Next steps for falls and fracture reduction.

In July the Department of Health (DH) in England published a toolkit of resources to promote more effective services to reduce the burden of falls and fractures in older people. Unfortunately, there is plenty of evidence that the present provision of falls services is suboptimal. The toolkit is part of a ‘Prevention Package’ aimed primarily at commissioners of care, in an attempt to achieve a more consistent and integrated approach to a range of prevention issues in older people [1]. Falls are a major international public health challenge because of the myriad effects on older individuals: direct physical and psychological injury; fear of falling and activity limitation; reduced social participation and quality of life; increased dependence [2–5]; and because of the economic impact on health and social care providers [6, 7]. Studies from various countries have shown that about one third of people aged above 65 years fall each year. In UK primary care populations, the rate rises with age to over 60% of nonagenarians, and is generally higher in women [8] and in socio-economically deprived populations [9]. Fragility fractures are the commonest significant injury, 300,000 annually in the UK including upwards of 70,000 hip fractures. Many falls go unreported, but nevertheless they account for 40% of UK ambulance call-outs, with the variable proportion being conveyed to hospital accounting for one in ten Emergency Department (ED) attendances of the over 75s [6], a third of whom are admitted, thus comprising about 14% of emergency admissions. Identifying all falls related activity is challenging but recent estimates suggest that it accounts for between 10% and 25% of all local health and social care spending on older people [10]. Care of fragility fractures is particularly expensive, total health and social care costs in the UK being around £2 billion, most of which relates to hip fractures [11]. Current population and incidence projections suggest that by 2020, this figure will rise by 50%. Early in the development of geriatric medicine, falls were identified as a ‘geriatric giant’—adverse in their own right but also a non-specific indicator of functional decompensation. Building on clarification of falls risk factors [12], randomised controlled trials demonstrated the effectiveness of risk factor based multi-factorial interventions [13, 14]. This led to the notion of ‘falls prevention services’. Based on international consensus about what constituted best clinical practice [15], broadly similar policies have been developed by the responsible government departments of the four UK nations, and in Ireland [16]. The National Service Framework for Older People in England (NSF, 2001) [17] required health services and their local council partners to develop integrated services by April 2005, incorporating case finding, assessment and referral systems and specialist falls and fragility fracture services. The NSF was launched without earmarked implementation funding, but there was plenty of activity, some enabled and directed by various government initiatives, encouraging community engagement. An independent postal questionnaire survey to health and social care agencies about their falls services in 2004 [18] reported most having made plans for an integrated service but implementation was patchy and focused on widely differing priorities. Only 30% included systems for identifying high risk individuals and only 13% of falls prevention programmes included exercise classes, the most effective prevention strategy [19] whilst interventions with little or no evidence base were promoted [20]. Implementation of these policies across England, Wales and Northern Ireland has been monitored in a series of government funded national audits run by the Royal College of Physicians of London (RCP). The first of these confirmed major gaps at the organisational level, particularly in case finding and referrals for secondary prevention [21]. A subsequent patient level clinical care audit of fragility fracture patients showed that most returning home from the Emergency Department were not offered a falls risk assessment and only one third were on appropriate treatment for osteoporosis 3 months later [22]. Despite intense interest among clinicians in the UK and appointment of many geriatricians with a focus on falls, syncope and orthogeriatrics, a repeat organisational audit showed that by 2008 there had been little improvement in service structure, capacity or processes [23]. Meanwhile the picture was clouded by the negative results of a DH funded systematic review with meta-analyses [24]. This suggested that the variable outcomes of clinical trials might be associated with the way that the multifactorial approach was organised. There are now several negative outcome trials employing the strategy of nurse led case finding linked to interventions intended to be provided by a range of unconnected professions acting on referral [25]. In clinical practice, it is likely that there is even more differential effectiveness depending on case finding and referral practices and contextual differences in service delivery. Research evidence is still lacking on how to achieve much that the NSF aspired to, but there is sufficient evidence and examples of successful implementation to do much better than most are currently doing. So how will the latest government action help? A key step is to clarify priorities and to put available resources into the activities likely to make most