What are the real costs of falls and fractures?

Comments: 3

Falls and fall-related injuries are a major challenge to health and care systems and to the older people who suffer them. Around one in three people over 65 and one in two people over 80 fall at least once each year. Falls account for around 40 per cent of all ambulance call-outs to the homes of people over 65 and are a leading cause of older people’s use of hospital beds. Each year there are around twice as many fractures resulting from falls as there are strokes in the over 65s.

In addition to broken bones, falls may lead to prolonged lies on the floor, with resulting complications, and they are a common precipitant for people moving into long-term care, or needing more help at home.

When I was National Clinical Director for Older People’s Services at NHS England, I co-led a national programme of work on falls and bone health that attempted to speed up progress in this area, with bodies such as Age UK, the National Osteoporosis Society and the British Geriatrics Society creating real momentum. But despite NICE guidelines on the prevention of falls and fractures, we still have a long way to go to get services right and embed approaches across local government, primary care and community services. There has been a sea change in the management of older people with hip fractures – a success story noticed in many international health systems. But national clinical audits, self-report data from the English Longitudinal Study of Ageing and research on care quality indicators in general practice have shown that even basic assessments of treatment for secondary prevention are inconsistently applied.

We have probably made a mistake by ‘silo-ing’ services into specialist secondary clinics and community falls teams. The sheer scale of the problem suggests that primary and community services must take the lead – especially for those not admitted to hospital. Falls prevention and better bone health also need to feature more highly in health and wellbeing strategies. 

We are also bedevilled by a lack of joined-up data on costs of falls across health and social care systems. We know that the Payment by Results (PbR) costs of hip fracture alone (more than £2 billion) account for a large chunk of the NHS budget. But what about other direct and indirect costs associated with falls and fractures? And how can we disentangle these from the costs of the multiple morbidities people who fall often live with?

In August, The King’s Fund published an innovative paper on the system-wide costs of falls in older people in Torbay. This was made possible by Torbay’s established use of linked health and social care data sets.

The Torbay analysis tracked costs for 12 months before and after falls leading to hospital admission. Costs were 70 per cent higher in the 12 months after admission; community health costs increased by 160 per cent and hospital and social care costs by one third. As a fall-related admission is often a marker of deteriorating health, this is perhaps unsurprising. However, even though only 1 per cent of over 65s in Torbay were admitted with falls, 4 per cent of all costs went on this group – getting their care right has to be ‘core business’.

The ability to use linked data and therefore ‘track value’ across systems and services should surely be made mainstream and used to help deliver integrated care. Currently, incompatible IT systems and a failure to balance the benefits of information sharing for patient care with concerns about data protection have prevented this. But if Torbay had the vision and courage to push the envelope – why are so few other health economies doing the same?

Torbay’s data also highlights the fact that clinical coding for acute hospital activity often doesn’t reflect the real case-mix. For instance, ‘UTI’ – urinary tract infection – is a frequent code for older people but generally reflects underlying frailty, with the UTI leading to a fall, acute confusion or immobility. Frailty syndrome (behind many falls, acute admissions and bed days in older people) is not routinely coded in clinical data at all – that in turn means we can’t routinely screen for it as part of risk stratification or case finding. Injuries are often coded without always coding the fall and falls risk factors which caused them. Falls, frailty and bone fragility are long-term conditions par excellence, but are often unmentioned in long-term condition plans or strategies.

The Torbay analysis has taken us a step further forward in understanding the impact of falls on service utilisation. But as we can’t readily disentangle costs attributable directly to the fall from those associated with the person’s underlying co-morbidities, perhaps we should attempt instead to track costs for all older people with complex needs using multiple services – reinforcing the need for integrated service provision – with data sharing as a key enabler.

Comments

#40814 Mitzi Blennerhassett
medical writer/author
Trustee Director, Rarer Cancers Forum

At 73 with osteoporosis diagnosed 3 years earlier, I felt something 'go' in my back as I bent and twisted to reach a low light switch. Then as I attempted to turn over in bed my back went into excruciating spasm. The GP examined me and pronounced 'probable muscular problem'. It took 4 months before offered x-rays and fractures diagnosed. The GP had ordered thoraco-lumbar x-ray, which was reported as fracture T11 Lumbar spine, resulting in 2nd x-ray to show full thoracic spine - with unnecessary radiation where x-rays overlapped. The hospital trust say, if GP had ordered separate thoracic and lumbar x-rays this unnecessary double radiation would not have occurred (I wonder how many GPs understand that) - and that there was only one fracture, the second being a case of miscounting...yet my GP had sketched precisely where the fractures had occurred in different parts of the two vertebrae reported. It took about 6 months to get adequate pain relief and I live alone, so I'd had to lift wood and coal for the fire. Access to my health records showed a significant number of errors or misunderstandings about the content of consultations, including my place of birth.

#40815 david oliver
consultant physician/visiting fellow
royal berks/kings fund

Dear Mitzi

I do want to answer your comments about your vertebral fractures and if you email me personally via the fund i will chat to you. I am curious about one thing though. I worked with a superb, professional, dedicated Occupational Therapist of the same surname as you (Hayley). I couldn't speak highly enough of her and i was just wondering if you were any relation?

David

#40833 Chris Edgerton

Hay, not just fractures!!
Simple fall? Skin tear, OH district nurse call out on a number of occasions. OH NO infection; call doctor of antibiotics. Is drug regime looked at, drugs? Not just antipsychotics but other drugs which also have psychomotor issues. NO, falls because of the person’s dementia, esidential care home can manage. OH NO another fall; skin tear … district nurse call out …OH NO infection; doctor cal out, more antibiotics, iodine bandage, regular district nurse visits to Warwickshire dementia care home. Care home manager …WE manage. Doctor … care home do a good job.
… another fall … … …

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