Meeting SLIC Provider Group

Date Thursday 17 December 2015

Time of Meeting 13.00 – 15.00

Paper Name Falls Business Case

Agenda Item Item 4

Paper Number Paper 5

Paper Owner Cathy Ingram

Purpose of the Paper (for information, for a

decision, for approval)

For approval

Can this paper be shared? Yes, this paper will be added to the SLIC

website

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Southwark and Lambeth Integrated Care Business Case Proposal

Falls

Mainstreaming

An Early Identification and Primary Prevention Service

Partner Lead: Cathy Ingram SLIC Lead: Fiona Martin Lead Authors: Emma Hanley ,Greg Battarbee , Corne Rossouw , Judith Hall Date: December 2015 Version: Final

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Table of Contents 1 Executive Summary .............................................................................................................. 5

2 Introduction ......................................................................................................................... 7

2.1 Vision and Aims ................................................................................................................................................. 7

2.2 Alignment with commissioner priorities ........................................................................................................... 7

2.3 The national falls picture................................................................................................................................... 9

2.4 The local falls picture ...................................................................................................................................... 10

3 Case for Change .................................................................................................................. 10

3.1 Summary of pre-existing service before test & proposed test model ............................................................ 10

4 Test models Evaluation Summary and Benefits Realisation .................................................. 14

4.1 Achievements of the test ................................................................................................................................ 15

Screening and Referral Outcome Including Exercise Prescription .......................................................................... 16

Review capacity and demand ................................................................................................................................. 16

Existing falls service capacity gap and backlog ....................................................................................................... 17

Adherence ............................................................................................................................................................... 18

Monitoring of outcomes and impact ...................................................................................................................... 20

4.2 Summary of Lessons Learnt ............................................................................................................................ 21

5 Future Commissioning intentions: Proposal to mainstream ................................................. 22

5.1 Commissioning proposal and recommendation ............................................................................................. 22

5.2 Recommended option .................................................................................................................................... 23

5.3 Description of service ...................................................................................................................................... 24

Access ...................................................................................................................................................................... 25

Triage....................................................................................................................................................................... 25

Primary prevention, the Community Exercise Classes............................................................................................ 26

Secondary prevention ............................................................................................................................................. 27

Attendance, adherence and graduate routes ......................................................................................................... 29

Support and influence the development of appropriate ‘follow-on’ community exercise options: ...................... 30

How will be programme be managed and run? ..................................................................................................... 30

Workforce development and community capital ................................................................................................... 30

5.4 Quality Assurance, Outcome and Benefit Realisation .................................................................................... 32

5.5 Projected savings: Cost impact over the next 5 years .................................................................................... 33

5.6 Financials: Direct Cost of service..................................................................................................................... 36

5.7 Interdependencies to delivery ........................................................................................................................ 38

5.8 Potential risks and Mitigation – all options .................................................................................................... 38

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Option 1 Risks and mitigation ................................................................................................................................. 38

Option 2 Risks and mitigation ................................................................................................................................. 39

Option 3 risks and mitigation .................................................................................................................................. 39

Option 4 risks and mitigation .................................................................................................................................. 40

6 Appendix 1 – modelling assumptions .................................................................................. 41

6.1 Falls business case modelling assumptions .................................................................................................... 41

Further detailed assumptions ................................................................................................................................. 43

Other assumptions used ......................................................................................................................................... 44

7 Appendix 2 - Demand, capacity and productivity existing community rehab and falls service 45

8 Appendix 3 – Health questionnaire used with clients ........................................................... 48

EuroQol Group EQ-5D ............................................................................................................................................. 48

9 Appendix 4 – FES-I .............................................................................................................. 50

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Mavis’s story: Strength and Balance

Mavis Adenekan speaks about her experience of the Strength

and Balance classes and explains the positive impact they have

had on her life.

Mavis, 74 years old, says: “I began having difficulties bending

my knees – I had to hold on to chairs for support when I was

standing up. Then last summer my knees gave up and I had to

start using a stick. It was a slippery slope from there, because I

started to develop back problems from walking differently. I

even changed my sofa, because the old sofa was too low for

me to get up from, and I thought I was going to have to move

out of my flat, because of all the stairs.

“Last year I moved to a GP in Lambeth and I was referred to

the Strength and Balance classes. I’ve been attending since last

September.

“When I first attended the class I took the walking stick with me, but the classes have now given me the confidence

and strength I need – I don’t use my stick anymore!”

Mavis, a former primary school teacher, went on to say: “Most importantly, the class instructor makes you aware

that your movements naturally change as you get older, and that it doesn’t mean you can’t keep doing things for

yourself.

“Everyone is getting older and going to need more support, but the exercises help to delay it and build muscle

strength.

“The classes made me conscious that I had started shuffling, instead of walking properly. Now I know I must pick my

feet up when I walk, so I don’t fall over again. And if I do fall, they’ve taught me how to get myself up, so I don’t have

to lie there waiting for help.

“I laugh with my friend about ‘when did we start shuffling and need help to stand up?’. I thought it was just part of

the process of getting old, but it’s in your mind. If others and you keep telling yourself that you are old and need

support, you believe it.

“Recently I went walking in Yorkshire, at one point there was a tough descent and in the past I might have fallen

down, but because I’m more confident and can process situations better, I managed to make it to the bottom.

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1 Executive Summary As can be seen from Mavis’s story, falling can have a devastating impact on a person’s life and wellbeing. It may

include loss of confidence, physical inactivity, social isolation, physical deterioration, anxiety and depression. On a

population level, the scale of the issue is catastrophic – 16,000 people in Southwark and Lambeth are at risk of falling

that is a third of the whole over 65yr population. This business case sets out a range of options for the future,

including the case to mainstream a successfully tested and evaluated primary falls prevention service operating

across Southwark and Lambeth.

The case for change

In 2012/13 there were 13,039 falls related attendances and ambulance call outs by the registered population of

Lambeth and Southwark, and 3029 admissions into a hospital bed. This amounts to a whole system cost in one year

of £8.25 million. A Briefing for NHS England set out the following in 2014;

Falls account for half of all accident related hospital admissions, and up to a quarter of ambulance callouts.

One-third of people who suffer a hip fracture die within a year – and a tenth within a month.

There is a heavy burden on social care in terms of care home admissions and dependence on domiciliary care.

The cost of a care home admission after hip fracture is estimated at £64,000

The current position, both in terms of public health, quality of care and use of resources, is unsustainable. Every

incident of a fall is a human story of pain and loss of independence, as well as wasted resource, when we have within

our skills and experience a service which can massively reduce these preventable events.

The falls service in Southwark and Lambeth provides a comprehensive range of services that meet the NICE and best

practice guidance for both primary (low risk, first falls) and secondary prevention (multiple and injurious falls).

However identification of people at risk is low. Prior to this project only 1,850 people per year were identified at risk

and referred for intervention i.e. 11.5% of the 16,000 at risk, of which only 285 (i.e. less than 2%) were offered

therapy for primary prevention. Later opportunities are missed for secondary prevention as we do not have the

capacity to manage the current levels demand for those at high risk of falls, with waiting times for one-to-one physio

of up to 20 weeks and evidence that significant numbers of people deteriorate and require urgent care such as ERR

and @home whilst waiting.

The innovative test

The intention of the project was to test and refine a method of early identification and triage for individuals at low

risk of falling. The test was funded by SLIC and implemented by GSTT Community Rehabilitation and Falls Service

(CRAFS) between June 2013 and November 2015. This included;

Re-designing the service delivery model, particularly for clinical triage and assessment

Introducing an innovative telephone triage system involving non-qualified clinicians as the decision makers

for allocation to the appropriate intervention.

Providing evidence based community exercise programmes.

Offering 1:1 physiotherapy for citizens at high risk of falls.

Creating rapid and easy access routes for the lower risk groups.

Ensuring reliable identification of citizens at lower risk of falls - for example using the Holistic Assessment

(HA) in primary care and the GP list mail outs.

Quantifying the increase in all service demand for falls prevention and treatment.

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Developing strategies for ensuring adherence and ‘graduate’ opportunities at the end of the 30 week

programme, engaging voluntary and community groups and citizens in co-production.

Developing reliable outcome measures and data collection methods.

Outcomes of the test

The test project has evaluated successfully on all outcome measures and on individual patient outcomes – increasing

people’s confidence, improving their activities of daily living and 76 % of people felt more able to be independent.

Of the 275 people triaged to be at risk of falls who have participated in the test over the 14 months of the project,

96.5% have not fallen at all, and there have been no injurious falls requiring attendance to hospital.

Options for future funding

An options analysis has been undertaken for commissioners to consider as set out below;

Option Shortlisted options Number of at risk people seen by 2019 Savings by end 2019

16/17 pickup Cost

1

Commission a year on year development of the service to deliver the transformational change required to reverse current large scale injuries and emergency care spend on falls.

3585 £7,172,879 £612,000

2

Commission the current activity level and expand at marginal rate 3050 £6,616,416 £448,000

3

Commission the SLIC activity level - remain static 1884 £5,814,148 £329,000

4 Do nothing - return to baseline

0 £64,000

wind down cost

Table 1: Options for commissioners

Our recommendation is option 1, which means to start the scale up in order to deliver the transformational change

which is required to reduce primary falls across Southwark and Lambeth. The mainstreaming of this case is an

opportunity for commissioners to make a real in year impact on falls incidence, and all their associated adverse

consequences.

Conclusion

This business case will set out our rationale for the preferred option for commissioners to consider. It will illustrate

one of the only evidenced population based interventions which can substantially reduce emergency admissions and

attendances at source, at a transformational scale.

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2 Introduction

This business case sets out the case to mainstream a successfully tested and evaluated primary falls prevention

service operating across Southwark and Lambeth. Evidence for the case is based on a test funded by SLIC and

implemented by GSTT Community Rehabilitation and Falls Service (CRAFS) between June 2013 and November 2015.

2.1 Vision and Aims The vision for this service is to provide an improved, equitable falls pathway which will ensure effective prevention opportunities for citizens at risk of falls.

This will be achieved by:

delivering a referral and triage process using non clinical staff as the primary decision makers for onward referral routes

Delivering community based falls prevention classes, working with the voluntary sector, and addressing social isolation and confidence building as much as the physical components of falls.

Developing, a range of adherence strategies, engaging with voluntary and community sector, councils and other leisure providers.

Ensuring equitable service across Southwark and Lambeth, including hard reach communities.

Increasing the falls service to meet the increased demand for falls interventions, for those at high and low risk, ensuring that care is delivered in the right place at the right time.

2.2 Alignment with commissioner priorities The falls prevention service described within this business case meets the following commissioning imperatives:

Meeting NICE Guidance - Research used by NICE (fall, assessment and prevention of falls in older people, June 2013)

to evidence the two national quality measures on falls shows that:

Specific Community based exercise is the best single intervention to prevent Falls

42% of falls can be prevented through these exercise programmes.

Everyday exercise such as walking is not enough to prevent falls

Biggest impact through frequent and sustained balance exercises

Should target general community as well as high-risk people.

NHS Outcomes Framework Domains & Indicators

The falls service has been included in the NHS Outcomes Framework for the first time in 15/16, and is relevant to the

following domains:

Domain 1 Preventing

people from dying prematurely

Domain 2 Enhancing

quality of life for people with long-term conditions

Domain 3 Helping people

to recover from episodes of ill-health or following injury

Domain 4 Ensuring

people have a positive experience of care

Domain 5 Treating and

caring for people in safe environment and protecting them from avoidable harm.

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NHS England CCG outcomes indicator set

Incidence of hip fractures is added in 2015/16 as a new indicator

Falls are also monitored through the following performance frameworks:

Adult Social Care Outcomes Framework 2015/2016 – reduction in falls incidence

Public Health Outcomes Framework 2013/2016- reduction in falls incidence

Local commisioning imperatives include:

Reducing whole system cost

Improving quality of care

Improving patient related outcomes

Local Public health analysis for Lambeth and Southwark – the ‘red box’ of high burden and increasing,

includes falls injury (older people), lower wellbeing levels and and social isolation, all of which are impacted

positively by this programme.

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Figure 3: Southwark and Lambeth health issues 2014

2.3 The national falls picture

Almost 200,000 falls could be prevented and £275 million saved each year through better access to rehabilitation and preventative therapies. The savings could be even greater because rehabilitation services can reduce the severity of a fall, should one still occur. Failing to invest in preventative rehabilitation services could see care home admissions caused by falls increase by 19 per cent by 2020 – at a cost of £124.8m annually. (These findings have been developed by the West and South Yorkshire and Bassetlaw Commissioning Support Unit to produce economic modelling that shows the dramatic impact falls prevention services can have in each clinical commissioning group area across England.)

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It is clear that falls are a priority for prevention both in terms of primary (a first time fall) and secondary (subsequent fall) events. NICE guidance on early identification of falls risk and prevention in 2013 and quality markers in 2015 reinforce support to address this need. A 2014 briefing from NHS England sets out key points below;

Falls and fall-related injuries are a common and serious problem for older people. They account for half of all

accident related hospital admissions up to a quarter of ambulance callouts.

People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of

people older than 80 falling at least once a year.

One-third of people who suffer a hip fracture die within a year – and a tenth within a month

2.4 The local falls picture SLIPS (Southwark & Lambeth Integrated Care Pathway for Older People with Falls) is an integrated falls service across health, social, voluntary and leisure sectors in Southwark and Lambeth and is part of the programme of work of the Adult Therapy Rehab Team. See http://www.slips-online.co.uk/

It provides evidence based assessment and management of clients who have experienced a fall, are at risk of falls or are fearful of falling. Falls Clinics are provided at Guy’s Hospital (GSTT) and the Betty Alexander Suite, Dulwich Hospital, (KCH) and the Whittington Centre, Streatham.

Following assessment, exercise based interventions are selected as appropriate for the client dependent on their level of need and risk.

Community exercise classes are provided in community venues accessible by walking or public transport eg

Peckham Pulse; Dulwich Library and leisure centres.

Otago 1:1 exercise programme usually delivered in the client’s own home.

High risk Strength and Balance exercise groups are provided at the three Falls Clinic bases with ambulance

transport.

Clients with more complex needs require 1:1 physiotherapy: this area of work is steadily increasing, a factor that has considerable impact on therapist time and service capacity. In 2010-11 1,612 people over the age of 65 were seen by the Adult Therapy Rehab Team out a service total of 1,861 i.e. 86.6%. One of the Lambeth and Southwark CQUIN quality improvement goals (Commissioning for Quality and Improvement and Innovation) is “to reduce the incidence of falls resulting in harm in community settings across Southwark and Lambeth, streamlining falls service provision, including falls prevention, by the introduction of an evidence-based, multidisciplinary and multiagency falls pathway”.

SOURCE: Older Peoples JSNA: Factsheet 12: Living independently in later life: Needs

3 Case for Change

3.1 Summary of pre-existing service before test & proposed test model The current falls service meets all evidence for best practice in terms of the components including multifactorial

assessment and matching the appropriate exercise intervention required to the level of need. Referral flows from

health care professionals for high risk clients attending A&E, Hospital and Primary care are good, as evidenced later

in in the document. The two major constraints of the pre-existing service are:

1. A lack of capacity for primary prevention on a large scale within the population. Up to 16,000 people (30%)

of older population are at risk of falls within Southwark and Lambeth, with no reliable method of

identification (low demand), and only 7 community exercise groups available to them to prevent their first

injurious fall.

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2. Capacity for providing higher risk people with timely 1:1 physiotherapy led interventions, with inevitable

backlog and waiting times up to 20 weeks. In addition, an extensive audit of those people waiting during that

time evidences substantial use of urgent care community services with referrals to ERR and @Home (271 in

an 18 month period).

In June 2013 the SLIC Operations Board was presented with a proposal for enhancing the existing falls pathway. The

proposal was to design, test and implement a new pathway for community falls exercise targeting high volume, low

risk patients who currently are not referred to existing falls exercise interventions. This aimed to be an extension of

the existing falls pathway utilising existing resources, services and systems wherever possible.

Figure 4: Existing SLIPS Pathway (Southwark and Lambeth Integrated Pathway for falls)

The current service provides differentiation for strength and balance exercise and interventions results in four clear

cohorts. The standard agreed is that people should wait no more than 3 weeks to start exercise interventions. The

service detail is set out below;

Intervention Delivered by Venues Length/type of

intervention

Current /pre -existing

capacity

Current /pre-

existing demand

Community

exercise classes

Later life trained

exercise instructors

Community venue

such as church

halls and leisure

centres

40 weeks, 1x a

week

12 patients per

7 groups

140 patients /year

7 groups

140 patients /year

12

group

Otago 1:1 Therapy assistants Own home 5 visits average 144 patients year 144 / year

High risk

strength and

balance groups

Therapy assistants

with Physio

supervision

Health centres

with ambulance

transport

8 weeks 2 x a

week – 16

sessions

48/yr 48 /yr

Physio 1:1 Physiotherapists Own home 4 visits average 800 per yr 1500 per yr

Table 2: Services provided in Southwark and Lambeth

The community exercise class programme is based on FaME Programme exercises (components of flexibility, muscle

strengthening, balance, endurance, tai chi and practice getting up from the floor). Classes are run by postural

stability instructors who have completed the Later Life training course. Class participants attend one class a week

and exercise at home an additional 1 hour a week. The programme lasts for 30 weeks during which time exercises

are gradually progressed. Each group takes a maximum of 15 participantsThe test began by addressing the key

elements of service which needed to be in effective in order for the community exercise programme to work;

Access and referral

Adherence

Agreeing the delivery vehicle

Monitoring effectiveness of the intervention for participants.

Problems the test was aiming to address

No method for proactive identification and limited intervention of citizens at primary risk of falls

Clients needed to be assessed by physio prior to prescription of appropriate exercise programme

Limited public-facing access to community exercise classes. Most referrals by health-care professionals

Referrers required to complete 2 page referral form to access service

Multiple access points designed for HCPs but confusing for referrers

Two objective clinical outcomes were collected at the start and end of intervention. No subjective outcomes were recorded

Awareness of drop-outs during the programme, and concerns re long-term adherence to falls prevention exercise, but no capacity to explore this

Unable to meet existing demand for all Physiotherapy (1500 referrals) or community group interventions due to limited capacity

Only 7 community groups (100 people /yr) and 8 wte physiotherapists (800 new referrals) across 2 boroughs.

Table 3: Problems the test was aiming to address

The test is currently running 17 exercise classes across Southwark and Lambeth and will be running 19 by April 15.

Lambeth Southwark

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Clapham Leisure Centre (2 sessions)

Elm Court School

Ferndale Sports Centre

Streatham Ice &Leisure (2 sessions)

West Norwood Old Library (2 sessions)

Darwin Court

Dulwich Library (3 sessions)

Salmon Youth Centre

Southwark Pensioner Centre

The White Horse, Peckham Rye

Liberal Club, Peckham (2 sessions)

Table 4: Problems the test was aiming to address

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4 Test models Evaluation Summary and Benefits Realisation The following section outlines the achievements of the test to date.

Pre-existing SLIP’s service

What was needed? What have we done differently? Measures of success

Limited proactive identification and intervention of citizens at primary risk of falls

Open access Open access to triage within targeted neighbourhoods

Longitudinal reduction in falls in high risk neighbourhoods

Only 7 community exercise classes

Set up more classes Recruitment of lay instructors Suitable non health centre venues. admin systems to place and track

Reduced length of classes to 30 weeks (from 40) Increased each group to 15 attendees per session- (from 12) Planned opening of classes for locations where demand arose

12 new classes (total 19) established close to peoples own homes Well attended

Clients needed to be assessed by physio or GP prior to prescription of appropriate exercise

Fast-track access to exercise with reduced assessment cost

Clinical triage by clinical assistants rather than Physiotherapists proven accuracy and safety of onward referral with an almost 99% success rate

Appropriateness of referral from triage measured by service.

Limited public-facing access to community exercise classes. Most referrals by health-care professionals

Increased public-facing access

Strength and balance helpline launched and service advertised leading to significant volumes of self-referrals , now public facing

Number of direct referrals by citizens and non-professionals

Referrers required to complete 2 page referral form to access service

Increased ease of access for referrers

Strength and balance helpline allows referrers to refer clients over the phone giving just their name and D.O.B. Helpline staff then contact the client to complete clinical triage.

Increase in referrals

Two objective clinical outcomes were collected at the start and end of intervention. No subjective outcomes or falls incidence were recorded

Increased frequency of outcome collection and implementation of subjective outcomes to allow improved analysis of effectiveness

Collection of two objective measures at 10 week intervals throughout the programme. Collection of two subjective outcomes at the start and end of intervention, falls incidence and severity and launch collection of patient feedback.

Collection of subjective and objective outcomes and falls incidence

Awareness of drop-outs during the programme, and concerns re long-term adherence to falls prevention exercise, but no capacity to explore this

Analysis of attendance. Implementation of strategies to improve access to the programme and adherence during and after attendance. A

defined ‘graduate

programme’

Analysed and reported on attendance and drop-out rates. Liaised with attendees to garner feedback regarding attendance, drop-outs and what strategies may be helpful to reduce adherence. Created a workbook to support attendees, Created an instructional DVD, Identified where partnership, accreditation or franchise with community organisations will be beneficial. Created directory of follow on groups Funding 1-2 tests of voluntary sector support

Longitudinal reduction in falls per individuals participating in the classes. Clear exit routes to effective on-going exercise

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Unable to meet existing demand for all Physiotherapy interventions due to limited capacity

Analysis of demand versus capacity in existing service. Increased capacity to meet demand where required

An audit of caseloads identified that 88% of clients on CRAFS waiting lists have either fallen or at risk of falls. Started 9 new exercise classes, employed 1.6 WTE physiotherapists, started a second strength and balance group, Analysed demand capacity and implemented service improvement and improved productivity.

Reduction in waiting times. Defined capacity required to meet on-going demand

Multiple access points designed for HCPs but confusing for referrers

Reduction in number of access points

Introduction of strength and balance helpline. Designed plan to bring all access points to single point for triage (if mainstreamed)

Increased referrals. Fewer steps from referral to treatment.

Table 5: Changes made as a result of the test

4.1 Achievements of the test To test and refine a method of early identification and referral of clients who would potentially benefit, through the

Holistic Assessment and possibly other routes.

It had originally been hoped that a number of appropriate clients would be identified through completion of the Holistic Assessment (HA). Unfortunately, this was slow to reach momentum, but is now developing to be a valuable source of referral for primary and secondary prevention services. It was therefore necessary to identify additional routes including leaflets, posters, information pieces in bulletins and staff attending meetings and groups. These were tried over a period of months. In addition, access routes into the services were confusing and multiple. Holistic Assessment (HA) Specific falls questions were included and adapted in the evolving versions of the HA. Although slow roll out, the analysis is now showing 10-13% of people reviewed with an HA identified at falls risk and are being referred to various access points in the falls service –not necessarily the helpline as this has not been widely advertised to all GP’s. Posters and leaflets New posters and leaflets have been designed by clinical staff and distributed to a number of organisations to market the service and encourage referrals. Leaflets have also been given to practice managers from eight SE Lambeth GP practices, Age UK Lambeth, Lambeth Resolve advice centres, SLIC GP clinical lead event, Waterloo Action Centre, supermarkets, Lambeth Country Show, pharmacies and Lambeth libraries. Marketing in the early months was focused upon Lambeth residents as the bulk of early referrals were for those living in Southwark via Southwark SAIL. Further distribution and increased publicity is planned across both boroughs. Partnership working From early stages we have worked closely with Southwark and Lambeth SAIL to incorporate a falls risk identification question on their referral form. They have been one of our biggest referral sources to date, especially in the early months of the project. This is one of the tests most valuable success stories. Mail shots Three mail shots were carried out using the entire over-65 register for patients at Norwood Surgery, attendees at the Southwark Pensioners’ Centre and Sheltered Accommodation residents across Southwark and Lambeth. A total of 3343 letters and leaflets were distributed with 53 resulting in self referrals. The rate was highest as a result of the GP mail out (5% for primary prevention) and lowest from Sheltered Accommodation. GP mailshots allow geographical location of new groups to be set up in advance of receiving new referrals. Plans for further mailshots are underway. Bulletins

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Since May 2014 details of the Strength and Balance Helpline and Community Exercise Classes have been sent out to be included in the following organisations’ e-bulletins:

Lambeth CCG & Southwark CCG

Community Action Southwark (CAS)

Health watch Lambeth & Health watch Southwark

Southwark Pensioners

Age UK Lambeth

Screening and Referral Outcome Including Exercise Prescription

We tested the methods for the screening of referrals and allocation of clients to appropriate exercise classes or other intervention. The standard practice for a SLIPS referral and accepted national requirement for referrals to Exercise Classes is for this to be done (prescribed) by a physiotherapist following face-to-face assessment to ensure safety. Given the desired volumes for primary care prevention, this would not be affordable. We aimed to test the safety and effectiveness of delegating falls screening and initial assessment to Band 4 assistant staff. This rapid, low cost , high volume process has proved to be safe, cost effective, high quality and meets the need to scale up the services The Strength & Balance Helpline went live in January 2014 and has been used as the vehicle for screening referrals into the new classes. A total of 400 referrals had been received by the end of September. 212 of those had been received since June, as a result of the targeted marketing (GP mailshot). As referral numbers have increased, the screening processes have been tested and improved using Plan – Do – Study - Act methodologies in line with the model of change. The phone lines are manned Monday – Friday by Band 4 staff and there is an answerphone to leave a message if phoning out of hours.

Review capacity and demand

Referral numbers to the Strength and Balance Helpline have increased over the months. One of the issues that have been identified is that significant numbers of people calling the Helpline have needed other Falls services i.e. 1:1 physio (30%) and Strength and Balance Group for more complex clients (7%), as fig 5 shows:

Figure 5: Triage outcomes – service level demand

Triage outcomes – service level demand

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The graph above show the effect that the primary prevention initative of community exercise classes has on also identifying people who need the other more expensive interventions eg one to one Therapy sessions. However the trend shows a greatly increased proportion of primary prevention to secondary as intended demonstrating the effectiveness of the methods of identification. Community Exercise Classes From the above referral data we have established that on average 58% of referrals received are for clients appropriate for Community Exercise Class. The test started enough classes in line with the uninformed demand, but as the marketing plan develops and participants spread the word through their communities, demand has grown exponentially. Another 12 classes will be in place by April 2016 Otago 1:1 The actual activity is sits at 2% and has been absorbed into the service largely because of the productivity improvement gains. 1:1 Physio The test proposal hypothesised that 5% of referrals would require 1:1 Physio. The data from December2014 – November 2015 has shown that this figure is actually an average of 34% which is a significant increase in demand. The project data shows us that patients are seen between one and six times by a physio for a 1:1 session. On average people appropriate for the service are seen four times. High Risk Strength and Balance Group The original proposal projected that 5% of patients identified would require high-risk Strength and Balance Group. The 7.5% volume of referrals has been greater than anticipated and the demand cannot be absorbed within existing groups. An additional group was required and was set up. Falls Clinic Approximately 1% require further investigation and specialist assessment in the falls clinic – this is a specialist medical geriatrician, nursing, Physio and OT assessment in a ‘one stop shop’ . This has been absorbed into the existing service at the three falls clinic sites, Guy’s, KCH and Whittington centre. Occupational therapy There has been no increase in requirement to date as part of this test.

Existing falls service capacity gap and backlog

The current SLIPS service is only able to see approximately 10% of the at risk population- less than 7% can be seen in

a timely way.

Whilst a number of people referred to the service are able to attend the classes a significant number of complex

patients require secondary prevention involving 1-1 individual physiotherapy to meet their needs.

The number of referrals to the service and the complexity of the patients has been increasing the staffing levels of

therapists have not, therefore the service is constantly operating with a significant waiting list or backlog of clients.

Patients waiting in the back log for individual 1-1 therapy input have a greater risk of deteriorating and being

admitted to hospital or requiring rapid response due to lack of earlier intervention.

An audit by GST Community Trust examined admissions to urgent care community services for people on the 20

week waiting list. The results of the audit are set out below. As can be seen , significant numbers of people on the

waiting list are at high risk of admission. (271 in an 18 month period)

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Figure 6: Impact of 20 week waits on urgent care services

There is a significant demand/capacity mismatch and patients are breeching 18 week referral times and 3 weeks falls

service standards. The 8 wte have a capacity for 100 new referrals and receive 1500 per year.

In Southwark only 57 % of new referrals can be seen creating a constant queue for the service of the remaining 43%

of accepted new patient referrals per month. In Lambeth 60% of new patient referrals are seen with existing

capacity.

A service improvement programme has been undertaken in the mainstream service –improving Productivity and

identifying demand and capacity constraints that cannot be met within existing resources (see Appendix 2)

Productivity improvements and mobile working implementation have been taken into account and the projected

capacity gap for physiotherapy after these improvements is 4 wte and we anticipate remains static as it has in recent

years (i.e. excluding project new activity)

Adherence

To maintain and update best practice a review of the current literature, and national and local programmes relating

to falls prevention and behavioural change strategies was completed. This informed our work with citizens during

focus groups, wider citizen co-production events, questionnaire design, and the development of the adherence

strategy.

Current falls prevention evidence recommends a ‘dose’ of strength and balance exercise in excess of 50 hours, 2-3

times per week (Charters, 2013), with benefits being rapidly lost when exercise is ceased (Sherrington, 2011, Hawley,

Impact of 20 week waits on Urgent Care services

19

2009). In addition, older adults have more co-morbidity, less social support, and more disability and depression than

the general population, and these factors are associated with lower exercise adherence (Picorrelli et al, 2014).

Adherence Outcomes

Average attendance at the classes is 70%, with 70% going on to complete the programme. This is consistent with

adherence rates reported in the literature (Picorelli, 2014) of between 58 and 85%. There is scope for further

improvement

Summary of Citizen co production

The adherence strategy has looked at:

Reducing the barriers to joining the classes

o Wider promotion of the classes through partnerships with Voluntary Sector Organisations (e.g.

AgeUK Winter Wellness Packs), posters and leaflets at community sites such as local libraries,

internet presence, and direct mail-outs from GP practices and Housing Associations

o Using volunteer support or ‘Buddy schemes’ to facilitate early class attendance

o Improving our health information strategies for promoting the benefits of the service both online

and in our initial ‘welcome packs’ for participants

Supporting participants to supplement their weekly classes with additional appropriate exercise either at

home or in other community settings

o Production of a class ‘workbook’ which explores making goals, monitoring achievements, and

planning for relapses, strategies consistent with NICE guidance (2014) on behavioural change

interventions

o Telephone review following each class non-attendance

o Provision of an exercise DVD of the programme to support self-directed practice

o Exploring a volunteer programme to facilitate peer group support

Improving the transition to other community ‘follow on’ exercise activities

o Visiting and reviewing appropriate physical activity options for class ‘graduates’

o Improving our guidance for appropriate ‘follow on’ options

o Exploring volunteer support to facilitate transition to other community exercise activities

Between 45-50 people took part in the group interviews. There was a good gender mix and people from a wide

variety of ethnicities were in attendance.

We found the following:

Benefits Students like the routine and appreciate being ‘pushed’ to do the exercises at classes; while at the

same time being able to do things at their own pace and without fear of feeling intimidated or embarrassed.

As well as the benefits of better balance and strength, and avoiding a bad fall, the classes improve their

confidence, motivate them to get out of the house and do the exercises. They also meet people too. There is

a sense, with some of the classes at least, of camaraderie and mutual support.

Support They struggle with doing the exercises on their own. While there was very little interest in (or

capacity for) using the internet and text messaging, there was general support for the idea of having a DVD

they can watch at home. It would also help them in doing the exercises ‘right’. But the general view is that

these technologies are no substitute for the classes.

20

Coproduction While they wanted to continue to do something after finishing the course, and were uncertain

what that might be; for most of the students there was little interest in organising classes themselves. They

want something that is free, convenient and tailored to their needs, but felt they were too old and wouldn’t

be able to do it. There was, however, some support for a buddying approach, and perhaps building on the

moral support they were already giving each other. A few students were enthusiastic about getting together

more informally as well as running their own classes with support.

Developing community capacity The very nature of the community exercise classes, the elements that take them away from a medical model are that they are accessed directly by people who have often assessed themselves to be at risk, that they not only develop strength and balance, but have the opportunity to improve their psycho social life, over a substantial amount of time.

Monitoring of outcomes and impact

Clinical outcome data is recorded at the start of class attendance, at 10, 20 weeks, and on discharge at 30 weeks. Evaluation has been undertaken by the SLIC and Provider Project Teams, along with the participants and citizen’s

forum. The table sets out the outcomes from the project measures. Despite challenges with data capture – the

results are impressive with 96.5% of attendees not falling whilst on the programme and no injurious falls at all. This

is in a group who had fallen at least once in the previous year.

Outcome activity

Quality measures Outcome standard Actual outcome

Adherence Measures complete programme completion % Attendance over the 30 week programme -65%

75%

Clinical Outcomes

Monitors participant’s clinical outcome measures for the duration of their class participation. The outcomes measured are: ● Chair Stand Test [normal: <12 seconds] ● 180 degree Turn [normal: <5 steps] ● Timed up and go: [normal <15 seconds] Measurements are taken at the start (baseline) and then at 10 week intervals and compared against previous intervals. They are recorded as follows: ● Start Baseline ● Ten week interval ● Twenty week interval ● Programme end

50 % of participants demonstrate Improvement in one or more clinical measures

76%

PROMS (Appendix 3)

The EQ-5D-5L is a standardised validated tool to measure an individual’s quality of life as a health outcome.

70% of people had improved outcomes

75% - part way through

programme

(Appendix 4) FES-I ,Falls Efficacy Scale International A recognised, responsive, validated tool developed to measure confidence in performing a range of daily activities related to balance and walking. It can be used to predict future falls and decline in functional capacity.

70% of people had improved outcomes

70% Part way through

programme

Number of falls during programme

Have any participants fallen during the the exercise programme-and if so have they sustained an injury

No national benchmark-

estimate eg 75% do not fall 95% do not

have an injurious fall

96,5% have not fallen

No injurious falls

Improving access to

Open access to triage within targeted neighbourhoods. 5% of older people on GP register

5% from mail drop & high

volumes from

21

services non-health professionals e.g. SAIL etc

Value for money and clinically safe processes

Triage by non-qualified band 4 assistant staff, proven accuracy and safety of onward referral

99% of triaged referrals are appropriate

99%

Table 6 : The test outcomes at evaluation

4.2 Summary of Lessons Learnt

The learning from this test has shown that there is a significant demand for the early intervention Community Exercise Classes and we have seen that there are effective methods of recruiting clients with limited marketing into the programme. The most effective, manageable, quantifiable and cheapest route to recruit appropriate clients has been through the mailshot from the GP practice.

We found that the safety and effectiveness of delegating falls screening and initial assessment to Band 4

assistant staff worked 99% of the time, when the standard practice for a SLIPS referral and accepted national requirement for referrals to Community Exercise Classes is for this to be done by a physiotherapist following face-to-face assessment. This triage point also allows for swift redirection to alternative treatment if the individuals condition has changed.

The analysis of the data shows that 58% of the referrals that come to the Strength and Balance Helpline are

suitable for the Community Exercise Classes with a further 34% requiring 1:1 Physio. The GP mailshot gave a return rate of 5%. 58% go to the community classes, Physio 1:1=34%, Strength and balance group = 7.5%, Otago = 1%, Falls Clinic = 1%. The trend is for higher primary prevention and lower secondary (physiotherapy).

We have evaluated and adapted our outcome monitoring processes throughout the project. collecting a

range of clinical outcomes, subjective measures and falls incidence rates. However, this volume is not sustainable and data quality and completeness is challenging. Local clinical information systems do not support this type or level of reporting. Clinical outcome measurement is not reliable when administered by the non-clinically trained community exercise group instructors. In order to scale up the service, we plan to focus on recording falls incidence/injurious falls, and the 2 PROM’s (Patient reported outcome measures) at start and finish as we believe these will be best measures of 1. The improvement to individuals and 2. The benefits of the interventions and of the service as a whole. Individual Clinical outcomes will be collected where clinical staff are providing/leading the intervention- e.g. physio and high risk strength and balance classes

We have seen very strong results on participant reported outcomes for actual falls and confidence in

activities of daily living. Participant scores on satisfaction are also very strong, as set out in table xxx. Five attendees from the Streatham Leisure Centre were interviewed on 8 December 2014. They agreed the classes where an opportunity to …”motivate, support and look after each other”, the social benefits reinforcing the group dynamics of mutual support.

We have identified the need and resource required to increase the capacity of the whole falls service in

order to deal with the demand, and maximise the opportunities for patients and value for money.

We have understood the power of word of mouth, of community resources, and the voluntary sector that can bring added value and be developed to create opportunities for improving both individual and community resilience. The majority of referrals are from the voluntary sector are for primary prevention. This has the potential to extend to supporting or providing service provision and graduate options. We have identified that this potential requires investment in terms of time and support to develop their expertise and that accreditation and franchise options can be established.

22

5 Future Commissioning intentions: Proposal to mainstream

5.1 Commissioning proposal and recommendation We know from a strong international evidence base that our service intervention can reduce falls by up to 61%. Locally, we have demonstrated through our 15 month test that for the 275 people who have completed a 30 week course, we have a non-fall rate of 96.5%. We have seen the success of the key elements of service;

Easy ,direct community based access

Cost effective triage

Primary prevention community classes

High risk prevention therapies

Adherence and engagement with voluntary and community groups We have explored four options in order to find the one which best meets the risk profile and needs of the population of Southwark and Lambeth, the statutory obligations of commissioners and providers, and benefits the whole system resources. The detailed activity and savings analysis for all four options are set out in the finance and cost savings sections The mainstreaming of this case is an opportunity for commissioners to make a real in year impact on falls incidence, and all their associated adverse consequences. Our preferred option is to recommend option 1, which means to start the scale up in order to deliver the transformational change which is required. Overall for the service, we predict a still substantial but conservative 40% reduction in the incidence of falls, as this includes higher risk older groups. The organisational and whole systems savings are substantial through clarity of referral processes and streamlining of delivery, and these are set out in in the financial analysis section.

23

Table 7: Options for commissioning

Option Shortlisted options Quality No of at risk

people seen end of 2019

Savings by end 2019

16/17 pickup Cost

1 Commission a year on year development of the service to deliver the transformational change required to reverse current large scale injuries and emergency care spend on falls.

Service will be managed by its own service manager, developed to deliver transformational change working across community and voluntary sector.

Increased physio capacity will reduce waiting times to 3 weeks maximum avoiding deterioration and injury

Will meet quality imperatives from NHS England. CCG Outcomes indicator set 2015/16 - Hip fracture incidence included as a new measure

CQUIN reduce incidence of falls Southwark and Lambeth Adult Social Care Outcomes Framework 2015–2016 Public Health Outcomes Framework 2013–2016. NICE Guidance for Falls prevention 2013 and 2015

3585 £7,172,879 £612,000

2 Commission the current activity level and expand at marginal rate

Service will need to be managed by its own service manager

Will fail to address the scale required for maximum impact and will not have capacity to meet needs of hard to reach communities.

Current waiting times for one to one physio therapy for high risk patients may reduce to 10 or 12 weeks. Some of those waiting will experience deterioration, falls and injuries such as fractures.

3050 £6,616,416 £448,000

3 Commission the SLIC activity level - remain static

The service will not be equitable, meeting only the need of the neighbourhoods where the classes are currently placed. Without development and service management funding, the service will fail to address the needs of hard to reach communities, or those at high risk who need one to one physio to prevent falls. There will be no capacity to develop the voluntary or community sector, missing opportunities and value added resilience work.

Current waiting times for one to one physio therapy for high risk patients will remain at 20 weeks and rising. Some of those waiting will experience deterioration, falls and injuries such as fractures.

1884 £5,814,148 £329,000

4 Do nothing - return to baseline

Please see risk chart in section 5 0 0 £64,000 wind down cost

5.2 Recommended option Of the four options identified option one is the recommended option. This will provide the highest impact both in

terms of savings and prevention of falls.

24

The proposed service will include the following elements:

1. A falls prevention service which by 2020 will have provided interventions to reduce or prevent falls in 57% of

the at risk 16,000 population. This will deliver transformational change.

2. Establishment of a widely marketed permanent Falls Strength and Balance help line, and a central triage hub

providing a single point of access for members of the community and professionals, manned by band 4

Therapy assistants.

3. Incremental growth at scale in primary prevention, the Community Exercise Class, in both Southwark and

Lambeth to have capacity for over 1000 people per year.

4. Additional resource (physiotherapists and high risk strength and balance groups) to meet the demand for

the existing and the increased level of identification for secondary prevention

5. Develop voluntary and community organisation capital to augment provider options for attendance,

adherence and graduate routes after completion of the programme

Increased activity in the four exercise components – numbers of people

Figure 7: Service level activity

The management team will develop a marketing and communication plan to support this expansion.

The development of the voluntary and community sector will be specifically supported with some funding to

increase the capability, skills and capacity.

5.3 Description of service The range of strength and balance falls exercise interventions are a population based preventative service, which is

set within a whole system approach, described in fig 8 below. The service will be fully integrated within the existing

SLIPs falls service.

25

Figure 8: Contextual diagram for the service

Access

There will a central hub for all referrals for people identified at risk of falls – reducing the points of access and

confusion for referrers

The Helpline will maintain the public facing simple access point for citizens, carers, voluntary and other referrers who

have not undertaken an assessment of the person. It will be widely marketed using a variety of methods tested in

the pilot.

Health care and other professionals, who have assessed the person and are currently referring to a number of access

points, will have a single electronic point of referral within this hub.

We will support Local Care Networks and Primary care to identify at risk individuals, including a continued rollout of the over 65 maildrops that were shown to be are a very low cost and reliable method of attracting approriate self referral for 5% of the over 65 population. Demographic differences across the two boroughs may result in different response rates; Future mail outs would be coordinated with local care networks and public health advice to establish priority areas of high risk populations. The team will work closely with each group of GP practices, working on the ground with the health navigators in each practice to enable us to increase referrals from HHA’s and hard to reach groups and non-English speaking clients.

Triage

Triage by the Ban 4 Therapy Assistants to relevant exercise intervention or multifactorial assessment will be

undertaken by maintaining and developing the skilled clinical assistant roles within the hub and will triage every level

of need to the approporiate service/ intervention. This greater value for money and is scaleable.

During the test this has achieved 99% success at direction to the most appropriate falls intervention. This has proved

popular with professionals and the public alike. It also provides a route back to alternative intervention if required –

eg the person deteriorates or improves. This will reduce the steps, time and qualified physiotherapy resource

needed to safely commence the relevant exercise programme as shown in the revised flow diagram below

26

:

Figure 9: New service pathway

Primary prevention, the Community Exercise Classes

The roll out of community exercise classes in leisure and other community centres throughout Lambeth and

Southwark presents a range of operational challenges that the team are now very skilled in resolving. The rollout

plan is practical and achievable.

The classes will be delivered by instructors qualified to level 4 PSI, who are contracted with a specification which

includes the elements which can deliver our aspirations for the classes, as well as data and outcomes capture, and

recruited on a freelance basis, recruited by the Falls service manager.

A structured specialist-led group exercise element of one 1 hour session per week for 30 weeks supported by home

based physical activity, with a theraband provided at week 1 and a DVD at week 10.

27

The classes consist of essential evidence based components. Activities are specifically designed to improve balance

and strengthen specific muscle groups, not just to simply increase physical activity levels.

Venues will be chosen to take into account:

Close proximity to local residents

Easily accessible by public transport

Easy or step-free access

Spacious (a minimum of 100 sq. metres for a class of 15 participants)

Well lit, and welcoming environment

These classes have been redesigned during the pilot to be higher volume and lower cost per individual (currently

approx £220 a person for a 30 week programme or just over £5000 per year per group).

A service specification has been designed so that these can be delivered by other other organsiations on a franchise

basis under the governance of the overall falls service and this franchise model will be developed and tested in 2016-

17.

Other organsiations such as voluntary groups currently lack the expertise to provide these classes, however the

resource in the business case will help support their development to deliver these and respond to the franschise

partcularly for hard to reach communities.

We have already identified 2 popluations where this may be desirable ie the Portugese community and the project

team is working with a Mosque in the Old Kent Road area to develop a class that meets the criteria set out by the

project but will potentially be run by exercise instructors identified from their community.

Secondary prevention

The marketing of the falls helpline will help to identify unmet need, so a part of the business plan addresses the

current and predicted new capacity gap for those people who are at higher risk of falls and need more one to one

therapy led interventions.

Additional physiotherapy and high risk strength and balance groups will be recruited/ established to meet demand

and managed within existing clinical management resources.

The service will be able to achive waits of no more than three weeks from referral to offer of first appointment in

line with clinical evidence and standards.

The current cohort of people who deteriorate whilst awaiting intervention will be substabntially reduced as will the

preventable demand and cost on urgent response services such as ERR and @home (data shows this was 271 people

in an 18 month period).

The roll out plan will initially cover 4 years, and the activity schedule is set out overleaf (Table 8);

28

Number individuals Baseline14-15 Total 15-16 Total 16-17 Total 17-18 Total 18-19

Community exercise classes

140 440 640 750 1000

High risk Strength and balance group

48 96 96 120 144

Otago 1:1 144 150 154 159 164

Physio 1:1 1523 1640 1718 1816 1913

Total 1855 2326 2608 2845 3221

Table 8: Roll out plan option 1

number groups running each year -

Baseline14-15

total 15-16 total 16-17 total 17-18 total 18-19

Community exercise classes

7 19 27 37 47

High risk Strength and balance group

1 2 2 3 3

Total 8 21 29 40 50

Table 9 : Roll out plan option 1

29

Increased activity in the four exercise components – numbers of people

Fig 10: Planned activity schedule option 1

Attendance, adherence and graduate routes

Adherence during the exercise programme and long term maintenance of effective exercise is an essential

component of the service. The following strategies developed in co-production during the pilot have been identified

and will be implemented

Reducing the barriers to joining the classes

o Wider promotion of the classes through partnerships with Voluntary Sector Organisations (e.g. Age

UK Winter Wellness Packs), posters and leaflets at community sites such as local libraries, internet

presence, and direct mail-outs from GP practices and Housing Associations

o To further develop the web and social media presence. This would be particularly useful for

communicating with key stakeholders and citizens, and family members who are confident with

using the internet.

o Using volunteer support or ‘Buddy schemes’ to facilitate early class attendance

o Improving our health information strategies for promoting the benefits of the service both online

and in our initial ‘welcome packs’ for participants

Supporting participants to supplement their weekly classes with additional appropriate exercise either at

home or in other community settings

o Production of a class ‘workbook’ which explores making goals, monitoring achievements, and

planning for relapses, strategies consistent with NICE guidance (2014) on behavioural change

interventions

o Telephone review following each class non-attendance

o Provision of the exercise DVD of the programme to support self-directed practice

o The DVD can be sub-titled into different languages.

o Implement the text messaging service for those participants that would welcome use of this

communication channel.

o Developing a volunteer programme to facilitate peer group support

Improving the transition to other community ‘follow on’ exercise activities

30

o Visiting and reviewing appropriate physical activity options for class ‘graduates’ a compendium of

over 25 groups has already been created.

Support and influence the development of appropriate ‘follow-on’ community exercise options:

Develop our relationships with providers of health promotion classes such as Dance for Health in Vauxhall or

Parkour Dance in Bermondsey which have good balance and strength components. These could be become a

trusted accredited or ‘kite-marked’ as a follow-on option for clients in those localities.

To work with existing classes which do not currently have a very strong strength and balance components,

but could potentially, with some support from the project team. These could then become trusted ‘kite-

marked’ follow-on exercise options. Based on feedback from our citizens engagement work this should be

limited currently to £3-4.

Encourage Instructors from our current pool of PSI’s to set up their own ‘Pay as you go’ classes. If space can

be accessed for free or low cost through relationships with VCS’s then this would become affordable at £3-4.

Improving our guidance to individuals for appropriate ‘follow on’ options

Developing volunteer support to facilitate transition to other community exercise activities

How will be programme be managed and run?

GSTT Community teams will manage the services, and will assess and provide governance. There is resource

identified to develop the provider market in voluntary and community organsiations. The roll out programme for the

exercise classes will be fully integrated into the existing falls service.

The operational management structure is supported by a full time service manager and a clincial lead to enable the

ambitioius progreamme of expansion, francise, acdcrediation, partnership and alternative provider development.

Workforce development and community capital

The project team will be able to continue the development of a workforce of voluntary and community services and

citizens would be able to support the mainstream deployment of this early intervention pathway.

The evaluation of the test set out above demonstrates that the service is now ready to be commissioned for the

whole at risk members of our population, in order to achieve the substantial personal and whole system benefits as

specified by the SLIC Appraisal Framework is set out below

The benefits of mainstreaming the service as set out in the table below;

Benefit Impact

Population outcomes: [Life expectancy or quality of life not impacted by a fall related injury]

The fast track pathway for citizens at risk of primary falls into Community Exercise Classes allows a preventative approach to this common risk to older people’s health and wellbeing. Through early intervention and providing an appropriate designed intervention, this pathway will assist in maximising individual’s health and psycho social outcomes. The current service is only able to deliver services which reduce risk in fewer than 10% of the population. In addition to the wellbeing, financial, health and social impacts, consideration must be given to the impact on an individual who has fallen, even without major injury or hospitalisation. This impact on their quality of life is much wider and significant.

loss of confidence,

physical inactivity,

social isolation,

31

physical deterioration,

anxiety and depression

a greater dependence on family, friends

Increased demand on community health and social services.

Associated social care cost, including residential and nursing home costs. Most people who are unable to live in their own homes have suffered a fall in their past medical history.

Curbing the rise of total system cost

The physical and psycho social impact of falls in an economic context is catastrophic. The health and social care response to a person who falls and calls for assistance is at the very minimum an ambulance attendance, and can range to a 120 day stay in hospital, with discharge to a care home at £28,000 per annum. Please see the fiscal analysis in the Financial section for more detail

Patient and carer experience

This fast-track treatment pathway into Community Exercise Classes will improve patient and carer experience. Citizen engagement and partnership working has already been undertaken, with support from the SLIC Senior Engagement Officer with groups engaged have included citizens [class attendees] and the voluntary and community sector. Feedback received from citizens participating in classes includes: “I found the class hard work but very worthwhile and am sure it is the training I need to improve my balance and leg strength” Mrs N., London Two citizens from the Elm Court School class were interviewed on 5 December 2014. They stated they looked forward to their classes, finding them both useful and helping to improve their confidence when out walking and “getting on and off buses”. On 2 December 2014, five citizens at the Dulwich Library class were interviewed by the SLIC senior engagement officer. They said they enjoyed their class. They described the class as “something they needed and had waited some time for.”

Clinical improvements

76 % of the total course participants achieved at least one improved clinical marker

Has a strategic coherence taking into account other projects within the programme and the sector

Because of the significant impact that falls have across the local Health and Social economy, efforts to identify and implement effective preventative measures are high on the agenda of Southwark and Lambeth CCGs, Local Health Services and Local Authorities. This project also fits with the General Practice work aiming for early identification utilising ICMs and Holistic Health Assessments.

Organisational benefits

We will be able to demonstrate benefits to multiple agencies including Acute Hospitals [A&E attendances as well as admissions], London Ambulance Service and Southwark and Lambeth Councils [social care costs, including residential and nursing care through the following metrics;

Reduction in LAS attendance for falls against baseline 2014/15 figures

Reduction in A&E admission for falls in participant population.

Reduction in fractures as set out in our baseline metrics. The knock on benefits in acute bed usage cannot solely be attributed to this initiative, but it will play its part. Through engaging with Age UK Phase Two will help to identify how volunteers and community organisations can assist in supporting care in the community. This will help reduce overall system operational spend and improve value for the citizen due to approaches the third sector offer.

Table 10: the benefits of mainstreaming the service

32

5.4 Quality Assurance, Outcome and Benefit Realisation

The outcomes for the service will be monitored and measured with the tools set out in fig x

Outcome area Standard to be achieved Monitoring tool Outcomes per annum

Y1 Y2 Y3 Y4

Organisational We will be able to demonstrate benefits to multiple agencies including Acute Hospitals [A&E attendances as well as admissions], London Ambulance Service and Southwark and Lambeth Councils [social care costs, including residential and nursing care) Further, this initiative will support the development of voluntary sector support through the graduate programme. Specifically we can measure ;

Reduction in LAS attendance for falls against baseline 2014/15 figures

Reduction in A&E admission for falls in participant population.

Reduction in fractures as set out in our baseline metrics.

The knock on benefits in acute bed usage cannot solely be attributed to this initiative, but it will play its part.

Quarterly contract review of NICE guidance by commissioners

Satisfaction The proposed pathway has a positive impact on the following “I Statement” outcomes: I have systems in place to help at an early stage to avoid crisis I can manage my own health and wellbeing (or condition) and I am supported to do this I (am able to) live the life I want (and get the support I need to do that) 70% of participants will show an improvement

FES-I ,Falls Efficacy Scale International A

Clinical and individual outcomes

76 % of the total course participants achieved at least one improved clinical marker, and falls incidence in the participants is monitored. Monitoring the number of falls per participant during the 30 week course

Trainer records Service monitoring and commissioner review

Wellbeing 70% of participants will see an improvement on this scoring tool

The EQ-5D-5L is a standardised validated tool to measure an individual’s quality of life as a health outcome.

Activity Open access to triage within targeted neighbourhoods. Clinical triage by non-qualified staff, proven accuracy and safety of onward referral with an almost 100% success rate. Activity will be agreed with the emerging Local Care Networks and Public Health advisors, in order to target the highest risk neighbourhoods. Proposed New activity per

Monthly capacity and demand analysis - whole service

33

annum to be met.

Resources The 4 year roll out plan for this service acknowledges that the exercise class programme needs to meet demand from increasing percentages of at risk citizens per annum, and maximise the benefits set out above. Whole system cost saving will be seen against a local agreement to invest to grow this preventative service. Please see cost savings plan in section. This will be measured by ; Reduction in admissions for falls against baseline.

Quarterly review of data whole service with commissioners.

Table 11: Outcome monitoring tool

5.5 Projected savings: Cost impact over the next 5 years In order to define the cost impact, we have evaluated the following data and metrics below. Our assumptions and

analysis is set out in more detail in Appendix 1.

Our demand, defined by age and a third of each age grouping, is set out in the table below. We can see a steady rise

in year on year demand. Age is a significant marker as over the age of 80 years, falls risk doubles.

34

FY2014 FY2015 FY2016 FY2017 FY2018 FY2019 FY2020

65 to 69 4,967 5,133 5,233 5,200 5,267 5,400 5,567

70 to 74 3,767 3,733 3,767 4,000 4,133 4,267 4,400

75 to 79 3,033 3,100 3,067 3,033 3,033 3,100 3,067

80 to 84 2,133 2,133 2,200 2,200 2,233 2,300 2,367

85 to 89 1,300 1,300 1,367 1,367 1,400 1,400 1,400

Table 12: Demand for the service

Southwark and Lambeth spent £17, 183,543 in 2014 and 2015 on addressing the needs of patients who were

admitted to hospital with a fall. The breakdown is set out below;

Fig 11: Current whole system spend on falls (actual) Southwark and Lambeth

35

Savings assumptions are based on a conservative 40% decrease in falls across all risk levels, and the baseline falls

spend and programme savings from our planned activity levels set out in fig xxx are depicted below. The

conservative growth of the service reduces the savings we are able to achieve, but the trajectory of saving makes

this a very clear invest to save initiative in this first year. After this, the service pays for itself many times over.

Option 1

Fig 12 : Baseline spend and programme savings option 1

The cumulative savings against service cost are substantial and are set out below in fig 13;

Fig 13 : Cumulative programme savings option 1

36

Fig 14: Gross savings by option

The graph above illustrates the savings available from three of the options. Option 4 leaves commissioners with an

actual current spend on falls of £8.25 million a year, spent on emergency care and rehabilitation. The additional

2,000 people who would be seen in Option 1 afford additional savings of 4 million, cumulatively. As the first year is

pump primed, in order to set up the clinical and management team, the spend to set this option up is £164,000 more

than option 2, which delivers 1000 fewer participants a year. Detailed analysis is set out in Appendix 5.

5.6 Financials: Direct Cost of service The proposed enhanced services will be hosted within CRAFS - the Community Rehabilitation and Falls Service, which

provides a wide range of interventions for clients with complex rehabilitation needs.

The Total cost schedule set out below addresses the enhanced service requirement, and is set out to 2019 for Option

1 in fig 15, and Option 2 is set out in Fig 16.

37

Current SLIC project units funded Cost to run 1 group

for full year / staff

wte substantive

Groups per

year /wte

per year

Cost

substantive

Groups

/wte

Cost

substantive

Groups per

year /wte

Cost

substantive

Groups per

year /wte

Cost

substantive

Year Cost Per Unit

Community exercise group £5,313 12 £63,756 20 £106,260 30 £159,390 40.0 £212,520

High risk Strength and balance £18,924 1 £18,924 1 £18,924 1.5 £28,386 2.0 £37,848

121 Otago - (Meet through productivity gains) £30,270 0 £0 £0 £0 £0

Eliminate waits from 18-26 weeks to max 3 weeks £51,818 1 £51,818 1 £51,818 1.0 £51,818

£44,056 1 £44,056 2 £88,112 2 £88,112 2.0 £88,112

£36,559 1 £36,559 1 £36,559 1.0 £36,559

121 physio meet new referral flow (project) demand £44,056 0.8 £35,245 1 £44,056 1.5 £66,084 2.0 £88,112

Helpline and clinical traige and admin £30,270 3 £90,810 3 £90,810 4.0 £121,080 4.0 £121,080

Clinical development and triage, screening training

supervision and new group instructors £44,056 0.8 £35,245 £0 £0 £0

Project clinical leadership -( incorporate clinical

tasks above from 16-17) £51,818 0.8 £41,454 1 £51,818 0.5 £25,909 0.5 £25,909

Slic project support 0.2 0 0 0.0

service management/business support £44,056 0 £0 1 £44,056 1 £44,056 1.0 £44,056

£329,490 £532,413 £621,394 £706,014

Marketing costs £2,000 £2,000 £2,000

Staff travel and mobile devices 10 £10,000 10 £10,000 10 £10,000

Vol sector market stimulation and support £20,000 £10,000 £5,000

Clinical equipment 3,500 3,500 3,500

Non Pay Total £35,500 £25,500 £20,500

Total £567,913 £646,894 £726,514

Overheads at 10%- excl groups £44,273 £45,912 £47,615

Final Total £612,186 £692,806 £774,129

Non Pay

Groups Running Costs

Capacity Gap 121 physio

Core team

Pay Total

15-16 16-17 17-18 18-19

assume productivity with mobile working will

increase capacity from 108 NPts/ yr per wte to 144

Fig 15: option 1 service costs

Current SLIC project units funded Cost to run 1 group

for full year / staff

wte substantive

Groups per

year /wte

per year

Cost

substantive

Groups

/wte

Cost

substantive

Groups per

year /wte

Cost

substantive

Groups per

year /wte

Cost

substantive

Year Cost Per Unit

Community exercise group £5,313 12 £63,756 15 £79,695 22 £116,886 30.0 £159,390

High risk Strength and balance £18,924 1 £18,924 1 £18,924 1.5 £28,386 2.0 £37,848

121 Otago - (Meet through productivity gains) £30,270 0 £0 £0 £0 £0

Eliminate waits from 18-26 weeks to max 12 weeks £51,818 0.0 £0 0 £0 0.0 £0

£44,056 1 £44,056 2.0 £88,112 2 £88,112 2.0 £88,112

£36,559 0.0 £0 1 £18,280 0.5 £18,280

121 physio meet new referral flow (project) demand £44,056 0.8 £35,245 0.5 £22,028 1.0 £44,056 1.5 £66,084

Helpline and clinical traige and admin £30,270 3 £90,810 3.0 £90,810 3.5 £105,945 3.5 £105,945

Clinical development and triage, screening training

supervision and new group instructors £44,056 0.8 £35,245 £0 £0 £0

Project clinical leadership -( incorporate clinical

tasks above from 16-17) £51,818 0.8 £41,454 1 £51,818 1.0 £51,818 1.0 £51,818

Slic project support 0.2 0 0 0.0

service management/business support £44,056 0 £0 1 £44,056 1 £44,056 1.0 £44,056

£329,490 £395,443 £497,539 £571,533

Marketing costs £2,000 £2,000 £2,000

Staff travel and mobile devices 7 £6,500 8 £8,000 8.5 £8,500

Vol sector market stimulation and support £10,000 £10,000 £5,000

Clinical equipment 2,000 2,000 2,000

Non Pay Total £20,500 £22,000 £17,500

Total £415,943 £519,539 £589,033

Overheads at 10%- excl groups £31,732 £37,427 £39,179

Final Total £447,676 £556,965 £628,212

assume productivity with mobile working will

increase capacity from 108 NPts/ yr per wte to 144

Core team

Pay Total

Non Pay

15-16 16-17 Option 2 17-18 option 2 18-19 option 2

Groups Running Costs

Capacity Gap 121 physio

Fig 16: Option 2 service costs

38

5.7 Interdependencies to delivery

The service interfaces with the following organisations;

General Practice

Urgent care services

General rehabilitation services

Voluntary sector services

Care homes - residential and nursing

Acute Trusts.

Because of the specialist nature of this service, overlaps and duplications are not a risk. Opportunities for improved

access exist with these parties, and for relationships to develop with a view to supporting shared goals eg reducing

falls in hospital.

5.8 Potential risks and Mitigation – all options

Option 1 Risks and mitigation

Risk Mitigation

Lack of access by majority of people who need the service

Work with GP Practices and LCNs to support access

Inability to recruit trainers Service manager to monitor and encourage community resource by advertising training courses and seeking a sponsor

Inability to find appropriate venues Team develops a roll out plan based on areas of highest need , and working with community groups to discover appropriate venues.

Potential savings not delivered Regular commissioner / provider review

Lack of referrals Development of local marketing strategies

Number of people who fall increase Raise awareness of falls and service to the public

Staff recruitment problematic Flexible skill mix in team to be shaped around elements of team easiest to recruit

Losing skilled trained staff Commissioners to expedite their decision making to reduce risk of losing staff, and will affect roll out timescales and capacity.

Funding gap for the 30 week courses which have already started.

Commissioners to expedite their decision to prevent effect on existing courses. If full mainstream funding not supported – a wind down fund will be required.

Table 13: Option 1 risks

39

Option 2 Risks and mitigation

Risk Mitigation

Lack of access by majority of people who need the service

Work with commissioners to monitor outcomes and develop case for expansion when agreed

Inequity of access Agree target area priorities with GP Federations

Inability to find appropriate venues Team develops a roll out plan based on areas of highest need, and working with community groups to discover appropriate venues.

Potential savings not delivered Regular commissioner / provider review

Lack of referrals Development of local marketing strategies

Number of people who fall increase Raise awareness of falls and service to the public

Staff recruitment problematic Flexible skill mix in team to be shaped around elements of team easiest to recruit

Losing skilled trained staff Commissioners to expedite their decision making to reduce risk of losing staff, and will affect roll out timescales and capacity.

Funding gap for the 30 week courses which have already started.

Table 14 : Option 2 risks

Option 3 risks and mitigation

Risk Mitigation

Lack of access by majority of people who need the service

Work with commissioners to monitor outcomes and develop case for expansion when agreed

Inequity of access Agree target area priorities with GP Federations

Waiting times remain at 20 weeks for high risk referrals patients are a high risk of falling and emergency admission

Advise commissioners and agree action plan.

Potential savings not delivered Regular commissioner / provider review

Number of people who fall increase Raise awareness of falls and service to the public

Losing skilled trained staff Commissioners to expedite their decision making to reduce risk of losing staff, and will affect roll out timescales and capacity.

40

Funding gap for the 30 week courses which have already started.

Commissioners to expedite their decision to prevent effect on existing courses. If full mainstream funding not supported – a wind down fund will be required.

Table 15: Option 3 risks

Option 4 risks and mitigation

Risk Mitigation

Lack of primary prevention service for people at risk of falling

Whole system risk on activity and resources , raise as a risk on JSNA

Whole system cost continues at £8.25 million meeting emergency needs of people who fall. Organisational impact to LAS and acute Trusts bed capacity

Raise awareness of risk to Health and Social care partners

Potential savings not delivered Whole system risk on activity and resources , raise as a risk on JSNA

Incidence of falls continues unabated Agree action plan with commissioners.

Commissioners unable to meet statutory

obligations to Outcome Frameworks and

CQUINS

Commissioners to raise risk with Performance managers

Losing skilled trained staff Nil

Funding gap for the 30 week courses which have already started.

Commissioners to expedite their decision to prevent effect on existing courses. If full mainstream funding not supported – a wind down fund will be required.

Table 16: Option 4 risk

41

6 Appendix 1 – modelling assumptions

6.1 Falls business case modelling assumptions Metrics used to evaluate interventions impact:

The intervention: An improved Falls prevention pathway, to ensure effective proactive interventions for citizens at

risk of falls, utilising a refined referral and triage process, a range of adherence strategies, and engagement with

voluntary and community sector, councils and other leisure providers

To evaluate the intervention impact, we have analysed the following metrics:

A. Falls related A&E attendances (people aged >=65) B. Falls related ELIP (after trauma) and NELIP with hip procedure (aged >=65) C. Falls related ELIP (after trauma) and NELIP with no hip procedure (aged >=65) D. Falls related care home admissions (people aged >=65) E. Falls related ambulance conveyances (people aged >=65) F. Falls related ambulance call outs without conveyance (people aged >=65) G. Community spend specifically attributable to fall related ELIP / NELIP

Metrics

Data Source Data

Definitions /

Assumptions

Impact Assumptions Initiative Scale-Up

A - Falls

related A&E

attendances

(people

aged >=65)

Extrapolated using the

source data for metrics B

and C (see below)

See

nex

t sl

ide

40 % reduction in

activity and spend –

based on evidence

sources cited in the

business case

% of target population

(people aged over 65

susceptible to a fall) to

which the initiative is

rolled out.

This is dependent on

how long the

preventative benefits

last for an individual

once seen under the

programme (the

different scenarios are

modelled) Assuming

the preventative

benefits last on

average 4 years then:

FY2015 = 14%

FY2016 = 30%

FY 2017 = 48%

B - Falls

related ELIP

(trauma) /

NELIP with

hip

procedure

(people

aged >=65)

GSTT 12/13 episode level

dataset extrapolated for

all Southwark and

Lambeth activity

40 % reduction in

activity and spend –

based on evidence

sources cited in the

business case

C - Falls

related ELIP

(trauma) /

NELIP with

no hip

procedure

(people

GSTT 12/13 episode level

dataset extrapolated for

all Southwark and

Lambeth activity

40 % reduction in

activity and spend –

based on evidence

sources cited in the

business case

42

aged >=65) FY 2018 = 67%

FY 2019 = 71%

FY 2020 = 74%

With benefits lasting

up to FY2023 for

patients seen in FY2020

D - Falls

related care

home

admissions

- GSTT 12/13 episode level

dataset extrapolated for

all Southwark and

Lambeth activity

- Spend data: Health &

Social Care Information

Centre (avg cost per

resident per week = £525

in 2014/15)

40 % reduction in

activity and spend –

based on evidence

sources cited in the

business case

E - Falls

related

ambulance

conveyances

(people

aged >=65)

Estimated using results

from a report focussing on

falls in older people in

Greater Manchester (TIIG

Greater Manchester.

Themed Report June

2014) and applying this to

the number of A&E

attendances (metric A)

See

nex

t sl

ide

40 % reduction in

activity and spend –

based on evidence

sources cited in the

business case

% of target population

(people aged over 65

susceptible to a fall) to

which the initiative is

rolled out:

This is dependent on

how long the

preventative benefits

last for an individual

once seen in the

programme (different

scenarios are

modelled) Assuming

the preventative

benefits last on

average 4 years then:

FY2015 = 14%

FY2016 = 30%

FY 2017 = 48%

FY 2018 = 67%

FY 2019 = 71%

FY 2020 = 74%

With benefits lasting

up to FY2023 for

patients seen in FY2020

F - Falls

related

ambulance

call outs

without

conveyances

(people

aged >=65)

Estimated using results

from a report focussing on

falls in older people in

Greater Manchester (TIIG

Greater Manchester

Themed Report June

2014) and applying this to

the number of A&E

attendances (metric A)

40 % reduction in

activity and spend –

based on evidence

sources cited in the

business case

G -

Community

spend

specifically

attributable

to fall

related ELIP

/ NELIP

SLIC person level Year-Of-

Care database for 2012/13

40 % reduction in

activity and spend –

based on evidence

sources cited in the

business case

43

Further detailed assumptions

Metrics Data definitions / assumptions

A - Falls related A&E

attends (people aged

>=65)

• No falls diagnosis present in the GSTT A&E dataset. However, an audit at

KCH indicates the ratio between admissions and discharges for falls related

A&E attendances is 1:5. We have applied this reasoning to approximate the

number of A&E attends based on admissions from metrics B and C below

B - Falls related ELIP

(trauma) / NELIP with

hip procedure

(people aged >=65)

• Admissions (NELIP or ELIP) with an HRG relating to a hip procedure

(excluding hip procedures for non-trauma) :

- HA11A - Major Hip Procedures category 2 for Trauma with Major CC

- HA11B - Major Hip Procedures category 2 for Trauma with

Intermediate CC

- HA11C - Major Hip Procedures category 2 for Trauma without CC

- HA12B - Major Hip Procedures category 1 for Trauma with CC

- HA12C - Major Hip Procedures category 1 for Trauma without CC

- HA13A - Intermediate Hip Procedures for Trauma with Major CC

- HA13B - Intermediate Hip Procedures for Trauma with Intermediate

CC

- HA13C - Intermediate Hip Procedures for Trauma without CC

- HA14A - Minor Hip Procedures for Trauma with Major CC

- HA14B - Minor Hip Procedures for Trauma with Intermediate CC

- HA14C - Minor Hip Procedures for Trauma without CC

C - Falls related ELIP

(trauma) / NELIP with

no hip procedure

(people aged >=65)

• Admissions (NELIP or ELIP) with a diagnosis code relating to a fall:

- ICD-10 Chapters: W00 – W19

• Admissions (NELIP or ELIP) with a HRG :

- HA91Z - Hip Trauma Diagnosis without Procedure

D - Falls related care

home admissions

• Admissions which satisfy definitions for metrics B and C above, AND also with

a discharge destination code specifying ‘care home’

E - Falls related

ambulance

conveyances (people

• Estimated using results from a report on falls in older people in Greater

Manchester (TIIG Greater Manchester Themed Report June 2014) - 71% of

falls related A&E attendances arrive by ambulance, and ratio between

44

aged >=65) ambulance call outs with and without conveyance is 1:1

• The cost of an ambulance conveyance is assumed to be £195 in FY2015

F - Falls related

ambulance call outs

without conveyances

(people aged >=65)

• Estimated using results from a report on falls in older people in Greater

Manchester (TIIG Greater Manchester Themed Report June 2014) - 71% of

falls related A&E attendances arrive by ambulance, and ratio between

ambulance call outs with and without conveyance is 1:1

G - Community spend

specifically

attributable to fall

related ELIP / NELIP

• Community contacts spend (not including community inpatient) compared

individual patients for 3 months after a fall with the 3 months before a fall

Other assumptions used

Metric type Assumption

Activity baseline • Activity growth assumed to move in line with ONS trend based population projections – based on projections segmented by 5 year age bands for people aged 65 and above in Southwark and Lambeth

• Activity grows annually between 1.5% and 2.7% between FY2015 and FY2024

Spend baseline • The growth in the activity baseline compounded with spend factors such as NHS cost inflation, provider efficiency (negative inflation), and other case mix and volume growth - based on NHSE planning guidance

• Net annual spend inflation of 1.6% assumed between FY2015 and FY2024

Initiative Costs (Set-up costs / recurrent costs)

• Initiative costings supplied by the SLIC project team. We have modelled the case where the programme is only offered up till FY2020. Therefore there are no initiative costs beyond this year, though some levels of savings will still be seen till FY2024 as the preventative benefits of the intervention typically last more than a year (different scenarios modelled in the model)

6.2 Financial analysis

Business Case Model Falls Option 1 Business Case Model Falls Option 2 Business Case Model Falls

Option 3

SLIC_Business Case_Model_Falls_Option 1_20151209.xlsm

SLIC_Business Case_Model_Falls_Option 2_20151209.xlsm

SLIC_Business Case_Model_Falls_Option 3_20151209.xlsm

45

Business Case Model Falls Summary

SLIC_Business Case_Model_Falls_Option 3_20151209.xlsm

7 Appendix 2 - Demand, capacity and productivity existing community rehab

and falls service

The CRAFS service provides a wide range of interventions for clients with complex non neurological rehabilitation

needs including delivery of the falls service. Detailed Analysis of caseloads during 2014-15 showed 88% of all

referrals are related to falls risk, even if this is not identified on the referral. The remainder are a range of issues such

as backpain, post op elective surgery, some respiratory, cancer and end of life.

The service accepts referrals from all sources hospitals and community and consists of 3.8 wte physiotherapists in

Southwark and 4.6 wte in Lambeth. There is no other community physiotherapy service provided other than the

specialist neuro-rehab teams and MSK out patients. This service picks up all other needs.

Whilst a number of people referred to the service are able to attend Falls classes run by assistants, a significant

number of complex patients require 1-1 individual therapy intervention to meet their needs.

Whilst the number of referrals to the service and the complexity of the patients has been increasing the staffing

levels of therapists have not. Therefore the service is constantly operating with a significant waiting list or backlog of

clients ranging up to 20 weeks.

Figure 1. monthly referrals for 1-1 therapeutic intervention packages

46

Negative Impact of waiting lists on patient outcomes

Patients waiting in the back log for individual 1-1 therapy input have a greater risk of deteriorating and being

admitted to hospital, or requiring rapid response/ @home interventions due to lack of an earlier therapeutic

intervention.

Despite prioritising referrals for urgency, and seeing patients with an identified urgent need within 1-3 weeks , some

patients do deteriorate whilst on a waiting lists and end up in crisis and require acute intervention. This is

demonstrated by the number of patients referred to ERR and @home whilst on a waiting list. This was a total of 271

patients over an 18 month period. This not only requires a more costly intervention, it also has an adverse impact on

the well-being and confidence of the individual.

Number of individuals REFERRED TO ERR OR @HOME whilst on waiting lists for physio or other falls interventions April 14- Oct 15

121 PHYSIO OTHER TOTAL

LAMBETH 55 35 90

SOUTHWARK 127 54 181

TOTAL 182 89 271

Productivity gains

The service have implemented strategies to increase flow of patients through skillmix, rigorous use of diary/

timetabling of clients and setting targets for staff of new patient and follow up contacts. The data shows that

numbers of contacts have increased since these targets were set in April/ May and this has led to an increase in the

number of new patients being seen per month.

Figure 2. total contacts per month

Demand

The Southwark service receives and average of 60 referrals per month, whilst Lambeth team receive an average of

66 new referrals per month.

Capacity

Currently staff are delivering initial assessments to an average of 9 new patients per month per 1.0 wte, alongside

delivering 1-1 therapeutic intervention packages for existing patients and newly assessed patients.

47

Southwark Capacity

3.8 wte staff deliver 9 new patients per month ( this takes into account actual clinical capacity after annual leave/

training etc.) 9 x 3.8 wte = 34 new patients per month. This leaves a deficit of 26 new patients per month.

Lambeth Capacity

4.6 wte staff deliver 9 new patients per month 9 x 4.6 wte = 41 new patients per month. This leaves a deficit of 25

patients per month.

Demand /Capacity Mismatch

There is a significant demand / capacity mismatch and patients are breeching 18 week referral times and 3 week falls

standards. Approximately 1500 referrals a year with a capacity to see about 800.

In Southwark only 57 % of new referrals can be seen creating a constant queue for the service of the remaining 43%

of accepted new patient referrals per month. In Lambeth 60% of New patient referrals are seen with existing

capacity with 40% in the queue.

Figure 3: graph to show demand capacity mismatch and area under graph of unmet need.

Proposal to improve patient flow and resolve demand /capacity mismatch

It is proposed that the service continues the lean transformation work to realise efficiency to release more clinical

capacity and increase the number of new patients seen per month to a minimum of 10 per 1.0 wte.

This would mean that the service would require an additional 4.7 wte staff across the two teams to reduce the

waiting times and have more of an admission avoidance /preventative impact and to deliver health promotion

outcomes for clients referred.

In addition, mobile working is being rolled out and it is hoped this would enable each wte to stretch their targets to

see 12 new patients per month, limiting the additional requirement to approximately 4.0 wte , which is

incorporated into the business case.

This would reduce maximum waiting times to 3 weeks and achieve accepted standards preventing deterioration,

referrals to @home/ERR and avoidable admissions to hospital.

48

8 Appendix 3 – Health questionnaire used with clients

EuroQol Group EQ-5D

Under each heading, please tick the ONE box that best describes your health TODAY.

MOBILITY

I have no problems in walking about

I have slight problems in walking about

I have moderate problems in walking about

I have severe problems in walking about

I am unable to walk about

SELF-CARE

I have no problems washing or dressing myself

I have slight problems washing or dressing myself

I have moderate problems washing or dressing myself

I have severe problems washing or dressing myself

I am unable to wash or dress myself

USUAL ACTIVITIES (e.g. work, study, housework, family or leisure

activities)

I have no problems doing my usual activities

I have slight problems doing my usual activities

I have moderate problems doing my usual activities

I have severe problems doing my usual activities

I am unable to do my usual activities

PAIN / DISCOMFORT

I have no pain or discomfort

I have slight pain or discomfort

I have moderate pain or discomfort

I have severe pain or discomfort

I have extreme pain or discomfort

ANXIETY / DEPRESSION

The best health you can imagine

10

20

30

40

50

60

80

70

90

100

5

15

25

35

45

55

75

65

85

95

49

I am not anxious or depressed

I am slightly anxious or depressed

I am moderately anxious or depressed

I am severely anxious or depressed

I am extremely anxious or depressed

50

9 Appendix 4 – FES-I