Presentation at the Faculty of Public Health annual conference 2016

1. EFFECTIVE FALLS AND FRACTURE
MANAGEMENT WITHIN PRIMARY CARE: A
QUALITATIVE GENERAL PRACTITIONER
PERSPECTIVE
Dr Suhail Tarafdar
GP Registrar
Birmingham City Council
Public Health
Suhail.Tarafdar@nhs.net

2. AIMS OF SESSION
 Background
 Methods
 Results
 Key themes
 Limitations
 Conclusions

3. BACKGROUND (1)
 Major Public Health burden
 Estimated cost to NHS: £2.3 billion per year
 Redesign of services
 Opportunities for greater integration
Reference: NICE Guidelines (CG61); Falls: Assessment and Prevention in Older People. June 2013

4. BACKGROUND (2)
 Public Health Outcome Framework (PHOF)
(2014/15 data):
 Injuries due to falls in people aged 65 and over:
2,125 per 100,000 (England)
2,311 per 100,000 (Birmingham)
 Injuries due to falls in people aged 65-79:
1,012 per 100,000 (England)
1,165 per 100,000 (Birmingham)
 Injuries due to falls in people aged 80+:
5,351 per 100,000 (England)
5,635 per 100,000 (Birmingham)

5. RESEARCH QUESTION
 What are the issues for GPs in Birmingham and
Solihull in accessing and promoting falls
interventions services in the elderly?

6. METHODS
 Qualitative study
 Birmingham and Solihull
 Clinical Commissioning Groups
 Birmingham and Solihull Vocational Training Scheme
 Semi-structured questionnaire
 Face-to-face
 Post
 E-mail
 Long and short version questionnaire

7. RESULTS
 Total 17 questionnaires completed
 12 long version questionnaires
 5 short version questionnaires
 Thematic analysis
 3 researchers within Birmingham Public Health

8. THEMES
1. Key Priority
2. Lack of Integration
3. Awareness of Services
4. Complex Referral Pathways
5. Opportunities

9. 1. KEY PRIORITY
 Ageing Society
‘‘In the future, older population, it is becoming an increasing
priority.’’
 Falls Sequelae
‘It is important for the prevention of fractures and injuries in the
elderly… Once the elderly have fallen or had a fracture, they
need much input with increased needs, hospital care and
unnecessary hospital admissions.’’
 Resource Implications
‘‘It is a huge priority due to the significant morbidity, mortality and
cost associated.’’
‘‘Important as cost-effective.’’

10. 2. LACK OF INTEGRATION (1)
 Primary and Secondary Care
‘‘…hospitals see a patient and find they need an
assessment but then say can you refer in general practice
when they could have actually made it themselves…Just
putting in that extra step, you know, if we miss 10% or
20%...missed in that transfer across.’’
‘‘…Lack of co-ordination in discharge of patients from
hospital to community… Delays in SPA services
responding to referrals from GPs…Inability of GPs to
directly order falls preventing equipment.’’
 Ambulance Reporting: disparity in practice

11. 2. LACK OF INTEGRATION (2)
 Community-oriented interventions
‘‘I do not consider secondary care fall clinic using tilt tables
and 24 hour tapes to be sensible use of resources.
Patients need to be assessed in their home environment.’’
‘‘Very limited action following referral. A few physio
sessions only often . Nurse led services tend to look at
postural hypotension alone and not holistic enough.’’
‘‘…(patients) should be assessed at home to see where
they need support.’’

12. 3. AWARENESS OF SERVICES
 Services known
 Occupational therapy, physiotherapy and consultant-led
falls clinic
‘‘…if we don’t know the local services, then we’re
unable to refer…’’
‘‘I think GPs need to be informed on more than one
occasion for it to sink in.’’
 Services unknown
 Single Point of Access (SPA), nurse-led falls clinics,
fracture liaison, continence services, syncope clinic

13. 4. COMPLEX REFERRAL PATHWAYS
 Multiple methods of referral
 Choose & Book, telephone, post, fax
‘‘…time is everything. In general practice, it’s such a
precious commodity.’’
‘‘…There is competitive demand on GP time.’’
‘‘…Delays in SPA services responding to referrals
from GPs…’’
 Lengthy Process
 Time, workload, waiting times

14. 5. OPPORTUNITIES (1)
 Population Level: Public Health, Locally Enhanced
Services (LES)
 Individual Level
 Avoiding Unplanned Admissions (Case Management
Review)
 Medication Reviews
 Home visits
 Discharge from hospital
 Elderly care homes

15. 2. OPPORTUNITIES (2)
 Risk Stratification
‘‘…we need a coding system for falls prevention. We do
not have this at the moment.’’
‘‘FRAX score…which is useful…would be useful to
have…red, amber, green system giving specific
intervention recommendations.’’
‘‘…drowning in templates…’’
‘‘No more templates please!’’
‘‘Always ask about unsteadiness. BUT we do not have
time…for routine medication reviews…if there is a
problem…review is often opportunistic.’’

16. LIMITATIONS OF STUDY
 Small number of respondents
 Generalisability
 Methods of questionnaire completion
 Bias

17. CONCLUSIONS
‘‘…an already overstretched primary care living on
8% of the NHS budget.’’
 A national and major Public Heath problem
 Themes
1. Key Priority
2. Lack of Integration
3. Awareness of Services
4. Complex Referral Pathways
5. Opportunities

18. Time
Constraint
s
Lack of
Awareness
Complex
Pathways
Individual
Practice
Population
Opportunities
Barriers
GPs
Lack of
Integration
Key Priority
Time
Constraints
Lack of
Integration
EFFECTIVE FALLS MANAGEMENT IN PRIMARY
CARE

19. STRATEGIC DRIVERS / IMPACT OF STUDY
 Five Year Forward View
 Better Care Fund
 NHS England: Healthy Ageing
 PHE West Midlands: Healthy Ageing Priority Action
 Electronic Frailty Index

20. ACKNOWLEDGMENTS
 Birmingham & Solihull General Practitioners
 Birmingham and Solihull GP Vocational Training
Scheme
 Hashum Mahmood, Evidence Base Manager
 Nicola Pugh, Public Health Analyst
 Alison Doyle, Programme Lead Frailty (Public
Health)