Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...

Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...
Raising the bar on strength and balance:
The importance of community-based provision

Centre for Ageing Better
February 2019
Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...
Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...
About us

Centre for                              The Healthy Ageing Later Life
Ageing Better                           Research Group at Training
                                        the University of
The Centre for Ageing Better is a                          Later Life Training (LLT) is a not-
charity, funded by an endowment         Manchester         for-profit organisation who
from The National Lottery                                                      provide specialist evidence-based
Community Fund, working to              The Healthy Ageing Research            exercise training for health, social
create a society where everyone         Group is based in the School of        care and exercise professionals
enjoys a good later life. We want       Health Sciences at the University      working with older people and
more people to be in fulfilling         of Manchester and linked to the        older people experiencing
work, in good health, living in safe,   Manchester Institute for               significant loss of capacity.
accessible homes and connected          Collaborative Research on Ageing
communities. By focusing on             (MICRA). The Group’s research          To find out more visit:
those approaching later life and at     revolves around six inter-related
risk of missing out, we will create     themes for older people and
lasting change in society. We are       younger older people: falls and
bold and innovative in our              falls prevention, activity and
approach to improving later lives.      exercise promotion,
We work in partnership with a           musculoskeletal conditions and
diverse range of organisations. As      chronic pain management, use of
a part of the What Works network,       novel technologies, social and
we are grounded in evidence.            residential care, and access to
                                        services and treatments. The
To find out more visit:                 Healthy Ageing Research Group
                                        undertakes high quality research
                                        with an emphasis on healthy and
                                        active ageing so to ensure the
                                        promotion of good health and
                                        active participation in society. The
                                        Group aims to develop research
                                        capacity in the topic of healthy
                                        and active ageing and ensure that
                                        our work demonstrates change in
                                        policy and practice for older
                                        people at a local, national and
                                        international level, as well as
                                        engages the involvement of the
                                        public and patients in research

                                        To find out more visit:



                                                                          Raising the bar | Centre for Ageing Better   3
Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...
4   Raising the bar | Centre for Ageing Better
Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...
Executive summary
Maintaining and improving muscle strength and our ability to
balance is crucial to helping people live independently as they
age and to reducing their risk of a fall.
We know that poor muscle strength and balance are         The evidence that funding strength and balance
the two most common modifiable risk factors for           programmes in the community is cost effective is
falls. We also know that falls have a huge impact on      clear, yet such programmes are often underfunded
people who can lose mobility and confidence to            and there is a significant difference between what the
keep doing things on their own after having a fall,       evidence says and what is delivered on the ground.
often ending up requiring more hospital and social        Local services do not always join up and work
care. Every year there are over 210,000 falls-related     together, leaving a patchwork provision.
emergency hospital admissions among people aged
65 and older in England (PHE, 2018). It is estimated      To address this, the Centre for Ageing Better
that falls cost the NHS around £1 billion a year          commissioned the University of Manchester to bridge
(Leal J et al, 2016).                                     the gap between evidence and practice, to work
                                                          directly with communities to better understand their
For individuals who are experiencing a decline in their   local challenges and to identify practical examples of
ability to do everyday activities, or who have already    doing things differently. There is a great deal of
had a fall, there are some NHS rehabilitation services    variation in what is provided across England. This
that provide strength and balance programmes.             report presents the models of delivery, issues, barriers
However, these are often of limited length, making it     and innovative solutions that we found in our work. It
essential that there are effective community-based        focuses on community-based strength and balance
strength and balance programmes in their local areas      programmes targeting all older adults and includes
to move on to. What is needed is a more holistic          evidence-based programmes to reduce falls. The
response that doesn’t simply medicalise the problem       findings have been organised into five themes.
but focuses on supporting people to age well and
remain independent more broadly.                          Within each theme, there are five key points that we
                                                          believe should be taken on board to ensure that
Falls are not an inevitable part of ageing and can be     strength and balance exercise programmes are
prevented. Raising awareness of the risk of falls as      delivered to the right people, at the right time, and by
well as what older people can do to prevent them is       the right workforce/people with sufficient challenge,
an important part of engaging local populations,          so that older adults achieve positive results.
increasing uptake of community-based strength and
balance programmes.

                                                                        Raising the bar | Centre for Ageing Better   5
Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...
Executive summary

                                                   Raising awareness

                          1                        –
                                                       Fund and develop marketing campaigns
                                                       Tailor messages for target audiences
                                                       Make sessions appealing
                                                       Develop peer champions
                                                       Work across stakeholder groups

                                                   Encouraging uptake

                          2                        –
                                                       Challenge negative beliefs
                                                       Person-centred goals to increase motivation
                                                       Build relationships across organisations
                                                       Exercise sessions – something for everyone
                                                       Address barriers and provide solutions

                                                   Exercise referral pathways that work

                          3                        – Develop referral pathways collaboratively
                                                   – Share pathways throughout local networks
                                                   – Provide good assessments for appropriate referrals
                                                   – A recommendation is not the same as a referral
                                                   –	Succesful exercise referral pathways across England

                                                   Sticking to the evidence

                         4                         –
                                                       Provide person-centred assessment
                                                       Supplementary home exercise for success
                                                       Tailor programmes for individual progress
                                                       Moving on to other programmes/activities
                                                       Support instructors to deliver the evidence

                                                   Monitoring for outcomes

                                                   and improvement
                                                   – Create a monitoring framework
                                                   – What to include to capture success
                                                   – Identify tools for assesment and
                                                     monitoring progression
                                                   – Digital tools for monitoring progress
                                                     and recording outcomes
                                                   – Make the most of data

6     Raising the bar | Centre for Ageing Better
Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...
Executive summary

Recommendations for commissioners, providers, instructors,
health and allied healthcare professionals
We have also developed some key recommendations to share across localities, with commissioners,
providers, instructors and health and allied healthcare professionals to support successful programme
delivery across England.

Commissioners/Directors of                               Providers of strength and
Public Health                                            balance training
    nderstand that strength and balance exercise
   U                                                       Identify suitable levels of training for the
   programmes are cost-effective and will help               workforce
   achieve good outcomes with local populations
                                                            ffer ongoing training, support and CPD
    esign and support services that enable/
   D                                                       opportunities for staff
   encourage evidence-based approaches to
   be followed                                             Facilitate instructor meetings for shared learning
                                                             to standardise delivery across a locality, inform
   Include funding for education and awareness              how to deliver classes and to further staff
    raising campaigns to form part of a wider strategy       development
    for preventing falls
                                                            mbed messages about strength and balance
   Include funding for assessment time and for            across all exercise class provision (e.g. walking
    conversations around behaviour change and              sports and dance classes)
                                                           F oster good communication pathways between
   Develop a collaborative referral pathway with          referrers and across professions
     a supporting decision-making tool and share it
     with referrers                                        Allow time for pre and ongoing assessment
                                                             in programmes
    mbed quality assurance and evaluation into
   all programmes                                          Quality assure sessions to support workforce and
                                                             deliver in line with the evidence base
    mbed strength and balance messages in local
   programmes and map the activities that are              Ensure health and safety, plus risk assessments
   available locally                                          including emergency plans, are in place

                                                                       Raising the bar | Centre for Ageing Better   7
Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...
Executive summary

    Instructors delivering strength and                     Healthcare and allied healthcare
    balance training                                        professionals
     	Understand and respect the scope of practice that     	Collaborate on creating and developing referral
       your training provides. Ensure that it is informed      pathways and documentation to inform processes
       by evidence                                             and build relationships

     	Provide clear inclusion criteria to referrers to      	Observe the community session you are
       support appropriate referrals                           potentially referring into

     	Include conversations about goal setting and          	Ask exercise instructors about the qualifications
       motivation as part of all start, mid and end            they hold – it is your responsibility to understand
       point assessments                                       what programmes you are referring into

     	To achieve the required amount of exercise            	Ensure healthcare and allied healthcare
       needed, ensure your programme includes                  professionals understand the difference between
       supplementary home exercise as an integral              formal referrals and informal recommendations
       part of your programme and ask participants
       about completion                                      	Include/embed onward referral information as
                                                               part of physiotherapy interventions to better
     	Refer those who progress quickly onto exit              support and prepare people for longer term gains
       programmes as soon as they are ready
                                                             	Include information that strength and balance
     	Be aware that not all participants will be ready        gains made during physiotherapy will not be
       for an exit programme at the end of the                 sustained unless exercise is continued
       programme timeframe

8     Raising the bar | Centre for Ageing Better
Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...
Executive summary

Characteristics of local areas working towards success

                                          approach to
                  Lead person                                      Agreed,
                   promoting                                    well-defined
                  everybody's                                  pathways which
                 business model                                  are shared

      Collaborative                                                           Learning and
        approach                                                             feedback loops
       promoting                                                                for service
       partnership                                                            improvement

                                         Start with
                                        the person

                                                                         Local insight
          Older adults                                                  and community
          as volunteer                                                   consultation
          ambassadors                                                      to inform

                           Ensure the right          Well-trained
                            person, in the          workforces with
                          right programme             continued
                           at the right time         development
                               for them              opportunities

                                                             Raising the bar | Centre for Ageing Better   9
Raising the bar on strength and balance: The importance of community-based provision - Centre for Ageing Better February 2019 - Centre for Ageing ...
Executive summary

     Glossary of terms
     There is currently an active debate around use of the         Due to the variation in language that is used in
     term ‘frailty’. Added to this are a number of alternative     exercise provision and research, and with a view to
     terms often used in its place, including ‘low/limited         assist understanding of the content of this report, we
     function’, ‘capacity’, ‘mobility’ and ‘capability’. For the   have included a glossary of terms.
     purpose of this report we will use the term ‘capability’
     as a measure of someone’s ability to carry out
     activities of daily life, such as being able to wash,
     bathe, toilet and feed oneself without requiring help.

10      Raising the bar | Centre for Ageing Better
Executive summary

Commonly used words in the field of strength and balance exercise research
and provision

Capability              Refers to body systems/physiology being capable to perform given activity.

Community of Practice   Instructors meet together to share and learn from experiences, discuss
                         standardisation of delivery across a locality.

FaME                    F alls Management Exercise Programme. FaME progresses the Otago Exercise
                         Programme balance exercises to include other components of fitness and
                         activities. FaME includes upper limb strength exercises to support getting up off the
                         floor. Delivered by Postural Stability Instructors. Suitable for all older adults and
                         appropriate for a range of older people.

Fidelity                 eing true to the evidence/replicating what happened in research i.e. duration,
                        dose, frequency, progression, sticking to the evidence.

Multifactorial Risk      n assessment with multiple components that aims to identify a person’s risk
Assessment              factors for falling.

Otago                    he Otago Exercise Programme (OEP) is a lower limb strength and balance
                        programme (plus walking and motivational support strategies) of pre-set exercises
                        with progression guidance. Delivered by OEP Leaders.

Pathway                  n agreed ‘route’ of processes across/between services, sectors, teams and
                        professionals in order to get the older person to where they need to be to positively
                        affect outcomes (person-centred approaches).

Progression             A core principle of exercise training/science. When the principle of progression is
                        applied ‘effectively’ (appropriate overload/stimulus to body systems), gains in
                        components of fitness e.g. strength, balance, flexibility can be expected.
                        ‘Reversibility’ is another exercise training principle; when training progressions are
                        insufficient or when participation in the programme stops, the gains/benefits will
                        be lost.

Recommendation           ealth professionals may recommend a list of exercise programmes to attend in
                        the locality but without imparting any information (about health status,
                        medications, contraindications for exercise etc.) to the instructor.

Referral                 formally agreed system including inclusion and exclusion criteria and aligned
                        with best practice referral processes.

Strength and Balance     wo components of fitness (there are others) that inform our capacity to be
                        physically active i.e. reduced strength and balance will impact on our ability to
                        perform activities of daily living.

Uptake                  When an older person starts to participate in an activity or structured
                        exercise programme.

                                                                      Raising the bar | Centre for Ageing Better   11
12   Raising the bar | Centre for Ageing Better
Why is muscle strength and balance important for
older people?
As we get older, we begin to lose muscle and bone            This is to be performed in bouts of ten minutes or
strength and our balance gets worse. Low muscle              more, plus activity to improve muscle strength on at
strength is linked to a decline in our ability to carry      least two days per week.
out daily activities such as bathing and getting
dressed on our own, doing housework and going                In addition, adults 65 years and over should perform
out. Muscle weakness and poor balance are also the           balance and co-ordination activities on at least two
two most common modifiable risk factors for falls,           days each week (CMOs, 2011).
which can lead to injuries like hip fractures and make
us more likely to end up in hospital or need social care.    However, evidence tells us that the number of older
                                                             adults meeting these guidelines is low. The most
Recent evidence reviews, funded by the Centre for            recent Health Survey England (NHS Digital, 2016)
Ageing Better, in partnership with Public Health             found that, in adults aged 19-64, only 34% of men
England, have confirmed the importance of muscle             and 27% of women met both the aerobic and
strengthening and balance activities across the life         muscle-strengthening guidelines. This number
course as part of recommended levels of physical             declines rapidly with age. For those aged over 65, 13%
activity (Foster et al, 2018).                               of men and 10% of women meet both guidelines,
                                                             with those over 75 both reporting closer to 5%.
The UK’s Chief Medical Officers’ (CMOs) physical
activity guidelines, presented in ‘Start Active, Stay
Active’, recommend 150 minutes of moderate
intensity, 75 minutes of vigorous activity for those
already regularly active, or a combination of vigorous
and moderate physical activity per week.

Proportion meeting both the aerobic and muscle-strengthening guidelines, by age and sex






                  16-24         25-34         35-44           45-54       55-64         65-74           75+

                 Men         Women                          Age Group

                                                                          Raising the bar | Centre for Ageing Better   13

     To address the low activity levels amongst older           For active older adults who have high and stable
     adults specifically, additional guidance was produced,     capacity, it is recommended they incorporate
     based on the World Report on Health and Ageing             strength and balance activities into their existing
     (WHO, 2015), which identified three sub-populations        routines and exercise. Table 1 shows the types
     of older people aged 65 years and over: high and           of physical activities that are most effective at
     stable capacity; declining capacity and significant loss   improving muscle function, bone health and balance
     of capacity. This guidance recognised the different        (Foster et al, 2018).
     opportunities and physical limitations affecting older
     adults in these different phases of life.

     Advice and recommendations are tailored to
     individual abilities and circumstances, from increasing
     current physical activity and breaking up sitting to
     structured classes delivered by appropriately
     qualified instructors.

14      Raising the bar | Centre for Ageing Better

Table 1

  Type of sport,
 physical activity
    or exercise               Improvement in               Improvement                 Improvement
                              muscle function             in bone health                 in balance






          Tai Chi





      Strong effect          Medium effect          Low effect     No effect         Not known

For older adults whose capacity is declining, or for   When considering the types of activities and
those experiencing significant loss of capacity,       interventions that are most beneficial to the three
strength and balance training programmes need to       population groups identified, it is useful to think
steer towards evidence-based falls prevention          about appropriate settings for delivery, workforce
interventions, such as Otago and FaME.                 and qualification requirements, together with
                                                       opportunities to embed messaging around strength
                                                       and balance across the spectrum. Table 2
                                                       demonstrates these considerations.

                                                                    Raising the bar | Centre for Ageing Better   15

     Why is improving muscle strength and balance important for
     reducing falls?
     Table 2
                                                        Population group

                           High and stable                 Declining                  Significant loss
                              capacity                     capacity                     of capacity

                       Already active but could     Declining capacity due       Low physical or cognitive
                       benefit from increasing      to inactivity. This group    function, disease or ageing
                       physical activity or         represents the largest       process, requiring therapeutic
                       addressing specific          population subgroup          approaches and falls
                       aspects of fitness.          with the greatest to gain.   prevention.

     Activity          Sports: swim, cycle, run,    Programmes should            To achieve falls prevention
     types             walk, group exercise,        include a pre-exercise       outcomes, individuals should
                       gym programmes.              assessment due to            take part in evidenced-based
                                                    potential co-morbidities     falls prevention programmes
                                                    requiring liaison with GP.   requiring pre-exercise
                                                    Participants may need to     assessment and agreed
                                                    speak to their GP before     referral pathways.
                                                    participating in exercise
                                                    programmes.                  Other programmes exist for
                                                                                 outcomes relating to reducing
                                                                                 isolation and promoting
                                                                                 physical activity for example.

     Who can           Exercise instructors,        Exercise instructors,        Exercise instructors,
     deliver the       volunteers.                  support workers, carers,     physiotherapists, therapy
     activity?                                      physiotherapists.            teams, specialist teams.

     Qualification     Fitness specific             Additional fitness           For falls prevention outcomes:
     requirement       qualifications/leadership    specific qualifications      specialist training; Otago
     for those         awards for community         (e.g. Level 3 REPs           Leadership Award and REPs
     delivery          settings.                    Exercise Referral).          Level 4 Specialist Postural
     activity                                                                    Stability Instructor.

                                                                                 A range of qualifications exist
                                                                                 for exercise programmes that
                                                                                 do not primarily seek to
                                                                                 reduce falls.

     Settings          Recreation/leisure           Recreation/leisure           Home/packages of care,
     where             centres, parks,              centres, parks,              residential settings, day
     activities can    community venues,            community venues,            hospitals, rehabilitation
     be delivered      gyms.                        gyms.                        settings.

16     Raising the bar | Centre for Ageing Better

Poor muscle strength and balance is known to               In some localities, funded and co-ordinated
contribute to an increased risk of falling (NICE, 2015).   community-based SBEP are non-existent, and in
In the two years to 2016, more than a quarter (28%)        others provision is reliant on self-employed specialist
of adults over the age of 60 and nearly four in ten        instructors and private physiotherapists delivering
(38%) adults over the age of 80 reported a fall            group exercise sessions in our communities, which lie
(Banks et al 2018). About 5-10% of such fallers will       outside of funded or co-ordinated services. This lack
sustain a serious injury (McClure et al, 2008).            of consistent provision across the country impacts
This has implications for people’s independence,           greatly on opportunities and choices for older people
quality of life and cost to health and social care         to participate in quality evidence-based exercise
services (DH, 2009).                                       programmes. But in some areas this challenge has
                                                           been met with some creative and innovative models
The National Falls Prevention Coordination Group           of delivery, which we have sought to highlight in
(NFPCG), a group of over 30 member organisations           this report.
involved in the prevention of falls, care for falls-
related injuries and the promotion of healthy ageing,      For example, in several areas Age UK brand partners
recommend commissioning evidence-based                     are funded to deliver exercise programmes. This
strength and balance services as a key intervention to     means that participants attending SBEP classes can
reduce risk of falls (Public Health England, 2017).        also easily access other services those organisations
                                                           provide, including information and advice.
To be effective, programmes should comprise a
minimum of 50 hours or more, delivered for at least        In other areas, SBEP are delivered by Leisure Services.
two hours per week, for a minimum of six month.            The advantage here is that appropriately qualified
However, strength and balance exercise programmes          Leisure Services staff can signpost people on from
(SBEP) delivered by NHS falls rehabilitation services      the SBEP to other activities that incorporate strength
are often inadequate in length with usual duration of      and balance, such as Tai Chi, yoga, resistance training
strength and balance training ranging from six to          and circuit training.
eight weeks. Across the NHS, 73% of patients
supervised at home indicate that their programme           We came across a private health and leisure provider
lasted for three months or less (Royal College of          who has been commissioned to deliver a falls
Physicians, 2012), which does not provide a                prevention programme, with clear and challenging
sufficiently high exercise dose (Sherrington et al,        targets for success, reported quarterly. As a private
2017). This makes transitioning individuals from           provider, it is in their interest to hit, or exceed
NHS-based to community-based programmes, to                these targets.
continue delivering challenging balance training and
progressive strength training, of utmost importance.       This project focused on community-based strength
                                                           and balance programmes targeting all older adults
                                                           and includes evidence-based programmes to reduce
The current state of provision                             falls. The aim of this report is to highlight both the
of strength and balance                                    challenges and innovative solutions we found
programmes                                                 working with local areas across England (see
                                                           Appendix 1: project process for more information).
Within this project, we found great diversity in the       We have organised our findings and
ways in which SBEP are being delivered. In some            recommendations for those involved in
localities, programmes are commissioned by Public          commissioning, referring and delivering SBEP into
Health, in others by Clinical Commissioning Groups         five themes: Raising awareness, Encouraging uptake,
(CCGs), or a combination of both. There is huge            Referral pathways that work; Sticking to the evidence;
disparity in the amount of funding allocated to SBEP,      Monitoring for outcomes and improvement.
and no standardised approach to physical function
and quality of life outcomes exists.

                                                                         Raising the bar | Centre for Ageing Better   17


     Appropriately raising awareness that
     falls are not an inevitable part of
     ageing, and what older people at
     risk of falls can do to prevent them,
     is an important part of any SBEP.

18    Raising the bar | Centre for Ageing Better
There are opportunities to raise awareness at many
levels, and commissioners, local Public Health
                                                            Fund and develop marketing
bodies, service providers and class instructors all have    campaigns
a role to play in raising awareness. But it is equally
                                                            Marketing campaigns that include materials
important that this does not become the sole
                                                            describing strength and balance exercises, which are
message. Broad ranging SBEP should aim to target all
                                                            evidenced to reduce falls, were effective in increasing
population groups, supporting individuals to maintain
                                                            uptake in local areas we worked with.
their independence and enabling us to continue to
                                                            Communication plans that are developed together
live life to the full, regardless of age. These positive
                                                            between multi-agency groups ensure that all
messages are as important to get strength and
                                                            stakeholders and gatekeepers hear and disseminate
balance ‘on the map’ of the independently active
                                                            consistent messages regarding SBEP. Ensuring there
older people, not just those at risk of a fall.
                                                            is sufficient funding for this type of activity will result
Before engaging in SBEP, older people want to know          in an increase of referrals (self/healthcare) into SBEP.
how such a programme will help them specifically.           Awareness campaigns serve to provide ‘inroads’ to
Commissioners should understand which SBEP are              creating opportunities for one-to-one interactions
cost effective (and for which population groups) and        when truly person-centred conversations can take
will therefore help them achieve meaningful                 place and information and messages are tailored to
outcomes for older people living in their localities.       the individual.
Furthermore, raising awareness and agreeing
                                                            In Lambeth and Southwark leaflets promoting their
consistent messages among all those who come into
                                                            programme were posted out to local residents,
regular contact with older people, not just health
                                                            placed in prescriptions for anyone over the age of 65
professionals but also, for example, fire fighters, crime
                                                            and available in GP surgeries.
reduction officers, community pharmacists, and
neighbourhood schemes, further embraces and                 		     Lambeth and Southwark: Raising Awareness
reinforces the message that falls prevention is
everyone’s business and they all have a part to play.       Information printed on materials that older people
We have outlined five key ways to raise awareness           might have in their home, such as a tea-towel, a
which represents what we found in local areas:              calendar or a flyer that could be put up on a wall or
                                                            fridge, are further examples of ways to keep strength
– Fund and develop marketing campaigns
                                                            and balance exercises in mind. The ProFouND Falls
– Tailor messages for target audiences                      Awareness Campaign Pack offers a guide on running
                                                            campaign activities and includes information on
– Make sessions appealing                                   engaging older people, working in partnership, event
                                                            examples and measuring success. Scotland’s Active
– Develop peer champions
                                                            and Independent Living programme, ‘Take the
– Work across stakeholder groups                            balance challenge’ campaign, included promotion of
                                                            the ‘Super Six’ exercises evidenced to reduce falls.
                                                            Ageing Well Wales has a hub of resources that offer
                                                            guidance and advice for both older people and those
                                                            working with older people at risk of falls.

                                                                           Raising the bar | Centre for Ageing Better     19
Tailor messages for target                                 Make sessions appealing
     audiences                                                  Linking social activities to the classes can provide a
                                                                strong motivation for people to attend, as can linking
     The language that we use is a powerful tool for
                                                                other activities, such as visiting speakers, trips and
     raising awareness, therefore tailoring messages with
                                                                refreshments before or after the session. When
     a view to increasing uptake to SBEP is important. We
                                                                classes are provided as a follow-on from
     know that focusing on positive outcomes and using
                                                                rehabilitation, it is useful if the same venue is used to
     positive language is more appealing to older people
                                                                allow groups to stay together. This is particularly
     than focussing on risk of falling (Yardley et al, 2007)
                                                                helpful if classes are delivered to participants in local
     and where possible avoiding the ‘F’ word (fall) (Yardley
                                                                areas so that access is easier and venue familiarity is
     et al. 2005) .
                                                                established (Hawley-Hague, 2017).
     When promoting community exercise programmes,
     it is important to think about how the SBEP will be
     perceived by older people, using attractive and
     informative promotional materials that show local
     programmes are: easily accessible in terms of
     transport and connections; affordable; welcoming;             It’s great fun and it’s a social
     sociable; and that information about the class is             thing as well, three of us go
     provided before first time attendance (Boulton et al,         for coffee afterwards and so
     2018). Running local focus groups to find out what            it would be a great thing for
     messages appeal to your communities is a great way
     to co-create leaflets and flyers to raise awareness.
                                                                   people who are living alone
     This is especially relevant when targeting hard to            and don’t really see many
     reach communities.                                            people.
     Featuring personal stories of how attending a local
     strength and balance class has impacted on the lives
     of attendees acts as a powerful message and can
     work to increase uptake.

     		Derbyshire: Participant Stories

     In Cambridgeshire and Peterborough a positive and
     aspirational strength and balance social marketing
     campaign was developed with engagement and
     personal stories from women aged 70+ years old.
     ‘The Stay Stronger for Longer’ campaign messages
     were disseminated widely using a communications
     toolkit, posters, a locally adapted ‘Super six’ leaflet,
     and website. The person centred approach helped to
     attract TV and radio coverage. Preliminary analysis
     indicates an increased uptake of exercise classes.

     		Cambridge Stronger for Longer
        campaign toolkit

     		     Don’t Mention the F Word, Age UK, 2012

20      Raising the bar | Centre for Ageing Better
Develop peer champions                                    Work across stakeholder
Older people who have experienced the benefits of         groups
SBEP first hand, and believe in the difference regular    Falls need to be everybody’s business, which is why
attendance can make to their quality of life, are the     establishing a falls collaborative group that includes
most valuable of messengers. Training peer                representatives from all stakeholder and key
volunteers to deliver talks, presentations and            influencers, works as an important factor in
roadshows at local community and neighbourhood            developing a co-ordinated approach to falls and
groups and events, in residential and care home           strength and balance provision in a local area.
settings and in hospitals, can be of mutual benefit for   Appointing a person to convene and lead that group
all involved, the volunteers, and their audiences.        is a success factor that allows a whole-system
As part of the Royal Society Prevention of Accidents      approach to be realised.
(RoSPA) ‘Stand Up Stay Up’ programme, Blackburn           We found examples of this in Bolton, Bristol and
with Darwen have worked with a group of active            Leeds. Having a central point of contact, dedicated to
champions to develop a sketch show explaining how         the multi-component issue of falls prevention, has
falls can be prevented. This includes demonstrating       prevented some of the dilution of its importance
how to get up from the floor after falling, giving out    that we found in other areas. It means that awareness
copies of ‘Get up and Go: A guide to staying steady’      raising can take place as part of a co-ordinated
as well recruiting people onto the local SBEP.            approach, from acute hospital settings to general
		Blackburn with Darwen: Peer Champions
                                                          In Leeds, the local Falls Lead proactively delivers a
		‘Get up and Go: A guide to staying steady’             range of awareness raising and training programmes
   Chartered Society of Physiotherapists, 2015            to local stakeholder work forces (e.g. fire fighters,
In Wigan, peer champions form a central part of           community crime officers, community pharmacy,
provision being trained to support instructors during     neighbourhood schemes) on SBEP and falls
class as well as accompanying instructors on home         prevention.
visits to encourage community-based class
                                                            Raising Awareness in Leeds:
attendance. This has been particularly effective in
                                                            The Fallproof Programme
trying to engage older men in SBEP.

		    Wigan: Reaching out to men

                                                                        Raising the bar | Centre for Ageing Better   21


     To encourage uptake; when an
     older person starts to participate in
     an activity or structured exercise
     programme, there are a number of
     things that can be done and that we
     found to be effective in local areas.

22    Raising the bar | Centre for Ageing Better
– Challenge negative beliefs                             Person-centred goals to
– Person-centred goals to increase motivation            increase motivation
– Build relationships across organisations               We know from research that a desire to reduce risk of
                                                         falling is not a key motivation for older people to
– Exercise sessions – something for everyone             uptake strength and balance (Yardley et al, 2007). It is
– Address barriers and provide solutions                 for this reason that behaviour change strategies are
                                                         required, in order to encourage meaningful
                                                         conversations to support uptake and continued
Challenge negative beliefs                               attendance for SBEP.
The myth of ageing and the impact of a ‘what do you
                                                         Omitting or failing to provide pre-exercise
expect at my age’ narrative can significantly impact
                                                         assessments majorly influences opportunities to
on uptake of SBEP. It is important to understand these
                                                         support behaviour change in the longer term. To get
commonly held beliefs and to work to support older
                                                         people off to a good start instructors need sufficient
people, carers, families and to some degree
                                                         time to have person-centred conversations about
healthcare professionals to think differently about
                                                         individuals’ concerns, barriers and about what is
ageing. This can be done both through providing
                                                         important to them – thereby actively supporting
factual information about the potential for
                                                         them towards success and achieving their
improvement regardless of age and through correct
                                                         personal goals.
messaging and new narratives for ageing well.
                                                         People are more likely to remain engaged in
The Functional Fitness MOT approach is based on
                                                         programmes if they are achieving success and
this premise and has been developed to help those
                                                         enjoying themselves in the process. These successes,
working with older people to have meaningful
                                                         when captured and documented in terms of
conversations with older adults to support behaviour
                                                         functional ability and quality of life, contribute to
change, increase engagement in local programmes
                                                         achieving outcomes of the service as set out by
and to ‘move more’. Moving Medicine is a website
that delivers a step-by-step guide for healthcare
professionals to promote good quality conversations      		
                                                           Wigan: Asset based approach /
about prescribing movement, broken down into               motivational conversations
conversation blocks of one minute, less than five
minutes, five minutes or more.

                                                            I’m much more independent
                                                            now, I can do the garden,
                                                            I can go to town on the bus.
                                                            Coming to this class has
                                                            really made a difference to
                                                            me, I now have much more
                                                            balance, and I don’t use
                                                            my stick.

                                                                       Raising the bar | Centre for Ageing Better   23
Build relationships across                                 Exercise sessions – something
     organisations for consistent                               for everyone
     messages                                                   Offering choice to meet a range of preferences is
                                                                fundamental to increasing the number of people
     Transitions from physiotherapy settings to continued
                                                                who participate. Strength and balance are elements
     exercise in the community can be better supported
                                                                of physical fitness that are of importance across the
     when consistent messages are used during
                                                                life course and are integral to most well designed
     physiotherapy. The perception of ‘I’m fixed’ (therefore
                                                                exercise programmes, but they are of increasing
     no need to continue with suggested exercise
                                                                significance when it comes to preventing
     programmes/home exercise programmes) can be
                                                                age-related decline.
     a factor in the poor uptake of community-based
     programmes. In order to maintain or improve gains          Not all strength and balance programmes are
     achieved, both allied health professionals and             evidenced to reduce falls and not all older people
     exercise instructors need to repeat consistent             need ‘falls prevention’ programmes. Broader strength
     messages about the need for continued exercise.            and balance provision should be available in
                                                                localities, so that older adults have a choice of
     Specialist exercise instructors qualified to work with
                                                                activities and programmes, which suit their functional
     older people at risk of falls are best placed to work in
     partnership with therapy services. Partnership             abilities and needs. Commissioners and Public Health
                                                                bodies need to understand the evidence for falls
     working can build on gains made in physiotherapy
                                                                prevention exercise and the qualifications and skill
     and progress individuals towards longer term
                                                                sets required to deliver the evidence-based
     participation in exercise programmes to achieve
     sufficient exercise dose of strength and balance
     programme to reduce falls. Consistent messages to          Offering a range of provision, in a number of settings
     reinforce and explain how exercise benefits are lost       also works to increase participation. This is especially
     when the exercises stop is a critical educational          important when targeting people from a range of
     message and potential motivator.                           religious, cultural, ethnic and socio-economic
                                                                backgrounds. A commitment to work in partnership
     		Wigan Partnership Working: Physiotherapist
                                                                with local community centres and organisations that
     		Wigan Partnership Working: Occupational                 represent the diversity in local areas can effectively
        Therapist                                               increase engagement of a broad range of
                                                                community groups.
     		Wigan Partnership Working: Community Link

        CASE STUDY - Guy’s and St Thomas’ NHS Foundation Trust
        Community rehabilitation and falls service in Lambeth and Southwark

        Engaging with hard to reach communities                 Instructors have had to adapt their delivery style
                                                                and content to encourage uptake and regular
        In Lambeth and Southwark, engagement with the           attendance, whilst also religious festivals such as
        Somali Integration and Development Association          Ramadan are taken into account. Classes are
        (SIDA) has resulted in the establishment of two         hosted in SIDA’s venue and have resulted in some
        new classes aimed at the local Somali community.        fantastic outcomes.
        Hosted within SIDA, the two classes include one
        for women with a female instructor and one for          	Since coming to the class I’ve able to get
        men with a male instructor.                               down on the floor to pray at the mosque
                                                                  which I’ve not done for many years

24      Raising the bar | Centre for Ageing Better
Address barriers and provide solutions
Through our work with local areas during this project, we identified a number of common barriers to uptake as
well as some ideas on how to address these:

Common barriers            Ideas to address barriers

Time: busy life and/       Promote self-help strength and balance exercises through campaigns (e.g. Get up
or carer or family         and GO! booklet, NHS Choices).
                           Offer Lifestyle-integrated Functional Exercise (LiFE), which makes suggestions for
                           situations in which strength and balance exercises can be performed safely, yet
                           with sufficient challenge, as part of people’s existing daily routines (Clemson et al,

Money: session             Promote self-help strength and balance exercises through campaigns (e.g. Get up
admission fees             and GO! booklet, NHS Choices)
too expensive
                           Offer subsidised sessions initially to allow for behaviour change conversations to
                           increase motivation.

                           Offer subsidised sessions in areas of higher deprivation and in rural areas where
                           participant numbers may be low.

Transport: cannot get      Collaborate with volunteer organisations to provide community transport.
to the community
session                    Create buddy systems for participants to pick up friends to bring to the session
                           – class attendees often gain confidence and start driving one another.

                           Base classes near people’s homes to maximise attendance.

                           Offer supported home exercise programmes with monthly visits and interim
                           phone calls.

Venues: insufficient       Collaborate with local venues, libraries, GP surgeries, housing schemes, local
or inappropriate           community venues, halls etc. for space/affordable room hire.
community venues
available in the localit   Offer supported home exercise programmes with monthly visits and interim
                           phone calls.

No confidence in the       Clearly communicate information about instructor qualifications and expertise in
instructor: will they      areas important to older people/the ageing process and fall risks.
understand my
problems/are they          Provide information that instructors are part of a co-ordinated approach/referral
qualified?                 pathways/liaison with GPs, where required.

Family barriers: ‘my       Provide initiatives and literature to support understanding of strength and balance
family don’t think it’s    and physical activity for families and informal caregivers.
a good idea for me to
exercise’                  Have meaningful conversations that enable identification of person-centred goals.
                           These can form the basis of changing behaviours and challenging barriers.

                                                                         Raising the bar | Centre for Ageing Better   25
Referral pathways

                                          that work

     What is a
     referral pathway?

26    Raising the bar | Centre for Ageing Better
Engagement in evidence-based interventions to
improve muscle strength and balance has been
                                                              Develop referral pathways
shown to reduce both falls and the fear of falling            collaboratively
amongst older adults with low, moderate and high
                                                              Healthcare and allied health professionals as referrers
risk of falls (Campbell et al, 1997; Gillespie et al, 2012;
                                                              (e.g. GPs, physiotherapists) need agreed pathways to
Robertson et al, 2002; Skelton and Dinan, 1999). It is
                                                              efficiently refer older people onto the most
therefore essential that commissioners design and
                                                              appropriate programme for them. Effective referral
support services that enable evidence-based
                                                              partnerships are founded on trust and understanding
approaches as part of their broader strength and
                                                              between people working in different settings and
balance offer. Programmes with insufficient exercise
                                                              across health and leisure sectors. Those working in
dose (e.g. six, 12 or 16 weeks) will not be effective in
                                                              health settings must have confidence in the
reducing falls. Establishing referral pathways,
                                                              community-based SBEP instructors if they are going
processes and documentation serves to support a
                                                              to refer patients into programmes. In line with
progressive approach to longer term participation
                                                              professional standards of practice, specialist
(provided that a range of exercise programmes exist
                                                              instructors delivering SBEP must receive appropriate
in the locality that support onward signposting
                                                              incoming referral information so they can support
and progression).
                                                              success, enjoyment and safety. Developing local
Most health professionals acknowledge the benefits            referral pathways should be carried out as a
of referring individuals into community-based SBEP.           collaboration between all agencies working with
However, not being aware of availability in nearby            older adults, to ensure pathways are effective.
areas, lack of formally agreed pathways and concerns
about the credentials of the instructors/leaders were         Share pathways throughout
recurring themes across localities. Healthcare
professionals also commonly misperceive that their
                                                              local networks
patients either cannot get to community sessions or           To achieve appropriate and good quality referrals,
are not motivated to attend. For this reason, referrals       referrers need to be familiar with pathways and
into community provision can be problematic and               inclusion criteria. If older people are repeatedly not
ineffective.                                                  accepted onto SBEP, referrals will reduce or,
                                                              ultimately, stop altogether. Information sharing
To address these barriers, we have outlined five areas
                                                              between professionals in organisations, on-going
of creating more effective referral pathways:
                                                              analysis of referral numbers and criteria, and dialogue
– Develop referral pathways collaboratively                   about referral numbers and uptake, are important for
                                                              pathways to develop and adapt. Increasing the
– Share pathways throughout local networks                    number of appropriate referrals will result in stronger
                                                              partnerships and in more older people receiving
–	Provide good assessments for appropriate
                                                              effective durations/amount of appropriate exercise.
–	A recommendation is not the same as a
–	Successful exercise referral pathways across

                                                                            Raising the bar | Centre for Ageing Better   27
Provide good assessments for                               Successful exercise referral
     appropriate referrals                                      pathways across England
     Pre-exercise assessment is part of best practice           We came across a broad range of referral pathways
     delivery to support effective exercise programming         during this project. These are each outlined in the
     and goal setting and is essential in ensuring that older   case study examples available online:
     people are directed to the most appropriate
     programme for them at that time. For older people
     with high and stable capacity (active) and those with         CASE STUDY
     declining capacity (in transition) who may self-refer         Derbyshire
     onto programmes, it is important to complete a
     Physical Activity Readiness Questionnaire Plus             			
     (PARQ+, 2018). This will guide instructors as to            		Strictly No Falling Programme:
     whether or not further advice is required from a GP            Participant Referral Process
     before becoming more physically active. For those
                                                                			Ask Assess Act Falls Pathway
     older people who have experienced a significant loss
                                                                			Document (PDF)
     of capacity, in addition to a PARQ+, a more detailed
     assessment is recommended. Note currently the
     National Quality Assurance Framework (NQAF) (DH,
     2001) is pending review as part of the work being
     undertaken and co-ordinated by the Chartered                  CASE STUDY
     Institute for the Management of Sport and Physical            West Sussex
     Activity (CIMSPA).
                                                                   Private Sector Provision
     A recommendation is not the
     same as a referral                                         			
                                                                   Mid Sussex Falls Referral
                                                                   Pathway (PDF)
     The NQAF provides guidance for exercise
     professionals and referrers on the information a
     clinician should provide to the exercise professional.
     A recommendation, e.g. ‘there’s an exercise class in
     your local community venue you could go to’                   CASE STUDY
     (statement from a GP), does not constitute a referral
                                                                   Lambeth and Southwark
     and a self-referral does not necessarily exclude the
     need for liaising with the GP. Specialist exercise         			
     services working with older people at risk of falls        			
                                                                   Clinical Telephone Triage
     should have clear referral pathways in place. Whereby
     older people are screened and assessed for suitability     			
                                                                   Lambeth and Southwark Telephone
     for referral into community programmes and are                Triage Form (PDF)
     referred onto therapy services as required for multi-
     factorial falls assessment and can also be referred on
     to associated other health professionals as required.

28      Raising the bar | Centre for Ageing Better

Integrated Care Model: Referral pathway and decision-making tool
 ristol’s community-based ‘Staying Steady’ FaME
B                                                                           Observations on the programme include
programme is part of an integrated care model,                              feedback that people come for longer because
with clear routes supported by decision-making                              they have self-referred, compared to those who
tools for assessors (Figure A). Older adults can                            were ‘sent by a clinician to a clinic/intervention;
self-refer into the programme and health and                                older people are getting themselves along to the
social care professionals are encouraged to                                 sessions by various means of transport, despite
signpost people to it (Figure B). ‘Staying Steady’                          concerns that ‘if you don’t provide transport they
can also be a ‘step-down’ programme from the                                won’t come’; participants are happy to pay £3.50,
rehabilitation strength and balance exercise                                even in deprived areas; group sessions can be
provided by local health services. To ensure this                           popular and people from deprived areas attend,
service operates effectively, all instructors have                          including men and those from BAME groups.
been trained as Postural Stability Instructors (Level
4) so that they possess the necessary qualification
level to accommodate a broad range of older
people with a variety of needs.

               Cohort:                                         1. Person is interested and                            Provide general advice
  Fear of falling; Challenges with                              motivated to engage in                NO             about preventing falls and
 balance of walking; Risk of falling;                       strength and balance exercise?                                  staying well
  1 or more falls in last 12 months


         YES            2. Individual can sit to stand from a chair with or without arms AND independently walk around a chair           NO

                            Non Health Care           Health Care                                       Non Health Care            Health Care
    Self referral                                                                  Self referral
                             Professionals           Professionals                                       Professionals            Professionals

                    Signpost person to Staying Steady programme:                Person to discuss      Signpost person to     Refer person to BCH
                         www.bristol.gov.uk/stayingsteady                      any concerns about      their GP for further        or UHB S&B
                                                                                 falling with GP              advice           depending on their
  Person to contact Staying Steady provider of their choice directly:                                                         .org.uk/our-services/
                www.bristol.gov.uk/stayingsteady                                                                                    strength-

                                                                                                                                  UBH referral
        Person will be assessed by Postural Stability Instructor. If the person is deemed                                       criteria: Referrals
              more suitable for Tiers 2 or 3 then they will be referred to BCH via                                             are via GP letter or
     briscomhealth.org.uk/our-services/strength-balance-classes/. Otherwise they can                                           UHB referral form
    continue with Staying Steady for as long as they need with the aim of progressing their
                                     strength and balance

                                                                                                            Person may be suitable for S+B input
                                                                                                                    led by BCH or UHB
  KEY: Self referral = individuals, family and carers, Non health care professional = Voluntary
 sector organisations, volunteers, health champions, community navigators, social prescribers,
  Live Well Bristol Hub, Integrated Healthy Lifestyles Service, Adult Social Care, care direct etc;         On completion of S&B through BCH
 Health care professionals = GP/Primary care; Community Health - Physio, OT, falls specialist               or UHB, person may be signposted or
     etc; Acute Care; Ambulance service (non-urgent/medically stable falls “see and treats”):              referred to Staying Steady programme
               BCH = Bristol Community Health: UHB = University Hospitals Bristol                               to continue with S+B exercise

                                                                                                   Raising the bar | Centre for Ageing Better         29

     Leisure Services: Progressive Pathway
     In Wigan, the pathway includes a six-week                       Older adults can move through the pathway in
     supported home exercise programme, followed                     this order, or they can access groups directly
     by ten-week group-based ‘skilling up’ sessions,                 along the pathway, depending on their assessed
     15-week evidence-based SBEP and long-term                       level of need.
     maintenance sessions, all of which are supported
     by a home exercise booklet.                                     		      Wigan: Active Later Life Pathway

                       Referral                           Residential/Sheltered                          Self Referral
               E.g. Bridgewater, Early               Accommodation/CIC/Charity                       A result of word of
             intervention, GP/Practice             E.g. Bridgewater, Early intervention,            mouth, out reach work,
               Nurse, Healthy Routes,              GP/Practice Nurse, Healthy Routes,                  leaflets, articles
              Community Link Worker                      Community Link Worker

                                                  Setting funds a freelance instructor or
                                                  settings staff trained in-house, attend
                                                   YMCA CBE or Moving More Often to
                                                           continue the activity

             Home Exercise                10 Week Skilling Up Groups                   6 Week Home Exercise Programme
               Continue                  Two groups per week. Includes                  Instructors visit the home on week
               exercise at                 speakers as well as strength                  one, three and six. Phone support
             home. Booklet                    and balance exercise.                      in between. Participant receives a
                provided                       Transport provided                           booklet and resistance band

                                             Community Strength and Balance Classes
                               An evidence based 15-week exercise programme delivered in a number of
                               community venues across the borough. Ring and Ride transport available

                Maintenance Sessions                      Other Programmes                          Home Exercise
             Exercise group for participants            Participant attends other             Continue exercises at home.
               who have completed the                   programme sessions e.g.                    Booklet provided
                 strength and balance                  Stroke Rehab, health walks

30   Raising the bar | Centre for Ageing Better
Cambridgeshire and Peterborough

Onward Referral Pathway
Cambridgeshire and Peterborough’s ‘Falls                      Referral depends on their ability to walk safely and
Prevention Exercise Onward Referral Pathway’ is a             independently, and their ability to access
good example of an effective onward referral                  community provision.
pathway. Following a multi-factorial falls risk
                                                              Those receiving the community Home Exercise
assessment identifying a need for strength and
                                                              Programme are also encouraged to attend quality
balance exercise, individuals are referred into
                                                              assured community-based strength and balance
either an NHS Strength and Balance Rehabilitation
                                                              classes alongside the 1-2-1 support to improve
class (with six months motivational support and
                                                              motivation and compliance of recommended
home exercise) or community Home Exercise
                                                              level of exercise. Those referred into the
Programme provided by the Falls Prevention
                                                              Rehabilitation Strength and Balance classes are
Health Trainer Service of Everyone Health or
                                                              signposted to the community-based classes on
Solutions4Health (also with six months
                                                              completion of the programme, for long-term
motivational support).
                                                              maintenance of exercises.

                                         Falls assessment indicates strength
                                             and balance onward referral

        Individuals walking independently but                           Individuals able to walk safely and
         with difficulties, with or without aid.                         independently, with or without a
         Physically able to leave the house to                          walking aid. Physically able to leave
             access community provision                                        the house to access

      Strength and Balance Rehabilitation, with                     Community home exercise programme as
      6 months motivational support and home                        stand alone intervention or to supplement
                exercise programme                                 community class, with 6 month motivational

                                              Community Strength and
                                                  Balance Class

        Cambridgeshire and               Everyone Health or            Statutory & volunteer organisation where
        Peterborough NHS                 Solutions4Health              staff have completed appropriate strength
        Foundation Trust                                               and balance qualifications and agreed to
                                         Prevention Health             regular monitoring of classes be CPFT
                                         Trainer service               Falls Prevention Services

                                                                               Raising the bar | Centre for Ageing Better   31
Sticking to the


     Right person, right programme,
     at the right time for them.

32    Raising the bar | Centre for Ageing Better
Carrying out a person-centred pre-assessment is a          Achieving the required dose for programmes to be
key factor in ensuring the right person is on the right    effective depends on instructors having the
programme, at the right time for them. This is critical    knowledge and skills to apply principles of exercise
for programme effectiveness, and individual                progression and to tailor the evidence-based
enjoyment, safety and achieving anticipated                programmes to the needs of individuals within group
functional and quality of life outcomes. Having the        exercise formats. An ineffective instructor will result in
wrong person in the wrong programme, at the                an ineffective programme, which is not evidence-
wrong time will not support uptake, longer term            based at all. This level of ‘sticking to the evidence’,
participation or health outcomes. For example, the         which is also known as ‘fidelity’, is only really achieved
Otago Exercise Programme has been shown to be              if it is monitored through a supportive quality
most effective for older adults with significant loss of   assurance process. We outline five areas to ensure
capacity, aged 80 years and over (Robertson, et al,        programmes achieve this fidelity:
2002), Tai Chi for those with mild deficits in strength
and balance (Gillespie et al, 2012) and falls              – Provide person-centred assessment
management exercise (FaME) for independently living        – Supplementary home exercise for success
frequent fallers (Skelton and Mavroedi, 2018).
                                                           – Tailor programmes for individual progress
Once the appropriate people are in the right
programme, the next step is to support and ensure          – Moving on to other programmes/activities
instructors stick to the evidence base. For exercise
programmes to be effective for falls prevention,           –	Support instructors to deliver the evidence
individuals need to reach a minimum effective dose            (quality assurance)
(at least two hours per week totalling 50 hours over
six months), be progressive and contain highly
challenging balance activities before a significant
reduction in falls is achieved. Exercise programmes
also need to be ongoing for reduced falls risk to be
maintained (Sherrington et al. 2017) and for the return
on investment to be realised (PHE ROI, 2017).

                                                                          Raising the bar | Centre for Ageing Better    33
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