South Tees Integrated Falls Prevention Strategy


South Tees has had a CCG commissioned falls service since 2007 and has had significant year on year growth in referral rates. Despite this, the team have operated on the same resource and the service had become reactive rather than proactive.


Year    Male    Female    Total Referrals
2013 462 861 1323
2014 585 1027 1612
2015 684 1096 1780
2016 678 1047 1725
2017 639 1081 1720


Proposed key outcomes of the review were: A mapping exercise of existing services against NICE guidance was used to identify areas for improvement which created an opportunity to review the current service with a view to develop a system-wide approach to falls prevention.

  • Reduced falls and injuries
  • A region-wide falls pathway
  • Coordinated, individualised risk assessment and interventions
  • Improved partnership working


An Integrated Falls Prevention Strategy was developed with buy-in from a range of sectors.

A tiered approach was developed to ensure the maximum number of people benefitted from falls prevention information, support and guidance and a single point of access for referrals was agreed to streamline referrals.


Please see Reference Image 1.1. in the attached Innovations poster under 'Additional Notes' below. 

Tier 0/1

  • Primary prevention supported by health promotion and public health messages
  • Falls prevention work from a wide range of services such as local council housing providers, fire Brigade, voluntary / charitable organisations, etc.

Tier 2

  • Secondary prevention for those in contact with health and social care
  • Includes multifactorial risk assessment and interventions based on NICE guidelines

Tier 3

  • Specialist assessment services for complex cases that require specific input


Individuals in each tier will “Make Every Contact Count” and understand that they have a role to play in public health service delivery.

To support this pathway, the Falls Team have developed:

  • A rolling programme of training to increase falls awareness and to support each service area in managing the risk of falls
  • Online and paper-based “self-help” resources to promote self-care for the public
    • Website (
    • Paper-based Falls Prevention Guide and Home Safety Checklist for those without access to the internet
  • Electronic and paper inpatient and community falls assessment tools based on RCP / NICE guidelines


  • Use of the website (period between 7th Sept and 7th Dec 2020)
    • 1,197 users
    • 1,539 visits
    • 139 self-assessments, 86 completed (62% completion rate)
  • Facebook reach during October launch period – 7439
  • Positive verbal feedback from website users:
  • Training sessions completed to date – 46
    • Number of staff trained 283
    • Tier 0 – 10
    • Tier 1 – 39
    • Tier 2 – 203
    • Managers awareness session – 31
  • In the longer term, data will be analysed against baseline data of 2016-17 looking for 10% reductions in the following:

               - hospital admission rates due to falls

               - rate of hip fractures as a result of a fall

               - number of falls in care homes

               - patient falls within acute settings


Cost and savings

This project only went live in October 2020 so total cost and savings data is not yet available. 


  • Increased awareness of falls prevention across South Tees with increased completion of risk assessments and interventions
  • Increased capacity of South Tees Falls Team to deal with complex fallers and allow engagement with local community falls prevention initiatives
  • A shared responsibility across the whole of South Tees for:
    • Education
    • Evidence-based exercise programs
    • Referral and reporting
    • Risk assessment
  • Overall reduction in falls and injuries and reduced cost to the NHS and social care


Future developments:

  • Website to include blogs from local services and a professional specific area for up to date resources and educational information
  • Members of the falls team will visit local services on a regular, basis to deliver updates and to ensure that they are a visible source of expert advice
  • Virtual training delivery will be completed via a narrated presentation to free up the team to offer profession specific training (e.g. training for community physiotherapists on effective exercise interventions for people at risk of falls)



  • The South Tees Integrated Falls Prevention Strategy has now been published and agreed upon. Both inpatient and community falls policies will be amended to reflect the changes

Top three learning points

  1. Progress doesn’t have to be linear - adapting the initial plan was key as the timing and source of funding was unknown at the start
  2. Engagement with organisations with strong community links and public health involvement is key for prevention work
  3. Engaging with teams on an individual basis during a staggered roll out is much more likely to bring about change

Funding acknowledgements

With thanks to Ageing Better Middlesbrough for funding the project. 

Additional notes

The website has been viewed by a member of the Northamptonshire Public Health Team who wants to utilise the website in other localities. These discussions are in their infancy but it is hoped that this may be an avenue through which additional funding can be sourced to further improve the resources.

Please see the attached Innovations poster below.

For further information about this work please contact Louise Egan.