24 September 2026
About the project
A six-month pilot in Keighley has shown how health, care and community organisations can work together to identify people at risk of falling and offer support before a crisis happens. The proactive falls prevention pilot used health data to identify older people who may be at increased risk of a fall, then connected them with a range of support. This included home assessments, medication reviews, exercise and education sessions, digital health monitoring and community activities.
Finding people before they need urgent help
Falls are a major cause of injury and loss of independence among older adults. Around one in three people aged 65 and over experience a fall each year, with consequences that can include fractures, hospital stays and reduced quality of life. In Bradford District and Craven, there were 2,207 falls-related admissions among people aged 50 and over in 2024, at an estimated system cost of £12 million.
Richard Carr, GP at Modality Partnership and GP Senior Responsible Officer (SRO) for Neighbourhood Health, explains:
“Rather than waiting for someone to have a fall and then responding, this project helped us identify people who might be at risk earlier and offer support before a crisis happened. Using the eFalls tool meant we could look at information already held in primary care records and reach people who might not otherwise have asked for help, including those who were housebound.”
Brendan Kennedy, Executive Partner of Modality Partnership (Airedale, Wharfe & Craven) and a GP in Keighley for more than 20 years, said:
“As a GP, one of the things I’ve always wanted to do is find people before they reach a point of crisis. Too often, we only see someone when something has gone wrong - when they’ve fallen, ended up in hospital or reached a point where they can no longer manage safely at home.
“The eFalls tool has given us the opportunity to change that. It means we can identify people who may be at risk and reach out to them while they’re still independent, still living in their own home and, importantly, before they need us in a crisis.
“For me, that’s what good healthcare should be about - not simply responding when something goes wrong, but getting there early, understanding what matters to that person and connecting them with the right support to help them stay well, safe and independent for as long as possible.”
A partnership approach
The project brought together Modality PCN, Keighley Healthy Living, Bradford Council, Bradford District Care Trust, Airedale NHS Foundation Trust and West Yorkshire Integrated Care Board (ICB) to offer targeted support to people identified as being at increased risk of falls. Elements included:
- Home assessments: 383 people received a visit from a GP or healthcare assistant to identify falls risks and wider health and care needs. This led to medication reviews, cognitive assessments, ReSPECT planning and referrals to other services where needed
- Falls prevention exercise: Keighley Healthy Living delivered a nine-week programme combining seated exercise, practical information and peer support, covering topics such as staying active, making the home safer, medication, nutrition and hydration
- Remote monitoring: Airedale NHS Foundation Trust’s Digital Care Hub offered eligible people 24/7 monitoring through the Luscii app, using daily health readings and symptom checks to identify when clinical support might be needed
- Community engagement: Bradford Council worked with local community groups to raise awareness of falls prevention and connect people aged 50 and over with local activities, exercise and wellbeing support
Together, these approaches aimed to identify risks earlier, build people’s confidence and strength and help them stay safe and independent at home.
Rita's story
Rita, who is nearly 76, joined the Falls Prevention course at Keighley Healthy Living after falling and breaking her wrist. Before the course, she was worried about falling again and lacked confidence in her balance. Walking her dog had become stressful because she constantly watched the pavement for uneven ground.
The combination of exercise, practical information and peer support helped her feel stronger and steadier. She noticed particular improvements in her legs and found everyday activities easier, including working on her allotment.
The course also opened the door to other activities. Rita joined a ballet-based exercise class, as well as other sessions and a cooking group. She says the social side has been just as important as the physical benefits, helping her make new friends and feel part of a community.
She would recommend the Falls Prevention course to others and says coming to Keighley Healthy Living has “genuinely added value” to her life.
John’s story
John, not his real name, is a 75-year-old man who had a 19% predicted risk of falling within 12 months.
A healthcare assistant’s assessment identified several issues that could increase his risk, including a previous fall, increasing unsteadiness, a drop in blood pressure when standing, concerns about memory, multiple medications and increasing pressure on his wife as his carer.
The assessment led to a range of actions. John was signposted to support with handrails and mobility aids and care. He joined exercise classes and valued the peer support that this brought. Colleagues reviewed his medication reducing them from four to two blood-pressure medicines. His blood pressure when standing subsequently returned to normal. The assessment also identified possible cognitive impairment, leading to an early referral to a memory clinic.
A ReSPECT conversation helped John record his wish to remain at home unless hospital treatment was essential, while his existing do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decision was confirmed.
The case illustrates how identifying falls risk can provide an opportunity to address several physical, social and care needs at the same time - before a serious fall occurs.
What did the pilot teach us?
Lisa Oldfield, Programme Manager Neighbourhood Health said:
“The pilot showed us that a joined-up approach can help us reach people earlier, but it also taught us that one size doesn’t fit all. Digital support worked well for some people, but not everyone had the technology, confidence or circumstances to use it. We need to offer different ways for people to access support and make sure the approach works for them as individuals.”
What happens next?
Richard said:
“The pilot has given us a strong foundation for developing proactive falls prevention across Airedale, Wharfedale and Craven. The next step is to build on what we’ve learned, look at potential for longer-term funding and more inclusive ways of reaching people as well as simpler referral and assessment processes. Strengthening the links between primary care, community services, social care and voluntary organisations, so people can access the right support in the right way, is also key.
“The pilot was short, and the group used to assess changes in healthcare use was too small to draw firm conclusions about whether the interventions reduced emergency attendances or admissions. What it has demonstrated is the value of finding people earlier and looking at the whole picture around them.”
This activity supports Neighbourhood Health which brings together the NHS, councils, voluntary, community and social enterprise (VCSE) organisations, and other partners such as the West Yorkshire Combined Authority to improve health, reduce inequalities and help people live well for longer.
You can also read the 'preventing falls before they happen – how a Keighley pilot is helping people stay safe, active and independent' case study as a PDF.