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Stepping Forward Together – Co-production for Falls Prevention in Aberdeen

Introduction

As people grow older, their strength and balance often deteriorates which can result in reduced mobility and subsequently lead to an increased risk of falling. It is crucial that older people are aware of ways in which they can manage their falls risk, who they should talk to if they have had, or are worried about having a fall and the importance of strength and balance exercises to improve their stability in later life.  Falls prevention is therefore an important way to improve the quality of life for older and less mobile people.

A group of staff from the Health and Social Care Partnership in Aberdeen, in collaboration with service users and third sector partners developed ‘Stepping Forward Together’ during a series of Co-Production Labs as part of the Governance International Co-Production Star Training Programme. In this innovative co-production initiative health professionals work with voluntary ‘Falls Ambassadors’ to visit communities and support behaviour change through self-management.

Find out why co-production with ‘experts by experience’ has made a difference. We now aim to widen and deepen this co-production initiative so we’re eager to learn from other co-production champions enabling behaviour change.

 

Objectives

This project aims to make falls prevention more effective by enabling self-management and supporting behaviour change on the part of people at risk in the city of Aberdeen. In particular, the project seeks both to increase people’s awareness and also to trigger sustainable behaviour change. In terms of awareness raising, we especially want people to be much clearer about what they can personally do to prevent a fall. In addition, we want them to be confident that, if they have a fall, they would know who to go to for an assessment and rehabilitation.

The behaviour change objectives are two-fold – first, that people will make changes to their lifestyle – or at least the way they go about daily activities around the house and in their neighbourhood – so that they are less likely to experience a fall. Second, that if they do experience a fall, they will be able to take positive actions toward recovery.

Change management

We know falls have a huge psychological and physical impact on people’s lives. As well as the pain and decreased mobility they cause directly, they often also lead to increased care needs and social isolation. In the two years up to March 2019, the total number of hospital admissions related to falls across the region of Grampian, in which Aberdeen is located, was 7838.The cost of falls has been estimated at over £470 million a year or £1.3 million a day in Scotland and is set to rise to £666 million by 2020 (Craig et al. 2013).

During 2018, workshops delivered by Governance International familiarised staff of Aberdeen City Health and Social Care Partnership with the Co-production Star toolkit (see http://www.govint.org/our-services/co-production), which provided an overall framework and a step-by-step process for the project, providing examples of co-production from across the UK and internationally, and encouraging us to build on local community engagement.

Four locality based co-production projects were developed and in the North Locality of Aberdeen the project chosen was Falls Prevention. The first step was to listen to people’s experiences and stories, so an eclectic group of service users came together with representatives from the public and third sector to co-design a project that continues to gather pace.

Discussion with service users highlighted the lack of easily accessible information about falls prevention and self-management approaches. Listening to the stories of people living in the community who had fallen and tried to find help, was a powerful experience and led to discussion about how we could make improvements.

These conversations resulted in the co-design of a falls prevention session for people at risk of falls. The suggestions of service users made us aware that we had to go to the places where older people naturally meet - for example, in friendship groups, coffee clubs and lunch clubs - rather than expecting them to come to hospitals or clinics, which was convenient for us but not necessarily for them.

Moreover the co-design process led to thinking about co-delivery, as well, in which service users who had previously experienced a fall would deliver part of the session. This sparked the idea of ‘Falls Ambassadors’, people who had used falls services in the past and who were now willing to play a co-delivery role in supporting others to prevent falls in the future.

The co-production team comprises staff from Occupational Therapy and Public Health, service users, members of the community and staff from third sector organisations. This group has named itself Stepping Forward Together.

We now aim to recruit further Falls Ambassadors from a wide range of groups in the community, so that these groups can benefit from the Stepping Forward Together Sessions – these new groups in turn will then keep the work going by identifying other groups in the community and running similar sessions. They will be supported in their role via a Falls Ambassadors support group and by public sector staff linked to the project.

A successful bid was made for Health Improvement Funding to develop a model to scale Stepping Forward Together. This resource has enabled the use of students from a local University to design a video, which the Falls Ambassadors use as a teaching tool to support the spread of this work. The students also developed a website and a Facebook page and created promotional materials supporting recruitment of more Falls Ambassadors.

Leadership and change management

Both at national and local level there is a focus on prevention, anticipation and supported self-management, the vision being one of a significant culture change in how people access and receive support. There is a clear emphasis on living active and independent lives and participation in local communities.

Co–production is important to the Scottish Government’s health and social care policy as outlined by Sir Harry Burns (former Chief Medical Officer for Scotland) - “Conventional approaches disempower people, failing to recognise that service users have assets which can contribute to solutions. Conventional approaches preserve dependency, … co-production has the potential to transform the way public services are delivered...”. A co-production approach to service redesign has therefore been encouraged at a local level and is consequently included in Aberdeen City Health and Social Care Partnership’s strategic plan. The commissioning of the Governance International Co-production Star Training Programme was part of the action taken to put this strategy into practice.

Within Stepping Forward Together, leadership is shared among group members, depending on their skills and interests.Everyone plays an equal part in the project and this releases a stream of rich and diverse ideas. As a result there is endless scope to do things differently. One Ambassador has started a “Conversation Table” in the cafe at the Music Hall in Aberdeen. She talks about falls prevention to members of the public who are interested.

The change management has evolved over time. Initially, the intention was to trigger awareness of the need for behavioural change among people who were unlikely to refer themselves to the exercise classes offered by the Partnership. Working with the ‘Falls Ambassadors’ made us realise that not everybody wishes to attend public strength and balance exercise classes - some people much prefer to exercise at home. It is therefore important that the ‘Stepping Forward Together’ sessions encourage people to undertake exercises at home. Further to this we have recently tested a “short course” of three falls awareness sessions in collaboration with the Aberdeen Library Service which has required local people to sign up at the library to attend. This has resulted in the group starting their own exercise group at the library with support from a Falls Ambassador and is due to start in the New Year. Ultimately, our co-production initiative has created a new service offer – support for self-management – which complements the traditional ‘strength and balance’ exercise classes offered to older people in Aberdeen.

Obstacles

The project met a number of obstacles, most of which have now been (at least partly) overcome:

  • We needed to find a way to host the volunteers, so that they could be provided with the necessary insurance and governance. In the long term we see this project being hosted by a 3rd sector organisation. However, in the interim we found a solution by placing them as volunteers with NHS Grampian.
  • The project has benefited from small short-term pockets of funding. However, in the longer term it will require investment if it is to be sustained or scaled up. The group is currently exploring different options to make it sustainable, while maintaining a co-production approach.
  • The systems within the public sector inhibit the use of social media but we have recognised that this is key to reaching people in the world we currently live in. We are currently researching ways of tackling this.

Outcomes

Stepping Forward Together has gathered qualitative feedback from participants in the 15 groups in the community which have so far been visited. This feedback has told us that participants are making significant changes to their lifestyle and environment, are more carefully considering the tasks they perform and are reducing multi-tasking.

Moreover, a number of participants have expressed a wish to set up their own local exercise groups or start attending local exercise groups.

Performance indicators

Stepping Forward Together has visited over 15 groups in the community, working with over 240 individual participants to date, with bookings now stretching several months ahead.  Baseline and post-session data were collected, using questionnaires. This data indicated that 100% of attendees found the session useful or very useful. There was a 44% increase in respondents reporting knowledge about falls prevention after the session and there was a 13% increase in those doing strength and balance exercises.

Costs and savings

So far there has been no cost-benefit analysis of the ‘Stepping Forward Together’ initiative. However, according to our model of change, we expect a significant reduction of costs to the public sector through four pathways of change:

  1. Falls Prevention: The Falls Ambassadors are all volunteers who are visiting groups to increase awareness of falls prevention and self-management. This is something that is difficult for stretched public sector services to achieve in the current financial climate. However, it is firmly on the agenda of the Scottish Government.
  2. Falls Reduction: People attending the groups visited by Stepping Forward Together are often at risk of experiencing a fall but can be ‘hard to reach’ by health professionals. In this way, the ‘Falls Ambassadors’ enable us to target support to those who need it and have not been referred to formal services. In the long term we envisage that the approach of Stepping Forward Together will, in collaboration with Public Sector Services lead to a reduction in falls. Traditionally, this type of work would have rested solely with health professionals and been paid for from the local health budget. In the current climate this is not viable. The work of the Falls Ambassadors therefore represents a substantial saving to the Health and Social Care Partnership.
  3. Improved health and well-being outcomes: The joint sessions co-delivered by the Falls Ambassadors and health professionals to do exercises at home have enabled people to undertake more self-management and even triggered the desire of local people to set up local exercise groups. It is expected that ‘Stepping Forward Together’ (as opposed to stepping forward alone!) will create other health and social benefits and bring increased well-being through reduced loneliness and isolation.
  4. Reduced demand for traditional ‘strength and balance’ exercise classes: The scaling of ‘Stepping Forward Together’ will mean a reallocation of resources towards more support for self-management. This may well reduce pressure on stretched public sector ‘strength and balance’ classes, which saves resources. Public sector classes are more expensive to run than informal falls prevention sessions in community settings. At a time when resources are limited these classes should be targeted at people who will benefit most from professional intervention in a group environment.  

This shows that ‘Stepping Forward Together’ has wider benefits than simply a reduction in falls. We’re in the process of building up an evidence base to demonstrate those wider benefits.

Lessons learnt and next steps

Using a co-production approach has been a worthwhile and valuable learning experience for all concerned. However, it does take time and investment if it is done correctly – this should not be overlooked by strategic planners and commissioners.

Service users having ownership and investment in the design and delivery of services they use leads to empowerment, which brings other benefits for those involved. Moreover, the Falls Ambassadors are championing the falls prevention cause, not only in the organised group sessions they are delivering but in all walks of their lives. This wider marketing of the important falls prevention issue is an added bonus from this co-production initiative.

The project continues to attract interest and infiltrate other key areas of health and social care. Recent developments include:

  • working with British Red Cross to test out an ‘ambassador’ approach in a local hospital;
  • delivering a short course on falls prevention within community libraries; and
  • sharing co-production experience locally, nationally and internationally.
About this case study
Main Contact

Janet Thompson
Senior Occupational Therapist
E-mail: jthompson3@nhs.net

Elaine McConnachie
Public Health Co-ordinator
E-mail: 
elaine.mcconnachie@nhs.net

This case study was written by Janet Thompson and Elaine McConnachie in December 2019.

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