Falls and Osteoporosis

Joint Strategic Needs Assessment and Strategy

Falls and osteoporosis prevention and services for

older people in Oldham

(Including recommended Service Model)

Jon Hobday, Speciality Registrar in Public Health, Public Health Directorate, NHS Oldham

Dr Lisa Wilkins, Consultant in Public Health Medicine, NHS Oldham

December 2012

Contents Page Acknowledgements 3 Executive Summary 4

1. Introduction 6 1.1 Scope of needs assessment and strategy 8

Section one - Falls and Osteoporosis Needs Assessment 2. Older people in Oldham 8 3. Falls 3.1 Causes of falls 10 3.2 Burden of falls in Oldham 10 3.2.1 Unplanned admissions due to falls and hip fractures 10 3.2.2 Trends in falls admissions 12 3.2.3 Accident and Emergency Attendances 13 3.2.4 Ambulance service 14 3.2.5 Primary care consultations 15 3.2.6 Total health care costs from falls in Oldham 15 3.2.7 Social care utilisation and costs 15 3.2.8 Costs to families and the communities 15 4. Osteoporosis 4.1 Definition, prevalence and consequences of osteoporosis 16 4.2 Bone mineral density 17 4.3 Risk factors for osteoporosis 17 5. National guidance 5.1 Falls 19 5.2 Osteoporosis 24 5.3 Summary of key elements of a falls and osteoporosis pathway 25 6. Economic Assessment 26 7. Current Service Provision 7.1 Falls Prevention Programme Pennine Care (Falls Coordinator) 26 7.2 Age UK 27 7.3 Oldham Community Leisure Limited (OCLL) 29 7.4 Pennine Acute Falls Clinic 30 7.5 Primary Care 30

7.6 Intermediate Care 31 7.7 Community Occupational Therapy Team 32 7.8 Local Authority - Reablement team 34 7.9 Helpline, Response and Key-Safe services 34 7.10 Care Homes 34 7.11 Hospital 35 7.12 Fracture Liaison Service 35 8. Residents’ and Service Users’ Views 36 9. Value of programme on wider mental health 38

10. Gaps between best practice and current services 39 11. Needs Assessment Summary 40

Section two Falls and Osteoporosis Strategy 12. Aims of the strategy 42 13. Recommendations 42

14. References 48

Acknowledgments

I would like to thank the following stakeholders for all their input and support during this piece of work

Helen Ashton Falls Coordinator, Pennine Care NHS Foundation Trust

Jackie Hanley Senior Health and Physical Activity Development Officer, Oldham Community Leisure Ltd

Julie McBride Falls Programme Coordinator, Age UK Oldham

Yvonne Lee Chief Executive, Age UK Oldham

Adele Major Team Manager (Reablement and Rapid Response), Oldham MBC

Stacy Duggins Public Health Analyst, Oldham PCT

Dorothy Phillips Social Services, Oldham MBC

Vicki Elcock Lead Nurse – Butler Green Nursing Home, Pennine Acute Hospitals NHS Trust

Nadia Baig Associate Director Commissioning, , Oldham CCG

Dr Hugh Sturgess Director Pennine MSK, GP and Clinical Advisor Oldham CCG

Caroline Poole Strategic Lead for Long Term Conditions, Pennine Care NSH Foundation Trust

Dr Raj Parikh Consultant Geriatrician – Falls and Orthogeriatrics, Pennine Acute Hospitals NHS Trust

Karen Partridge Fracture Liaison Nurse, Pennine MSK

Dr David McMaster Clinical Director for Urgent Care, Oldham CCG

Tanya Roberts Associate Director Quality and Governance Oldham CCG

Grace Ward Continuing Health Care team, Oldham CCG

Josie Kershaw Borough Lead Manager and Older People Services Manager, Oldham Borough, Pennine Care NHS Foundation Trust

Executive Summary

Falls and osteoporosis are significant public health problems, particularly for older people. Falls and osteoporosis are associated with significant morbidity and mortality and have long- term impacts on quality of life. Preventing falls and osteoporosis is thus a priority within the Oldham Health and Wellbeing Strategy and nationally.

Falls and fractures for the over 65’s result in 4 million bed days a year in England alone – resulting in a cost of £2 billion annually (HES, 2009). The number of bed days for fractures in the over 60s exceeds the bed occupancy attributable to diabetes, ischaemic heart disease, heart failure or chronic obstructive pulmonary disease.14,000 older people die in the UK each year as a result of an osteoporotic hip fracture (DH, 2006). The risk of sustaining a fracture, a major cause of morbidity and mortality after a fall, is increased if a person has osteoporosis. The ageing of the UK population will give rise to a doubling of the number of osteoporotic fractures over the next 50 years if changes are not made in present practice.

The document consists of two sections: A Joint Strategic Needs Assessment (JSNA) for falls and osteoporosis. And recommendations from the JSNA form the basis of the strategy given in section two. The needs assessment and strategy covers the identification, assessment, treatment and rehabilitation aspects of the falls and osteoporosis assessment and prevention service. The recommendations outline specific ways in which falls and osteoporosis can be addressed within Oldham.

Effective falls prevention services have been shown to both reduce the number of falls and increase the proportion of people who have fallen who retain their independence following falls (Gillespie et al. 2012). A national audit was undertaken in 2010 which found unacceptable variation in the quality of falls and fracture services in the UK (Royal College of Physicians, 2011).

In 2004 NICE guidance which outlined the key priorities for the assessment and prevention of falls in older people was published (National Institute of Health and Clinical Excellence, 2004). From an osteoporosis perspective NICE have developed a range of specific guidelines for a number of aspects including prevention, assessment and management.

It is estimated that in Oldham 8,700 people over 65 fall each year. The North West Ambulance Service attends approximately 250 calls for falls per month in Oldham. Last year Oldham residents had 1,183 unplanned hospital admissions due to falls or fractures of the lower leg, femur or forearm in the over 65s. This is 48% increase in the number of

4 admissions compared to 2006/2007 and cost £3.5 million. Of the 1,183 unplanned admissions, 182 had a primary diagnosis of a fractured neck of femur (NOF). These alone accounted for £1.1 million of the £3.5million total costs, with an average cost of £6,082 per NOF fracture.

Significant gaps exist in Oldham between the current provision of falls assessment and prevention services and national guidance on best practice. There are pockets of excellent practice and the specialist services are delivered, in the main, in line with the evidence base and have good feedback from patients who have accessed the services. However, the falls assessment and prevention programmes have not been commissioned to have sufficient capacity to meet need resulting in inequity of access to the services and long waiting times. There is also a lack of publicity for the services; lack of referral pathways from all relevant services and suboptimal multidisciplinary working.

The Fracture Liaison Service identifies patients with or at risk of osteoporosis through identifying potential fragility fractures in the 65’s and over from the Royal Oldham Hospital x- ray data. However there are substantial delays with the data being collated only once every 6 months. The rate of requests for the main method of assessing bone densitometry(DXA scan) are lower in Oldham than the national average and the prescribing rate of bisphosphonates (the commonest bone sparing range of drugs used in the prevention and treatment of osteoporosis) is also low in Oldham. Both of these suggest room for improvement in identifying people with or at risk of osteoporosis in Oldham.

Based on the findings from the JSNA a comprehensive series of recommendations have been made and grouped under the following high level recommendations:

1. Increase the identification of people who have fallen or are at risk of falls or osteoporosis and improve the referral pathways into the falls/osteoporosis assessment service 2. Commission one comprehensive, community based, multidisciplinary falls and osteoporosis service, which delivers care in line with the NICE clinical guidelines for falls and osteoporosis, and has sufficient capacity to have a population health impact 3. Work with care homes, intermediate care, respite care and day care settings to reduce falls and fall-related fractures 4. Additional recommendations include further engagement with health professionals to develop new referrals mechanisms, training of other health professionals to raise awareness of the falls service and the development of an action plan to deliver the strategy

Conclusion

Evidence-based falls prevention programmes have been shown to be a cost effective method to reduce falls and fall related costs. They not only have financial benefits but have a significant impact on individuals’ quality of life from a physical, mental and social perspective. The current falls programme is evidence-based; however there is inadequate capacity with only a small minority of fallers being offered the service. It is estimated that a service redesign with a fivefold increase in capacity of the service is required together with enhanced multidisciplinary working, to meet need and have a population health impact. This increase in capacity would reduce inequalities and prove cost effective as there would be significant reductions in health and social care costs related to the reduction of falls.

1. Introduction

Falls are a significant public health problem, particularly for older people. Evidence indicates that around 30% of over 65’s and 50% of those over 80 living in the community will fall each year (Cryer and Patel, 2001). Falls are associated with significant morbidity and mortality and have long-term impacts on quality of life. Preventing falls is thus a priority within the Ageing Well theme of the Oldham Health and Wellbeing Strategy.

On a national level falls are also a priority, the NHS framework 2013/2014includes an indicator measure of the proportion of fragility fracture patients recovering to their previous levels of mobility/walking ability at (i) 30 days and (ii) 120 days. The Public Health Outcomes Framework 2012 also includes an indicator measure of acute admissions as a result of falls or fall injuries for over 65s. In addition the Adult and Social Care Framework 2013/2014 has an outcome around the proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services.

Falls and fractures for the over 65’s result in 4 million bed days a year in England alone – resulting in a cost of £2 billion annually (HES, 2009). 14,000 older people die in the UK each year as a result of an osteoporotic hip fracture (DH, 2006). The risk of sustaining a fracture, a major cause of morbidity and mortality after a fall, is increased if a person has osteoporosis.

The clinical significance of osteoporosis lies in the fractures that arise. In the UK osteoporosis results in over 200,000 fractures each year. These fractures cause severe

6 pain and disability to individual sufferers which cost the National Health Service (NHS) over £1.73 billion per year (National Osteoporosis Guideline Group, 2010). More than one-third of adult women and one in five men will sustain one or more osteoporotic fractures in their lifetime (National Osteoporosis Guideline Group, 2010). The ageing of the UK population will give rise to a doubling of the number of osteoporotic fractures over the next 50 years if changes are not made in present practice. The admission rate for hip fractures has increased in England by 2.1% per year since 1999, whilst hospital bed days have increased by 5.9% per year (National Osteoporosis Guideline Group, 2010).

Not only are falls a frequent cause of A&E attendances and hospital admission but they affect the wider physical and mental wellbeing of individuals. As well as the physical functional issues, falls can result in loss of confidence, social isolation and reduced independence. This can then impact on the lives of those around them, with family members regularly becoming informal carers. The loss of independence also frequently precipitates the need for domiciliary care or admission to a care home. Falls are thus costly not only to the health and social care economy but to the individual and their family.

This document is separated into two sections:

Section 1 - A Joint Strategic Needs Assessment (JSNA) for falls and osteoporosis. This will: - Identify the population need - Summarise key national reports, guidelines and other evidence - Identify the key local stakeholders and current provision - Summarise the views of people who have fallen or are at risk of falling - Identify gaps where the provision does not meet the need

Section 2 – Recommendations from the JSNA form the basis of the strategy, this section will: - Outline the aims of the strategy - Provide evidence-based recommendations to enhance the current falls system, reduce falls and fall-related injuries and the burden of falls - Suggest a new pathway/service model for the falls assessment and prevention programme and estimate the costs for implementing the model - Outline amendments for the Fracture Liaison Service to improve robustness and efficiency

1.1 Scope of needs assessment and strategy

The needs assessment and strategy aims to cover the identification, assessment, treatment and rehabilitation aspects of a falls and osteoporosis assessment and prevention service. It does not look at wider environmental factors that may precipitate a fall.

A range of methodologies have been used to ensure a robust overview is achieved. These include literature reviews, meetings and semi-structured interviews with stakeholders and focus groups with service users.

Section one - Falls and Osteoporosis Needs Assessment

2.Older people in Oldham Oldham is made up of 6 district partnership areas and has a population of 224,000 (JSNA, 2012). Just over 15% of this population is 65 and over, which is 33,100 older people. The distribution of older people in Oldham is not uniform and certain wards have a larger percentage of older people. The wards with the higher percentage of older people include Failsworth West, Crompton, Saddleworth South, Saddleworth North, Royton South and Royton North all having around 20% who are 65 and older. This is visually represented in figure 1.

Figure 1 – Map of Oldham identifying the numbers of people aged 65 and over falling per lower super output area in 2010

Oldham’s older population are a mix of 95% white, 1.9% of Pakistani heritage, 1.5% of Bangladeshi heritage and 1.6% are from other BME groups. However it is projected that these minority groups will increase in the coming decade.

As with all areas throughout England the proportion of people over 65 in Oldham is projected to increase in the future. With predictions suggesting that by 2022 the 65 and over population will increase by 9,500 to 40,400, which will represent almost 18% of Oldham’s population (Projecting Older People Population Information, 2012 cited in JSNA, 2012). The number of over 85’s is also due to significantly increase, with projections from the Office of National Statistics suggesting there will be over 5,300 people 85 or over in Oldham by 2021. These are the group which are most likely to have a fall and have long term consequences. The implications of this are that the health and social care needs will increase, and more work will need to be done to prevent health and social problems before they occur.

3. Falls

3.1Causes of falls Falls can occur due to a wide range of reasons which can be classified as either internal or extrinsic factors (Table 1). As there are so many factors which can contribute to falls, it is important that the falls strategy takes a multi-dimensional approach to tackling falls.

Table 1. Causes of falls

Internal Causes Extrinsic Causes Cardiac disease Poor footwear Neurological disease (e.g. Parkinsons) Trip hazards Musculoskeletal problems Poor lighting Metabolic conditions (e.g. diabetes) Flooring Mental health issues (e.g. dementia) Incontinence Visual conditions (e.g. cataracts or glaucoma) Balance problems Medication (e.g. side effects such as dizziness)

3.2 Burden of falls in Oldham

3.2.1 Unplanned admissions due to falls and hip fractures

It is estimated that in Oldham 8,700 people over 65 fall each year (POPI, 2012). Last year Oldham residents had 1,183 unplanned hospital admissions due to falls or fractures of the lower leg, femur or forearm in the over 65s.All admissions from fractures of the lower leg, femur or forearm have been included in the data. This is because there is a high likelihood that fractures at these sites would be due to falls, and that many admissions from falls which have resulted in a fracture are not coded as falls.

The average stay during 2011/2012 in a hospital following a fall or fracture for the over 65’swas 11 days with the calculated average cost for each of these falls being £3,019. Between 01/04/2011 and 31/03/2012 the total number of hospital days due to falls were 13,139, costing just over £3.5 million or the equivalence of £106 per Oldham resident aged over 65.

Table 2 – Number and costs of unplanned admissions for those aged 65 and overdue to falls, fracture of the lower leg, femur or forearm by ward in Oldham 2011/2012

Ward Unplanned admissions for Total costs falls and/or, fracture of lower leg, femur and forearm Alexandra 74 £233,074 Chadderton Central 49 £152,218 Chadderton North 53 £147,648 Chadderton South 62 £201,188 Coldhurst 61 £142,028 Crompton 68 £192,011 Failsworth East 47 £134,515 Failsworth West 70 £190,259 Hollinwood 50 £119,021 Medlock Vale 51 £147,843 Royton North 67 £220,027 Royton South 104 £308,069 Saddleworth North 70 £190,899 Saddleworth South 63 £244,002 Saddleworth West and Lees 52 £150,806 Shaw 69 £194,187 St James’ 43 £124,651 St Mary’s 38 £123,672 Waterhead 57 £159,412 Wenworth 35 £135,683 Oldham Total 1,183 £3,511,222 (Source – Secondary Uses Services inpatient data)

Of the 1,183 unplanned admissions, 182 of those admissions had a primary diagnosis of a fractured neck of femur (NOF). These alone accounted for £1.1 million of the £3.5million total costs, with an average cost of £6,082 per NOF fracture. The average length of stay in hospital in this group was considerably longer at 23 days.

Table 3 – Number of unplanned admissions for fracture neck of femur, average stay per patient and the total costs for those aged 65 and over by ward in Oldham 2011/2012

Ward Unplanned admissions Average length of Total Cost for neck of femur hospital stay fracture

Alexandra 14 25 £83,739 Chadderton Central 7 19 £47,259 Chadderton North 6 25 £37,730 Chadderton South 9 18 £58,170 Coldhurst 4 30 £28,947 Crompton 9 19 £58,601 Failsworth East 7 27 £47,009 Failsworth West 10 18 £56,021 Hollinwood 6 18 £31,298 Medlock Vale 7 21 £39,977 Royton North 9 36 £73,923 Royton South 15 22 £89,878 Saddleworth North 9 19 £42,252 Saddleworth South 12 23 £75,393 Saddleworth West and 10 16 £69,365 Lees Shaw 13 22 £73,790 St James’ 8 31 £49,812 St Mary’s 8 21 £42,700 Waterhead 6 17 £31,234 Wenworth 13 26 £69,961 Grand Total 182 23 £1,107,068 (Source – Secondary Uses Services inpatient data)

3.2.2 Trends in falls admissions

During the last 6 years the number of unplanned admissions due to falls, fracture of lower leg, femur and forearm has been increasing year on year from 797 in 2006/2007 to 1,183 in 2011/2012 representing a 48% increase in the number of admissions. In contrast to this, apart from a small increase in the average cost per unplanned admission in 2011/2012, the average cost per admission for the over 65s has been reducing year on year. The average cost went from £4,254 in 2006/2007 to £3,019 in 2011/2012, representing a 30% reduction.

A significant contributor to this reduced average cost is likely to be the reduction of average days spent in hospital. This has been reducing year on year from 17 in 2006/2007 to 11 in 2011/2012.

Table 4 – Number of unplanned admissions in Oldham residents aged 65 and over due to falls and fractures, average costs and average bed days per patient from 06/07 to 11/12

Admin Unplanned Average Cost Average days financial admissions due to of admission in hospital year falls and/or fracture (length of stay) of lower leg, femur and forearm in the 65s and over 06/07 797 £4,254 17 07/08 802 £4,076 17 08/09 894 £3,995 15 09/10 1,056 £3,292 14 10/11 1,151 £2,983 11 11/12 1,183 £3,019 11 Total 5,883 £3,522 14 (Source – Secondary Uses Services inpatient data)

If the current rate of increase in the number of admissions continues in the 65s and over at the same rate by 2017/2018 the number of fractures of lower leg, femur and forearm would by 2,920, which based on today’s average cost would result in an annual spend of over £8.7 million.

3.2.3 Accident and Emergency Attendances

There were 1,313 A&E attendances in Oldham residents aged 65 and over for dislocation, fractures, amputations, sprain and ligament injuries in 2011/2012 (Table 5). Many of these would have been as a result of a fall. Some of these attendances would have resulted in a hospital admission as above, others in follow up appointments in fracture clinic. The A&E attendances and outpatient appointments would be additional costs to the admissions above but it does need to be acknowledged that coding of A&E data is often inaccurate or incomplete. Therefore, the exact numbers and costs related to these attendances are difficult to accurately estimate.

Table 5 – Accident and Emergency Data for Oldham residents who are 65 and over2011/2012

Ward Number of Number of Total A&E Dislocations/fractures/joint sprains/ligament attendance for injuries/amputations in the injuries in the over potential fall over 65s 65s related injuries

Alexandra 52 13 65 Chadderton Central 37 16 53 Chadderton North 46 21 67 Chadderton South 41 27 68 Coldhurst 26 16 42 Crompton 55 25 80 Failsworth East 39 22 61 Failsworth West 49 28 77 Hollinwood 33 28 61 Medlock Vale 52 27 79 Royton North 64 24 88 Royton South 60 29 89 Saddleworth North 58 16 74 Saddleworth South 47 25 72 Saddleworth West 48 and Lees 23 71 Shaw 46 30 76 St James’ 35 22 57 St Mary’s 32 15 47 Waterhead 30 13 43 Wenworth 34 9 43 Oldham Total 884 429 1,313 (Source – Secondary Uses Services inpatient data)

3.2.4 Ambulance service Falls also result in significant costs to the North West Ambulance Service (NWAS). Figures from NWAS show in Oldham from 31st October 2011 to 1st November 2012 the ambulance service attended 2,999 calls for falls which were treated at the scene (these include calls which NWAS attended that didn’t require transfer to A & E). This is an average of 249 per month; while this data is for people of all ages who have fallen, feedback from NWAS staff

14 suggests approximately 75% of these would be aged over 65. This is equivalent to attending 187 falls per month for older people in Oldham. (Awaiting further data)

3.2.5 Primary care consultations

At present there are no robust methods of accurately measuring the number of GP consultations for falls or falls-related injuries or determining the quality of the care given.

3.2.6 Total health care costs from falls in Oldham We have seen above that hospital admissions for Oldham residents aged 65 and over from falls and fractures cost just over £3.5 million in 2011/12. On top of this there are additional costs including A&E attendances, fracture clinic appointments, primary care attendances, and rehabilitation. If these costs are all factored in, the total health care costs will be greater than the £3.5 million due to hospital admissions.

3.2.7 Social care utilisation and costs Falls, and the subsequence loss of function and / or confidence of the person who has fallen, often precipitate the need for social care support such as a domiciliary care package or admission to a care home. Unfortunately, it is difficult to quantify the numbers for this in Oldham due to the way social care is coded. Information from the SWIFT social services database suggests there have only been 232 admissions into care homes in the last 10 years in Oldham as a result of falls. In the last 5 years there has been between 17 and 40 admissions into care homes for falls each year. However, feedback from ex-admission panel staff suggests that this is a significant underestimation and many admissions are not specified/coded as due to falls where falls are often the major contributory factor.

3.2.8 Costs to families and the communities Many older people lead active lives, supporting their families and contributing to communities. This may stop following a fall or if people at risk of falling fear falling. Therefore the cost of these falls is not just confined to the individual but also has wider implications to families and communities. As noted previously, family members may also need to take on a caring role as their relatives lose independence.

4.Osteoporosis

4.1 Definition, prevalence and consequences of osteoporosis A major contributor to falls and fractures is poor bone health. The World Health Organisation (1994) defines Osteoporosis as ‘a chronic, progressive condition associated with deterioration of bone tissue that results in low bone mass.’ As the condition progresses there is an increase in bone fragility that consequently increases the susceptibility to fracture.

The clinical significance of osteoporosis lies in the fractures that occur. In the UK osteoporosis results in over 200,000 fractures each year (Osteoporosis Guideline Group, 2012). More than one-third of adult women and one in five men will sustain one or more osteoporotic fractures in their lifetime (National Osteoporosis Guideline Group, 2010).

Fractures for the over 60’s result in 2 million bed days a year in England (Osteoporosis Guideline Group, 2012). This exceeds the bed occupancy attributable to diabetes, ischaemic heart disease, heart failure or chronic obstructive pulmonary disease (Osteoporosis Guideline Group, 2012).The ageing of the UK population will give rise to a doubling of the number of osteoporotic fractures over the next 50 years if changes are not made in present practice.

The fractures are most commonly observed in the vertebrae, the femur and the radius, which result in substantial morbidity. The most serious consequence arises in patients with hip fracture, which is associated with a significant increase in mortality (15-20%), particularly in elderly men and women (Royal College of Physicians 1999).The cost to the NHS of hospital care alone, just for fractured NOF in 2009 was £250 million (Royal College of Physicians

1999) and this is likely to have increased substantially in the last 13 years. The admission rate for hip fractures has increased in England by 2.1% per year since 1999, whilst hospital bed days have increased by 5.9% per year (Osteoporosis Guideline Group, 2012).

4.2 Bone mineral density In the UK it has been shown that the lower the bone mineral density (BMD) the higher the fracture risk (Kanis et al. 2004).Bone mass can be assessed at a number of sites including the lumbar spine, the hip, the forearm, and other sites. BMD (usually of the hip and the spine) assessed by dual-energy X-ray absorptiometry (DXA) remains the gold standard for the diagnosis of osteoporosis.

BMD can be expressed as:

- T-score (the number of standard deviations (SD) above or below the mean BMD values for a Young healthy adult) - Z-score (the number of deviations above or below the mean BMD values for a population of the same age and gender)

Based on the 1994 WHO report (Assessment of Fracture Risk and its Application to Screening in Post Menopausal Women), osteoporosis in women is defined as a BMD value of at least -2.5SD below the mean value of a young healthy population (T-score-2.5).

Dependant on the T score, individuals can be placed into different groups

- T score of -1 or more = Normal - T score of -1 to -2.5 = Osteopenia - T score of -2.5 or less = Osteoporosis - T Score of -2.5 or less and at least one previous fragility fracture = Severe Osteoporosis

4.3 Risk factors for osteoporosis

The risk factors for osteoporosis are given in table 6. Some of these risk factors act independently of Bone Mineral Density to increase fracture risk whereas others increase fracture risk through their association with low BMD.

At present there is no universally accepted policy for population screening in the UK to identify individuals with osteoporosis or those at high risk of fracture. Patients are identified opportunistically using a case-finding strategy on the finding of a previous fragility fracture or the presence of significant clinical risk factors.

Table 6 Risk Factors for Osteoporosis

Non-modifiable risk factors

Age Being past the menopause for women, and over the age of 65 for men

Sex Women are at greater risk of osteoporosis as they have smaller bones and hence lower totalbone mass. Additionally, women lose bone more quickly following the menopause, andtypically live longer.

Low body mass Weight loss or low body mass index (BMI) is a risk factor for lower index (<19kg/m2) BMD. Post-menopausal women with a BMI of less than 19kg/m2 should be considered as being at increased risk of osteoporosis (Ravn et al.1999).

History of Women who have suffered a previous fragility fracture (defined as a previous fracture fracture occurring aftera fall from standing height or less) are at increased risk of further fractures, independent ofBMD (Nelson et al. 2003).

Parental history Lower BMD is found in women and men with a family history of of hip fracture osteoporosis, a familyhistory being defined as a history of osteoporosis or brittle bones, kyphosis (“dowager'shump”), or low trauma fracture after age 50 years as reported by the offspring. IndividualBMD decreases as the number of family members with osteoporosis increases. Overallfamily history is a more sensitive predictor of osteoporosis risk than maternal or paternalhistory alone (Soroko et al. 1994).

Ethnicity African-Caribbean women have a higher BMD than white women at all ages due to a higherpeak bone mass and slower rate of loss (Snelling et al. 2001). White women have a 2.5-fold greater risk of getting osteoporosis (Snelling et al.2001).

A late menopause is associated with higher BMD. There is consistent Reproductive evidence that low BMD is associated with early menopause (Melton et factors al. 1993). Consequently, women with an early menopause should be considered at higher risk of osteoporosis than others at a similar age.

Modifiable risk factors

Glucocorticoid In 2002 Christodoulou and Cooper reported that only 14% of UK treatment (any patients taking continuous oral glucocorticoids received treatment to dose, by mouth prevent bone loss, which is a major complication of Glucocorticoids. for 3 months or Bone loss is highest in the initial months of treatment and between 30- more) 50% of patients taking long-term corticosteroids will experience fractures (Lukert and Raisz, 1999).

Smoking There is an inverse relationship between cigarette smoking and BMD. Many factors are believed to contribute to this including reduced body weight, an earlier menopause, and increased metabolic breakdown of exogenous oestrogen in women. In a meta-analysis, although there

was no significant difference in bone density between smokers and non-smokers at age 50, bone density in women diminished by 2% more in smokers than in non-smokers for each 10 year increase in age, with a difference between the two of 6% at age 80 years (Law and Hackshaw, 1997).

Alcohol intake of Consumption of large quantities of alcohol may be detrimental to bone. 3 or more units This might be due to adverse effects on protein and calcium daily metabolism, mobility, gonadal function, and a toxiceffect on osteoblasts. However, moderate quantities of alcohol appear to be protective against bone loss at the hip and against the risk of vertebral fracture (Seeman, 1996).

Physical It has been shown that physical loading and mechanical stress inactivity increase BMD and that certain forms of exercise may retard bone loss. Studies have shown that a relationship exists between physical inactivity in the elderly and the risk of hip and vertebral fracture (Snow et al. 1996).

Secondary causes of osteoporosis

Rheumatoid arthritis • Untreated hypogonadism in men and women • Prolonged immobility • Organ transplantation • Type I diabetes • Hyperthyroidism • Gastrointestinal disease • Chronic liver disease

5.National guidance

5.1 Falls

Effective falls prevention services can both reduce the number of falls and increase the proportion of fallers who retain their independence following falls (Gillespie et al. 2012). Falls prevention is multifactorial and there are a range of aspects that need to be addressed as part of a falls programme. Different agencies including housing, social services, environment and health, need to work together in partnership to maximise the impact upon individuals. Maintaining the independence of older people should be prioritised and emphasis should be placed upon prevention and management of falls (Gillespie, 2012).

The importance of falls was first nationally acknowledged in the National Service Framework (NSF) for older people in 2001 (Department of Health, 2001). Standard 6 within the NSF aimed to reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation of those who have fallen. The standard also recognised

19 the issue of osteoporosis and how this contributed to fractures in older people. The key interventions highlighted by the NSF were:

• Introduce public health strategies to reduce the incidence of falls • Increase the identification, assessment and prevention measures for those most at risk. • Improve the prevention and treatment of osteoporosis in the high risk groups. • Falls services should improve care and treatment provided to those who have fallen, preventing long-term disability and preventing future more serious falls. • Rehabilitation and long-term support should be provided to help fallers gain confidence, independence and mobility.

In 2004 NICE guidance which outlined the key priorities for the assessment and prevention of falls in older people was published (National Institute of Health and Clinical Excellence, 2004). The guidance includes an action plan to support the delivery of the recommendations. The actions are summarised in the table below.

Table 7 – A summary of the actions from the National NICE guidance for falls 2004

Priority Action Case/risk • Older people in contact with healthcare professionals should identification be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s. • Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance.

Multifactorial falls • Older people who present for medical attention because of a risk assessment fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by healthcare professionals with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. • Multifactorial assessment may include the following: • identification of falls history o assessment of gait, balance and mobility, and muscle weakness o assessment of osteoporosis risk o assessment of the older person's perceived functional ability and fear relating to falling o assessment of visual impairment o assessment of cognitive impairment and neurological examination

o assessment of urinary incontinence o assessment of home hazards o cardiovascular examination and medication review.

Multifactorial • All older people with recurrent falls or assessed as being at interventions increased risk of falling should be considered for an individualised multifactorial intervention. • In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors): o strength and balance training o home hazard assessment and intervention o vision assessment and referral o medication review with modification/withdrawal. • Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk, and individualised intervention aimed at promoting independence and improving physical and psychological function.

Encouraging the • Individuals at risk of falling, and their carers, should be participation of offered information orally and in writing about what older people in falls measures they can take to prevent further falls. prevention programmes including education and information giving

Professional All healthcare professionals dealing with patients known to be at risk education of falling should develop and maintain basic professional competence in falls assessment and prevention

A national audit undertaken by the Royal College of Physicians in 2010 found unacceptable variation in the quality of falls and fracture services in the UK (Royal College of Physicians, 2011). The audit found that there were major gaps in what organisations reported they were doing and what patient notes showed was actually being done. In addition it identified that patients with non-hip fragility fractures are only half as likely to receive assessment and management for both falls risk and bone health. The audit made 3 key recommendations

• Preventing fractures and hospital admissions is clinically and economically effective and will result in net cost-savings for the NHS and social care; PCT clusters and commissioning consortia must work with local authorities to commission falls and

fracture pathways and public health campaigns on bone health and falls prevention in all localities.

• Indicators which aim to slow the rise in hospital admissions for fragility fractures must be included in the NHS, adult social care and public health outcomes frameworks; commissioners should use outcome measures linked to financial incentives to drive improvements in the quality of care; patients must be empowered to maintain their health, wellbeing and independence.

• National audits are a very effective tool for improving standards of care. A real-time national database of non-hip fragility fractures is needed.

Another document was produced by the Royal College of Physicians (2012)entitled ‘Falling standards, broken promises’, based on the audit of falls prevention services in the UK. It identifies 4 key objectives as to how the care of fallers and those at risk of falling could be improved. These were:

1. Improve care and quality of life for patients with hip fractures. It was suggested that this could be achieved by hospitals reviewing the time taken following a fracture to be admitted to hospital, receive a specialist assessment and undergo surgery.

2. Provide correct assessment and treatment. To ensure all localities purchase a fracture liaison service which follows the Glasgow model. The Glasgow model is the gold standard model of how a fracture liaison service should function. The model was initially developed in Glasgow in 1999. In 2011 a formal cost effective analysis was carried out which showed it is cost effective. In addition the model is endorsed by a range of professional bodies including the Royal College of Physicians, the National Osteoporosis Society and the International Osteoporosis Foundation (Breaking Point, 2011).It includes providing routine assessment to all men and women aged >50 years who present with a new low-trauma clinical fracture at any skeletal site to Accident & Emergency/Trauma/Orthopaedic fracture services. “Low trauma” is defined as occurring in all contexts other than in Road traffic Accidents (RTA) or in fall from above head height. In addition it should be ensured that comprehensive assessments which looked at future risks of falling were carried out, to provide appropriate treatment to reduce risk, to routinely screen older people attending A&E for minor injuries for falls and fractures at least annually.

3. Provide timely hospital community services. To be delivered via joint funded evidence-based therapeutic exercise, by ensuring local adequate provision is purchased and that there are multi-disciplinary falls clinics.

4. Promote healthy lifestyles. Increasing the number of care homes that deliver exercise sessions by training up of staff and by ensuring regular medication reviews are done on older people in care homes

Exercise interventions

There is a significant body of research into the type, frequency and duration of exercise required to significantly reduce falls and the risk of falling. Evidence by Skelton (2005) reviewed all the available studies and concluded that the most effective interventions were, 9 months in duration, group exercise based, individually tailored, and delivered by a trained Postural Stability instructor. The evidence also suggests there should be 1 class per week, for one hour and two twenty minute home based sessions. By delivering this falls risk should decrease by half and there should be significant improvements in strength, power, functional ability, balance and reaction times. functional ability, balance and reaction times.

People with dementia are at high risk of falling. However, the evidence base for the prevention and management of falls in people with dementia is limited. The current literature around exercise interventions is predominantly from trials with individuals without any form of dementia. There are certain aspects of the interventions (e.g. medication reviews and screening) which can be applied to people with dementia; however, there are no specific evidence-based effective interventions for this group. A recent webinar has been developed by a national organisation which specifically looks at all the available evidence around dementia and falling giving a review of everything that is available (Age UK, 2012). The webinar gives some useful practical tips on how falls in people with dementia can be approached prevented including –

- Consider the patients severity of dementia, type of dementia and if there is the presence of any gait disorder or previous fall history - Consider the setting e.g. does the patient live in their own home or a care home? Where and why was the assessment triggered? and the goals of the professional using the information – e.g. is it for Falls prevention or management of recurrent falling

- Consider regular re-orientation to their surroundings and adaptations such as visual cues such as pictures on doors to identify toilets and bedrooms, these may contribute to reduce their risk of falling, e.g. pictures on doors to identify toilets or bedrooms. - The physical environment generally can have a huge impact such as lighting, floor coverings and safe outside spaces.

5.2 Osteoporosis

From an osteoporosis perspective NICE have developed a range of specific guidelines for a number of aspects, these include

- Primary prevention of osteoporotic fractures (http://www.nice.org.uk/ta160) - The use of drugs in secondary prevention of osteoporotic fragility fractures (http://www.nice.org.uk/ta161) - The use of drugs for the prevention of osteoporotic fractures in postmenopausal women (http://www.nice.org.uk/nicemedia/live/13251/51293/51293.pdf) - The management of hip fracture in adults (http://guidance.nice.org.uk/CG124) - Assessing the risk of fragility fracture (http://publications.nice.org.uk/osteoporosis-assessing-the-risk-of-fragility- fracture-cg146)

These guidelines provide clarity on what should be done for differing individuals in the event of falls or fractures. Key points form the guidelines are summarised in table 8 below.

In addition a recent document produced by Age UK in conjunction with the National Osteoporosis Society entitled ‘Breaking Through: Building Better Falls and Fracture Services in England’ summarises the themes discussed at the October 2011 falls and fractures summit. The summit was a national event which aimed to bring together patients, professionals and commissioners from across England to discuss best practice and share ideas and experiences around barriers, opportunities and partnerships. The recommendations of this document highlight that preventing fractures and hospital admissions is both clinically and economically effective and will result in net savings for the NHS and social care.

Table 8 Summary of NICE Recommendations for Osteoporosis

Population base There are no recommendations for population based strategies strategies such as exercise, calcium and vitamin D supplements, smoking cessation, reduced alcohol consumption, falls prevention programmes or hip protectors - High risk - It is recommended that elderly people in residential care strategies homes and housebound elderly should be supplemented with 800 IU of vitamin D and 1.0-1.2g Calcium Daily - Correction of poor protein nutrition in patients with recent hip fractures is recommended to lower rates of complications - There is no distinction between prevention and treatment - Approved treatment for preventing fractures in postmenopausal women when given with calcium and vitamin D include Alendronate, Etidronate, Ibandronate, Risedronate, Zoledronate, Denosumab, Calcitonin, Calcitriol, Raloxifene, Strontium Renelate, Teriparatide, Recombinant Human and HRT - Approved treatment for preventing fractures in men include Alendronate, Risedronate, Zoledronate and Teriparatide

Treatment of - Collaboration between multi-disciplinary teams Fractures - Full assessment of all individuals with fractures

Case Finding - No universally accepted policy for screening - The FRAX tool to be used to calculate the fracture probability and enhance decision making

It also recommends: • the inclusion of indicators relating to hospital admissions for fragility fractures in the NHS, adult and social care public health outcomes framework • that financial incentives should be used to drive improvements. • that national audits are a very effective tool for improving standards of care, • a real time national database of non-hip fragility fractures is needed.

5.3 Summary of key elements of a falls and osteoporosis pathway

NICE guidelines for both the management of falls and osteoporosis are clear on what the pathway should include. These pathways are outlined in appendix 1 and 2. The main components of the falls care pathway are case identification, multi-factorial assessment, multi-factorial interventions and education and information. While the main components in the osteoporosis care pathway are a falls risk assessment, measuring of bone mass density, bone sparing agents along with calcium and vitamin D supplementation and reassessment.

6. Economic assessment

Evidence suggests that with a multi factorial risk assessment and an evidence based falls programme, the number needed to treat to reduce one fall is eleven (Chang et al. 2004). The average fall which results in an unplanned admission costs approximately £3,019 in Oldham and takes up 11 hospital days. In addition to these costs a significant number will require support through community physiotherapists and occupational therapists to assist their recovery. From a social care perspective many fallers will require long-term social care support in the form of home support or residential care. The average cost of a care homes is currently around £36,000 per year with nursing homes higher still. People who fall may end up living for prolonged periods in these care homes leading to considerable expense. There are also the additional costs of falls which are more difficult to quantify particularly around quality of life. These include aspects such as social isolation, depression, stress and anxiety. In addition there is the extra time required of informal carers to support the fallers. This may mean carers have to take time away from their usual jobs and life activities, which can cause them stresses and strains.

7.Current Service Provision

An essential step in reviewing the provision and developing a strategy was to identify all the stakeholders who are linked to falls and falls prevention. This allowed an accurate plan of the current provision to be mapped out so that any gaps in the service could be identified. The key stakeholders for the current falls prevention programme include:

7.1 Falls Prevention Programme Pennine Care

The falls coordinator is a physiotherapist contracted 34 hours per week who is employed by Pennine Care. They have been in post since 2009 and have responsibility for the delivery of the falls prevention programme. There is currently no defined service specification of what should be provided and the post is within the general physiotherapy contract. The cost of the service is currently difficult to define as informal links and shared working have been established with other community teams.

The referrals come from a range of health professionals including Ortho-Geriatricians, General Practitioners, A & E, other health professionals, and social care. Only a hand fall of GPs currently refer to the service. A telephone triage system is in place which ensures that any referrals get filtered to the correct team. The potential services include occupational therapy, intensive physiotherapy or the falls service which includes the OTAGO falls

26 programme or the FaME AgeUK postural stability falls programme (this is carried out by Age UK and details will be included later). Those that come through to the falls service receive a formal multi factorial assessment including a home check. The falls service presently receives around 40 referrals per month for assessment. The assessment includes taking a falls history, enquiring about concerns, medical history, functional capacity, vision, lifestyle, continence and fears, carrying out cognitive assessment, foot health and doing a Falls Risk Assessment Tool (FRAT).

The OTAGO falls programme is an evidence-based programme delivered to individuals at home (Campbell et al. 1997).The programme is delivered by physiotherapists and trained physiotherapy assistants. The programme consists of an initial assessment by a physiotherapist and up to 4 other home visits (predominantly done by physiotherapist assistants). The individuals are taught a range of exercises by the physiotherapist and encouraged to carry them out 3 times per week. The subsequent visits are to monitor progress and to appropriately increase the type, time, frequency and intensity of the exercises. The OTAGO programme is carried out over 6 months and functional tests are carried out before and after to monitor progress. The current capacity in the falls team allows 48 individuals to go through the OTAGO programme each year.

7.2 Age UK Oldham

AgeUK Oldham (previously ‘Age Concern’) are commissioned by Oldham Primary Care Trust and Oldham Local Authority to deliver evidence-based falls exercise classes. The contract contains two elements:

- A six month programme of FaME Postural Stability Instructor (PSI)falls classes. - A further six month follow on programme – the ‘next steps’ classes - for people who have completed the initial FaME course or those who are more physically able and would benefit more from the more advanced classes.

Age UK receive the referrals and carry out the administration duties but they subcontract the delivery of falls classes to Oldham Community Leisure Limited (OCLL). Age UK currently receives referrals to the programme from the falls coordinator. Due to lack of capacity and long waiting lists the falls programmes are not currently actively promoted to GP’s and other Health Professionals and referrals all come through the falls coordinator, who receives her referrals from a small number of GP practices who are aware of the service. Before 2013 some referrals went straight from health professionals to Age UK. This process has been

27 amended from 1st January 2013 so there is one point of referral and all are sent directly to the falls coordinator for triage.

The Age UK FaME PSI falls classes are evidence-based (Gillespie et al. 2009) group exercise sessions delivered by appropriately trained exercise professionals. The instructors have completed the later life training PSI course (a level 4 qualification on the register for exercise professionals).

The FaME PSI programme is currently delivered at 3 different venues across Oldham and is free to participants. Age UK also arrange and cover the costs of Ring and Ride transport to the FaME PSI classes. The programme consists of 2 supervised sessions per week, and one to be done at home without supervision, over a six month period. The classes consist of strength, endurance, dynamic balance and backward chaining (practising getting up and down from the floor) training. Like the OTAGO programme, functional tests are carried out before and after the 6 month programme to monitor progress.

Once the 6 month FaME PSI programme has been completed ‘next steps’ classes are available. This is a further 6 month tailored programme delivered by OCLL to support participants to continue to exercise. The format used is similar to the FaME PSI falls classes. Again this is provided twice a week and is free to the participants. Currently no transport is provided for this; however individuals are assisted to access transport.

Current capacity of the Age UK service is:

- FaME PSI Classes –6 x 6 month courses per year each with a capacity of 10 clients, giving a total of 60 spaces per year - Next step classes – 4 x 6 month courses per year each with a capacity of 10 clients, giving a total of 40 spaces per year

The dropout rate is approximately 15% (based on figures from 06/12 to 12/12) and not all classes currently run to capacity due to drop outs. However, every 12 weeks new participants can be introduced to a class if it is not running at capacity. Over the last 12 months 148 persons have gone through the falls programme. This is over and above the fixed capacity with the reason being that initially 12 people are signed up for each class. This is done as through experience it has been established that in any one session PSI exercise session there is likely to be at least 2 members of the group unable to attend. In addition people do drop out, so these numbers also include individuals that may not have completed the full programme.

There are currently around 50 people on the waiting lists, which corresponds to a 6 month wait.

The Age UK contract value for the above activity is approximately £20k per year.

When this falls service is compared to what the evidence suggests is required, Oldham’s programme is more extensive in regards to frequency and duration of the falls sessions. The FaME guidelines (Skelton 2005) suggests that group based exercise classes should be delivered once per week with the participants required to carry out 2 home based sessions. The evidence also suggests that the sessions are most effective when participants attend for 9 months (Skelton et al. 2005). This again is less than Oldham’s current practice, where sessions run for 12 months when both FaMEPSI falls sessions and ‘next steps’ sessions are included. By going over and above the guidelines some patients may be achieving additional benefits but it does mean that less people have access to the service and the additional gains of those who take part may not justify reducing the opportunities for others to go on the programme.

Age UK have also been working with care homes over the last 5 years to roll out the “Home not Away” scheme, which consist of delivering exercise sessions and training to Care staff in Oldham’s Care Homes. This is part of the Fit as a Fiddle programme and has provided 8 week sessions in virtually every Care home in the Oldham area. Age UK are currently selling the service to home owners in order to sustain the sessions when the funding ceases in May 2013.

7.3 Oldham Community Leisure Limited (OCLL)

As outlined above OCLL delivers the falls session on behalf of Age UK. OCLL are responsible for ensuring they provide appropriately trained postural stability instructors to deliver evidence-based sessions. In addition they must ensure the sessions are delivered in suitable venues that meet the needs of the participants. At present the PSI and next steps sessions are run in 3 venues including Oldham sports centre, Throstle Court and Elm Leigh – both in Royton (which are sheltered housing). There are currently no sessions being run in the city centre or West of the city centre.

OCLL are also responsible for monitoring attendance and carrying out regular assessments, and feeding this information back to Age UK.

In addition OCLL run community falls sessions aimed at those who have completed the next steps programme and want to continue to exercise. These chair-based exercise sessions, aim to maintain strength and balance and reduce the likelihood of further falls .These sessions are ongoing and are run in community venues and sheltered housing throughout Oldham. These classes are self-funding with participants paying £2.90 per session to cover venue and instructor costs and they provide their own transport.

7.4 Pennine Acute Falls Clinic

A consultant geriatrician falls clinic is held at the Royal Oldham Hospital each week. Referrals are accepted from General Practitioners and the Pennine Care Falls Coordinator refers those who fit specified criteria. There is one clinic per week which would typically see 4 new patients and 14-18 follow ups. The waiting lists for this clinic are long and in some cases patients get sent to North Manchester General Hospital to be seen.

At the clinics patients are diagnosed and treated as appropriate, and are often referred on to the physiotherapist lead falls service. Feedback from the consultant geriatrician suggests that regular meetings or joint clinics with both the falls physiotherapist and the fracture liaison nurse could help to triage patients more effectively, so that more patients can be seen and treated.

7.5 Primary care

No local data is available regarding the care received in primary care relating to the identification and management of falls.

The exact role of GP’s in regards to the falls service is currently quite vague. Feedback from GP’s suggest they would be happy to carry out a simple identification tool with patients and refer them to a central point of contact if they were more clear on the process of what would happen to their patients if they were referred. At present there are significant inconsistencies with some GP’s regularly referring to the falls service and others not referring at all.

In regards to osteoporosis, since April 2012 GP’s can obtain quality outcome framework (QOF) points by diagnosing and treating osteoporosis. They receive funding for the following:

• Producing a register of patients (a) aged 50-74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan; or (b) aged 75 years and over with a record of a fragility fracture after 1 April 2012 • Ensuring that patients on the register who are aged between 50 and 74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, are treated with an appropriate bone-sparing agent • Ensuring that patients aged 75 years and over with fragility fractures are treated with an appropriate bone-sparing agent.

As of 31 December 2012, 125 patients have been identified who have had a fragility fracture since the 1 April 2012 and are either over the age of 75 or have had osteoporosis confirmed by a DXT scan. (see appendix 4). The data also highlights that only 53% of those 75 and over who have had a fragility fracture are on bone sparring agents. However it needs to be acknowledged that this is in year data and some GP practices may not have yet uploaded data.

From 2008/09 to 2010/11there was a Direct Enhanced Service covering the same objectives.

Comparative data from the 2011 Atlas of Variation in Health Care (http://www.sepho.org.uk/extras/maps/NHSatlas2011/atlas.html) suggest that the number of DXA scans being requested in Oldham is just below the national average with 5.53/1,000 weighted population being requested in Oldham compared to 5.88/1000 weight population nationally in 2010/11.

The most recent prescribing data from Jul 2012-Sept 2012 suggests the average daily quota for prescribing Biphosphanates after standardisation is 0.906 (Figure 2). This is less than the North West mean of 0.948, with Oldham’s Average Daily Quota being 10th lowest out of 24 areas. In addition, based on the costings of Bisphosphonates for the months between April and October 2012, the average annual spend for Oldham on Biphosphonates is £138,281.

7.6 Intermediate care

Butler Green is Oldham’s main intermediate care centre which provides either ‘stepped up or ‘stepped down’ care. The centre provides physiotherapy and support to inpatients to increase mobility and reduce falls. On arrival all patients are assessed for risk of falling and appropriate steps are put in place to minimise these. This includes taking standing and lying

Figure 2 – Shows the Average Daily Quota / Specific Therapeutic group Age Sex Related Prescribing Units for areas within the North West Strategic Health Authority between July – September 2012

blood pressure to check for postural hypotension. Following each fall there is an extensive route cause analysis to identify the cause of the fall and put steps in place to prevent further falls. There are also links between Butler Green and the falls service so when appropriate referrals are made to the falls team.

7.7 Community Occupational Therapy Team

The Community Occupational Therapy Team (COTT) is provided by Pennine Care and is part funded by the Local Authority. The key aim of the service is to assess for equipment and adaptations needs. Referrals come from a range of avenues including self-referrals, physiotherapists and housing associations. There are specific criteria for referrals and all the calls that come through to the service are triaged to ensure they are appropriate. Many older people are referred to the service; they will then either get a home visit or be invited to a home clinic run in the LiNK Centre. The clinics in the LiNK centre allow more people to be seen at any one time and demonstrate the different types of aids and adaptions that can be done. All equipment provided is loaned to them and they are asked to inform ROSS care (the provider) if they do not need the equipment anymore. The service is free to all those who meet the criteria, however if individuals pay for adaptations through private companies they cannot get reimbursed.

Some equipment is expensive – when this is the case the decision often has to go to a panel. The adaptations are carried out by different people dependant on who owns the property. Anything over £1000 is classed as ‘major’ and has to go through the ‘disabilities facilities grant’ and is then means tested.

The COTT regularly refers people who have fallen onto the community physiotherapy team, but it is not recorded how many go on to the falls programme. The team has good links with the programme but have suggested that yearly updates on what the falls service offers and its referral protocols would be useful.

Development training has been provided by the COTT for the LA reablement team and as a result a number of the staff are now classed as ‘Trained Assessors’. This means that they can go out and assess the homes of those requiring aids and adaptations. This allows the occupational therapists to focus on more severe cases and is an effective use of resources.

7.8 Local Authority - Reablement team

The reablement team within the local authority offers a service for people who are struggling to live independently but if supported can stay in their own homes and relearn the skills considered necessary for living unsupported. They assist people who have come out of secondary or intermediate care and need temporary support to regain the coping skills

33 required to live independently. The service is not restricted to specific diseases, but the service is time limited for up to 6 weeks with a maximum of 4 visits per day. Qualified Trusted Assessors do assessments of the home environment making minor adaptations and alterations as necessary.

7.9 Helpline, Response and Key-Safe services

This is a Local Authority service provided to the 65 and overs which offers 24 hour support in the case of emergencies. Subscribers pay to have a pendant or alarm which provides a rapid response service in an emergency situation. These services ensure that if anyone falls they can be attended to quickly and appropriately without having to use the North West Ambulance Service. In 2012 the service responded to 2083 calls for falls.

There is currently a pilot programme happening which provides a referral route from the Local Authority staff to the falls service. If the Local Authority staff attend to person who has fallen but does not require an ambulance they are assessed. Then if they meet the pre- determined criteria they are then referred to the falls service for a full falls assessment.

7.10 Care Homes

The extent to which care homes provide falls exercise sessions and suitable policies and procedures to prevent falls is variable throughout Oldham. There is no official guidance on what care homes should provide however there are some self-assessment tools developed in Scotland (NHS Scotland Care Inspectorate, 2011) which could potentially be used to both reduce falls in care homes and assist care homes to achieve key care quality commission outcomes.

In addition there is the ‘Harm Free Care – safety thermometer’ initiative, which looks at improving safety in care homes with one of the three key aspects being reducing falls. The 14 Nursing homes within Oldham have all signed up to submit monthly falls point prevalence data (the number of falls within the last 72 hours of the set time to submit).(Awaiting data)

7.11 Hospital

The Royal Oldham Hospital is part of Pennine Acute Trust and they have extensive patient safety policies and procedures to reduce the likelihood of falls and injuries in patients while in hospital. A range of assistive technologies are used to support these.

There are currently no clearly established links with A&E where automatic referrals are made to the falls service. Any current referrals from A&E are dependent on individual health professionals knowledge of the service.

7.12 Fracture Liaison Service

The Fracture Liaison Service (FLS) is delivered by Pennine MSK partnership. The service consists of one full time fracture liaison nurse and one full time administrator. The service currently extracts the details of all those over 50 who have gone to the Royal Oldham hospital accident and emergency with a suspected fracture. This is done via the Advanced Light Source (ADL) X-ray data kept at Pennine Acute. The medical notes are then checked for all those individuals, and the ones which have suffered low impact fractures are followed up. A letter and questionnaire is sent to all men over 50 and women between the ages of 50-75 who have had a fracture. The letter advises them that they could be at risk of osteoporosis and that if they would like further investigations they should complete the questionnaire and return it to the service.

The questionnaire asks about a number of risk factors including age, sex, smoking status, alcohol consumption, medical history and medications. Patients have 6 weeks to respond following the letter being distributed. If when returned they meet a specified criteria they are then invited for a DXA scan. In addition a letter is sent to their GP advising that following completion of the questionnaire, they have been deemed appropriate for the scan. The waiting time for a scan is usually 4-6 weeks.

Following the scan, if the patient’s bone mass density (BMD) falls into the range classified as osteopenia or osteoporosis, they are invited to attend a clinic (this is usually about 70% of all those who receive a DXA scan). There are currently 5 clinics per week and there is usually a 4 week wait for these. In the clinics patients are given education around supplementation, lifestyle and medication and if they are osteoporotic treatment is initiated. If appropriate the clinic also refers to the falls prevention service.

In contrast to this women over 75 who are identified through the ADL data as having a low impact fracture do not have to go through the same process. They will immediately have a letter sent to their GP advising them to start medication for osteoporosis (In line with NICE guidelines).

Currently there are no specific targets for the FLS. The service aims to identify and contact all those over 50, who have a GP in Oldham and have a fragility fracture. For a significant

35 period during 2011 the fracture liaison service ceased to function due to disputes over data sharing. These issues have now been resolved and the data is supplied twice per year. This is currently being trialled but there is potential to change the frequency in which the data is provided to quarterly or monthly if appropriate. The disadvantage of the current system is that if a person falls and has a fracture the week after the data is collected they would have to wait up to 6 months before they are identified and any information is sent to them. This increases the amount of time where they could experience secondary osteoporotic fractures before any interventions.

The fracture liaison nurse would welcome the introduction of multi-disciplinary clinics with the Consultant Geriatrician and the Falls Coordinator. She raised concerns that some patients are passed around the system and seen several times for the same conditions. Multidisciplinary meetings would help to reduce any duplication in assessments and treatments and improve communication between different stakeholders in the service.

8. Residents’ and Service Users’ Views

To obtain the views of Residents and Service Users in Oldham several focus groups were held. These focus groups included one group who had been through the OTAGO (home- based) falls programme, one group who had been through the PSI (community group based) falls programme and one group that were from a luncheon club who had no experience of the falls programme. In addition two mini focus groups were carried out with female BME groups who had also had no experience of the falls programme.

The attendees were all volunteers and were happy for their thoughts and views to be shared. The focus groups were recorded for accuracy and the main themes were identified from the recordings. The focus groups were asked about their experiences of falls, what their perceived risks were, whether they feared falling and what support they received after falling.

The findings are summarised in the text box on the next page.

9. Value of falls programme on wider mental well being

It is clear from the focus groups findings that falls programmes have much wider positive impacts than just physical. The feedback from residents suggests falls programmes have a positive impact on mental health promoting independence, reducing social isolation and reducing anxiety. Evidence from Skelton (2005) reinforces these findings, with her study

36 finding that those who went through the FaME PSI programme had improvements in caring skills, were more likely to use public transport again, had reduced fears and anxiety and were generally more confident.

Box 1Views of participants of the residents’ focus groups

Experience of falls

- A real mixture of falls experiences throughout all hours of the day both inside and outside the home - Various reasons given for falling e.g. out of the blue, not sure what caused it, knee shunt - There were no specific patterns with the falls - Some individuals cited a gradual decline in balance coordination with others suggesting they felt fine right up until the fall

Following falls

- Many chose to have helpline alarms around their necks – there were disparities on what services people received and how often the devices were checked

Adaptations - home assessments were done for all fallers referred to the falls service

- The most common adaptations included stair rails, bed rails, grab rails in the bath and seat in the shower

- Many who were not referred to the falls programme still had adaptations including chairs in the kitchen, sticks and frames - No advice given on where to get the equipment for those without formal assessments, - most of them got free sticks from social services

Feelings around falling

- Fear of falling was common in the majority of the people in the focus groups

- Anxiousness and a loss of confidence was also common

Quotes

“I have no confidence, I am terrified – I have fell and fell, it’s only since I came here that the instructors have helped me, I can’t go out on my own – I can’t go to the shops”

How falls have affected their life

Quotes

“I no longer go shopping on my own or chase my great grandchildren” “I don’t put myself in a situation where I can fall” “I’m scared of having to rely on others” “I have lost the confidence in getting on buses”

Box 1 Cont Views of participants of the residents’ focus groups

Views on the programme (for those who have been part of the programme)

- Excellent

- Very supportive – and has helped to increase the confidence of many - Good form of social support and reduces isolation

- Good for the family as well as individual

What fall service would you like to receive?

- More of the same

- Exercise classes at luncheon clubs - A mixture of views some stating that a group environment would work best for them others

would prefer to do it at home - Not everyone knew about this or other supportive services

- Some people were unsure where to get any relevant information and find it difficult to get out to them

- A card with all the information would be useful – a useful number card - One person had information with all the numbers

Other comments

- Lack of knowledge of the service for those who have not been referred onto the falls programme

- Transport is an issue, with buses and taxi’s offering an inconsistent service - Unsure who to get information around falls from

10. Gaps between best practice and current services

The table below summarises the gaps between best practice and current provision.

Table 9 –– Gaps between best practice and current provision of falls prevention and fracture liaison services in Oldham

Current position Case/risk Falls identification - Lack of clarity about what activity is being undertaken in primary care and nursing homes to identify people who have fallen or are at high risk of falling - No local guidance for primary care or other services on identifying people at risk of falling or use of a standardised tool to aid identification - Currently only a small number of GP’s and health professionals refer to the falls service leading in inequities of access for patients. - Currently no referral pathway from the Ambulance Service to falls services but work commencing to establish this. - Pilot in place for referrals from Local Authority’s reablement and rapid response service. - Lack of clear referral criteria and referral pathways for the falls related services - Lack of promotion of the falls services

Osteoporosis - No data available locally on numbers of people who have been identified as having or being at risk of osteoporosis. - Variation in Health Care Atlas data shows just below average rate of DXA scanning suggesting we may not be identifying all those under 70s at risk. - QOF indicators for osteoporosis only in year one so no data yet available. - The Fracture Liaison service identifies patients through identifying potential fragility fractures in the 65s and over from X-ray data but data only collected once every 6 months. No direct liaison with A&E, fracture clinics or orthopaedic wards. - The Fracture Liaison Service currently calls patient in twice once for DXA scan and once for Clinic – potential for a one stop scan/clinic visit.

Multifactorial - Robust falls risk assessment carried out through falls team, Risk including a home assessment but numbers being referred and Assessment assessed very small compared to need - Unclear if primary care undertaking multifactorial risk assessments for falls and/or Osteoporosis. - Limited Multidisciplinary working – no MDT between consultant, falls coordinator and fracture liaison nurse. Separate consultant falls clinic. - Limited links with community pharmacy and may benefit from links with vision and urinary incontinence clinics. Some duplication of assessments due to lack MD working between consultant clinics, falls service and fracture liaison service. Multifactorial - Range of evidence based high quality, high frequency exercise Interventions sessions delivered with very good patient feedback. But due to

lack of capacity, six month waiting listfor Age UK programmes putting those patients of increased risk of falling before starting the programme - Age UK programmes have greater number of patient contact sessions than needed according to evidence base - Inequity of access to the interventions following on from the inequity of access to assessment - Falls groups not run from all districts of Oldham, potentially further decreasing access for some frail clients. - Lack of follow up following interventions to check long term adherence to exercises - Lack of exercise or other multi-factorial interventions in care homes. - Prescribing data show low bisphosphonate prescribing rates. - Lack of information as to whether patients not seen in falls or fracture liaison service receive lifestyle advice and relevant education re OP.

Overarching - Under capacity – services not commissioned in sufficient quantity leading to unmet need, inequity access and long waiting times. Increased provision is needed to have the required impact on a population level. - No service specification for Pennine Care Service

Professional - Standardisation and enhancement of training on falls and OP Education risk and interventions for healthcare, social care and care home staff needed.

11. Needs Assessment Summary

Falls are a major cause of morbidity and can have significant impacts on quality of life. The costs that relate to falls and fall related injuries are huge stretching across both health and social care. The reduction of falls and fall related injuries has been identified as both a local priority with the Health and Well Being Strategy, and a National priority through the NHS Outcomes Framework, Public Health Outcomes Framework and the Adult and social Care Outcomes Framework.

The 2004 NICE guidelines around what an effective falls programme should contain are clear as is the guidance for the identification and management of osteoporosis.

The present falls programme offers elements of good practice but is delivered on too small a scale to have significant population impacts. There is currently significant inequity in services with those receiving it getting a robust service but many unable to access any service at all. The referral pathways are, in places fragmented and there is limited multidisciplinary working.

There is clear evidence that falls programmes can reduce falls and prevent the fear of falling, as well as improve quality of life following falls. In addition there is literature to suggest, and focus group results to confirm, that falls programmes have much wider benefits than this. They have a major impact on mental well-being by reducing isolation, improving independence and reducing depression. The increased independence and confidence gained reduces reliance on carers and families and the exercise sessions can act as carer breaks for several hours at a time.

In addition to being clinically effective, the evidence base supports the cost effectiveness of a comprehensive falls and osteoporosis programme.

Section two Falls and Osteoporosis Strategy

12. Aims of the strategy The overall aims are to:

• Reduce the number of falls and levels of osteoporosis in older people within Oldham • Ensure at risk individuals are identified early and preventative steps are taken to prevent falls and osteoporosis • Ensure the treatment and support received following a fall is to a high standard and steps are taken to mitigate the impact of the fall on the persons quality of life.

13.Recommendations

Based on the findings from the JSNA a series of recommendations are outlined below.

Recommendation one: Increase the identification of people who have fallen or are at risk of falls or osteoporosis and improve the referral pathways into the falls/osteoporosis assessment service

- Increase public awareness: o Continue and increase awareness-raising events which are led by voluntary organisations to include a falls awareness day, sloppy slippers campaigns and local press releases around how to prevent falls o Increase awareness that falls are not an inevitable part of aging and that much can be done to prevent them o Improve communication material – working with a range of local media, community and voluntary organisations to promote self-care with advice on what to do if falling regularly o Undertake targeted work with BME communities who tend to have low uptake rates of falls prevention services o Improve awareness of osteoporosis, through public health campaign encouraging individuals to take up positive lifestyle habits and visit their GP if concerned

- Provide training for health and social care staff on falls, risk assessment and available local services.

- Promote the use of tools such as the Falls Risk Assessment Tool (FRAT)in primary care and community services to enhance the early identification of people at risk of falling.

- Develop links with the long-term conditions QIPP programme ensuring that those patients GP’s identify as the top 5% or risk of emergency admissions are assessed for risk of falls with referral to falls services where suitable.

- Continue the development of a single point of access to the falls service to ensure all individuals being referred come through the same route. This needs to be supported by clear referral criteria, referral pathways and triage.

- Provide guidance and support for those who do not fit the referral criteria e.g. those with dementia

- Expand the range of services referring to the falls assessment service: o Continue to develop referral mechanisms within the Local Authority including from the helpline and Reablement Service. This should ensure the details of all those using their services who fall are referred onto the falls team.

o Work with the North West Ambulance Service (NWAS) on a North East Sector Approach (including Heywood, Middleton and Rochdale, Bury and Oldham) to develop an urgent care deflection system where all people who have fallen who are not taken to A&E are automatically referred to the falls team.

o Develop referral pathways from A&E and appropriate outpatient clinics eg fracture clinics.

o Promote services amongst GP’s and other health professionals including neighbourhood LTC teams, cardiologists and pharmacists.

o Work with all other out of hours providers to ensure they are clear and understand how to refer onto the falls team.

Recommendation two:

Commission one comprehensive, community based, multidisciplinary falls and osteoporosis service, which delivers care in line with the NICE clinical guidelines for falls and osteoporosis, and has sufficient capacity to have a population health impact

- Bring together the current fragmented services (PAHT Consultant Geriatric Falls Clinic, PCFT falls coordinator and physiotherapy and OT input, Age UK Falls Exercise Classes, Oldham Community Leisure and Pennine MSK Fracture Liaison Service) to form one multi-disciplinary service delivered by a partnership of providers, from community settings, which provides care in line with NICE and other relevant guidelines.

- Ensure a single robust assessment, triage system and pathway is in place to increase clarity around the treatments and support patients receive (see appendix 1).

- Maximise the efficiency and capacity of the service by:

o Holding weekly multidisciplinary team meetings.

o Having a single point of access with all referrals being triaged, with the Consultant only seeing those fulfilling certain criteria.

o Increasing the proportion of physiotherapy led multifactorial assessments which are undertaken in a community clinic setting instead of the person’s homes. Home assessments to be undertaken by physiotherapy assistants (or if the person is receiving support from the LA reablement team, their Trusted Assessors), with Occupational Therapists/Physiotherapists only undertaking home assessments for people with more complex needs.

o Decrease the number of supervised sessions in the FaME Age UK postural stability falls programme offered to each patient from 2 sessions per week for 6 month to 1 supervised sessions each week for 6 months and change the next steps programme to once per week for 3 months. This is in line with the evidence base which suggests similar levels of effectiveness are obtained with 1 supervised sessions per week for 9 months (Skelton,

2005).Promote home based exercises and long-term adherence to exercises and enhance the signposting of patients to the OCLL self-funding community chair based exercise sessions.

- Significantly increase the capacity of the falls assessment and exercise prevention elements of the service

- Enhance access by increasing the number of venues where the exercise sessions are delivered ensuring they are delivered in each of the district partnership locations.

- Improve current case finding systems for those with osteoporosis o Recall the data from Pennine Acute NHS Hospital Trust monthly (rather than 6 monthly) to identify all fragility fractures on a more regular basis

o Regular liaison between the fracture liaison nurse and hospital wards, fracture clinic and A&E

o Provide a one stop shop for Patients who come in for a DXA scan to include the clinic, which will reduce the number of times patients have to travel

Develop systems to more effectively monitor the progress and long-term outcomes of those going through the falls and OP programme.

- Improve the data flow by developing a data system which identifies a patient’s journey once they enter the falls/OP pathway. This will map their progress throughout and identify their exit strategy.

- Ensure outcome measures and activity levels are incorporated into a falls/OP service specification

- Hold quarterly meetings with all stakeholders to discuss processes to see where improvements could be made.

Recommendation Three:

Work with care homes, intermediate care, respite care and day care settings to reduce falls and fall-related fractures

- Ensure there is a falls prevention champion/point of contact within all care homes, intermediate care, respite care and day care services.

- Continue the regular monitoring of number of falls in the 14 nursing homes through the ‘Harm Free Care – Patient Safety Thermometer’ initiative, with data being passed onto the falls team to support those homes with the most falls. Expand to cover residential homes, intermediate care and respite care settings.

- Promotion of self-assessment within both nursing and other settings as above around the management of falls and fractures using an evidence-based model o Falls prevention policy o An assessment on admission o Systems to record, analyse and routinely review resident falls

- Ensure the developing health care support package for care homes has a focus on falls prevention and links with the specialist fall team to provide advice and support to care homes.

- Specialist falls team to provide advice and support for intermediate care, respite care an day care settings about changes they can make to reduce falls

- Promotion of chair based exercise classes in care homes, intermediate care, respite care and day care settings.

- Explore the feasibility of delivering some of the falls service exercise programmes from day care settings and incorporating a falls prevention programme into all day care programmes.

Recommendation Four:

Additional Recommendations

- Improved engagement of GPs and pharmacists in regards to regular medication reviews in people who frequently fall.

- Work with GP’s to promote identification of patients with or at risk from osteoporosis using the QOF points as an incentive.

- Provide training with reablement staff from the LA to reinforce messages and encourage long-term adherence of home exercises in patients.

- Ensure appropriate equipment for inpatient settings to minimise harm for patients who are at risk of falling, including those with dementia – to include lowered beds, chair alarms.

- Review in detail the management of people who have had a fracture neck of femur.

- Develop an action plan to take the strategies recommendations forward, including timescales and ownership of tasks. This should be developed by a collaboration of the key falls prevention stakeholders and requires engagement from all partners.

Summary

The strategy should act as a catalyst to ensure all the positive work which is currently happening is effectively coordinated. This in turn will prevent any duplication and ensure that the patient pathway is clear and seamless and that resources are used efficiently.

14. References

Age UK (2011) Preventing falls in older people living with dementia a webinar, accessed at http://www.ageuk.org.uk/fallswebinar.

Aloia J, Vaswan IA, Yeh J, Flaster E. (1996) Risk for osteoporosis in black women. Calcif Tissue Int;59(6):415-23.

Breaking Point (2011) Osteoporosis in the UK at... Breaking Point, available at http://www.breakingpoint.org/best-practice/fracture-liaison-services/ [accessed on 18.12.12]

Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. (1997) Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women, BMJ.;315(7115):1065-9.

Chang, JT, Morton, SC, Rubenstein, LZ, Mojica, WA, Maglione, M, Suttorp, MJ, Shekelle, PG.(2004) Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials, BMJ; 328:680

Christodoulou C, Cooper C. (2003) What is osteoporosis? Postgraduate Medical Journal; 79: 133-138.

Cryer C, Patel S (2001) Falls, Fragility&Fractures. Alliance for Better BoneHealth.

Department of Health (2001) National Service Framework for Older People.

Department of Health. (2001) National service framework for older people, standard 6, Falls

Department of Health.(2006) A new ambition for old age – Next steps in implementing the NSF for older people, London: DH.

Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. (2003) Interventions for preventing falls in elderly people. Cochrane Database Syst Rev.(4):CD000340.

Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE (2012) Interventions for preventing falls in older people living in the community (Review), The Cochrane Library 2012, Issue 11.

Hospital Episode Statistics ‐Inpatient data, (2008‐9) www.hesonline.org.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=192 [Accessed Kanis JA, Johnell O, De Laet C,(2004). A meta-analysis of previous fracture and subsequent fracture risk. Bone; 35: 375-82.

Law MR, Hackshaw AK. (1997) A meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture: recognition of a major effect. BMJ; 315: 841-6. London: DH.

Lukert BP, Raisz LG. (1998) Glucocorticoid-induced osteoporosis: pathogenesis and management. Annals of Internal Medicine; 244: 271-92.

Melton L, Bryant S, Wahner H, O'Fallon W, Malkasian G, Judd H, (1993). Influence of breastfeeding and other reproductive factors on bone mass later in life. Osteoporos Int;3(2):76-83.

National Osteoporosis Guideline Group (2010) Osteoporosis: Clinical Guideline for prevention and treatment, http://www.shef.ac.uk/NOGG/NOGG_Executive_Summary.pdf [accessed on 12 November 2012]

National Osteoporosis Society (2012) Breaking Through: Building Better Falls and Fracture Services in England, Available to download at http://www.nos.org.uk/document.doc?id=987 . [Accessed on 6 September 2012]

Nelson H, Morris C, Kraemer D, Mahon S, Carney N, Nygren P. (2001) Osteoporosis in postmenopausal women: diagnosis and monitoring. Portland: Oregon Health & Science University Evidence-based Practice Center;

NICE (2004) The assessment and prevention of falls in older people NICE Guideline 21.

NHS Scotland Care Inspectorate (2011) Managing falls and fractures in care homes for older people, Available to download at http://www.scswis.com/index.php?option=com_content&task=view&id=7907&Itemid=695 [Accessed on 12 December 2012]

Oldham Joint Strategic Needs Assessment (2012)

Projecting Older People Population (POPI) (2012) Institute of Public Care, http://www.poppi.org.uk/index.php [accessed on 12 November 2012]

Ravn P, Cizza G, Bjarnason NH, Thompson D, Daley M, Wasnich RD, (1999) Low body mass index is an important risk factor for low bone mass and increased bone loss in early postmenopausal women. Early Postmenopausal Intervention Cohort (EPIC) study group. J Bone Miner Res;14:1622-7.

Royal College of Physicians (2011) National audit of the organisation of services for falls and bone health in older people.London: RCP.

Royal College of Physicians. (2010) Falling standards, broken promises: report of the National Audit of Falls and Bone Health in Older People Commissioned by the Healthcare Quality Improvement Partnership, 2011. Available to download from: http://www.rcplondon.ac.uk/sites/default/files/national_report.pdf. [Accessed on 12 October 2012]

Seeman E. (1996)The effects of tobacco and alcohol use on bone. In: Marcus R. Feldman, Feldman D, Kelsey J eds. Osteoporosis. San Diego: Academic Press: 577-97.

Skelton, D., Dinan, S,. Campbell, M. and Rutherford, O. (2005) Tailored group exercise (Falls Management Exercise — FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 34 (6): 636-639.

Snelling A, Crespo C, Schaeffer M, Smith S, Walbourn L. (2001) Modifiable and nonmodifiable factors associated with osteoporosis in postmenopausal women: results from the Third National Health and Nutrition Examination Survey, 1988-1994. J Womens Health Gend Based Med10(1):57-65.

Snow CM, Shaw JM, Matkin CC. (1996) Physical activity and risk of osteoporosis. . In: Marcus R. Feldman, Feldman D, Kelsey J eds. Osteoporosis. San Diego: Academic Press: 511-28.

Soroko S, Barrett-Connor E, Edelstein S, Kritz-Silverstein D. (1994) Family history of osteoporosis and bone mineral density at the axial skeleton: the Rancho Bernardo Study. J Bone Miner Res;9(6):761-9.

World Health Organisation (2004) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. Geneva, World Health Organization, 1994 (WHO Technical Report Series, No. 843).

Appendix 1 – 2004 NICE guidelines on how a falls prevention pathway should be structured

Appendix 2 – Osteoporosis pathway based on 2012 NICE guidelines

Appendix 3 – Current community fall prevention pathway in Oldham

Patient over 65 years falls and makes contact with GP, health Care Professionals or A&E

All >65 years falls patients referred to single point of access Falls lead physiotherapist decides which service is required

Community Falls Clinic Community Falls Prevention Programme Triaged by Falls Lead Physiotherapist Triaged by Physiotherapist

Request for bloods to Therapy assistant Therapy assistant be taken if needed assess patient at home for assess patient at home for Results sent to clinic home hazard check. home hazard check

Results sent to clinic Results sent to clinic

Patient attends Falls clinic in community setting* With triage, bloods and home hazard information Patient attends Falls Prevention Programme completed and available in community clinic** At clinic reviewed by falls lead physiotherapist With triage and home hazard information (band 7) & receives completed and available • Multi-factorial assessment with bone At clinic reviewed by physiotherapist (band 6) health review & receives + • Multi-factorial assessment with a • Medicines review bone health review • Osteoporosis Assessment • Lying and Standing BP • Vestibular assessment where necessary

Referral to Pennine Acute Falls clinic for consultant review if problems cannot be resolved in community Falls clinic Referral to appropriate strength and balance programme

Otago Home Exercise programme Referral to the Oldham 6 Months Evidence based exercise Community Leisure to programme Age UK and NHS Oldham Falls increase activity levels Prevention exercise class organisations) 53

Appendix 4 – QOF data on osteoporosis for Oldham GP’s from 1st April 2012 to December 2012.

QOF 2012 Indicator - Osteoporosis: secondary prevention of fragility fractures (OST), 1 April 2012- Dec 2012. Source: QMAS, 5 Jan 2012 NB:- data reflects part year activity only. Some practices may not have yet submitted data. Number Denominator % OST1. The practice can produce a register of patients: 1. Aged 50-74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan, 125 and 2. Aged 75 years and over with a record of a fragility fracture after 1 April 2012 OST2. % of pts aged 50 to 74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, who are 7 7 100 currently treated with an appropriate bone-sparing agent OST3. % of pts aged 75 years and over with a fragility fracture, who are currently treated with an appropriate bone-sparing 62 116 53.45 agent