing against standards and guidance Doing it better is possible and cost-effective The 4 key aims - why and how to achieve them Objective 1: Improve outcomes and efficiency of hip fracture care Objective 2: Respond to the first fracture, prevent the second Objective 3: Early intervention to restore independence after falls Objective 4: Prevent frailty, preserve bone health, reduce accidents What will be done nationally to support this What PCTs and councils and providers need to do locally This morning’s messages

5. What about your other priorities ? Issue Strokes/TIAs Heart attacks Fragility Fractures Incidence/year 110,000 275,000 310,000 Current trend Falling Falling Rising NHS bed days*1.85 million 1.15million 1.57 million (hips) Annual costs £2.8 Billion £ 1.7 Billion £ 1.7 Billion Thanks to Jonathan Bayly for bar chart

6. > 15,000 will fall each year, >6000 twice or more Most will not call for help >70/week will attend A&E or the MIU A similar number will call the ambulance service 350 hip fractures/year ~1000 other fragility fractures Average PCT & council costs on falls are £50m per annum Ageing demography means this will increase 50% by 2020 For a typical 300K PCT :

7. Understanding falls and fragility fractures as long-term conditions Genetics and maternal factors Lifestyle etc Events and illnesses and chance Well woman with first fracture, usually wrist Age 50-70s Postural instability and falls Osteopenia and osteoporosis First fracture in frail person Age 70-80s Fall, injury, loss of confidence  strength, balance, vision or judgment 50% Second fracture, usually more serious, often hip - average age 82 y Reduced activity The vicious cycle into dependency

8. Fragility fracture through the life span1Osteoporosis + falls = fragility fractures Additional morbidity from fragility fractures Morbidity from other causes “Hip fracture is all too often the final destination of a 30 year journey fuelled by decreasing bone strength and increasing falls risk”2 1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell 2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ

9. Efforts to tackle the problem with policy and guidance etc NSF NICE NICE falls 20 prevention RCP audit ------------------------------------I NHFD ------------------------I Toolkit PbR best practice increasing incidence of fragility fractures 2001 2011 ?

10. RCP national audits 2005 to 2011 Clinical Audit 2006/7 • Individual patient level data • Fragility fractures rather than falls because • simple to define • good evidence base for benefit (NICE) • Patients attending Emergency Departments with • Non-hip fractures (40) - radius, ulna, humerus, pelvis or vertebra • Hip fractures (20) • Total scores calculated from all domains of acute care and secondary prevention of falls and fractures

11. Total audit scores showed variation ++ non-hip fractureship fractures Best practice

12. No SHA has got it sorted - non hips

13. Not even in centres of excellence • QJM 2009 e-pub 28 Oct Premaor M.O. Et al • http://news.bbc.co.uk/1/hi/health/8333834.stm

14. DH Systematic approach to falls and fracture care & prevention: four key objectives Stepwise implementation Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards Hip fracture patients Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care Non-hip fragility fracture patients Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention Individuals at high risk of 1st fragility fracture or other injurious falls Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards Older people 20 September 2014

15. DH Systematic approach to falls and fracture care & prevention: four key objectives Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards NSF, TA161, CG21, Blue Book & NHFD Hip fracture patients Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care NSF, TA161, CG21 & Blue Book Non-hip fragility fracture patients Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention NSF, TA160 & CG21 Individuals at high risk of 1st fragility fracture or other injurious falls Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards NSF, LTC programmes Social care Older people 20 September 2014

16. Fracture Liaison Services Case finding in A&E, MIUs and hospital fracture services Apply NICE guidance care pathways Link straight to falls services Monitor and maintain medication adherence Case find for those with previous fractures Agree who needs specialist investigations and services from local Osteoporosis experts Objective 2: Respond to the first fracture, Prevent the second How is this achieved? What do the NHS and local councils need to do? • Commission a Fracture Liaison Service from the acute hospital • Appoint an Osteoporosis champion in primary care • Implement the DES for Osteoporosis • Broker the local service level agreements

17. Consider a PCT population of 300,000 Post-menopausal women with new fracture each year Fracture Liaison: Acute-care based 900 Post-menopausal women with priorfracture history Fracture Liaison: Primary-care based 6,900 Post-menopausal women with osteoporosis 17,400 GP case-finding stratified by risk + Direct Access DXA Services Post-menopausal women 55,000 1. http://www.statistics.gov.uk/pdfdir/popest0808.pdf 2. (Adapted from) Curr Med Res Opin 2005;21:4:475-482 Brankin E et al

18. It improves care ------- as shown by the FLS in UK, Europe and N America Kaiser Permanente Southern CaliforniaSurgeon Led Fracture Prevention Program 1. JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730

19. Kaiser Permanente Southern CaliforniaSurgeon Led Fracture Prevention Program And it reduces incidence of hip fractures 1. JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730

20. Fallers who are unsteady need a falls risk assessment medical conditions, gait & balance, vision, medication review Fear of falling and restricting activity leads to further falls re-enablement and rehabilitation Increase opportunities for social participation Successful programmes are multidisciplinary BUT coordinated Exercise to improving strength and balance is the most powerful Objective 3: Early intervention To restore independence How is this achieved? What do the NHS and local councils need to do? • Review the local falls pathway with the community and acute providers • Agree who does what? Who attends specialist clinics? • Build falls prevention into mainstream services and intermediate care • Commission effective exercise programmes • Consider using the leisure services and voluntary sector

21. Promote healthy ageing and preserve bone health Physical activity (as per the NHS physical activity strategy) 30minutes x 5 per week Maintain optimal weight Quit smoking Alcohol only in moderation Targeted home assessments and Telecare Medications reviews Safe environments for promoting social participation Objective 4: Prevent frailty, preserve bone health, reduce accidents How is this achieved? What do the NHS and local councils need to do? • Use JSNA and develop local strategies • Involve the local population

22. What is in the DH falls & fractures commissioning toolkit 2009 Overview guide and narrative slide set Economic evaluation Joint Strategic Needs Assessment advice note Web based care pathways for acute care of fragility fractures from presentation to secondary prevention for primary care and community services based on long term conditions model Business planning tool for Fracture Liaison Good practice examples Exercise for fall and fractures: advice note