This successful AHSN NENC study demonstrated that the identification and prevention of falls is feasible as part of routine Care and Support Planning (CSP) for people with (largely) mild and moderate frailty. Modified pathways, resources, training, and support for general practice teams are now available, and important lessons for implementation have been identified.

CSP is a systematic approach to providing the space for a ‘better conversation’ between a prepared person and a trained practitioner which brings together all the issues the person may live with, and includes prevention. CSP is forward looking and solution focused and combines traditional clinical issues with support for problem-solving during day to day living. Practical modifications and specific training developed for this project enabled issues of falls and frailty to be included in CSP, with reported benefits for patients and staff. This project provides the first step of an exploratory phase of learning about how to incorporate early intervention within routine general practice settings.

• The project demonstrated that the identification and engagement of people with frailty at risk of falls is feasible and welcomed in routine general practice using a CSP approach.
• The project involved a cohort of 2,016 individuals aged 65+ with a validated ‘functional’ frailty score who were already receiving routine CSP for long term conditions between July 2019 and January 2020.
• The overall size of the cohort and wide range of size, demographics, social deprivation, and prevalence of frailty for the 8 pilot practices means the learning can be generalised .
• The training programme that was developed could be used to support future learning on falls and frailty. Key modules could be delivered to groups or in-practice.  In-practice delivery (the preference of staff) addressed practice variation while group learning provided powerful peer learning and problem solving.
• Training and learning in-practice led to an increase in staff understanding about falls as an issue, including their knowledge and confidence in talking about frailty and falls which some said they were extending across their other work. Enabling staff to probe issues of falls including balance, trips and slips etc. identified a group of people, previously unidentified, for whom measuring lying and standing BP revealed postural hypotension and resulted in a focus on their medication. Whether this reduces the risk of falls in this group needs further study.
• Detailed numerical data triangulated with 6 robust themes identified by qualitative methods, along with local intelligence, has enabled several headline conclusions to be drawn and hypotheses generated which could form the basis of further in-depth work.

Learning Points

• It has been possible to include falls identification, and potential prevention within the routine CSP process (rather than as a separate recall project) and this has been achieved with limited resources and time.  Practical processes have been adapted to allow for screening questions and measurement of lying and standing blood pressure (BP)
• It has provided an opportunity to show how the iCARE Toolkit can be used within a primary care setting. In doing so, this has highlighted the issue of frailty to primary care clinicians, validating the view that frailty and falls can be included in the generic approach to planned care previously focussed on specific longterm conditions such as diabetes and respiratory conditions, helping change mind-set and agendas.
• It has demonstrated an opportunity for truly preventative interventions early in the frailty pathway providing a positive and practical approach for those with mild and moderate frailty – not just for those with severe frailty. As a pilot it lays out a vision of what might be achieved in the future for this group using a CSP approach.
• It has enabled staff to ‘speak’ with patients about falls and frailty and feel confident to offer preventative advice and interventions, reframing falls conversations from negative to positive ones.
• It has identified asymptomatic and undiagnosed postural hypotension as a potentially important issue requiring further investigation.

Key observations:

• It is important to note that practice teams were able to get up and running quickly and contribute important insights to the project because they were already experienced in running CSP routinely in their practices as part of a Newcastle/Gateshead CCG Local Incentive Scheme (LIS). Practices without this background would require greater time and resource to implement the changes.
• The culture, organisation and approach to team working in some practices made it easier to incorporate the project changes than in others who required more intensive individual and ‘just in time’ input.
• The project team developed excellent working relationships and proved responsive to implementation challenges throughout the pilot term. This involved adapting and sharing roles as implementers and evaluators.  This approach, together with close and supportive relationships with practices, proved essential to the successful outcome.  Clinical credibility and expertise from a range of disciplines within the project team has also been enormously important.

This was a feasibility not an outcome project.   However, within the pilot practices 2,016 people have been involved in an expanded approach to falls identification, awareness raising and discussion.   It has demonstrated an opportunity for truly preventative interventions early in the frailty pathway providing a positive and practical approach for those with mild and moderate frailty – not just for those with severe frailty.  As a pilot it lays out a vision of what might be achieved in the future for this group using a CSP approach.

Within pilot practices staff have:

• become more aware of issues related to frailty and falls
• developed new skills about how to discuss these with patients and
• increased confidence in using these in their day-to-day practice.

A summary of benefits for patients, staff and NHS include:

• A complete suite of resources has been developed on falls for practices to use as part of CSP for people with long term conditions and frailty including:
• a practice recall pathway
• templates for data collection by healthcare assistants
• data sharing prompts for preparation for the CSP conversation
• information for patients
• Specific guidance on discussing falls with patients and measuring lying and standing BP in practices
• A training programme for use with new practices
• Recommendations for coding new falls discussion (2 out of 3 new codes available)

The AHSN NENC commissioned the pilot project during 2019 to enable a robust evaluation to inform local work and make the learning available across the iCARE community and more widely.  The necessary resource development and learning required by the CCG to include frailty and falls within the incentive schemes would not have been possible without AHSN NENC funding.

AHSN provided additional support via an extension to the project due to firstly the delay in setting up meetings with the practices, being able to record the last of the planned interviews, and then a second extension as a result of the COVID-19 pandemic which caused a delay to the whole project.

Formative learning will be used within the CCG to inform local planning with a final report providing the guidance needed to design the Local Improvement Scheme (LIS) for 2020 – 2021.  Findings will be disseminated locally in presentations and workshops using opportunities provided by the AHSN NENC and the Ageing Well Community of Practice.

Next steps include:

• To complete the wider and more detailed evaluation report for the CCG
• To produce a paper for publication in a peer reviewed journal
• To disseminate findings
• To incorporate the falls questions into this year’s CSP LIS
• To provide ongoing training and advice based on the learning to those practices which are delivering CSP and model good practice around falls prevention
• To develop an ongoing research strategy based on the gaps and issues identified in the project and to seek further funding.

• Frailty iCARE Toolkit: http://frailtyicare.org.uk/
• Frailty iCARE Website: http://frailtyicare.org.uk/
• Regional Ageing Well Community of Practice: http://frailtyicare.org.uk/making-it-happen/community-of-practice/
• Falls, frailty and care and support planning final report https://www.ahsn-nenc.org.uk/wp-content/uploads/2021/03/Falls-Report-Final-V1.2-Jan-2021.pdf