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Reducing Falls and Preventing Fractures Strategic Framework Fusion Consultation December 2012 1.0 Background

NHS Devon and Devon County Council have developed a strategic framework for Reducing Falls and Preventing Fractures, in partnership with new Devon locality commissioning teams, Torbay Commissioning Team, NHS providers and voluntary sector representatives. The framework provides a comprehensive action focussed plan for reducing falls, fractures and other related injuries among older people living in Devon.

Fusion coordinated a consultation event on the 13th December, with the purpose of gathering the views of service users and carers on their priorities in relation to reducing falls and preventing fractures.

People with physical and sensory disabilities, older people, people with learning disabilities, people with mental health issues and carers took part in the consultation. A total of 21 people took part. (Please see appendix 2 for equality and diversity information.)

2.0 Key findings

The key findings are presented in the following sections:-

 Personal experiences of falls and their impact (2.1)  Equality issues (2.2)  Prevention services (2.3)  Service user and carer priorities for Reducing Falls and Preventing Fractures (2.4)  Priorities for the Reducing Falls and Preventing Fractures framework (2.5)  Steering Group (2.6)

2.1 Personal experiences of falls and their impact

Most participants had either experienced falls themselves or described the experiences of their friends or neighbours. Various themes emerged during discussion:-

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 1 2.1.1 Causes of falls

 Most of the falls experienced by participants happened in the home or in the garden.  Lack of handrails or banisters in the home.  Medication – causing loss of balance and or unsteadiness.  Poor eyesight.  Falls on stairs were common.  Incorrect footwear.  Frailty due to a recent operation.  Unsteadiness due to medical condition.  Falls as a result of medical conditions such as Menieres Syndrome.  Trips outside the home.  Poor lighting.  Trying to be independent in the home – changing a light bulb – causing a fall.  Slipping on ice or wet leaves.  Reaction to pain.  Failure of health services to carry out a full examination after first fall.

2.1.2 Treatment and support

Participants described the treatment they had received following a fall. Some people were taken to A & E; others received a visit from the GP a few days afterwards. Participants had received support from occupational health, SW commissioning groups Care Advisors, physiotherapy, acupuncture and hydrotherapy. Some participants had equipment installed in their homes, e.g. handrails and hoists and some began to use mobility aids such as walkers, walking sticks and stand aids. Some participants began to use alarm pendants. Some participants now attend exercise classes at local leisure centres, although some classes have been stopped due to low referrals. Some of this support and equipment was provided by the NHS and some was purchased privately.

Some themes emerged during discussions about treatment and support which are outlined below.

 It appears that people are not experiencing a consistent care pathway. There was significant concern amongst participants about the perceived lack of follow up and after care and support, following discharge from hospital after a fall. Some participants described how the only support they received was from family, friends and neighbours.

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 2  It was frequently highlighted that people would like to be given more information and advice about falls prevention, support services and equipment following discharge.  It was strongly agreed that, as well as more after care and support, there should be routine risk assessments for people in their homes following a fall.  Some participants suggested that the cause of their fall was not sufficiently explored and/or they were not observed adequately. Participants described being discharged without proper examination. Participants expressed their fears medical staff ‘don’t actually listen to the whole story’ or spend time with the patient to explore the reasons for the fall. It was suggested that if medical staff were able to offer more time to each patient, perform through assessments and explore their situation fully, the reasons for falls may become apparent thus preventing further falls in the future.  It was queried whether there is a lack of trained staff out of hours.  Participants suggested that there are delays in receiving social care support when falls take place on weekends and that this should be addressed. One person described how s/he was admitted to hospital following a fall, as appropriate support at home was not available.  Participants commented on the excellent service provided by the out of hours GPs and the ambulance service.  Lack of financial assessment – to take into account the cost impact of a fall (e.g. equipment aids, extra care etc.).

2.1.3 Impact and consequences of falls

 The ‘stress’ of falling – emotionally and physically.  Lack of confidence, isolation.  Fear of falling again.  Impact on emotional wellbeing – especially when recovery is not quick.  Becoming housebound - fear of going out.  Loss of independence, limiting activity.  Reliance on services such as Care and Repair.  Loss of dignity.  Increased reliance on family, friends and neighbours.  Costs to self -funders for housing adaptations, equipment, extra care, medication and support - installing handrails for example or attending hydrotherapy sessions. Costs when visiting family members who have fallen e.g. car parking etc.  Family members become carers. Care responsibilities increase after a fall.  Impact on cared for people when a carer falls.  Impact on a carer having to care for people whilst on crutches for example.  Increase in hospital admission and associated costs.

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 3 2.2 Equality issues

This section outlines the themes which emerged during discussions about how equality issues may increase a person’s risk of falling and affect a person’s ability to access services.

 Rurality – participants highlighted the importance of recognising that a large proportion of people in Devon live in isolated areas which will affect their ability to access services or puts them more at risk. Transport issues need to be considered within the strategic framework.  The growing population of older people in Devon was a concern.  Access to services if you live in residential care.  Increased risk for people with hearing and visual impairments and more difficult to access services.  Language barriers e.g. Deaf people who use BSL.  Challenges faced by people with dementia.  Lack of financial resources to buy care / equipment or appropriate footwear  Fuel poverty.  Inequalities in service provision in different areas, ‘postcode lottery’.  Disability and lack of accessible housing (making falls more likely in unsuitable accommodation).  Certain medical conditions increase risk such as Parkinsons, diabetes, epilepsy, blood pressure problems.  People were fearful for those who live alone and may fall and are left for a long time before help arrives. In addition people living alone may take more risks and don’t want to ask for help.

2.3 Prevention Services

Participants discussed the 3 levels of prevention as outlined in the Reducing Falls and Preventing Fractures framework. Participants comments are highlighted below:-

2.3.1 Level 1 (‘Primary prevention’)

The first level of prevention focuses on population based approaches that address the risk factors for falls and fall related injuries through the roll out of public health programmes in the wider community. Comments are summarised below.

Information / awareness  Participants highlighted the importance of raising awareness and providing information and awareness of healthy living and nutrition.  Education and awareness about the right shoes to wear.

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 4  Information should be widely available, particularly at GP surgeries and pharmacies.

Promotion of healthy living – children, young people and schools  Reinforce health education in schools – exercise, nutrition etc.  Participants commented on the good practice taking place in some primary schools, where children start the day with warm up exercises.  Encourage food preparation in schools (all ages) and include food hygiene, balanced diets, nutrition info.  Participants suggested that the selling off of school playing fields has had an impact on child obesity.  Participants were interested in whether reintroducing free milk in schools would have a positive impact.  Lack of parental supervision and encouragement for children to participate in sports activities.  Parental fears and anxieties about children playing outdoors without supervision.  Children and young people are less active than they used to be – taking part in too many sedentary activities e.g. computers and TV and not getting enough exercise.

Promoting exercise  Encourage sport through the use of ‘Wii Fit’.  Ensure sports halls are accessible with loop systems installed  GPs should refer more people to exercise classes.  Concerns about the lack of and closure of sports facilities

Breastfeeding  there are increasing pressures on mothers to return to work thus limiting opportunities for breastfeeding. Participants also commented on the need to address the ‘image of breastfeeding’ in society. Participants agreed that breastfeeding should be encouraged and promoted.

Housing and public spaces  Housing design needs to take peoples’ mobility needs into consideration – e.g. furniture, fittings, and lighting.  Attention to public spaces – e.g. obstructions on pavements, overhanging hedges and trees. Councils and contractors need to be more aware of the importance of dropped kerbs, rails which aren’t slippery etc.

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 5 Other issues  Resources and respite for carers to be able to attend falls prevention workshops.  More promotion of falls awareness for people on medication. This should be cross referenced so that people on particular combinations of medication are flagged up.  Peoples’ financial situation will affect their ability to improve their health e.g. better nutrition and more exercise. Exercise classes and leisure centres can be expensive.

2.3.2 Level 2 (‘Secondary Prevention’)

The second level of prevention includes interventions that reduce the risk of falls in people already identified as being at increased risk, often because they have a history of falls. Comments:-

 It was strongly agreed that there is a need for more and better information about available support for people at risk of falls and what an individual can do to help prevent falls and fall related injuries. Better information should be available in hospitals, at GP surgeries and in the community, for example at local groups and clubs such as Womens’ Institutes. It was suggested that volunteer groups could visit people at home to advise and support.  The need for regular assessments for people at risk was frequently highlighted. Many participants questioned why assessments are often not done following a fall. It was agreed that OTs should visit and assess risk as well as advice on equipment and adaptations.  It was commented that trained professionals should visit people in their home to make people aware of and minimise hazards within the home.  A common concern was the perceived inadequate support provided to people after a first fall, with the consequence that many people fall again. Participants highlighted a need for better reablemement services and smoother pathways from hospitals back to the community.  It was agreed by many participants that routine bone density scans should be undertaken, particularly for those at high risk.  It was suggested that this level of prevention needs to be monitored and reviewed.  Participants commented on their perception that preventative care is being cut back.  It was suggested that geographical boundaries can affect seamless care – people can miss out on assessments and follow up care.

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 6  Participants highlighted the need for systems to be in place to ensure that GPs make people aware of and flag up particular combination of medications and their possible effects on balance, so that support and risk assessments are in place.  With regard to exercise classes, the following points were raised:- - the benefits of falls prevention classes were commented on and it was suggested that GPs should more actively promote them and refer people - home based exercises are helpful, however, the need to assess people to ensure the exercises are appropriate was highlighted. One participant had a fall as a result of the exercise class; - exercise classes are expensive for those without a GP referral; - one to one support is helpful. Some people feel embarrassed to go to groups; people need to be referred to strength and balance groups – ‘shame that you can’t just turn up’; and - the benefits of Tai Chi and ‘Best Foot Forwards’ classes were discussed

2.3.3 Level 3 (‘Tertiary Prevention’)

This third level of prevention is activity to reduce the negative consequences of falls related harm. Interventions are targeted on those with a history of fracture and those at high risk of osteoporotic fractures. Comments are summarised below.

 Medication for bone strengthening has proved beneficial but can have negative side effects.  Participants highlighted the need for much more information to ‘know how to help yourself or family member’  Some participants objected to the term ‘post menopausal women’ and felt it was disrespectful.  Teach people ‘how to fall’ in order to minimise risk of injury  Ensure there are follow up visits and assessments  The need for joined up services  Group activities e.g. ‘Walks for Life’ , interest groups  All agreed: - Fracture liaison service based at all hospitals for whole country. Linking Hospital and community services is the key.  Services such as physiotherapy need to be put in place in a timely fashion.  Need to target people at high risk.  Ensure people continue with bone density medication. Regular review of medications “people are just given medication and left to get on with it.”  Support around physical activity perhaps not enough. People also need support for the psychological and emotional impact, helping people to get their

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 7 confidence back e.g. befriending services for those who feel isolated and lose confidence

2.4 Service User and Carer Priorities for Reducing Falls and Preventing Fractures strategic framework

A number of priorities for service users and carers emerged during discussions and work groups. This section aims to give an overview of the responses and to provide an indication of the themes that were raised most frequently. (See appendix 1 for a full transcript of peoples’ top 4 priorities.)

2.4.1 Information / awareness

A consistent priority for the participants was the need for improved falls prevention information, good pathways and better information about services available for people who have experienced falls or are at risk of falls as well as for carers.

Working group discussions highlighted the importance of information both for preventing falls and for people who have experienced a fall, following discharge from hospital. 61% of the participants (13 people) included improved information as one of their top 4 priorities.

Participants particularly highlighted the following points:-

 participants have experienced a lack of information about available support services, falls prevention information and classes and equipment. ‘knowing who when and where to get help’;  more information at the point of discharge;  GPs are an important source of information and support for people and should improve their knowledge and practice in terms of falls prevention and support  the importance of ensuring adequate distribution of information;  target awareness leaflets at people who are over 60;  produce information about falls prevention and support services in all formats including DVDs, leaflets, posters, BSL clips etc. ;  information about equipment and adaptations and other preventative measures (even if not provided by the NHS);  information to be available at a local level;  instructions for people about ‘how to fall’;  awareness raising about services already available such as Care Direct; and  introduce support groups/clinics where people can go for information and advice. GPs could run health awareness groups in surgeries.

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 8 2.4.2 ‘Joined up' services

The importance of integrated services emerged as a high priority for service users and carers. 43% of participants (9 people) included this in their top 4 priorities and it was a consistent theme in working group discussions.

Participants highlighted the need for joined up services between health, social care and the voluntary sector, and for services to work together from the outset following a fall. Participants felt that integrated services would help to ensure that every person who has had a fall receives an assessment and follow up care and support, rather than some people slipping through the net as they do currently. Furthermore integrated services would ensure that people are made aware of and access the care and support they require.

“Services to work together for the good of everyone” “Integrated services including clinics for several potential risks under the one roof.” “Pathway should start at admission. Discharge is not thought about until last minute.” “At the hospital they are only concerned about your stay in that environment and when you get out, you’re almost left on your own..should be part of a complete care plan.”

It was frequently suggested that the Fracture Liaison Service currently being provided in Torbay should be extended throughout Devon.

A point was also made about IT systems and peoples’ medical notes not being automatically available to professionals within the health system with the result that patients are having to explain their circumstances repeatedly, or do not feel confident that the medical professional they are dealing with is aware of the full picture.

2.4.3 Care and Support

A widespread concern was the lack of a consistent care pathway and follow up care following a fall. In relation to this, participants also highlighted a lack of responsiveness from social care. This was a strongly felt issue emerging from working groups and 38% of participants (8 people) included follow up care and support in their top 4 priorities.

Participants identified a need for the provision of specialist referrals and equipment advice and provision. There was agreement on the essential role of GPs and OTs and a concern that the response from the OT department is not swift enough (one participant waited 3 months following a fall before seeing an OT).

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 9 Participants highlighted the need for health and social care professionals to better understand the impact of a fall and to provide a holistic approach to care and support, taking into account the emotional impact of a fall.

“Equal attention given to the emotional and physical limiting effects of a fall.”

The need to consider the impact of a fall on carers was also highlighted.

2.4.4 Routine bone density scans

A consistent theme in discussions was the importance of introducing routine bone density scans and tests for osteoporosis amongst ‘post menopausal’ women in particular. 33% of participants (7 people) included this in their top 4 priorities.

2.4.5 Assessments and reviews

The need for regular assessments and reviews for people at risk of falls was frequently highlighted by participants, in working groups and in individual priorities. 28% of participants (6 people) included assessments and reviews in their top 4 priorities.

3 assessment areas were identified:-

i) General assessment and reviews by GP and OTs for people who have experienced a fall or at risk of falling. Participants commented:-

- should include checking whether people live alone or have had any falls in the past; - more effective if the assessor knows the individual they are assessing; and - regular reviews and incorporation of up to date information/techniques.

ii) Follow up assessment following a fall.

Participants described a lack of consistency with regard to assessments at hospital following a fall as well as at home after discharge. The need for assessments to be performed for everyone who has fallen was a strongly felt concern amongst many participants.

“Ensure assessments after fractures ARE undertaken” “Implementation in every A & E department of assessments on those presenting with fractures.”

iii) Risk assessments in the home

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 10 As well as the need for individuals to be assessed, participants agreed that risk assessments should be performed in peoples’ homes to remove hazards where possible and minimise the potential of falls.

2.4.6 Promotion of exercise

Analysis of the feedback demonstrates a consistent priority for service users and carers is the need to promote specific falls prevention / strengthening exercises for those who have experienced falls or are at risk. 24% of participants (5 people) included falls prevention exercise / strengthening exercises in their top 4 priorities. Participants particularly highlighted the following:-

 the role of GPs in promoting exercise as well as referring people to exercise classes was frequently highlighted;  the lack of available exercise classes and the need for more falls prevention exercise classes was identified;  the financial cost of exercise classes was a frequent concern;  the value of one to one advice on appropriate exercises in peoples’ homes was highlighted as more appropriate for some individuals and circumstances;  the role of physiotherapists in advising on appropriate strengthening exercises was commonly highlighted;  there was a suggestion that ‘Wii Fit’ could be used; and  Tai Chi was mentioned by some participants as being particularly effective.

2.4.7 The ‘built environment’

A common concern was the need to consider the built environment in terms of housing design and adaptations as well as the maintenance of pavements, roads, kerbs, hedges, railings etc. 19% of participants included this issue in their top 4 priorities and it was frequently raised during working group discussions.

“Housing design – there are requirements to build social housing. Can the council influence planners and builders to build more accessible accommodation?”

“Improve dropped kerbs, the drainage to avoid the water splash and reduction in height of pimples or a half and half paving.”

“Funding from DCC in regard to highways and pavements has gone down and if we are looking at a proactive and holistic attack on this particular issue, then we should have ring fenced monies for that area.”

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 11 2.4.8 ‘Population based’ approaches

Participants highlighted some population based preventative measures as a high priority, during discussion groups and in their list of priorities:-

i) Education / raising awareness of healthy diet and exercise ii) Exercise iii) Promotion of breast feeding.

2.4.9 Effects of medication

A frequent concern amongst some participants was reassurance that the effects of medication and in particular combinations of medication should be flagged up by GPs and/or during risk assessments. It was suggested that patients should be given cards to highlight that they are on medication which may cause dizziness.

“GPs and pharmaceutical companies should ensure that people are aware of the side effects of medication – in particular that it may cause loss of balance.”

2.4.10 Financial concerns

It was clear from feedback that service users and carers have significant financial concerns with regard to the impact of falls and falls prevention. 19% of participants (4 people) included financial concerns in their four priorities and it was frequently raised during discussions. The following points were highlighted:-

 recognise the financial impact of a fall for individuals, carers and families;  address the affordability of exercises classes;  consider whether it is appropriate that some treatments and equipment are only available privately;  address the affordability of equipment and adaptations;  address the affordability of suitable footwear; and  consider the impact of fuel poverty in relation to falls risk.

2.4.11 Research into osteoporosis

It was commented that more funding should be put into researching osteoporosis.

2.4.12 Training and staff time pressures

It was suggested that there is a need for better training of medical staff and social care professionals to understand the impact of falls and to ‘listen’ to patients better, fully exploring the reasons for a fall. In addition, as well as more integrated services, it was

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 12 felt that training would better enable professionals to be aware of and be able to share information about all the services and support available.

It was recognised that medical and social care professionals are under considerable pressure which results in less time being given to each individual. Removing the pressures on resources and time would ensure that every individual presenting at A & E with a fall related injury receives a thorough assessment and receives adequate support.

2.4.12 Monitoring and evaluation

Some participants commented on the importance of monitoring and evaluating the impact of and quality of services and equipment and building an evidence base.

2.5Priorities for the Reducing Falls and Preventing Fractures framework

Participants made some comments with regard to the four key priorities of the Reducing Falls and Preventing Fractures strategic framework:-

 importance of focusing on prevention of first fall as much as preventing the recurrence of falls. Some participants emphasised the need to focus funding on population based prevention measures;  importance of working in partnership with care home providers, ensuring people are encouraged to exercise etc.;  the issue of rurality and the need to consider transport and access to services;  a Fracture Liaison Service should give equal attention to the emotional and psychological impact of a fall as well as the physiological effects; and  focus on individual exercise programmes as well as groups.

2.6Steering Group

Participants agreed with the importance of having service user and carer representation in a County Wide steering group, but also highlighted the importance of the views of individuals’ being heard as ‘experts by experience’.

3.0 Summary

Participants had a considerable amount of experience and knowledge to share at the consultation event. Service users and carers were broadly supportive of the Reducing Falls and Preventing Fractures strategic framework, but had some important concerns and strongly felt views and opinions with regard to their own priorities for reducing falls and preventing fractures. Key messages from the consultation are summarised below.

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 13 Key Messages from Reducing Falls and Preventing Fractures consultation

 The considerable emotional and physical impact of a fall for individuals, families and carers. The need to address the psychological and emotional impact of a fall as well as the physical impact.  The fundamental importance of people having access to information (in various formats and locally available) both to prevent falls and for people who have experienced a fall.  The need for integrated ‘joined up’ services and improved care pathways.  Improved follow up care and support after a fall.  More consistent and thorough assessment of all individuals who present at A & E with a fall related injury.  Routine bone density scans.  Regular assessments and reviews – including risk assessments in the home.  Promotion of exercise – specific falls prevention / strengthening exercises - (individual and one to one).  Recognition of the financial impact of a fall for individuals, families and carers and the unequal resources people have to prevent falls.  The need to address the ‘built environment’ – housing design, maintenance of pavements etc.  Population based approaches – education, healthy diet, exercise, promotion of breastfeeding.  The need to flag up the effects of medication.  The need to consider the high proportion of older people in Devon who live in rural areas and to address access and transport issues within the framework.  The need to consider the particular needs of carers i.e. increased care responsibilities following a fall or if a carer themselves falls.  The essential role of the GP to provide information, referrals and support.

Reducing Falls and Preventing Fractures Fusion consultation report December 2012, Final -Kelly Mavro Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 14 Appendix 1 – participants top 4 priorities

Information is well distributed. Ensure assessments after fracture ARE undertaken Joined up services and information between Health and Social Care, GPs, Voluntary Sector when needed. Integrated services Holistic treatment of patients (to include carer) Education – school curriculum, GPs, mums (new births) Provision of specialist referrals /medication reviews/OTs recruitment/Consultants/Quality of products Money for falls prevention awareness day that is already being carried out by Devon Senior Voice. Integrated services including clinics for several potential risks under the one roof. Perpetual information and advice Follow up services after incidents and/or falls Make a standard blood test of bone density. Automatic knowledge of the effect of multiple medications such as wooziness. Introduce physical exercise Make a publication available about falls prevention Promoting good bone density with adequate provision for breast feeding. Disability adaptations Promotion of exercise especially Tai Chi Equal attention given to the emotional and physical limiting effects of a fall. Communication and information Training Prevention work not follow up Better understanding of impact Testing of people who are postmenopausal age, possibility of using a mobile clinic More falls prevention exercise classes Education of children about diet and food. Assessments Follow up Information Financial help Training by information Education by information Communication by information Action through information Bone state House and garden state Breast feed Exercise

Appendix 1 Reducing Falls and Preventing Fractures Fusion consultation report December 2012 Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 15 Information / education Review Torbay Fracture Liaison Service to try to implement it as it stands or what could be taken out and used, Monitoring on going follow up Regular reviews and any new information/techniques to be incorporated. Improve dropped kerbs, the drainage to avoid the water splash and reduction in height of pimples or a half and half paving. Greater awareness of what is available as shown by Dementia pathways for carers or sufferers of dementia. Improve exercise and diet education in schools at all ages. Enable greater self help facilities to be available. Magic wand Scanning for all post menopausal women for osteoporosis Better information for GPs to pass on to patients More support for people who suffer from loss of confidence or depression as a result of accident Promotion of exercise especially Tai Chi as good for balance. Services to work together for the good of everyone Follow up support for people who have had falls. Difficulty with finances for person who has had fall. Routine blood tests for signs of osteoporosis Home [sp. Assessments?] Bone strength Diet and exercise balance Follow up after hospitalisation – GPs Joined up services (so saving monies).This must include hospitals e.g. two way exchange of information Implementation in every A & E department of assessments on those presenting with fractures. Information - Good pathways, Care Direct Better or improved testing for Osteoporosis – e.g. bone density checks at same time as mammograms Improve ways of awareness and information Improve inter service communication Financial costs implications Fracture Liaison Services all over Devon eventually but start with highest evidenced first Useful to have assessments Reason Fracture Liaison Service is in Torbay and not throughout Devon? Lack of information – not knowing where to go as a carer when I go to hospital Costs of all this?? Provide Wii Fit type exercise equipment on loan – for people in their own home after tuition from physiotherapists Fracture Liaison Service everywhere

Appendix 1 Reducing Falls and Preventing Fractures Fusion consultation report December 2012 Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 16 Clear pavement edges for visually impaired GPs to provide cards to patients on medicine that may cause dizziness Include hydrotherapy pools at all new build swimming pools Councils target those households with over 60s with awareness leaflets Maintain paths drop kerbs cut back hedges. Encourage GPs to run health awareness groups in their surgeries Awareness campaign about services already available like the Fracture Liaison Service and Care Direct Osteoporosis test for people with conditions or medication that makes a fall more likely. More local and affordable Falls Prevention exercise classes. Quicker response from OT department after a fall (3 months is too long) Free fall alarms for those unable to pay, particular in villages with no mobile signal Prioritise spending (at this point) on what has already been proved to work in other areas of the country

Appendix 1 Reducing Falls and Preventing Fractures Fusion consultation report December 2012 Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 17 Appendix 2

Equality and Diversity Monitoring Information

All participants indicated that their ethnic origin was ‘white British’. All participants were either retired or did not indicate their employment status.

Appendix 2 Reducing Falls and Preventing Fractures Fusion consultation report December 2012 Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 18 Appendix 2 Reducing Falls and Preventing Fractures Fusion consultation report December 2012 Fusion/Engagement Contract/ Gateway/ Consultations/ GR-1012-RFPF 19

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