Steve Parry

Creative Commissioning: The North
Tyneside Falls Prevention Service
Dr Steve W Parry, Clinical Lead, North Tyneside Falls Prevention Service and
Senior Lecturer, Institute for Ageing and Health, Newcastle University

The North Tyneside Falls Prevention
Service
• Multi-agency falls prevention service
• Local gaps in service provision
• Idea to fill the gap
– Enhance case finding
– Preventive service provision
• Involvement of key stakeholders to further the vision
• Commissioning perspective and involvement
• Service delivery, evaluation and justification

• Falls and blackouts
Overview
– Common and overlapping
• 35-60% of over 65 years
– A Fib 1%; Heart failure 5%
• 10% suffer fractures
– Expensive
• >£4 billion per annum
– Devastating
• Personal, carer, health economic effects

NICE guidance on falls 2004
“ All health professionals coming into contact with older
patients should ask whether they have fallen in the last year”
“Refer for specialist assessment if 2 or more falls”
Chapter 8 CHD NSF Quality
Requirements:
“Service improvements locally via…improving access to
a higher level of expertise by the development of
multi-disciplinary arrhythmia and/or blackout clinics”
“People presenting with arrhythmias, in both emergency
and elective settings, receive timely assessment by
an appropriate clinician to ensure accurate diagnosis
and and effective treatment and rehabilitation”

The North Tyneside context…..
• 192,000 patients
– 44,160 >60 years
– 15,900 >75 years
• Lower prevalence estimate of 35%
– 15,500 fallers
• Approx 1500 seen by existing services
• Seen late in falls and blackouts “career”
– (14,000 not being seen at all)
• >60 years to rise from 23% to 32% in next decade
• Good evidence base to show that MDT approach is
both clinically and health economically effective

• Get your facts straight
Tip #1
– Help your commissioners to “see the light”
– Show why your service is needed within the local
context
– Don’t shroud wave
– Don’t over-egg the pudding; present the facts
without spin – its always obvious
– Understand that your commissioning team also
want to promote good healthcare
– Make extrapolations explicit and sensible
– Cost savings estimates rarely do as they say they
will – be realistic

Tip #2
• Get the right team around the table BEFORE you
tackle commissioning issues
– Newcastle Hospitals Foundation Trust
– Private primary care provider (Norprime)
– Age UK
– Newcastle University
– North of Tyne PCT
– North Tyneside Social Services
– North East Ambulance Service

Targeted specialist falls and blackouts
assessment in community setting
• Senior physiotherapy assessment and treatment
• HCA review
• ECG, lying and standing blood pressure
• Depression scale, MMSE, falls and balance confidence scale,
visual acuity
• Medical assessment
• History, examination, bone health risk assessment
• Review of findings, education, counselling
• Recommendations to primary care
• Referrals to 2ry care, Age UK strength and balance
training classes, social services
• Individualised care plan

Tip #3
• Ensure service users are represented in the
development of your service plan
• Ensure appropriate partnership in terms of service
provision
– Age UK key partner
– Service design and development
– Novel service provision using existing
infrastructure and organisation
• Targeted strength and balance training classes

Tip #4
• Destructive innovation and serendipitous planning
• Aka pick your moment and don’t be afraid to escalate
given the opportunity
– Partnerships in place
– Service model developed
– Commissioning team interested and going through
usual channels
– Opportunity to present to PCT Executive
• Rapid escalation to service provision

What can be accomplished:
The first 2 years.....New diagnoses
• 2554 patients seen in the first 2 years of operation
• 985 (40%) ADDITIONAL DIAGNOSES
– Diagnoses making a difference to falls and syncope
risks or relevant to national guidance and targets (eg
early identification of cognitive impairment)
– NOT existing diagnosis
• 986 (39%) gait and balance abnormalities
– All given home exercises
– Additional physio advice, day hospital, community
physio
– 25% referred for Age UK strength and balance training
classes

Others of note......
Atrial fibrillation 26
Stroke, cerebellar syndrome 16
New murmurs 43
Benign positional paroxysmal vertigo 70
Orthostatic hypotension 92
Permanent pacemaker referral 17
Further 35 with significant, possibly culpable brady 35
Parkinsonism, newly diagnosed 8
Vasovagal syncope 75
Significant depression per GDS score 73
Significant cognitive impairment per MMSE

• Osteoporosis
– All undergo FRAX
The first two years....
– 31 high risk “recommend treatment”
– 145/1560 (9.1%) referred for DEXA, 1/3 treated
• 693 with falls efficacy scale score >23
• Ongoing £840k NIHR HTA funded RCT of cognitive
behavioural therapy for this patients
• Independent data from DH evaluation of patient
satisfaction (3.8/4 overall)

The first 2 years....referral patterns
• 25% to Age UK for strength and balance training
classes – part of pathway rather than “referral”
• 25% suggest see GP for meds modification, review of
new Afib, cognitive impairment, depression etc
• 10.5% referred for secondary care review
– Cardiology, falls and syncope, day hospital, ENT

Tip #5
• Ongoing service evaluation and reporting to those
commissioning
– Make your evaluation relevant to the local health
economy
– Refer to local, regional and national priorities and
guidelines
– Without this, you are doomed……

•No changes to services
apart from N Tyne Falls
Prevention Service
•North Tyneside population
over 60:
•40,572
•Newcastle population over
60
•46,670
Difference in 2010-11
of 51 hip fractures
Average tariff of
£10,000
£510,000 saved
Note 30% mortality
rate
25% res/NH care
330
320
310
300
290
280
270
260
250
Fracture Neck of Femur
2008-09 2009-10 2010-11
North Tyneside Newcastle

NOF %
15
10
5
0
-5
-10
Year on year change in FNOF rates
2009-10 2010-11
Newcastle 3.21 11.42
North Tyneside -6.27 2.46

Non-elective admissions: N Tyne Falls Prevention Service
Patients versus Cramlington Control Group
Rate free from fall related hospital ad
0.90 0.92 0.94 0.96 0.98 1.00
Control group
Intervention group
420 day Kaplan-Meier surv
0 100 200 300 400
Days

Non-elective admissions: N Tyne Falls Prevention
Service Patients versus Cramlington Control Group
• N Tyne Falls Prevention Service
– 741 non-elective admissions per 10,000 population
• Cramlington Control Practice
– 768 non-elective admissions per 10,000 population
– 27 non-elective admissions saved @ £5,000 ie
£135,000
• For North Tyneside with 40,000 >65s: £540,000
• For whole of NoT with 160,000 >65s: £2,160,000
• 50% reduction in mortality for those seen by Service v
not seen after A&E admission p=0.0000007

So...getting your service commissioned…an
approach….
• Evidence-based approach based on national and
international guidance and best practice
• Informed by local and regional priorities
• Partnership approach
• Multi-agency, multidisciplinary
• Coherent case, with qualitative, quantitative and
health economic dimensions
• Measurable, reportable, sustainable in the longer
term
• Importance of third sector and other partners in
informing service design and providing service
delivery

…and what can be achieved….
• Service that all partners can take credit for
• Clear benefits to patients previously not seen by
services
– Significant additional diagnoses with further quality
and cost implications
– Case finding for atrial fibrillation, osteoporosis,
dementia, depression, recurrent syncope
– 25% strength and balance training classes with
enormous benefits
– Less tangible public health dimension
• Smoking, weight loss, alcohol intake, exercise

…and what can be achieved….
• Clear early evidence of reduction in fall related
hospital admissions
• Clear early evidence of reduction in hip fracture
• Further data awaited (other fragility fractures,
syncope, A&E data)
• Tangible initial cost savings conservatively estimated
at £645,000 (annual cost to PCT £280k)

• Pilot versus permanent
Problems and pitfalls
– Runner up in BMJ Innovation Awards
– DH Integrated Care pilot winner
– Superb results, 3600 seen in 3 years
– Still not permanently commissioned
• A little too novel, commissioning climate state
of flux, pilot schemes more common
• Destructive innovation and serendipitous planning
– Private primary care provider
– Deep dislike from some of “usual route” team
– Keep all onside

Hazel’s tale....post Age UK classes
“I don’t use the walking sticks at all in the house now,
and use them much less outside as well. It’s easier
to get in the shower above the bath, and up and
down the back step. Because I’m not holding the
sticks any more I can reach things, cook and clean
more easily – it’s great to be able to do these myself .
I’m also finding it easier to use public transport again,
instead of always needing to get a taxi.”