Case-Finding for Falls Prevention: Wigan Pilot

3564
B.Badrock
Greater Manchester Combined Authority
Clinical Quality
CQ - Improved Access to Service

Abstract

Introduction
Falls are a significant health concern, with one in three people over 65 experiencing at least one fall annually. Greater Manchester is leading a world-first pilot of eFalls technology to support healthy ageing and reduce fall-related injuries in older adults. The pilot aims to proactively identify individuals at moderate risk of falling and offer early interventions to maintain their independence and wellbeing.

Method
The eFalls pilot launched in February 2025 and will run for nine months within the South Wigan Ashton North (SWAN) primary care network in Wigan, Greater Manchester, serving approximately 37,000 people. The digital eFalls tool analyses GP records using indicators such as frailty scores, fall history, medications, and long-term conditions to categorise patients by risk. Searches are conducted by the NHS Greater Manchester data team, and patients identified as at moderate risk are invited for a health check and offered enrolment in the Falls Management Exercise (FaME) Programme, along with referrals for vision checks and other preventative support.

Results
While the pilot is ongoing, early implementation efforts are focused on validating the digital search process, ensuring appropriate patient identification, and facilitating uptake of effective interventions such as FaME.

Conclusion
This pilot marks a significant shift towards proactive prevention using digital tools to identify and support older adults before a fall occurs. Funded by a £100,000 grant from the Office for Health Improvement and Disparities (OHID) and the Centre for Ageing Better, the initiative offers a scalable model for early intervention. If successful, it will hopefully develop as a future model for prevention for Greater Manchester and hopefully Nationally. 

Comments

Hello. Thank you for your poster. Can you tell me how the eFalls tool discriminates between different risk factors, weighting them accordingly to create the risk factor? And what is the falls rate risk that makes someone low, moderate or high risk, (eg 10%/year falls risk)?

Submitted by alasdair.macrae on

Permalink

Hi Alasdair, Thanks for the comment. Here is the research paper that provides more information about the eFalls tool that should help!

Development and external validation of the eFalls tool: a multivariable prediction model for the risk of ED attendance or hospitalisation with a fall or fracture in older adults | Age and Ageing | Oxford Academic 

Submitted by bethany.mitche… on

Permalink

Outcome data would be interesting when available. On the whole seems sensible. To be proactive rather than reactive.  Future outcome data and subsequent cost effectiveness analysis will be important

Submitted by h-shahbaz@hotm… on

Permalink

Thank you for your poster, are you able to tell me how you have tailored the communication to those identified as requiring intervention to reduce the barrier to entry for the those with alternative communication needs, digital literacy differences and health literacy?

Submitted by samdavidolden_27620 on

Permalink

Yes of course. We attended around 3-4 groups in the neighbourhood of the PCN we are working with, and we tried to gather as much information as possible as to how people who want to be engaged with, would they like to receive a letter? a phone call? a text message? and we took a draft script to the sessions which we shared with the attendees to ask them to feedback on. They told us which language to avoid, how to frame the conversation in order to make them want to engage. We then adapted the approach based on the feedback I hope this is helpful!

 

 

I have been involved in a falls prevention project where I manually reviewed patient records to proactively identify individuals for further falls prevention interventions. We are excited to follow your work. Currently, we are in the first wave of our pilot, and our findings so far indicate that data coded from GP medical records, such as falls risk and frailty, can be incomplete or inaccurate. Many falls go unreported.

Have you encountered this issue in your study? If so, how have you addressed or plan to improve the accuracy and completeness of information recording to better identify at-risk patients?

Submitted by vicki.starkey_38199 on

Permalink

Hi Vicky, thanks ever so much for your comments and question. This sounds really exciting, and I would equally be keen to connect to find out more about your work. I can confirm that this is certainly the case in Greater Manchester, we are doing a lot of work to try to improve the accuracy of our data and data dashboards. We are doing a lot of work with the GM Data Intelligence team to bring together a number of dashboards to get a clearer picture of what is going on, such as the GM Frailty dashboard, the GM Falls Dashboard, the GM Care Home dashboard etc. Please do get in contact as I would be happy to discuss this further!

Submitted by bethany.mitche… on

Permalink

“Thank you for this excellent initiative; it’s a very innovative use of digital tools for prevention

 

What strategies are in place to support primary care teams with the additional workload of contacting, assessing, and referring patients identified through eFalls?

Submitted by muhammadrahib… on

Permalink

Thanks for your question. With regards to the primary care teams, we have worked with the PCN to build this into the existing capacity of the Additional Roles that the PCN has. The PCN that we are working with for this pilot have both Care Coordinators and GP Assistants. When developing this pilot, we worked with the Business Transformation lead for the PCN who supported us to build this into the model as 'business as usual'. We still need to have conversations across GM as to how we do this at scale in order to deliver this model. 

Submitted by bethany.mitche… on

Permalink

Looking forward to the results. 

The patients who are invited for a review, are the seen in a geriatrics clinic, primary care or a joint primary-secondary care clinic? 

Submitted by m.s.khan1@doct… on

Permalink

Thanks ever so much for your question. They are invited in for a two-part appointment. The first 15 minutes with a GP Assistant for a brief health check (weight, BP etc), and the second part is another 15 minute appointment with a Care Coordinator to talk about the reasons why they have been contacted, share information on the strength and balance offer, and also to provide other key information such as home hazards for falls prevention, advice on having a vision assessment if they haven't had a test in the last 2 years, information on the broader community programme, and finally a digital strength and balance option (Keep On Keep Up), that they might want to do at home should they wish. We have built the pilot so that this approach can be delivered in all PCN's, no matter what AARS (Additional Roles) they have within their PCN.