the presentation

PRELIMINARY DRAFT FOR DISCUSSION Developing together the blueprint for a sustainable health care system for West Kent Physical Frailty/Falls: a briefing on West Kent’s challenges PRELIMINARY DRAFT FOR DISCUSSION IntroducLon •  The material in this slide pack was put together by AcLve IntegraLon – a consorLum of two independent consultancy organisaLons (IHP and Loop2) for the West Kent Clinical Commissioning Group as part of the Mapping the Future programme •  The material draws on published data for West Kent, naLonal staLsLcs and evidence from other places •  The slide pack includes some extrapolaLons and esLmates of the challenges facing West Kent which are intended to illustrate the scale of the problem that lies ahead rather than being definiLve figures: discussions with clinicians in West Kent confirmed that they are realisLc and may even understate the situaLon. 2 PRELIMINARY DRAFT FOR DISCUSSION Key findings •  The incidence of falls in older people in West Kent is high and increasing •  People who fall over are at risk of further falls. Injuries from falls and the fear falling again can cause people to become physically frail and in need of greater health and social care support •  As well as the personal consequences for the individual and their carers, injuries from falls present significant costs for the NHS and for social care •  There are opportuniLes to prevent falls, to limit the severity of the injuries that they cause and to improve the way that physically frail older people are cared for •  If the West Kent does not tackle the problem of falls it will face significant increases in demand for care in the future which will be unaffordable. 3 PRELIMINARY DRAFT FOR DISCUSSION Mapping Event -­‐ Physical frailty/Falls Focus on prevenLng, treaLng and recovering from physical frailty What’s included • Both Emergency and ElecLve admissions • PaLents > 65 years • Falls: fractured neck of femur (hips) other fractures, Reablement, Falls risk assessment, Hip and knee replacement • Rheumatology: Osteoporosis What’s not included • Accidents other than falls • Planned procedures other than hip/knee operaLons • Foot & Ankle procedures • Other Musculo-­‐skeletal condiLons • PaLents < 65 years 4 PRELIMINARY DRAFT FOR DISCUSSION What happens when an older person falls Fall To A&E Discharge to GP Falls/Frac. OP Discharge to GP Admission; Surgery Discharge to GP Community nursing Discharge to GP Care home Death 5 PRELIMINARY DRAFT FOR DISCUSSION Falls are common in older people   Those over 65: one in three will fall each year   Those over 80: one in two will fall each year 100 falls a day among West Kent over-­‐65s Elderly Popula;on in West Kent 65-­‐79 yrs 80+ yrs 60,000 55,700 50,000 40,000 30,000 20,000 35,000 30,500 18,500 10,000 0 2013 2018 2023   Number of falls in West Kent in 2013 esLmated at 21,000   This could increase to 34,000 in 2028 (60% increase in 15 years) 2028 Source: Kent County Council’s housing-­‐led Strategy Forecast (Nov 2012); Sum of Tonbridge & Malling, Tunbridge Wells and Sevenoaks
6 PRELIMINARY DRAFT FOR DISCUSSION Those who fall tend to fall more than once • 
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One in two hip fracture paLents have had at least one prior fracture Many falls are “missed” by the health system. In a recent study of 800 paLents aged 85+ in Newcastle, UK: –  Over 38% had fallen at least once in the previous 12 months –  Of those who fell, only 30% had aoended an emergency department; only 37% had specifically discussed their falls problem with their general pracLLoner; only 13% had seen a falls specialist Source: Incidence and costs of unintentional falls in older people in the United Kingdom, J Epidemiol Community Health 2003;57:740-­‐744 doi:
10.1136/jech.57.9.740; Fracture Liaison Services Resource Pack, NovarLs, Jan 2010
7 PRELIMINARY DRAFT FOR DISCUSSION Incidence increases dramaLcally with age Age Group (yrs) A&E ADendance per 10,000 popula;on Hospital admissions per 10,000 popula;on 60-­‐64 273.5 34.5 65-­‐69 287.3 52.0 70-­‐74 367.9 91.9 75+ 945.3 368.6 Source: Incidence and costs of unintentional falls in older people in the United Kingdom, J Epidemiol Community Health 2003;57:740-­‐744 doi:
10.1136/jech.57.9.740
8 PRELIMINARY DRAFT FOR DISCUSSION Many falls carry a significant human cost •  Medical aDen;on: 1 in 5 fallers require medical aoenLon and 1 in 40 fallers are hospitalised. Around 5% of falls in older people result in fracture, with 1% resulLng in a hip fracture. 10% of falls in people aged over 70 result in serious injury (fracture, joint dislocaLon, or severe head injury). •  Long-­‐term disability: Up to 90% of older paLents who suffer hip fractures fail to recover their previous level of mobility and independence. Up to a third become totally dependent and need insLtuLonal support. 7% of paLents with fragility fractures (US study) have some degree of permanent disability and 8% require long-­‐term nursing care. •  Death: Injuries due to falls are the leading cause of accidental death in people aged over 75 in the UK. One in five older people who suffer a hip fracture will die in the first year. 1,150 people die every month in the UK following a hip fracture -­‐-­‐equivalent to 104 deaths a year in West Kent Source: Age UK
9 PRELIMINARY DRAFT FOR DISCUSSION “Fear of falling” makes the situaLon worse •  Fear of falling can make people less acLve, can accelerate physical decline, mean loss of independence, and social isolaLon – it is a predicLve factor for future falls. •  In the Newcastle study –  ‘Worry about falling’ was experienced by 42% of fallers, ‘loss of confidence’ by 40%, and ‘going out less oren’ by 26%; each was significantly more common in women •  In other studies: –  Up to 70% of recent fallers and 40% of those not reporLng recent falls acknowledge fear of falling Source: Age UK; Incidence and costs of unintentional falls in older people in the United Kingdom, J Epidemiol Community Health 2003;57:740-­‐744 doi:10.1136/jech.57.9.740
10 PRELIMINARY DRAFT FOR DISCUSSION Osteoporosis is strongly associated with falls/fractures Typical fracture progression and quality of life for a paLent with osteoporosis • 
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Half of hip fracture cases come from the 16% of the post-­‐menopausal female populaLon with prior fracture history –  In West Kent: 1,350 post-­‐menopausal women have a new fracture each year; 10,350 post-­‐menopausal women with prior fracture history; 26,100 post-­‐
menopausal women with osteoporosis Prevalence of osteoporosis in men is 6% for those aged 60-­‐69, 14% for 70-­‐79 and 24% for those over 80. For women, corresponding figures are 14%, 37% and 61%. Other reasons for falling suggested by the Newcastle study include dizziness and blackouts -­‐ reported by 40% and 6% respecLvely Source: Fracture Liaison Services Resource Pack, NovarLs, Jan 2010
11 PRELIMINARY DRAFT FOR DISCUSSION Falls make up a large proporLon of Ambulance calls •  An esLmated 17% of Ambulance call-­‐outs in West Kent are for falls (England: 10%) •  Of these –  70% were for people aged over 65 years –  40% of fallers are taken to A&E •  Cost esLmate: –  Each call-­‐out costs about £115 –  14,000 ambulance call-­‐outs in West Kent in 2012-­‐13, of which 10,000 for 65+ –  Total cost £1.6m West Kent Falls-­‐related calls to SECAMB 16000 15% 14000 12000 10000 8000 6000 4000 2000 0 2009-­‐10 Source: WK JSNA Falls 2011; SECAMB data
2010-­‐11 2011-­‐12 2012-­‐13FYE 12 PRELIMINARY DRAFT FOR DISCUSSION Falls create addiLonal stress on A&E •  People wait longer for treatment at Maidstone and Tunbridge Wells Trust hospitals (MTW) A&E than at peer Trusts •  PopulaLon-­‐based esLmate: ~4,000 A&E aoendances in West Kent are due to Falls/fractures in over 65s •  Alternate esLmate (MTW, 2011-­‐12): –  4,373 A&E aoendances related to falls and fractures –  Cost: £500k (EsLmated as proporLon of total cost of A&E aoendances for over 65s at MTW: £2.6m) Source: MHI Diagnostic Benchmark, 2010; Falls and Fracture Final (04012013) MM
13 PRELIMINARY DRAFT FOR DISCUSSION Fracture Clinics perhaps not used enough • 
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An esLmated 1,350 OutpaLent Fracture Clinic first aoendances (referrals from A&E) in 2012-­‐13 were related to falls in the elderly (over 65) Cost: £180k (first aoendance only) Assuming there are 2 follow up visits and the cost of a follow up visit is 40% of cost of First Aoendance, then total cost of falls in Fracture Clinics is around £324k A valuable opportunity is being missed to offer prevenLve care when people aoend these clinics –  Only 32% of non-­‐hip fracture paLents had mulL-­‐factorial falls risk assessment whereas 68% of hip fracture paLents had this assessment. –  Similarly, only 32% of non-­‐hip fracture and 67% of hip fracture paLents had an assessment for osteoporosis/fracture risk In the 2010 NaLonal Falls and Bone Health Audit regarding uptake of home hazard assessments West Kent performed poorly (0%), prescribed exercise programmes (6%), anL-­‐bone restoraLve therapy (21%) and provision of falls prevenLon informaLon for paLents (0%). Source: Falls and Fracture Final (04012013) MM
14 PRELIMINARY DRAFT FOR DISCUSSION InpaLent costs for injuries from falls are high •  Falls and fractures, in people aged 65 and over, account for over 4 million bed days each year in England alone (2008) => 30,000 bed days for West Kent •  At est. £200/bed day, esLmated cost = £6m •  Elderly paLents who had a fall which did not require surgery spent on average 19 days in hospital (ranging from less than a week to 25 days) •  Trauma (falls and fractures) accounts for 14% of admissions and 14% of bed days at MTW for WK paLents >65 Source: Age UK; MTW SLAM data
•  West Kent emergency admissions related to Falls (SUS, 2011-­‐12) = 3,079 admissions at total cost of £9m 15 PRELIMINARY DRAFT FOR DISCUSSION InpaLent acLvity related to falls is increasing   Falls-­‐related hospital admissions (largely at MTW) have increased by 53% in 5 years   Almost 65% of these admissions were for paLents with no fracture or injury. The fall is more oren due to medical and social reasons such as UTIs, demenLa or pneumonia. Source: WK Urgent Care Needs Assessment, 2012
16 PRELIMINARY DRAFT FOR DISCUSSION People over 85 have a higher admission rate Emergency Admissions per 1,000 patients relating to falls, 11/12
Source: SUS data
17 PRELIMINARY DRAFT FOR DISCUSSION Falls in hospital sewngs are also a problem • 
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208,000 falls in England and Wales in acute hospitals, 36,000 in mental health trusts and 38,000 in community hospitals/primary care organisaLons. Average rate of falls per 1000 bed days: Acute 5.6, Mental health 3.8, Community health 8.6 => West Kent esLmates –  1,845 falls/year at acute Trusts –  270-­‐285 falls/year at mental health/community IP Trusts MTW total bed days for over 65s = 170,000 in 2011-­‐12 => It is esLmated that in Maidstone and Pembury hospitals there were around 918 falls in 2011-­‐12 • 
InpaLent falls cost the NHS over £15m per year => WK esLmate £112.5k Source: National Patient Safety Agency 2010 Slips, trips and falls data update, NPSA London
18 PRELIMINARY DRAFT FOR DISCUSSION Falls – community services •  KCHT provides falls reducLon services in Tonbridge and Coxheath –  Specialist falls teams have been absorbed into intermediate care/rapid response services –  Community rehabilitaLon/therapy services cater for rouLne falls cases •  Total spend on Falls in 2013/14 is £250k (over 9000 paLent contacts) Source: KCHT
19 PRELIMINARY DRAFT FOR DISCUSSION Falls remain a serious issue in care homes •  40% of admissions to nursing homes were precipitated by falls •  However, 60% of people in care homes fall each year. Up to 40% fall more than once a year. •  Older people living in care homes are three Lmes more likely to fall than older people living in the community •  According to 2001 census data, roughly 4.5% of people aged over 65 the West Kent PCT area lived in residenLal care => Est. 2,400 falls from West Kent paLents staying in care homes Source: Age UK; Census 2011
20 PRELIMINARY DRAFT FOR DISCUSSION Costs of long-­‐term social care •  Total cost to NHS of falls in the Elderly –  £2.3 bn (2008: £1.7bn) –  £4.6m every day –  EsLmate of cost to West Kent = £12.8m -­‐ £17.25m •  NHS costs represent 60% of total costs –  Social care costs associated with Falls = £5.1m -­‐ £6.9m Source: Falls in the Elderly, KE Anderson, J R Coll Physicians Edinb 2008; 38:138–43; Incidence and costs of unintentional falls in older people in the
United Kingdom, J Epidemiol Community Health 2003;57:740-­‐744 doi:10.1136/jech.57.9.740 21 PRELIMINARY DRAFT FOR DISCUSSION Death •  Injuries due to falls are the leading cause of accidental death in people aged over 75 in the UK. •  One in five older people who suffer a hip fracture will die in the first year => 104 deaths a year in West Kent from hip fractures Source: Social care and hospital use at the end of life. M Bardsley, T Georghiou, J Dixon. The Nuffield Trust. 2010
22 PRELIMINARY DRAFT FOR DISCUSSION Economic implicaLons of the “Falls” Story Fall To A&E Discharge to GP £0.32m Discharge to GP Falls/Frac. OP £1.6m £0.5m Admission; Surgery £9.0m Discharge to GP 2012/13: £19m £7.6m Discharge to GP Community nursing £19m is bigger than the enLre savings programme for West Kent Care home this year! Death 23 Note: Hospital figure includes £112k for falls in hospital; Social care figure includes £250k for community care; Final figure includes £1m for end of life care