Falls Deep Dive

Healthy People
Difficulties in Daily Life
Ageing Well
Ageing
Older age
Ageing Population
Quality of Life
Elderly Care
Long-term care
Falls
Frailty
Falls deep dive
Published

February 28, 2023

Falls Deep Dive

Why is the topic important?

Falls are a common risk factor for older adults, with one in three people aged over 65 years experiencing a fall each year in the UK1. Whilst the majority of falls do not result in severe injury, with every fall there is a risk of significant physical and/or psychological harm and consequent disability. Even in the absence of injury, the experience of falling can be life changing, and can result in distress, loss of confidence, loss of independence and pain. A fall is a symptom, not a diagnosis. It can be a marker for the onset of frailty, the first indication of a new or worsening health problem and/or can represent a tipping point in a person’s life, triggering a downward decline in independence. Falls are commonly associated with frailty, but it is not only frail people who fall.

The World Health Organisation defines a fall as,

“An event which results in a person inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects”2

Falls and their consequences are a common and serious health issue amongst older people in England and are a major public health concern. People aged 65 and over have the highest risk of falling; around a third of people aged 65 and over, and around half of people aged 80 and over, fall at least once a year. Falling is a cause of distress, pain, injury, loss of confidence, loss of independence and mortality3.

In terms of annual activity and cost for health services:

  • The Public Health Outcomes Framework (PHOF)4 reported that in 2017 to 2018 there were around 220,160 emergency hospital admissions related to falls among patients aged 65 and over, with around 146,665 (66.6%) of these patients aged 80 and over

  • Falls were the ninth highest cause of disability-adjusted life years (DALYs) in England in 2013 and the leading cause of injury

  • Unaddressed fall hazards in the home are estimated to cost the NHS in England £435 million

  • The total annual cost of fragility fractures to the UK has been estimated at £4.4 billion which includes £1.1 billion for social care; hip fractures account for around £2 billion of this sum

  • Short and long-term outlooks for patients are generally poor following a hip fracture, with an increased one-year mortality of between 18% and 33% and negative effects on daily living activities such as shopping and walking

  • A review of long-term disability found that around 20% of hip fracture patients entered long-term care in the first year after fracture

  • Falls in hospitals are the most commonly reported patient safety incident with more than 240,000 reported in acute hospitals and mental health trusts in England and Wales

There are numerous risk factors that increase the likelihood of falls in older people. Increasing age is a key risk factor for falls and falling, with people over the age of 65 years having the highest risk5. Gender also has a bearing, with falls being more common in older women than older men6 , although gender related differences cease to be evident amongst those aged 85 and over7.

The causes of having a fall are multifactorial – a fall is the result of the interplay of multiple risk factors. These include:

  • Muscle weakness

  • Poor balance

  • Visual impairment

  • Polypharmacy - and the use of certain medicines

  • Environmental hazards

  • Some specific medical conditions, which might make a person more likely to fall

The Derbyshire picture and how we compare

Population & Geographic patterns

In 2020, there were an estimated 807,183 people living in Derbyshire, of which 176,969 (21.9%) were aged 65 years or over, with 44,803 (5.6%) being aged 80 years and over8.

Within the population as a whole, the age group most at risk for falls are those aged 65 years and over; within that age group, those aged 80 years and over are at the highest risk.910

Figures 1 and 2 below therefore provide two breakdowns of the 2020 population of Derbyshire, those aged 65 to 79 years and those aged 80 years and over, by district.

It can be seen that the district with the highest number of people aged 65 and over is Amber Valley (28,847); the district with the lowest number is Bolsover (16,417). Although the relative proportions of the two age groups vary little, the total number of older people resident in each district varies considerably.

Figure 1: Number and proportion of Derbyshire population age 65 and over, by district, 2020

Area 65 - 79 yrs 80 yrs & over 65 yrs & over
Derbyshire 132,166 (75%) 44,803 (25%) 176,969
Amber Valley 21,752 (75%) 7,095 (25%) 28,847
Bolsover 12,454 (76%) 3,963 (24%) 16,417
Chesterfield 16,597 (74%) 5,914 (26%) 22,511
Derbyshire Dales 14,788 (74%) 5,138 (26%) 19,926
Erewash 17,149 (72%) 6,660 (28%) 23,809
High Peak 15,137 (76%) 4,836 (24%) 19,973
North East Derbyshire 18,961 (75%) 6,437 (25%) 25,398
South Derbyshire 15,328 (76%) 4,760 (24%) 20,088

Source: ONS LA mid-year population estimates: England and Wales, 2020

Figure 2:  Number of Derbyshire population age 65 and over, by district, 2020 

Gender

Although increasing age is the most significant risk factor for falls, gender also has a bearing, with women having a higher risk of falls than men.

Of the population aged 65 and over in Derbyshire, 46.5% (82,225) are male and 53.5% (94,744) are female. This includes 18,169 males and 26,635 females who are aged 80 years and over, making up 10.3% and 15.1% respectively of the total population aged 65 years and over.

Figure 3: Number and proportion of people aged 65 years and over, by gender, 2020

Age group Males Females
65 - 79 yrs 64,056 (36.2%) 68,110 (38.5%)
80 yrs & over 18,169 (10.3%) 26,634 (15.1%)
65 yrs & over 82,225 (46.5%) 94,744 (53.5%)

Source: ONS LA mid-year population estimates: England and Wales, 2020

Age

Although population increases will not be evenly distributed across the county, it is anticipated that numbers will continue to increase year on year across all age groups in Derbyshire. The number of people aged 65 and over is expected to increase from an estimated 177,570 in 2020, to an estimated 244,860 by 2040. This will give a concomitant increase in the number of people in Derbyshire aged 80 and over, from 45,150 in 2020, to an estimated 76,360 by 2040. Figure 4 below breaks down the projected increases in people aged 65 and over in Derbyshire to 2040 by 5-year age groups.

Figure 4: Derbyshire population aged 65 and over, projected changes to 2040

Age group 2020 2025 2030 2035 2040
65-69 yrs 47,480 51,667 60,038 62,721 56,746
70-74 yrs 49,385 44,787 48,949 57,018 59,663
75-79 yrs 35,560 44,254 40,414 44,482 52,088
80-84 yrs 23,527 28,793 36,069 33,332 37,158
85-89 yrs 13,901 15,852 19,675 24,919 23,506
90 yrs & over 7,718 8,382 9,689 12,119 15,699
Age 65 yrs & over 177,570 193,734 214,834 234,591 244,859

Source: ONS 2018-based subnational principal population projections

What we’re doing and the assets and services we have in place

UK guidance published in relation to falls since 2013 has a strong emphasis on proactive, multifactorial, and multidisciplinary intervention. The need for community-based strength and balance activity is embedded within key recommendations from the National Institute for Clinical Excellence (NICE), Public Health England (PHE, now UKHSA) and the National Health Service (NHS).

In 2013, the National Institute of Health and Care Excellence (NICE) published Clinical Guideline 161, “Falls in older people: assessing risk and prevention”.11 This recommends the development and delivery of multifactorial interventions to prevent falls in older people who live in the community, consisting of:

  • Strength and balance training

  • Home hazard assessment and intervention

  • Vision assessment and referral

  • Medication review with modification/withdrawal.

This guidance is due to be updated following a 2019 surveillance report,12 with publication of the updated version expected in June 2024.

Additional evidence/policy guidance

Source Guidance Key Points
Office for Health Improvement & Disparities 2022 Falls: applying All Our Health This brings together the key challenges presented by falls and focusses on the core principles for health and care professional acting in this field
NHS England 2019

NHS Long Term Plan

Supporting people to age well

 “Falls prevention schemes, including exercise classes and strength and balance training, can significantly reduce the likelihood of falls and are cost effective in reducing admissions to hospital.”
Public Health England 2017 Falls and Fracture consensus statement All commissioning activity related to falls and fracture prevention should be undertaken in a collaborative and whole-systems manner and promote healthy ageing across the life course, integrate multifactorial risk assessment and embed evidence-based strength and balance programmes for those at low to moderate risk.

NICE

2017

 Quality standard 86: Falls in older people

Building on previous guidance, NICE established 9 quality standards that the NHS and local partners should be working towards implementing with the aim of preventing falls, falls injuries, and hospital admissions whilst improving independence and care quality.

“Statement 8: Older people living in the community who have a known history of recurrent falls are referred for strength and balance training.”

NICE

2013

Clinical Guideline 161: Falls in older people: assessing risk and prevention

NB This guideline is undergoing revision – update due to be published 13 June 2024

Emphasis on the integration of primary and secondary prevention approaches to falls through early identification of older adults with an elevated falls risk.

Deployment of multifactorial risk assessment, leading to multifactorial intervention. This should include:

  • Strength and balance training

  • Home hazard assessment and intervention

  • Vision assessment and referral

  • Medication review with modification/withdrawal

NICE

2019

2019 Surveillance of falls in older people: assessing risk and prevention

Appendix A: Summary of evidence

This document summarises the areas of CG161 where surveillance has identified evidence that updating is required and gives the reasons for the decision to update.  Evidence that requires updating includes:

  • Exercise interventions

  • Multifactorial interventions

  • Falls risk assessment tools

The Derbyshire Health and Wellbeing Strategy 2022 has 3 priorities relevant to falls:

  • Outcome 1: All people in Derbyshire are enabled to live healthy lives

  • Outcome 3: All people in Derbyshire are enabled to have good mental health and wellbeing across the life course

  • Outcome 4: All vulnerable populations are supported to live in well-planned and healthy homes

There is currently no falls prevention strategy for Derbyshire.

In Derbyshire, falls prevention interventions are delivered through the Strictly No falling (SNF) programme. This is a secondary prevention service, targeting people aged 65 years and over, who have experienced one or more falls.  SNF is funded by Derbyshire County Council and delivered by Age UK Derby and Derbyshire, working in partnership with Derbyshire Community Health Services (DCHS).

Additional assets across the Falls system can be seen in the table below.

Service Provider Details
Falls Rehabilitation Service Derbyshire Community Healthcare Service (DCHS) Physios/ OT service

Operated on referral criteria and services/locations etc

Includes equipment

https://dchs.nhs.uk/our-services-and-locations/a-z-list-of-services/community-therapy
Falls Alarm Services Community alarms and telecare

Various independent Providers across Districts and Boroughs

Derbyshire County Council covering all districts.

Paid for service but some eligibility

https://www.derbyshire.gov.uk/social-health/adult-care-and-wellbeing/help-to-live-at-home/falls/falls-support-services/falls-support-services.aspx
Fracture liaison Service Acute Hospital based follow up for people presenting with fragility fractures who have increased risk of fractured neck of femur

Available at Chesterfield Royal Hospital

https://www.chesterfieldroyal.nhs.uk/our-services/orthopaedics
Tootsie’s footcare Paid for footcare services from Age UK Age UK Derby and Derbyshire | Footcare service
Adult Social Care & Health This service offers housing related support for people aged over 55 living in any type of home - private, rented, or local housing association home. https://www.derbyshire.gov.uk/social-health/adult-care-and-wellbeing/accommodation-and-housing/housing-support/independent-living-services/independent-living-services.aspx
Live Life Better Derbyshire Derbyshire County Council

Healthy Lifestyle service. Refer to physical activity services & Strictly No Falling strength & balance classes

https://www.livelifebetterderbyshire.org.uk/services/services.aspx
Derbyshire Fire Service Safe and Well check includes a falls assessment Safe and Well visits: Derbyshire Fire and Rescue Service (derbys-fire.gov.uk)
Primary Care

Medication checks

Enhanced Care Practitioners delivering proactive coordinated care to people at higher risk of admission

 Medication_&_falls_prevention_in_the_older_person.pdf (derbyshiremedicinesmanagement.nhs.uk)

Local and service user views

A falls conference was held in September 2016 that included representatives from a wide range of organisations including CCG’s, DCHS, Age UK Derby and Derbyshire, Adult Care, GP’s, Public Health, Voluntary Sector, and members of the public. Workshops were held and several gaps/issues for improvement were identified including:

  • Absence of an agreed pathway for the identification and referral

  • Need to improve the knowledge of health and social care staff on falls

  • Collation of data/information to demonstrate value/effectiveness of services provided

  • Improving links between services to enable data sharing and more efficient referrals

  • Inconsistency in the provision of services across the county

  • Need to improve awareness amongst older people/families/carers of falls awareness and prevention

Derbyshire County Council Public Health Department commissioned an insight report published in April 2019 by Unique Improvements, entitled ‘Qualitative Insight Research into Falls Prevention for Derbyshire County Council’ Below summarises the results of research activity across Derbyshire communities to understand the target audiences in terms of their awareness, attitudes, and behaviours regarding falls, falls prevention and healthy ageing. (need to add link to document)

  • Feedback from the staff survey included the need for further resources and training.

  • The residents survey highlighted the variation of attitudes towards falling with over half being worried about falling again.

  • The engagement activity themes included trusting a variety of sources for support and advice.

  • Healthy Ageing was a key theme, particularly around prevention. Other themes also included social isolation, loneliness, and protective behaviours.

Since this, there has been two reports on service user experiences of the Strictly No Falling (SNF) service. One report commissioned by Age UK Derby and Derbyshire and published by the University of Nottingham in March 2022, is entitled ‘Instructor and client views of a community falls prevention service in England: a qualitative exploration’. Key findings are:

  • All clients and instructors spoke about the enjoyment and fun they had during SNF classes, for some clients attending the class was the highlight of their week.

  • Clients praised instructors for their ‘person-centred’ approach and felt they went ‘above and beyond’ to support them during the pandemic.

  • Most clients were initially motivated to join a SNF class to improve their physical health. However, once they had joined, clients felt the benefits of the class went far beyond improving physical health and preventing falling and included mental wellbeing and an opportunity to socialise.

  • The importance of SNF, beyond an exercise programme, was amplified during the COVID-19 pandemic.

  • Unfortunately, not all clients were able to access online SNF classes during periods of COVID-19 lockdowns, however instructors worked hard to maintain contact with all clients.

The second report published by Age UK Derby and Derbyshire entitled ‘Strictly No Falling March 2020 – April 2021 Covid-19 Pandemic Response Report’ outlines the changes to service delivery due to the COVID-19 pandemic. Highlights include:

  • 40,000 wellbeing contacts were made by instructors and the funding provision to enable this.

  • 80% of SNF attendees felt they had been more active during the pandemic than they would have been without contact from their SNF instructor.

  • 11 online and conference call classes allowed some self-sustaining provision to continue, though demographics of attendees and challenges accessing technology meant that this has remained at a fairly small scale.

  • The project has retained 95% of the instructors working with Age UK prior to the pandemic. Retention rates for class attendees are as yet unconfirmed but are anticipated to be above 80%.

Opportunities for improvement and future development

Addressing falls enables older people in Derbyshire to increase healthy life expectancy. However, a number of factors will widen unmet need and gaps in service or evidence. These include:

  • Increasing population over 65 yrs.

  • Growth in the number of people with osteoporosis

  • Co-morbidities such as dementia

  • Limited data from falls system on the impact of falls to enable effective evaluation of the current picture and assess areas of inequity/inequality

  • Limited data collection from existing Strictly No Falling programme (SNF)

An element from National Institute of Health and Care Excellence (NICE) published Clinical Guideline 161, “Falls in older people: assessing risk and prevention13 with regard to home hazard assessment and intervention needs further exploration as it is unclear if this element is being undertaken and by which service.

The NHS Falls and Fragility Fractures pathway14 contains a number of key messages for commissioners including focus on the three priorities:

  • Falls prevention

  • Detecting and Managing osteoporosis

  • Optimal support after a fragility fracture

A gap within Derbyshire is our understanding of Osteoporosis, its prevalence, and its impact. Further exploration of its correlation with falls and preventative methods would be beneficial.

Taking a Population Health Management (PHM) approach may result in addressing unmet or future needs by ensuring health and care services are more closely joined-up and sustainable whilst making better use of public resources. PHM is the critical building block for integrated care systems and enables local health and care partners to deliver a core offer for local people which ensures care is tailored to their personal needs and delivered as close to home as possible. Our system partners will be integral to supporting this process and will support this document to ensure it reflects the current capacity.

Opportunities and the future

  • Older people need to have improved awareness of the risks of falls and that many are preventable. We also need to raise awareness amongst health and social care professionals.

  • Continue to work closely with system partners to ensure that core data sets and data collection/reporting are shared across the system, to facilitate more effective evaluation of existing falls services and the impact of falls across the health and social care system.

  • Integrate falls with wider risk factors including bone health, nutrition, and Vitamin D

  • Conduct a review of the current falls pathway across Derbyshire to ensure professionals understand their role, refer to relevant falls prevention/response services and coordinate on-going care.

  • The strength and balance intervention programme - Strictly No Falling (SNF) is to be re-procured with a new contract start date of 1st April 2024

  • Develop a Derbyshire Falls prevention strategy

Contributors

Caroline Waller, Advanced Public Health Practitioner, Healthcare Public Health, Derbyshire County Council