A Highland GP on life the universe and anything…

I have recently taken on the role of representing our local practices on the GP Sub-committee of the Area Medical Committee. Having previously helped NHS Highland on mental health projects I, somewhat hesitantly, agreed to represent the committee in designing a pathway to prevent falls in the elderly as part of the new quality and outcome (QoF) process for 2011-12. Previously I had found the process of working with NHS Highland colleagues rewarding and stimulating, even if it was hard to find concrete evidence that the work had resulted in real improvements in the care patients received and funding for GP time was always hard to secure and had a habit of evaporating with little or no notice! I was also inquisitive to be involved having found myself on the “Quality” subgroup of a project by the Royal College of General Practitioners “ The Future of General Practice in Scotland: A Vision”. One of my key beliefs is that good patient care needs to be: – focused on the patients needs, supported by excellent inter-professional communication and based on clearly defined professional roles. This project seemed to meet those criteria.

Preventing falls was chosen by NHS Scotland as a national pathway with a view to reducing emergency admissions. It was for the local Health Board and Local Medical Committee to agree and design the pathways and use new QoF criteria to motivate change. This pathway would be used by practices when undertaking retrospective reviews of the care received by patients who had fallen. I met with two Allied Health Professional (AHP) colleagues to discuss the way forward.

It was not and easy meeting. Proposals to ask every patient over 75 about their falls history and assess their gait seemed completely unrealistic in a routine GP consultation. Undertaking other falls screening and risk assessments were even less likely to be accepted. Capacity for others to undertake this work in the primary care team was equally unrealistic in the present climate of cuts and staff recruitment freezes. We then shifted our attention to what GPs will actually be asked to do and it became clear it was more a significant event audit (SEA) of patient who had fallen, identified as people >75years with a fractured hip or wrist. I proposed a series of stages: –

Proposed review template

What happened?
Describe what happened in relation to the individual patient admissions.

  1. What did you know of the patient’s circumstances before the fall?
  2. How did the fall occur?
  3. Describe the subsequent path to recovery
Could the falls risk be reduced?
  1. Have adequate secondary prevention measures been taken since the fall to reduce the risk of recurrence?
  2. Were there opportunities to identify that patient as being at risk of falls prior to the injury and did it lead to an appropriate multi-disciplinary prevention assessment?
  3. Is there evidence of general lifestyle advice having been offered to that patient prior to the fall that might have lessened the risk of falls?
What have you learned?
What reflection / learning has taken place on an individual or team basis? Consider, for example: – Awareness and knowledgeThe need to follow systems or procedures

Team working and effective communication

What have you changed?
What actions have been agreed / implemented to reduce the risk of falls? Consider, for example, if a protocol has been amended, updated or introduced; how this was done and who was involved; how the change will be monitored.

This is clearly not a pathway and it was clear that the pathway would be more a reflection of the services and roles of professionals in their approach to falls prevention. This will be presented as a single side of A4 covering recognition of risk, assessment, management, referral and secondary prevention.

Reducing Emergency Admissions Pathway for Falls (2)[1]

Outcomes

I hope the guidance produced, despite being rushed, reflects best practice in a useable way.

I am hopeful that the process will  encourage all of us to be more proactive in falls prevention with an increased knowledge of the evidence.

Furthermore there is an opportunity to further develop the service, improving communication and clarifying roles to the patients benefit.

Conclusions

I have found the process intriguing but also frustration. I have had to quickly get up to speed with the subject but there is still I would like to know: –

  • I am unclear of the evidence for primary prevention, all the studies I have found so far relate to people who have already fallen. This group seems to be easiest to identify and where the most cost effective health care gains can be made.
  • We should ensure our interventions are evidence based e.g. NICE counsels against advising those at risk to exercise without supervision as, not unexpectedly, this led to more falls.
  • Will this be supported by a robust public health message? GPs are surely only a small part of the solution.
  • Likewise, will our hospital colleagues work with us to assess and treat those who have fallen and communicate that assessment to us to avoid omissions or duplications?
  • There appears to be interest in setting up a freestanding falls prevention service. Is this the correct model or should it be undertaken by existing services, ensuring workload does not swamp capacity?
  • In future will there be opportunities for the patient experience and preferences to be included?

Overall I am gratified that the focus of QoF is shifting to processes of review and reflection and away from the cold collection of empirical data. It has also increased my admiration for my non-medical colleagues skill and dedication in this area.

8.10.2011 A Recent letter in the BMJ (BMJ 2011;343:d6320) adds to the doubt about the advisability of screening for falls on cost effectiveness grounds. MM

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