Case Study 6: NHS Leeds South & East – Proactive Falls Prevention in Primary Care

In a nutshell: Older people presenting with one of the frailty syndromes (such as falls or immobility) may already have established frailty. Frail older adults are more likely to fall than those who are not frail. NHS Leeds South & East CCG is exploring the role of primary care in falls prevention and in reducing hip fracture incidence by using the eFI to identify people with moderate frailty, offering these people proactive falls screening, medication review and falls prevention health promotion interventions.

As part of the Hip Fracture Improvement Programme with Leeds Institute for Quality Healthcare*, a multidisciplinary team passionate about reducing falls have undertaken an improvement project at Oulton Medical Centre within NHS Leeds South & East CCG. The project involved using the electronic Frailty Index (eFI) to identify patients with whom to explore the role of primary care in proactive falls prevention. In a practice size of 13, 500 patients, a population level eFI report showed more than 50% of patients had mild, moderate or severe frailty (n=7825 patients). The eFI was used to identify people at risk of falling on the basis of a frailty diagnosis; a cohort of patients with an eFI score of 0.25 - the lower end of the moderate frailty category - was selected. This group was chosen as the vast majority live independently yet have significant risk factors for falls – therefore, prevention is key in this group.


At the practice, 97 patients had an eFI score of 0.25. For the project, a random sample of 49 patients with an eFI of 0.25 (moderate frailty) were selected – patients were asked to complete a falls questionnaire over the phone, medicine information was collected from their electronic health record (EHR) manually and healthcare activity analysed. The data highlighted little documentation in the patients’ GP medical record about falls - only 15% had a fall recorded in their EHR but 60%  patients reported a fall or stumble in the past 12 months during the telephone questionnaire. Many patients presented with polypharmacy (between 4-24 medications; average number 9); many were on medications which can increase the risk of falling (i.e. 22 patients were on anti-hypertension medication). No patients had a lying/standing blood pressure (BP) documented in their electronic records. Sixteen patients had attended A&E in the previous 12 months.

Figure 1: Flow chart demonstrating project process 

Phase two of the project involved inviting a small number of patients (n=20 invited; n=9 accepted) from the study cohort to the practice for a lying and standing blood pressure measurement, a GP led mini medication review, health promotion related to falls prevention, and/or onward referral to Falls Clinic/Community Services/Voluntary Sector/Social Care as required. Of patients attending the workshop 44% had evidence of a significant lying/standing BP drop when assessed and 78% required interventions to reduce their falls risk - such as medication changes, or referrals to secondary care (see figure 2). 

Figure 2: Falls action plan interventions

Next Steps

The results are promising and highlight primary care has a role to play in offering proactive falls prevention for patients with moderate frailty, particularly those who report falls or near misses the previous 12 months. Learning from the initial plan-do-study-act cycle (PDSA) highlighted trawling through the notes to be time consuming; but the actual medication review process was not resource intensive, especially when undertaken as a team. Another useful insight was self-reported falls/near misses in the last 12 months appeared to be a more sensitive means of identifying those likely to benefit from a falls prevention intervention than searching the EHR for falls history information.

 To build on the findings from the initial PDSA, the falls prevention intervention has been adapted and a further PDSA is planned. The second PDSA may involve the STOPP protocol developed for SystmOne by a GP and Healthy Ageing Collaborative partner (based on the original STOPP/START criteria by O’Mahoney et al, 2014) - a decision support tool to help reduce inappropriate prescribing in older people. It is hoped the findings from the PDSA cycles will aid the understanding of what a sustainable proactive primary care falls prevention intervention looks like. Ultimately, it is hoped the work will inform a Local Enhanced Service supported by Leeds South & East CCG which will enable scale up of such an intervention across all GP Practices within the CCG.

The overall aim of the programme is:

Outcomes being used to measure impact include:

*Leeds Institute for Quality Healthcare (LIQH) is a partnership between all the NHS Trusts and commissioners in Leeds, the City Council and the University of Leeds via CIHM. This project is preliminary work within the wider LIQH Hip Fracture Improvement Programme. More data is expected and this will inform the conclusions further – at this time, the plan is to present the work at academic forums to establish the next steps for the project and wider programme.

Contact: Freeman Lesley, GP at Oulton Medical Centre, NHS LEEDS SOUTH AND EAST CCG)