• GlaxoSmithKline UK
• Joint Working
• Case studies
• NHS Nottingham City

The implementation of the Joint Working Project is being overseen by a dedicated Steering Group of NHS and pharmaceutical industry partners, including GSK. Project implementation involves developing and implementing a case finding tool, improving risk registers and implementing existing pathways and protocols.

The Challenge

Falls are a major cause of disability and the leading cause of mortality resulting from injury in people aged above 75 in the UK1. More than 400,000 older people in England attend A&E departments following a fall each year¹, and it is estimated that one older person dies approximately every 4-5 hours as a result of a fall in the UK².

Osteoporosis (a condition characterised by a reduction in bone mass and density) increases the risk of fracture when an older person falls. 1 in 3 women and 1 in 12 men over 50 are affected by osteoporosis, and 50% of women experience an osteoporotic fracture by the time they reach the age of 70³.

Locally, Nottingham has an increasingly ageing population, with nearly 12% of the population over the age of 65⁴. Nottingham has the highest number of admissions caused by a fall for those aged 65+ when compared to the rest of the East Midlands⁴ with an annual spend of around £6 million⁵.

Nottingham's City Central PBC Group identified the opportunity to improve local services and adopt a strategy of early identification and intervention, with the potential to reduce avoidable admissions and realise significant productivity and efficiency savings in line with QIPP.

The Objectives

	Quality	Innovation	Productivity	Prevention
1. To reduce overall secondary care utilisation for falls and osteoporosis.
2. To identify patients who have experienced a fall, and ensure they receive appropriate assessment and support / clinical management to reduce the risk of further falls and / or fractures
3. To identify patients within primary care who have developed or are at risk of developing osteoporosis and develop detailed management plans.

The Solution

To address this challenge, a Joint Working Agreement has been initiated between NHS Nottingham City and three pharmaceutical companies: GlaxoSmithKline UK, ProStrakan Ltd and Shire Pharmaceuticals. The original financial budget for the project was £60k, split 50:50 between the NHS and pharmaceutical industry. The NHS has since increased their contribution by 18k to fund additional support for the project. This financial investment is in addition to the skills, resources and commitment each member brings to the group.

A Steering Group has been set up for the project, with representatives from the participating pharmaceutical companies, NHS Nottingham City, Nottingham University Hospitals Trust and Nottingham Citihealth.

The Approach

It was recognised early on in the project development that service improvement was needed to move from a reactive to proactive service model. However, although a risk register was in place across the city for patients who had experienced a fall, the number of patients on the list was significantly lower than predicted values, and there was no osteoporosis risk register in place. Therefore up to date and accurate data on the scale of the problem was not available to inform commissioning decisions on care pathways and management approaches.

As a result, the project was split into three phases: understanding the scale of the problem, identification and implementation of solutions and project evaluation.

Phase 1 – Understanding the problem (completed)

• Expertise was commissioned from Oberoi Consulting to conduct detailed searches of clinical systems throughout the pilot cluster to identify patients at risk of Osteoporosis and/or a future fall and develop detailed risk registers.
• The resulting data has been analysed and interpreted to intimately understand the scale of the problem and inform commissioning decisions.

Phase 2 – Solution identification and Implementation (in progress)

• An osteoporosis falls and fracture prevention nurse has been commissioned from the local falls service to work with each pilot practice through a mentorship scheme to review those patients identified on the new risk registers who have 2+ risk factors. This will ensure that these patients are managed in line with current clinical guidelines, receive appropriate assessments and interventions and access the right support services. This approach will ensure that a legacy is left behind with healthcare professionals having the necessary tools and skills to appropriately manage falls and osteoporosis patients.
• Review of local care pathways and services has taken place in parallel to check the right services are in place, that patients move through the care pathway in a logical flow, and that there is sufficient capacity in the system.
• The project has been launched to pilot practices through an initial engagement event where practices received detailed patient lists and were briefed on the improved care pathway and treatment algorithm. Practices also received training on conducting database searches, using the new recording template and clinical skills relevant to falls/osteoporosis. Time was built in for healthcare professionals to ask questions, feed in suggestions, and reflect on how they would embed the new management approach.
• A needs assessment is on-going to identify additional support and education required to enable primary care to manage the patients identified by the audit and ensure they are accessing services appropriately and optimally.

Phase 3 – Project Evaluation (planned)

• On completion, a full evaluation of the project will be undertaken.
• If successful, the project will be rolled out across the entire PCT (separate to this project) and communicated nationally within the NHS and industry to share best practice.

Key Performance Indicators

• Review of ≥ 90% of patients identified in the audit within the duration of the project.
• Increased adherence to the patient pathway and treatment algorithm.
• Improvement in data quality and recording.
• Reduction in overall secondary care utilisation for falls and osteoporosis.