The National Audit of Falls and Bone Health in Older People [Speaker’s name and designation] On behalf of the Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London Funded by Healthcare Quality Improvement Partnership [insert name] Strategic health Authority [date], [venue]

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

“We can only be sure to improve what we can actually measure” Lord Darzi, High Quality Care for All, June 2008 How do we know how we are doing?

National Hip Fracture Database National Audit of Falls and Bone Health Evidence based standards Where audit fits in this model Hip fracture patients Non-hip fragility fracture patients Individuals at high risk of 1st fragility fracture or other injurious falls Older people Clinical audit evaluation NSF Health promotion NSF, NICE Exercise programmes Falls clinics Bisphosphonates Blue Book, NSF, NICE Fracture Liaison Service Falls Clinic BOA/BGS Blue Book High quality hip fracture care

National Clinical Audit 2007 Sample and Results 3184 hip fractures o Mean age 83, 80% women o 57% left A&E within 4hrs (target 100%) o 87% to specialist ward o Mean LOS = 16 days o 25% > 26 days o 59% back to usual residence o 27% to intermediate care bed 5642 non-hip fractures o Mean age 79, 86% women o 64% attended in office hrs o 1/3 admitted o 96% of the rest went home Integrated acute-community pathways are needed Hip fracture Non-hip

Hip fracture management Pre-operative management was generally good for pain relief, fluids, routine observations only 46% pressure risk assessments, 54% mattresses Surgery within 24h - 35%, 48h - 69% Organisational delay was responsible for 29% Low rates of routine medical review Lack of acute orthogeriatric services Only 39% had multidisciplinary team review within 1 st week Hip fracture

50% osteoporotic Non-hip Hip fracture Secondary prevention - Bone health Hip fracture v Non-hip fragility fracture

Hippisley-Cox, J., Bayly, J., Potter, J., Fenty, J. & Parker, C. (2007) Evaluation of standards of care for osteoporosis and falls in primary care. The Health and Social Care Information Centre. n = 7860/31094 n = 1476/15025 n = 2551/15025 n = 1862/2551 n = 261/14651 n = 700/14651 n = 305/700

Secondary prevention - Falls risk assessment Hip fracture v Non-hip fragility fracture Individuals at high risk

n = 1,076 / 251,049n = 1,335n = 15n = 10n = 319 Aspects of integrated falls care in patients 75 and over (n = 270,028) Hippisley-Cox, J., Bayly, J., Potter, J., Fenty, J. & Parker, C. (2007) Evaluation of standards of care for osteoporosis and falls in primary care. The Health and Social Care Information Centre.

Secondary prevention Most patients receive inadequate secondary prevention so are at unnecessarily greater risk of further harm Non-hip fragility fracture patients receive less attention than hip fracture patients

The Second National Audit of the Organisation of Services for Falls and Bone Health in Older People (2008)

Acute trusts100% (158/158) Acute trusts100% (158/158) Primary Care Organisations88% (150/171) Primary Care Organisations88% (150/171) Health & Social Care Trusts88% (7/8) Health & Social Care Trusts88% (7/8) Mental Healthcare Trusts76% (44/58) Mental Healthcare Trusts76% (44/58) Care homes73 homes Care homes73 homes (sample drawn from 2 national providers) Participation

Key Results

TAG 87 = National Institute for Health and Clinical Excellence, Technology Appraisal Guidance, Number 87 Commissioning for falls and bone health

Acute trusts - case finding

Secondary prevention of falls

Key Messages

Services fail to achieve evidence based standards Services are variable in quality and many lack key evidence based components Lack of integration between falls services and fracture services Lack of integration between falls services and fracture services Significant gaps along patient journey for falls and fractures Significant gaps along patient journey for falls and fractures Inadequate levels of secondary prevention for both falls and bone health Inadequate levels of secondary prevention for both falls and bone health Secondary prevention for non-hip fragility fracture is less good than for hip fracture Secondary prevention for non-hip fragility fracture is less good than for hip fracture

Risk assessments in A&E departments and Fracture services are inadequate Risk assessments in A&E departments and Fracture services are inadequate Services with Falls Coordinators and Fracture Liaison Nurses have better case finding systems in place to identify high risk fallers Services with Falls Coordinators and Fracture Liaison Nurses have better case finding systems in place to identify high risk fallers Many trusts do not provide these important posts Many trusts do not provide these important posts Many of the exercise programmes being provided are not evidence based Many of the exercise programmes being provided are not evidence based Services for bone health appear less well developed than services of falls prevention Services for bone health appear less well developed than services of falls prevention Opportunities to prevent recurrent falls and fractures are being missed

Only 64% (110/171) of commissioning bodies have a written strategy on falls prevention Only 64% (110/171) of commissioning bodies have a written strategy on falls prevention Only 23% (38/171) have a strategy for bone health Only 23% (38/171) have a strategy for bone health Important public health information on fracture rates is inadequate or not collated Important public health information on fracture rates is inadequate or not collated Only 39% (67/171) of commissioning trusts report having a mechanism to assess local compliance with national guidelines on osteoporosis treatment Only 39% (67/171) of commissioning trusts report having a mechanism to assess local compliance with national guidelines on osteoporosis treatment Commissioning for falls and bone health is weak

Non-hip fragility fracture patients Thank You Individuals at high risk of 1st fragility fracture or other injurious falls Older people

Falls history Syncope considered Medication reviewed CVS examination Vision assessment Vision impaired Gait & balance assessed Exercise programme Home hazard assessed Non-Hip (%) (most treated) Hip (%) (most treated) Falls risk assessment