Unintentional Injuries Across the Lifecourse

Executive Summary

Unintentional injury is one of the key areas identified as a responsibility for local authorities within the new framework for delivering public health. Many of the themes can be applied across the spectrum of public health and local authorities, such as strategies and policies for transport, planning and environment. Unintentional injuries present a significant public health issue for individuals and families – they can cause premature death or disability, are expensive in terms of cost to society and have a negative impact on economic growth. Most injuries are preventable: therefore approaches to challenging unintentional injury must be embedded within current practice, and involve a range of partners and organisations.

This chapter highlights the level of need in the population in relation to unintentional injuries across the life course, describing current provision of services and interventions aimed at preventing or reducing the impact of injuries. This chapter also identifies potential and understood gaps in the current delivery mechanism; and offers a set of recommendations.
Who is at risk and why?

Those at either end of the life course are most at risk of unintentional injuries; specifically those aged between 0-4 and those aged 65 and over. The causes of injury are diverse and risks vary with age and social status. The main causes of hospital admissions due to unintentional injury in children and young people are road traffic injury (pedestrian injury in particular), falls, poisoning, drowning and burns. Infants and toddlers are most at risk injuries in the home, while older children are most risk of road traffic injuries. People over 65 experience high rates of death and hospital admission due to injury, with falls being the leading cause.
The level of need in the population

In Surrey, unintentional injuries account for approximately 13% of all emergency admissions and 4.5% of all hospital admissions. Unintentional injuries and accidents are the leading cause of mortality among secondary school children (10-19 years), with the risk increasing as children get older. Falls are the largest cause of emergency hospital admissions for older people, and significantly impact on long term outcomes.
Services in relation to need

There are a range of services and interventions in place across Surrey that support a preventative approach, assess risk and/or work towards reducing the impact of unintentional injuries. These often involve a multi-agency response from a range of organisations such as children and family services, acute providers, the fire service, road safety teams and the police.
Unmet needs and service gaps

The JSNA chapter recognises that there are service development opportunities due to the complexity of the issue and the need for a holistic, multidisciplinary approach.
What works?

Available evidence suggests a number of recommendations to reduce the prevalence of unintentional injuries, which can be summarised as follows:

  • Environment: Improvement in planning and design results in safer homes and leisure areas
  • Education: Increasing the awareness of risk of injuries in a variety of settings and providing information on ways of minimising these risks
  • Empowerment: Injury prevention initiatives, which have been influenced by the community, are more likely to reflect local need and therefore encourage greater commitment
  • Enforcement: Legislation – for example, risk assessment of hazards to privately rented homes.

Recommendations for Commissioning

Unintentional injury is a complex safeguarding issue: therefore any response should be multi-disciplinary and holistic. The recommendations detailed in this chapter are intended to inform operational delivery of existing services in order to embed key messages and approaches to injury prevention, and offer a strategic approach to reducing the impact of unintentional injuries on individuals and their families.

Introduction

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Unintentional injury is a vast subject encompassing a wide range of issues. The National Institute for Health and Care Excellence (NICE) defines unintentional injuries as “injuries and their precipitating events [that] are predictable and preventable” (1). In England, between 2008 and 2010, there were 36,637 deaths due to unintentional injury with many more experiencing a serious injury (2).

The term “unintentional injury” is preferred to “accidents” as the latter implies events are inevitable and unavoidable whereas a high proportion of these incidents are now regarded as being preventable. Unintentional injuries can occur in any age group, but children and the elderly are more vulnerable.

Injuries are a leading cause of hospitalisation and represent a major cause of premature mortality for children and young people. They are also a source of long-term health issues, including mental health issues related to experience.

Unintentional injury is one of the key areas identified as a responsibility for local authorities within the new framework for delivering public health. Many of the themes can be applied across the spectrum of public health and local authorities, such as strategies and policies for transport, planning and environment. Local authorities have for many years worked to improve rates of unintentional injury, through delivery of national legislation and best practice, road and transport policy and regulations, home safety, safety at work, fire and product safety and through multi-agency safeguarding work focusing on vulnerable children and adults.

Impact of unintentional injury

Unintentional injuries can cause premature death or disability; are expensive in terms of cost to society and have a negative effect on economic growth. It is estimated that unintentional injury costs UK society £150 billion every year.

In Surrey, unintentional injuries account for approximately 13% of all emergency admissions and 4.5% of all hospital admissions (3). Most unintentional hospital admissions are for falls, followed by injuries on the roads. Smoke, fire and flames, drowning and poisoning injuries also result in admissions to hospital but are less common.

Falls are the largest cause of emergency hospital admissions for older people, and significantly impact on long term outcomes, e.g. being a major precipitant of people moving from their own home to long-term nursing or residential care [4].

As well as causing injury and pain, falls can reduce an individual’s confidence, increase isolation and reduce independence. For older people, a fall can hasten a move into residential care, for example, after a hip fracture, 50% of people can no longer live independently.

The after-effects of even the most minor fall can be significant for an older person’s physical and mental health. Fear of falling again, among older people and those who care for them, reduces quality of life and well-being, even if a fall does not result in serious consequences.

Falls that result in injury can be very serious – approximately 1 in 20 older people living in the community experience a fracture or need hospitalisation after a fall. Falls and fractures in those aged 65 and above account for over 4 million bed days per year in England alone, at an estimated cost of £2 billion [4].

There are significant differences between socio-economic groups in terms of numbers of unintentional injuries. For example, children whose parents have never worked (or are long-term unemployed) are 13 times more likely to die from an unintentional injury compared to children whose parents are in higher managerial or professional occupations (1).

As mentioned previously, the majority of unintentional injuries are preventable; therefore reducing these injuries has enormous benefits to individuals, their families and society as a whole. Approaches to challenging unintentional injury must include cross-sectoral and partnership working to reduce injuries across the life course, including child and adult safeguarding.

Who’s at risk and why?

Those at either end of the life course are most at risk of unintentional injuries; specifically those aged between 0-4 and those aged 65 and over.

The causes of injury are diverse and risks vary with age and social status. The main causes of hospital admissions due to unintentional injury in children and young people are road traffic injury (pedestrian injury in particular), falls, poisoning, drowning and burns. Infants and toddlers are most at risk of injuries in the home, while older children are most at risk of road traffic injuries (1).

People aged over 65 experience high rates of death and hospital admission due to injury, with falls being the leading cause.

Children and young people

Some children and young people are at greater than average risk of an unintentional injury due to one or more factors (1). Those at greater risk are summarised as follows:

  • Under the age of 5 years (generally, under 5s are more vulnerable to unintentional injury in the home)
  • Over the age of 11 (generally, over 11s are more vulnerable to unintentional injury on the road)
  • Those with a disability or impairment (physical or learning)
  • Some ethnic minority groups
  • Children living in families on a low income
  • Children who live in accommodation which potentially puts them more at risk, for example, this could include multiple-occupied housing and social and private rented housing.

As noted previously, there is a relationship between deprivation and unintentional injury. For example, research indicates that emergency hospital admission rates for unintentional injuries among the under-fives is 45% higher for children from the most deprived areas compared with children from the least deprived, with research indicating that for some injury types this inequality may be much larger (5).

This social gradient is particularly steep in relation to deaths caused by household fires, where children living in disadvantaged communities are 37 more times likely to die from exposure to smoke or flames (1). In addition, there is evidence to suggest that children in the 10% most deprived wards in England are four times more likely to be hit by a car than children in the 10% least deprived wards (5).

There is also data to suggest that rates of injury resulting in death among adolescents is higher when there are coexisting chronic conditions, for example unintentional injuries accounted for nearly 70% of deaths among 15 to 18 year olds with mental or behavioural problems (6)

Furthermore, there is also a gender differentiation, with boys being most at risk, making up 60% of hospital admissions (7).

Road traffic incidents

Those aged 60 and over constitute over a quarter of all car occupant casualties, and in 2015 are the only significant age group to have experienced an increase in those who are killed or seriously injured (KSI). 16 to 24 year olds constitute a fifth of all car occupant casualties (all severities), despite experiencing the greatest reduction (of 45 per cent) compared with the five year baseline average from 2005 to 2009*.

The “16 to 24” age group constitute about a third of all KSI and total motorcycle casualties (all severities). There were comparatively large percentage increases experienced by older age groups over 50 in 2015 when compared with previous years, but the total numbers of casualties in these age groups are smaller (about a fifth of KSI and total motorcycle casualties).

Falls

The highest risk of falls is in those aged 65 and above and it is estimated that about 30% people (2.5 million) aged 65 and above living at home and about 50% of people aged 80 and above living at home or in residential care will experience a fall episode at least once a year [4].

Studies have identified over 25 separate risk factors associated with falls, including pre-existing medical conditions, the effect of prescribed medication, environmental hazards, lack of physical activity, alcohol consumption and malnutrition (8). Thus, it is important to consider these factors whilst determining the causes of falls.

Furthermore, other vulnerable groups at particular risk of falls include those living in care homes or those with a diagnosis of dementia. Dehydration in older people has also been identified as an important but preventable risk factor of falls (8).
* Where appropriate, Surrey’s performance has been compared against the five-year baseline average from 2005-2009. This is the baseline set by the Government’s Strategic Framework for Road Safety published in 2011.

The level of need in the population

Children and young people

In England, unintentional injury is a leading health burden and cause of death and illness among children and young people with more being admitted to hospital each year for that reason than for any other. Unintentional injuries and accidents are the leading cause of mortality among secondary school children (10–19 years), with the risk increasing as children get older.

National figures from 2014/15 note that unintentional injuries led to around 106,043 admissions to hospital among children and adolescents aged 0–14 (9).

Around 295,000 under-16s attend A&E with head injuries each year in England. Most head injuries are minor; but 1 in 10 is classed as moderate to severe. In England during 2010/11, around 36,500 children under 14 were admitted to hospital with head injuries. Falls and road traffic incidents are the most common causes of head injury, with falls most predominant in the under-2s (10).

Furthermore, each year in the UK around 2,000 children attend A&E following bath water scalds. In England during 2010/11, around 400 children aged 0–14 were admitted to hospital with bath water scalds. In 2010-11, almost 1,200 children under the age of 16 were admitted to hospital in England and Wales with hot drink scalds (10).

Data collected over a five year period 2009/10 – 2013/14 for emergency hospital admissions for the 0 to 4 years reported that the most common cause in Surrey was falls from furniture and poisoning from medicines (11).

There is one Public Health Outcomes Framework (PHOF) indicator relating to unintentional injuries for children and young people (2.07 Hospital admissions caused by unintentional and deliberate injuries in children and young people aged 0-4, 0-14 and 15-24 years). Limitations to this data are as follows:

  • It does not distinguish between deliberate and unintentional injuries.
  • The data refers to the crude rate of hospital admissions caused by unintentional and deliberate injuries in children per 10,000 resident population. Please note that this kind of rate is not age-standardised and therefore does not adjust for possible confounding effects, such as the age structure of a population. However, evidence suggests that unintentional injuries in the under 18’s are 18 times higher than in the number of hospital admissions due to deliberate injuries.
  • This data is limited to hospital admissions due to injury, it is therefore not possible to establish the cause or where the injury took place.
    Note that we are currently awaiting updated Hospital Episode Statistics focusing on emergency hospital admissions for injuries in children and young people. This will allow for in depth analysis of cause. The chapter will be updated accordingly when this data is available.

0-4 year olds

A full analysis of trend data is provided in the unintentional injuries dashboard, however, for 0-4 year olds, Mole Valley (174 per 10,000) had the highest rate of hospital admissions in 2015/16 in Surrey for unintentional and deliberate injuries, followed by Guildford (155 per 10,000) and Epsom and Ewell (143 per 10,000). These are higher than the Surrey average (121.79 per 10,000), and exceed the England and the South East averages (130.47 per 10,000 and 123 per 10,000 respectively). At 84 per 10,000, Runnymede had the lowest rate of hospital admissions.

In Surrey, the rate of hospital admissions for injury does not appear to be associated with deprivation. One difference which may be a contributing factor is that Waverley has a greater number of the population living in rural areas. Evidence suggests hospital admissions for injury are significantly higher in rural communities, and that the risk of injury from different causes varies between urban and rural areas (12).

0-14 years

In 2015/16 for the age group 0 – 14 years, Guildford had the highest rate of hospital admissions, 114 per 10,000 population, followed by Mole Valley (112 per 10000) and Surrey Heath (109 per 10000); all of which are higher than the rates for Surrey (96 per 10,000), England (104 per 10,000) and the South East (99 per 10,000).

Data for Surrey Heath suggests a general upward trend from 2011/12 (68.5 per 10,000). Investigation is required to understand this fully and a coordinated approach will be required in order to halt this increase.

15-24 years

In 2015-16, Mole Valley, Reigate and Banstead, Surrey Heath, Tandridge and Waverley have higher rates of hospital admissions per 10,000 population in the 15-24 age group than in Surrey as a whole, England and the South East. Mole Valley saw a significant year on year increase from 130.3 per 10,000 in 2013-2014 to 187.33 per 10,000 in 2014-15. In spite of a decrease in 2015/16 to 169 per 10,000), further investigation is still recommended to establish the reason for this rise.

Road traffic incidents

In 2015, there were 28 fatal casualties, which was lower than the previous year, but not as low as in 2012-2013 when there were 18 fatal casualties. However, it should be noted that the number of fatal casualties in 2015 was 47% lower than the baseline average . This reduction was greater than the national decrease of 38% over the same period * (13).

In 2015, 679 people were killed or seriously injured (KSI) on Surrey’s roads. This was fewer than the previous year (735), but still higher than any other year since 2002, and 19% higher than the baseline average.

Car occupants

Fatal car occupant casualties reduced in recent years to a record low of 6 in 2013. There was an increase in 2014 to 16 fatal casualties followed by a reduction to 10 in 2015. However, this is 59% less than the 2005-2009 baseline average of 24.4. Prior to 2014 there appeared to be a small long-term downward trend in serious injury to car occupants however in 2014 there was a sharp increase to 252 casualties. This reduced in 2015 to 201 (14% lower than the baseline average). It would appear that the comparatively large number in 2014 was unusual and the number for 2015 has reduced to a level closer to the longer term trend. The long term downward trend indicates that there are a number of factors that have combined together to improve some aspects of safety on Britain’s roads.

Pedal cycles

There has been a general upward trend in pedal cycle casualties since 2008. In 2015, 139 cyclists were seriously injured on Surrey’s roads (three of which were fatal). This was 124% higher than the baseline average, but less than the record high of 166 in 2014 . The total number of pedal cycling casualties (all severities) was 586, which was 41 per cent higher than the baseline average. Although all adult age groups have suffered an increase in pedal cyclist injuries compared with the baseline average, there has been a reduction in child pedal cyclist injuries.

Pedestrians

There has been an increase in pedestrian casualties in recent years. The number of pedestrians who were seriously injured in 2015 (126 – nine of which were fatal) was a stark increase compared with the previous year when there were 98. This was 51% higher than the baseline average.

Motorcyclists

There has also been an increase in motorcycle casualties in recent years. The number of motorcycling serious injuries in 2015 was 176 (six of which were fatal). This was less than the record high in 2014 when there were 185, but still 22% higher than the baseline average.

Over two thirds of serious casualties took place on built-up roads (with speed limits 40 mph or less). In 2015, 492 serious injuries out of a total of 679 took place on built-up roads (72%). It is likely that this is a result of the busy nature of these roads, which also have a greater proportion of vulnerable road users such as pedestrians and cyclists.

Head injuries

Head injury data is collected at CCG level and demonstrates that in 2013/14, Guildford and Waverley CCG (389 per 100,000) has a significantly higher rate of head injury than the national average of 321 per 100,000 (males). Furthermore, East Surrey, Guildford and Waverley and Surrey Downs CCGs have significantly higher rates of head injury in females than the national average (225, 317 and 234 per 100,000 respectively compared with 192 per 100,000 for England). Further investigation is required to explore the reasons for this in order to support a reduction.

Falls

Data on the location and circumstances of falls are generally poorly recorded. However, where this information is recorded, most falls tend to occur in the home. Women are significantly more likely to suffer an injury as a result of a fall compared to men (2,489 injuries/100,000 population compared to 1,696 injuries/100,000 population). Similarly, people aged 80 years and over have a much higher frequency of falls resulting in injury compared to those aged between 65 and 79 years.

Ambulance call-outs for falls amongst those aged 65 years and over are very common and are estimated to make up 13% of all ambulance call outs in Surrey. The total cost of ambulance call outs over one year for this group is very high, with North West Surrey CCG estimated to spend the most out of all the other Surrey CCGs at £1.7 million. For each Surrey CCG, a large proportion of call outs for a fall do not result in conveyance to a hospital. East Surrey CCG has the highest proportion of ambulance call outs for falls where individuals are not conveyed to hospital at 61%, followed by Guildford & Waverley CCG at 58%.

Numbers of calls made for falls by the top ten households* by CCG are also high and the proportion of call outs not conveyed to hospital was between 84% and 94% for each CCG. This suggests that better follow up and support to prevent further falls is required for someone who has fallen and required ambulance services.

In terms of all fracture admissions in those aged 65 years and over, East Surrey CCG has a rate of 18.16/1,000 population and Guildford & Waverley CCG has a rate of 18.74/1,000 population. Both of these rates are statistically significantly higher than the English average (14.53/1,000). For hip fractures, the median duration of stay in hospital in 2013/14 was 6 days for those aged between 50 and 64 years, and 14 days for those aged 65 years and over. Total spend on hip fractures for those aged 50 years and over is estimated to have been over £8.5 million in 2013/14 for Surrey.

Finally, when benchmarking each Surrey CCG’s performance against ten other similar CCGs, most CCGs have a statistically significant higher rate of injuries due to falls in the 65 years and over population with the exception of North West Surrey CCG. Guildford & Waverley, Surrey Heath and Surrey Downs CCGs also perform significantly worse than their benchmarked CCGs for the rate of hip fractures occurring in the 65 years and over population. Finally, East Surrey and Surrey Heath CCGs have a significantly higher spend on non-elective admissions for trauma and injuries, while Surrey Downs CCG actually spends significantly less than its benchmarked CCGs.
*Where appropriate, Surrey’s performance has been compared against the five-year baseline average from 2005-2009. This is the baseline set by the Government’s Strategic Framework for Road Safety published in 2011.
*Data on the number of call outs per household for a fall where the age of the resident was 65 and over were provided by SECAmb. The top ten households with the most call outs for falls were then identified, and the number of call outs for these was aggregated.

Services in relation to need.

There are a number of services across Surrey that either focus on reducing unintentional injuries or include elements relevant to prevention. An outline of current local services is provided below.

Children and young people

Children centres

Children centres in Surrey provide injury prevention advice, which is embedded throughout their session plans. This is a priority in the “Healthy Children Centre “programme, which is currently being rolled out following a successful pilot. Although this is a voluntary scheme it is expected that all children centres in Surrey will work towards being recognised as a “Healthy Children Centre”.

The priority for improving health literacy and reducing unintentional injuries in children has three elements. For example, the Healthy Children’s Centre Programme Indicators state that each children centre will:

  • Identify resources and have a hot drinks policy which endorses thermal injury prevention and is reinforced in the centre’s food policy
  • Support National Child Safety and Family Safety Weeks, display resources which raise awareness, provide guidance for parents and families and support national and local campaigns, and
  • support parents and families to find a balance between encouraging play and physical activity and minimising risk of injury

Local service specifications for health visiting and school nursing include delivering the Healthy Child Programme (0 to 19 years), which provides a framework in which advice and support is provided to families, and in which key messages on preventing harm from injuries can be given. For children up to 2/2.5 years, universal reviews present structured opportunities to reinforce safety issues.

Relevant activities currently undertaken by health visitors and school nurses are summarised below:

  • When a child attends A&E services a report is sent to their GP and health visitor. The health visitor is then responsible for following up with appropriate guidance and support. However, it should be noted that they would only work with individual families on unintentional injuries when there is another reason to visit.
  • Where considered appropriate; school nurses are informed by the safeguarding team when a child attends A&E and appropriate guidance is provided.

Family information service

The Family Information Service provides information on unintentional injuries on their web pages together with information on services within their directory. Information is provided via a range of resources which includes social media via Twitter and Facebook.

Head injuries leaflet

Following on from the NICE guidance and a recommendation from the Surrey Child Death Overview Panel, the South East Coast Clinical Network, in collaboration with CCG colleagues in Surrey and Surrey’s Public Health team, have worked together to produce a leaflet for parents on head injuries. The leaflet has been distributed to schools, childcare, early years, voluntary and sports settings across Surrey.

Surrey Fire and Rescue Service

Surrey Fire and Rescue Service (SFRS) provide fire safety sessions in schools for children and young people who have a high risk of unintentional injury including Pupil Referral Units and Special Educational Needs Schools.

Furthermore, SFRS also works in partnership with the Royal National Lifeboat Institute (RNLI) to support the ‘Respect the Water’ Campaign, the RNLI’s national drowning prevention campaign. Furthermore, SFRS also supports the Chief Fire Officer’s Association with local implementation and activity in line with their annual drowning prevention and water safety campaign – three districts and boroughs,

They also deliver a youth engagement scheme to support young people’s development and provide a diversionary activity to prevent fires. A citizenship scheme funded by Boroughs and Districts, the Fire Service and the Police Youth Team has been running successfully for 10 years and aims to raise the profile of fire safety In addition, SFRS deliver the FireWise initiative, which is a 0 to 18 counselling scheme for fire starters.

Road traffic incidents

In Surrey, the Drive SMART Partnership Board has overall responsibility strategic direction of activities to improve road safety and reduce anti-social driving. The Board is responsible for monitoring success through scrutiny of the number of reported casualties on Surrey’s roads and public confidence associated with road safety and anti-social driving.

The Partnership was renewed in 2015 with the following aims:

  • Reduce and prevent death and injury on Surrey’s roads
  • Work with road users to reduce and prevent anti-social use of Surrey’s roads
  • Provide oversight and scrutiny of the Surrey Safer Camera Partnership
  • Inform the strategic direction of casualty reduction in Surrey

The Board is chaired by the Cabinet Associate for Community Safety Services, and is attended by the Deputy Police and Crime Commissioner, Surrey/Sussex Police Assistant Chief Constable and the Chief Fire Officer.

The Surrey Drive SMART Road Safety and Anti-Social Driving Strategy aims to tackle anti-social driving and reduce casualties. The strategy outlines education, training and publicity, engineering and enforcement interventions adopted in Surrey. A summary of these can be seen in the table below and further detail can be found in the Drive SMART Road Safety and Anti-Social Driving Strategy (13) or on the Drive SMART website.

Falls prevention

Following the Health and Social Care Act (2012) the commissioning of falls services is split between primary prevention (LA) and secondary prevention (Clinical Commissioning Groups (CCGs) (14).

A full description of services in the health and community sectors is provided in the falls prevention health needs assessment (4) available on Surrey-i, however a high level summary is provided below:

  • Supportive community services
  • Telecare
  • Reablement
  • Handyman and Occupational Therapy
  • Medication Use Reviews (MURs): these reviews occur in pharmacies across Surrey and are commissioned by NHS England.
  • Exercise Referral Schemes (ERS) and Exercise Classes
  • Fire and Rescue Services: These services are playing an increasing role in falls prevention and management primarily via the ‘Fire as a Health Asset’ national working group (15). The working group, which recognises the important role of fire services in prevention and public health, is currently working on a multi-agency falls consensus statement.
  • Age UK Surrey currently delivers support at home and in the community to help older people maintain their independence. For example, One Stop Surrey is a simple model of onward signposting and referral launched by a collaboration of organisations in Surrey, and is led by Age UK Surrey. This is aimed at multidisciplinary use, for example Surrey Fire and Rescue Service use this as part of their ‘safe and well’ home visits.
  • Sight for Surrey is a registered charity which works to help people with visual impairment to obtain support including: assessment, reablement, rehabilitation and specialist equipment.
  • Dementia navigators provide support to individuals affected by dementia who are at particular risk of falls. There are currently four dementia navigators working across Surrey.

Community falls services

Three service providers are commissioned by CCGs to deliver falls services*.

  • Central Surrey Health Falls Service: Central Surrey Health (CSH) is commissioned by Surrey Downs CCG and delivers a falls service in East Elmbridge, Mole Valley and Epsom and Ewell.
  • First Community Health and Care (FCHC) provide the community falls service for the East Surrey CCG area.
  • Virgin Care: Virgin Care Rapid Response Teams provides a community falls assessment service covering service users who are either registered with a Surrey GP practice or residing within the area covered by the following Surrey CCGs:
  • North West Surrey CCG
  • Guildford & Waverley CCG
  • Surrey Heath CCG
  • North East Hampshire & Farnham CCG (Farnham area only)

Acute services responding to residents who have had a fall

  • Ambulance service – according to the South East Coast Ambulance service (SECAmb), in 2015/16 falls accounted for nearly 15% of all calls. In many cases, the individual is not conveyed to hospital and a notification by the ambulance service is made electronically to the community falls service.
  • Hospital provision – In Royal Surrey County Hospital, elderly patients who have fallen are first assessed in Accident & Emergency. Patients who may be able to be discharged are usually reviewed by the Integrated Discharge Team (IDT). In some cases, patients are referred to the Older Person and Liaison service (OPAL). Patients who require follow-up are either referred to the community falls service or the Hospital Outreach Services Team (HOST). It should be noted that other hospitals will have falls provision, but due to time constraints the needs assessment only collected information from one acute trust.
  • Fracture Liaison Services – Fracture Liaison Services (FLS) are secondary fracture prevention services. They ensure that all patients presenting with a fragility fracture receive a fracture risk assessment and treatment where appropriate.

* Please note that this section is subject to change as a result of recent restructuring of provision and delivery.

Unmet needs and service gaps

Unintentional injury is a complex issue, which requires a multi-disciplinary and cross-agency response. The key issues are summarised below:

  • The complexity of risk factors relating to unintentional injury presents challenges for consistent and structured delivery of messages about injuries in children and young people. However, the move to an integrated service provider for the healthy child programme will provide an opportunity to discuss how prevention messages are delivered.
  • There are a number of challenges when attempting to establish a true picture of falls in Surrey’s older population. These include but not limited to how a fall is recorded, the variance of delivery of services in the different geographical localities, the capacity issue as there are limited resources (many services are currently at capacity, with little potential for extra funding to implement falls prevention), a fall may not be reported by individuals due to fear of loss of independence and control, and that there is a wide spectrum of providers with a remit of falls. This makes it difficult to have a co-ordinated, joint approach to falls prevention across the county.
  • Services are more reactive than proactive in relation to falls prevention. A preventative approach to this issue is fundamental but this has its challenges due to the demand in providing immediate care and treatment for fallers in the acute and community sectors along with no gold standard risk assessment tool being utilised.
  • To date, uptake and use of the One Stop Surrey referral mechanism has been limited, however, efforts are being made to raise awareness of this system throughout the health and social care economy.

What works

Unintentional injury contributes significant costs to local authorities and to society as a whole. Injury reductions can be achieved at low cost if local authorities strengthen the offer provided around unintentional injuries via existing programmes and by working in partnership.

Available evidence (1, 5, 6, 7) suggests a number of recommendations to reduce the prevalence of unintentional injuries in children and young people, which have been summarised as follows:

  • Environment: Improvement in planning and design results in safer homes and leisure areas
  • Education: Increasing the awareness of risk of accidents in a variety of settings and providing information on ways of minimising these risks
  • Empowerment: Accident prevention initiatives, which have been influenced by the community, are more likely to reflect local need and therefore encourage greater commitment
  • Enforcement: Child safety legislation; local councils assess hazards to privately rented homes.

Road traffic incidents

There is a large body of evidence on what works to reduce unintentional injuries on the road (1, 16, 17, 18). A summary of the recommendations is outlined below.
– A whole systems multi-disciplinary approach is needed to make road traffic systems less hazardous that include: –

  • good road design and management
  • improved vehicle standards
  • speed control
  • use of seatbelts
  • enforcement of alcohol limits.
  • Local Transport Plans should include measures for reducing injuries and improving health through active measures such as walking and cycling reduce noise and air pollution from road traffic.
  • The use of 20 miles per hour (mph) limits to reduce cycling and pedestrian casualties, especially to impact on inequalities in road casualty figures. This approach can protect the most vulnerable, and socially disadvantaged road users whilst encouraging people to walk or cycle.
  • Consider opportunities to develop engineering measures to provide safer routes commonly used by children and young people, including to school and other destinations (such as parks, colleges and recreational sites).
  • Include school governors and head teachers in discussions about changes relating to school travel.

Falls prevention

According to NICE guidance (19), healthcare professionals should routinely ask older people whether they have fallen in the past year and if so, ask about the frequency, context and characteristics of the fall/s. Furthermore, evidence also suggests that older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance (20).

In successful multifactorial intervention programmes the following specific components are common:

  • strength and balance training
  • home hazard assessment and intervention
  • vision assessment and referral
  • medication review with modification/withdrawal

There is also consistent evidence that exercise and individually tailored multifactorial interventions are effective in reducing falls in community-dwelling older adults (21). In addition, as mentioned previously, older people are vulnerable to dehydration; as such hydration and good nutrition is especially important in maintaining bone health and balance thus reducing risk of falls (22).

Recommendations for Commissioning

Unintentional injury is a safeguarding issue: it cuts across most directorates in county, boroughs and districts as well as health and the community and voluntary sectors. It should be noted that, within the current financial climate, prevention of unintentional injury should not require a great deal of additional spend; as such a coordinated approach to prevention will help identify those most at risk, support signposting and tailored support using existing mechanisms and interventions.

There are a number of recommended activities and approaches that should be applied locally in order to support a reduction in unintentional injuries in Surrey. A summary of the recommendations is as follows:

  • Embed principles of prevention within existing policies and strategies
  • Ensure unintentional injury prevention is within local plans and strategies that impact upon health and wellbeing
  • Sustainability Transformation Plans (STPs) provide a crucial opportunity to embed principles of prevention of unintentional injury given its clear role in exacerbating pressures on frontline NHS and social care services. Therefore, this should be taken into account in the operationalisation of the plans.
  • Ensure relevant staff are aware of the principles of unintentional injury prevention and able to support early identification and risk reduction
  • Using the principles of ‘Making Every Contact Count’ (MECC) ensure that members of the workforce are able to opportunistically raise the subject of the risks associated with unintentional injury and signpost where required
  • Ensure robust data collection and improve the mechanism for sharing this information across organisations. Use data to target areas identified as “most at risk”
  • Support unintentional injury prevention for children and young people via delivery routes such as the Healthy Schools and Healthy Children Centre programme
  • Relevant organisations provide home safety assessments where possible and make use of assistive technology to help predict, monitor and alert those at risk of injury
  • Provide, monitor and evaluate the effectiveness of injury prevention training for front line staff.
Organisation Recommended actions
Children and young people Older adults Road safety
Surrey County Council
  • Explore opportunities to promote and embed unintentional injury prevention across Surrey and support a coordinated and multidisciplinary approach to prevention
  • Support national and local campaigns e.g. child and road safety, Chief Fire Officer Association’s drowning and water safety weeks
  • Engage health in unintentional injury prevention e.g. primary and secondary care (including GP practices and A&E), antenatal clinics, Clinical Commissioning Groups (CCGs), school nursing, health visitors, and other community providers
  • Develop key messages for frontline staff in order to develop skills in relation to unintentional injury prevention, such as for those working in children’s centres, nurseries, education etc
  • Explore opportunities to promote falls prevention across Surrey. For example, incorporate messages on falls into other relevant awareness-raising campaigns e.g. the Health and Wellbeing Board ‘Winter Wellbeing’ and ‘Right Care, Right Place, Right Time’ campaigns.
  • Within the Making Every Contact Count (MECC) programme, consider incorporating training on validated falls risk assessments and how to refer to appropriate services.
  • Support other organisations e.g. Fire and Rescue Service, in using evidence-based tools to identify individuals at risk of falls.
  • Promote use of the One Stop Surrey referral form
  • Work in partnership with relevant local organisations in order to focus on halting upward trend in road traffic incidents in cyclists and motorcycle users
  • Embed prevention of road traffic incidents in relevant policies not limited to transport, roads etc
  • Engage health and other colleagues in prevention of road traffic incidents
  • Work in partnership with schools to explore how to develop ‘safer routes to schools’ schemes
  • Explore development of infrastructure in support of active travel schemes and to promote safer cycling routes across Surrey
  • Support robust data collection road traffic injuries
  • Ensure relevant organisations and agencies are aware of Drive SMART activities and interventions and know how to signpost into these interventions where relevant
Districts and Boroughs
  • Embed principles of unintentional injury prevention within local policies and strategies
  • Support national and local campaigns e.g. child and road safety weeks
  • Explore innovative ways of making services which could prevent injurious falls, such as telecare, exercise classes and handyman services both affordable to individuals as well as sustainable into the future.
  • Work in collaboration with CCGs to support falls pathways by providing equitable falls prevention services and strengthening referral pathways to those services.
  • Promote use of the One Stop Surrey referral form
  • Use data provided on local incidents to target interventions and activities related to road safety
Clinical Commissioning Group (CCG)
  • Provide leadership in primary care around unintentional injury prevention, early identification of risk, data recording and signposting
  • Embed principles of unintentional injury prevention within relevant service redesign pathways
  • Support national and local campaigns e.g. child and road safety weeks
  • Ensure consideration is given to unintentional injury prevention when operationalising STPs
  • Consider effective ways of ensuring opportunistic screening of older people for falls risk is undertaken by health professionals
  • Develop integrated falls pathways, including links/referrals from organisations which may identify individuals at risk of falls e.g. the Surrey Fire and Rescue Service
  • Consider ways of reducing the number of emergency responses to non-injurious falls e.g. multi-disciplinary meetings to manage the underlying needs of “frequent flyers”.
  • Use redesign of falls pathways as an opportunity to collaborate and develop a Surrey-wide integrated approach to falls prevention, championing examples of local best practice.
NHS Acute Trusts/Providers
  • Provide leadership around unintentional injury prevention, identification of risk and safeguarding
  • Support robust data collection relating to unintentional injuries
  • Signpost to relevant supportive agencies and/or provide information/guidance such as head injuries leaflet
  • Provide regular training to staff and clear patient pathways on the prevention and management of falls.
  • Establish a falls working group consisting of staff from the hospital and community falls service to facilitate learning on the outcomes of patients referred between services.
  • Consider auditing the management of patients presenting with a fall against compliance with NICE guidelines.
  • Care homes should consider training of care home staff around falls management and prevention.
School nurses
  • Act as ‘safety ambassadors’ – proactively providing prevention information to relevant groups such as on road safety etc
  • Support national and local campaigns e.g. child and road safety weeks
  • Support dissemination of head injuries leaflet
DriveSMART partnership
  • The Drive SMART Partnership continue to monitor the number of casualties, and will continue to invest, monitor and evaluate road safety interventions based upon analysis of road collisions, national research and best practice.
Health visitors
  • As part of the Healthy Child Programme, all health visitors should ensure that families are aware of the risks of unintentional injury and how these injuries can be prevented.
  • Signpost/refer families to support services where relevant
  • Record and highlight where safeguarding risk is identified
  • Support dissemination of head injuries leaflet
  • Ensure that families are aware of key messages around road safety in children and families and how these injuries can be prevented
Children’s centres
  • Managers and staff are provided with overview training containing information about unintentional injuries
  • Ensure that families are aware of the risks of unintentional injury and how these injuries can be prevented
  • Signpost/refer families to support services where relevant
  • Record and highlight where safeguarding risk is identified
  • Ensure that families are aware of key messages around road safety in children and families and how these injuries can be prevented

Key contacts

  • Leads within Surrey County Council, CCGs, Partnerships Boards or non-statutory organisation as appropriate
  • Also list relevant JSNA coordinator

Chapter References

  1. National Institute for Health and Care Excellence (2010), Unintentional Injuries in the home: interventions for under 15s
  2. South West Public Health Observatory (2012), Injury Profiles
  3. Health and Social Care Information Centre (2014) Hospital Episodes Statistics 2012/13
  4. Surrey County Council (2016), Health Needs Assessment of Falls Prevention and Management (available from /dataset/health-needs-assessment-of-falls-prevention-and-management)
  5. Public Health England (2014), Reducing unintentional injuries in and around the home among children under five years
  6. Royal College of Paediatrics and Child Health (2014), Why Children Die: Death in infants, children and young people in the UK: Part A
  7. Department for Children, Schools and Families (2009), Accident Prevention amongst children and young people: a priority review
  8. National Institute for Health and Care Excellence (2013), Falls: assessment and prevention of falls in older people. NICE clinical guidance 161.
  9. Public Health Outcomes Framework (2016)
  10. Child Accident Prevention Trust, 2013
  11. Health and Social Care Information Centre (2015) Hospital Episodes Statistics 2013/14
  12. Boland, M. (2015) Urban-rural variation in mortality and hospital admission rates for unintentional injury in Ireland. Inj Prev. 2005 Feb;11(1):38-42.
  13. http://www.drivesmartsurrey.org.uk/
  14. NHS England (2012) Commissioning fact sheet for CCGs http://www.england.nhs.uk/wp-content/uploads/2012/07/fs-ccg-respon.pdf
  15. Consensus Statement on Improving Health and Wellbeing between NHS England, Public Health England, Local Government Association Chief Fire Officers Association and Age UK http://www.cfoa.org.uk/20354
  16. World Health Organisation (2008), World Report of Child Injury Prevention
  17. ROSPA (2013), Delivering accident prevention at local level in the new public health system
  18. Department of Transport (2011), Strategic Framework for Road Safety
  19. National Institute for Health and Clinical Excellence (2015), Falls in older people: assessment after a fall and preventing further falls.
  20. Royal College of Physicians (2011), NHS services for falls and fractures in older people are inadequate, finds national clinical audit. Available at: https://www.rcplondon.ac.uk/news/nhs-services-falls-and-fractures-older-people-are-inadequate-finds-national-clinical-audit
  21. Stubbs B, Brefka S, Denkinger MD. What works to prevent falls in community-dwelling older adults? Umbrella review of meta-analyses of randomized controlled trials. [Phys Ther. 2015;95:xxx–xxx.
  22. British Nutrition Foundation (2016) https://www.nutrition.org.uk/nutritionscience/life/dehydrationelderly.html