Shared learning database

Type and Title of Submission


Community based Falls Prevention in Older People


Development of a comprehensive multi-agency community based Falls Prevention Service for People aged 65+. Please note that this example was originally submitted to demonstrate implementation of CG21 Falls. CG21 has now been extended and updated by CG161. This example continues to align with guidance, particularly recommendation 1.1.2 Multifactorial falls risk assessment.


Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG161 - Falls

Category(s) that most closely reflects the nature of the submission:

Is the submission industry-sponsored in any way?


Description of submission


The aim of this pilot project was to utilise existing guidance and best practice in order to develop a comprehensive multidisciplinary community based falls prevention service for older people. Delivered in a defined geographical joint working 'patch', the service was designed to reduce the incidence of falls and subsequent injury following 3 key stages: 1. Firstly identify people 65+ in the community who are at highest risk of falling, based on a simple validated Falls Risk Assessment Tool (FRAT). This involved basic training for front line staff from the statutory services and the third sector to deliver FRAT routinely with people 65+. 2. All FRATs then sent to clinical database where they were triaged (all those scoring 3+ being positive for higher risk). Those scoring 3+ then offered Multifactorial Risk Assessment (MRA) done in commnunity setting (AgeWell Centre on Anglesey). The MRA delivered jointly by both Leisure Services Exercise Officers and Physiotherapy Assistant (clinical governance provided by physiotherapy). These individuals also sent on PSI (Postural Stability Instructor)training course prior to project initiation. 3. Following MRA, clients referred to further evidence based intervention (based on need) to reduce the risk of falls e.g. PSI classes (delivered in the community), Tai Chi, Optometrist, Podiatry, Care and Repair, Fire & Rescue Service, Social Services, Physiotherapy, Telecare / Telehealth. As an exit route, clients further referred to existing ongoing community based activities /services, such as those offered in the AgeWell network across the Island.




Falls identified as a significant public health concern Outcomes for older people following a hip fracture were not good-many failed to regain their previous levels of functional capacity, confidence and independence.Many also developed secondary problems following a fall & injury, which meant they required prolonged or indefinite spells in care institutions. Historical data from the local DGH revealed there to be an incidence of between 100-125 hip fractures per year for patients registered with an Anglesey GP. This presented a huge economic burden (approx >2m per annum based on health and social care year costs following hip fracture) on something that was largely preventable. Baseline assessments revealed there to be non-equitable services for falls prevention, and it was clear that a multidisciplinary approach was required to develop a comprehensive service model based on guidance and best practice. The Welsh Older People's NSF and NICE guidelines, in addition to other academic literature, provided the opportunity to develop a comprehensive Falls Prevention Pathway, which was commissioned as a Pilot Project by the Anglesey Health, Social Care and Well-being Partnership Board in late 2008.The pilot project was officially launched in late January 2009,and is due to end in October 2009. On Anglesey, we embraced a unique culture where Leisure and Physiotherapy services were already working closely together, and maximised this relationship by jointly delivering the FRAT and MRA processes. Physio have taken the clinical need, and both agencies benefit from each others' resources and knowledge. During the lifetime of the pilot, an active learning approach has been adopted, where regular multidisciplinary meetings have offered the opportunity to share and implement lessons learned to adapt and refine the service. A member of the team is doing a PhD jointly between the Local Authority and Bangor University,and is providing ongoing evaluation as part of the pilot.


Please find supporting material attached which presents the functional capacity test findings after 20wks (half the intervention period) of PSI class intervention for those who went through the MRA process. Clearly, as more patients move through the service (@30 & 40wks), the statistical power of the data will be improved, but current outputs are already 'significant' to a-priory alpha levels. Data on annual hip fracture incidence is not yet available (will be end of March 2010). 7 months into the 9 month pilot, 180 FRATS have been completed, with 91 scoring positive (3+ yes answer to the 5 question Tool). of the 91, 65 have been given an MRA with the others waiting for assessment or have DNA'd. The objective relating to "Improve quality of life" is currently being assessed by the PhD student @ 20wk intervention point via qualitative questionnaires, and will be available in the next 2 weeks (mid-September). Main challenges have included: - Promoting use of FRAT by frontline staff. We have developed a comprehensive training programme to improve FRAT usage and referral rates, and envisage this will improve once the service is rolled out to other areas of the Island (funding has recently been secured through WAG grant). - Transport/Access. Anglesey is a rural area and presents a challenge in particular to older people to access services on a weekly / bi-weekly basis. We have worked with local third-sector providers to improve the situation, in addition to holding MRA & PSI classes in a second location in the GP Surgery Catchment Area. - Capacity - we have relied heavily on an individual's input (Physio Assistant) into delivering the pilot successfully, and fortunately this has worked out well (except to times when cover was required). However, as the pilot comes to an end, we have identified additional funding to secure dedicated WTE posts to deliver the service across the Island.

Results and evaluation

As highlighted above, we are fortunate to have a PhD student as part of the team, who has been at the core of the project development from the onset i.e. has helped design the evaluation & monitoring systems. All FRAT data is being held on a bespoke database within a Community Hospital, and provides the monitoring output required to inform monthly progress meetings. As per standard clinical practice, progress registers are kept and inputted on an ongoing basis, which tracks individual clients. In addition to the functional capacity data, the PhD student has also developed a qualitative evaluation framework(Falls Efficacy Scales), of which the early finding will be available in the very near future. The added value of the project is also significant, and data such as referral to other AgeWell activities / services which contribute to improving quality of life by boosting self-confidence and social capital, reducing isolation, providing new opportunities to contribute and engage in society.

Key learning points

1. Possible to work effectively and add value by sharing aspirations and working in a multiagency /multidisciplinary partnership. 2. With enough ambition, drive and enthusiasm, possible to utilise guidance and best practice to develop new and effective community based preventative services 3. Be clear about limitations of any pilot projects, and be ready to be flexible and utilise learning as the project develops. 4. Balance between the significance of delivering safe services i.e. sound clinical governance, and the need to be innovative and dynamic e.g. utilising community venues which have never been used for this purpose before 5. Importance of establishing a sound and robust evaluation methodology from the onset - and one that continually feeds into regular monitoring procedures 6. Have clear exit strategies, both for patients who are part of the project e.g. set up clear referral routes and criteria, and for the end of the pilot funding e.g. secure mainstream funding or grants.

View the supporting material

Contact Details

Name:Dafydd Gwynne
Job Title:Health Partnerships Advisor
Organisation:Anglesey County Council
Address:Social Services Dpt, Council HQ
Postcode:LL77 7TW
Phone:01248 751812


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This page was last updated: 26 August 2009

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Selected, reliable information for health and social care in one place

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.