The FLEXI Study (FaLls EXercise Implementation)

Lay Summary

Falling can cause injury, pain, loss of confidence and independence. This is undesirable for the individual and their families, and places significant demands on health and social care services.

Falls are not inevitable. By improving an individual’s strength and balance, alongside skills to help getting up from a fall (should this happen), the likelihood of a fall occurring or having damaging consequences, such as a long lie on the floor, can be minimised. 

The Falls Management Exercise (FaME) programme is a group-based, face-to-face, six-month exercise programme specifically aimed at improving the strength and balance of people aged 65 and over.  Research has shown that FaME results in fewer falls, improved confidence, and reduced fear-of-falling. Despite this, FaME is still not available everywhere across England.  More needs to be understood about how best to increase its availability and ensure high quality delivery.

To improve our understanding of this, we previously studied FaME’s set-up, delivery and quality in the East Midlands. We learnt a lot about how to get FaME running and showed that the programmes worked outside of a research setting. Using learning from the East Midlands, we developed a guide for implementing FaME called the implementation toolkit.  This evidence-based toolkit contains all the information needed to set up and run a FaME programme, from making the initial business case to promoting it to participants.

What have we discovered?

What works to foster (encourage) the adoption (initial decision to choose or take up something) and spread (roll out over a large area) of The Falls Management Exercise (FaME) programme?

• Using implementation frameworks, we successfully identified key barriers and enablers of adoption, implementation and spread of the Falls Management Exercise (FaME) programme across the three localities.
  

• We found that the adoption, implementation and spread of FaME into community settings is complex and faces multiple health system challenges.
  

• In order for the FaME programme to be chosen as a community fall prevention intervention by commissioners, the programme must be able to demonstrate how successful it is in reducing falls for older adults (this is often determined by internal service evaluation).
  

• The programme was also required to fit the needs of those receiving the intervention, for example, FaME was primarily provided where there was a growing, aging population in need of fall prevention interventions.
  

• The spread of the FaME programme within organisations and into new regional areas was dependant on the input of commissioners passionate about fall prevention. Commissioners were required to support this role out and provide funding, whilst also ensuring that there was a sufficient expert instructor workforce available to deliver FaME.
  

• The programmes were further required to be monitored regularly to evidence how successfully each programme was in reducing rate and risk of falls for older adults receiving the intervention. This was often the role of the postural stability instructor. Future funding is required to build in paid time for this to ensure that programme outcomes can support future funding cycles as often instructors are funding on an hourly basis.

Does FaME work in the real world, how is it adapted (altered or changed), and does it reach the intended audience (older adults at risk of falling)?

• The collection of routine class data across three regions in England demonstrated that FaME was associated with benefits for participants at 12 and 24 weeks of the programme.
  

• Those benefits included improved balance and mobility and reduced falls.
  

• Programmes that provided higher ‘dose’ (i.e. ran over 24 weeks rather than 12 weeks) found that older adults experienced greater improvements in balance and mobility and were less likely to be concerned about falling again.

What works to maintain the quality (the standard) and fidelity (how well something is reproduced) of the FaME programme over time?

• One of the key findings of the FLEXI study was that sites demonstrated a lack of clarity of essential components or key ingredients of the FaME intervention. This influenced both implementation and the  providers' ability to assess adherence. The need for an understanding of central components was also clear in understanding delivery adherence and, therefore, the ability to evaluate programmes for their effectiveness.
  

• At the point of implementation, it became apparent that commissioners and managers are prioritising aspects of the intervention, with these decisions mediated by knowledge (or lack ) of the intervention, economic culture and organisational priorities. Adaptation of Evidence Based Interventions s is key to improving their fit in a new context, however, essential components should not be adapted as intervention effectiveness cannot be guaranteed.
  

• We have proposed a new framework of implementation fidelity, that shows that mediators were key both in the implementation and delivery of complex interventions, as well as the mediating more of global mediators.
  

• Understanding of essential components is paramount at the point of implementation in order to ensure fidelity is implemented, maintained, and assessed. We suggest that complex interventions have a standard of evaluation (based on core components) and insights on fidelity/value negotiations within toolkits. We highlight that local fidelity evaluation is key to standardisation across programmes and delivery.

What difference does this knowledge make?

We have worked collaboratively with the Health Innovation Networks, local Integrated Care Systems and Combined Authorities to study ‘spread in action’.  As a result, in one of our areas (Devon), where we have applied AHSN-based spread methodology, we have seen a near trebling of available programmes from 13 to 41 (without intervention costs from the study).

The study has highlighted the need for an increased frequency of local Quality Assurance to monitor delivery (instructors given the opportunity to observe each other deliver and provide constructive feedback). This has improved the quality of delivery. 

We have also hosted Greater Manchester-wide collaborative events, which resulted in quality improvement initiatives relating to FaME provision across GM and have established the National FaME Implementation Team (N-FIT) which is now primed and ready to work in new areas to support spread, using the methodologies we have tested.

We are refining our implementation toolkit, which is ready to be tested in new areas and we want to refine and improve our quality assurance framework and costing tool using data collected from the study to support future FaME provision.

What next?

Our future planned work aims to address:

Gaps in our understanding about what works to reach underserved communities in relation to FaME participation.

We are currently working to explore the provision of FaME in ‘neighbourhood’ areas where there are good examples of reach into underserved groups (e.g. minority ethnic groups, male participants and socioeconomically deprived areas).

We are conducting case-study research methodologies to further investigate this aim.

The original FLEXI project highlighted that the monitoring and evaluation of programme outcomes are not captured well by local areas delivering programmes. We are, therefore, now developing a more structured evaluation framework for sites to use a legacy of the project.

New data on the costs of implementing FaME have been determined and we would live to use these figures to update the national return on investment tool for FaME, developed by Public Health England and York University, to see if this improves the economic case for FaME roll-out.

Lastly, we have also tested quality assurance tools for FaME and can see that improvements can be made to increase the tools’ internal and external validity. Moving forward, we would like to refine our preferred tool using academic methods test this in new areas.

We would like to thank:

Principle Investigator:  Dr Elizabeth Orton

Team members: Professor Denise Kendrick, Professor Stephen Timmons, Professor Carol Coupland, Professor Pip Logan, Professor Tahir Masud, Professor Vicki Goodwin, Professor Claire Hulme, Professor Chris Todd, Dr Helen Hawley-Hague, Dr Paul Wilson, Professor Dawn Skelton, Mrs Margaret Beetham  

Study researchers and study staff:

Dr Fay Manning

Dr Jodi Ventre

Dr Aseel Mamood

Dr Michael Taylor

Grace Brough

Dr Amar Shukla

Dr Robert Vickers

Tina Patel

Study public contributors:

Mary Murphy

Margaret Beetham

PPIE Workshop participants from Greater Manchester, Devon and East Midlands

Our Partners: NIHR ARC Greater Manchester, NIHR ARC South West Peninsula , Health Innovation South West , Royal Society for the Prevention of Accidents, Health Innovation Manchester, Later Life Training, Torbay and South Devon NHS Foundation Trust, Leicester-shire and Rutland Sport.

Research sites: Devon Integrated Care System (ICS), Manchester combined authority, Leicester, Leicestershire and Rutland ICS, Derby and Derbyshire ICS

Starts: 1/10/2021

Ends: 30/9/2023 

Original lay summary below

Falling can cause injury, pain, loss of confidence and independence. This is undesirable for the individual and their families, and places significant demands on health and social care services.

Falls are not inevitable. By improving an individual’s strength and balance, alongside skills to help getting up from a fall (should this happen), the likelihood of a fall occurring or having damaging consequences, such as a long lie on the floor, can be minimised. 

The Falls Management Exercise (FaME) programme is a group-based, face-to-face, six-month exercise programme specifically aimed at improving the strength and balance of people aged 65 and over.  Research has shown that FaME results in fewer falls, improved confidence, and reduced fear-of-falling. Despite this, FaME is still not available everywhere across England.  More needs to be understood about how best to increase its availability and ensure high quality delivery.

To improve our understanding of this, we previously studied FaME’s set-up, delivery and quality in the East Midlands. We learnt a lot about how to get FaME running and showed that the programmes worked outside of a research setting. Using learning from the East Midlands, we developed a guide for implementing FaME called the implementation toolkit.  This evidence-based toolkit contains all the information needed to set up and run a FaME programme, from making the initial business case to promoting it to participants.  We now want to use this toolkit to see if FaME can be made more available in two new, and very different, regions: Greater Manchester and Devon, and assess whether FaME works in these populations too, particularly if adaptations are made because of Coronavirus. 

We aim to:

1) Understand how best to increase availability of FaME in two new areas and assess the role that the toolkit plays in this.  Using the toolkit we will work with local experts to promote FaME to organisations that decide what health services should be funded locally.

2)  Study the delivery of FaME in the new areas and see if programmes work in these populations by measuring improvements in participating individuals.

3) Test ways of maintaining the quality of FaME programmes over time.  Working with Later Life Training, a national not-for-profit organisation with expertise in FaME, we will measure the quality of programmes and test what works to make them better.

We will use this information to improve the implementation toolkit and develop plans to support national implementation of FaME.