RCP: Confusion over purpose of falls clinics comprimises effectiveness of service

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Thursday, 18, Sep 2008 12:00

An RCP survey of 40 patients in England who had attended a falls clinic following a fall shows that while patients felt the clinics had helped them, they were not always sure about the purpose of the clinic and how it related to their own needs. This misunderstanding leads to patients not continuing with exercises and other activities which could help prevent another fall. In addition, patients were not always given the results of health tests or told about ways of reducing their risk of falling again, and were often unaware of what services were available.

In the UK, 28-33% of the population over 65 years, and 32-42% of the population over 75 years will fall each year, causing death, injury, and loss of independence. The commonest serious injury from a fall is hip fracture, which affects approximately 60,000 people per year in the UK, costs the National Health Service (NHS) approximately £1.7 billion and results in up to 14,000 deaths.

In 2001 the National Service Framework for Older People (NSFOP) set out a model for service provision for falls and bone health. The NSFOP required all local health and social services to have an integrated falls service in place by April 2005. Since falls services are new there is limited experience in the health service of how to operate them. This survey shows both the benefits and failings of falls clinics, and makes recommendations for improvement.

The survey was carried out by the RCP's Clinical Effectiveness and Evaluation Unit, and funded by the Healthcare Commission, HQIP and Help the Aged. Patients were questioned at focus groups in 9 locations in England and asked questions on the following themes:

* Access to falls services

* Assessment, intervention, evaluation and follow-up

* Interpretation of falls: causes, consequences and impact

* Perceived benefits and critiques of falls services

Results from the survey:

* Participants were often unaware of what falls services were available, how referral took place and how they related to other primary and community services

* Participants often thought that their GPs were probably not aware of these services

* Some participants felt that the name 'falls clinic' was odd and off putting and open to misinterpretation - sometimes misheard as 'fools clinic'

* Most participants reported having experienced a thorough assessment but some were not aware of the outcomes or conclusions or of their right to ask for the results

* On the whole, participants reported their attendance at falls clinics to have been a positive experience, highlighting both physical and psychosocial benefits

* They considered their thorough health assessment or 'MOT' to be an added benefit, but it was generally unclear to them how the assessment outcomes were used to develop individualised management plans, or how interventions might reduce their own falls risk

* The range of treatments and advice offered reflects many of those recommended in the NICE 2004 guidelines e.g. strength and balance training, home hazard and safety intervention, medication review, dietary advice and where patients can seek further advice

* Some participants found the experience of falling very frightening with fear of a recurrence affecting their confidence and they appreciated the chance to reflect on this as part of the focus group discussion.

* Once participants had accessed falls services few had any negative comments on the treatment provided except some issues with regard to the lack of reliable transport and the wish for longer-term follow-up in group settings.

The report recommends ways of improving the service to patients:

1. Letters of invitation to patients to attend falls clinics/services should reflect GPs' support and include details explaining why this is happening and describe what benefits patients may get from attending the service.

2. Information about falls services for service users and the general public should be easily accessible and available in libraries, council offices/buildings as well as healthcare settings. The style and content of the information should be written in plain English, with adequate sized text and contain easily digestible information and useful contact details.

3. Local referral pathways and the criteria for recommending specific components of the falls service, such as exercise programmes should be easily accessible to healthcare professionals, and include contact details.

4. Providers should consider renaming falls services to emphasise the priorities of potential service users, which are usually the preservation of mobility and functional independence.

5. Patients should be involved in agreeing their individualised management plan, based on clarification through discussion of how specific risks can be reduced. Management plans should be based on a discussion of risk assessment results, patients' own priorities for outcomes and the drawbacks as well as the potential safety benefits of activity modification or limitation. Once a management plan has been agreed, everyone involved in its delivery should work towards these agreed goals.

6. A friendly environment which promotes individual and group discussion and sharing of experiences between attendees is likely to favourably impact on uptake and adherence and therefore the effectiveness of falls and bone health prevention programmes.

7. Healthcare professionals should also explore the psychological impact of the fall (including the fear of falling) and incorporate this in individual treatment plans.

8. Follow-up should include exploring patients' experience of the service, highlighting any unmet needs and facilitating patients' to participate in long term exercise interventions.

9. Service providers should ensure reliable transport arrangements are in place to enable older and less mobile people to attend services.

Professor Finbarr Martin, Associate Director for Falls and Bone Health at the RCP Clinical Effectiveness Unit, said:

"It is clear from the results of the audit that patients' understanding and priorities differ from those of health professionals. The lesson we need to learn from this is to individualise rehabilitation programmes, focusing on the patient's goal, which in most cases is independence."

Robin Burgess, Chief Executive of HQIP said:

"Clinical audit often focuses upon the clinicians measuring the standard of care provided to patients. However, it is equally as important to ask patients how they perceive the standard of care received from healthcare professionals.

This report obtains detailed information on patients' experiences of falls services, providing specific insight into the improvements required in order to meet patients' needs more effectively."

Pamela Holmes, Head of Healthy Ageing at Help the Aged comments:

"Once someone has recovered from a fall, the main purpose of follow-up services should be to ensure that patients understand how they can minimise the risk of falling again. This research suggests that those services are failing their patients in far too many cases. There is much work still to do to improve the situation.

"Help the Aged hopes that the materials that will be developed as a result of this research will help clinics to markedly improve the quality of their care."

The report, which includes anonymised but revealing quotes from the focus groups, is attached to this email. The report will be available on the RCP website from 00.01 hours on Thursday 18 September.

For further information please contact RCP PR Manager Linda Cuthbertson on 020 7935 1174 ext.254, 0794 105 7494 or email Linda.cuthbertson@rcplondon.ac.uk