Here we show that the number of emergency hospital admissions in England due to falls on snow and ice varies considerably by year; in 2007/08 there were 890 hospital admissions in England, while there were 16,064 in 2009/10 (Figure 1). There is an inverse relationship between the rate of weekly emergency hospital admission due to falls on snow and ice and weekly temperature and this relationship is exponential (Figure 2). For temperatures below 1°C the prediction underestimates the true rate suggesting that the exponential increase in the rate of emergency admissions for falls on snow and ice may be stronger for lower temperatures. The association between the rate of emergency hospital admissions due to falls on snow and ice and temperature would likely be even stronger if daily temperature had been used and the effects of short fluctuations in temperature that can occur during a week had been captured. However, the focus of this paper is the impact of the prolonged cold temperatures lasting more than a couple of days; circumstances which are relatively unusual in England and which we hypothesised would result in increased admissions for falls on snow and ice because the infrastructure is less able to cope than during the more common occurrence of a day or so of cold temperatures.
The winter of 2009/10 was particularly cold  and in many areas of the UK, pavements and roads were left untreated allowing snow and ice to accumulate . During this period, the highest rate of emergency hospital admissions due to falls on snow and ice were among the elderly, and particularly among men aged over 80 (Figure 3). Interestingly, the relationship between gender and age and the rate of emergency hospital admissions for falls presented here was similar to previous work conducted in Sweden, which also showed a higher rate of admissions among women than men aged 50 and 79, followed by a higher rate among men aged over 80 . Implementing measures such as organising snow clearing and assistance with shopping for elderly people would decrease their exposure to falls, while the use of anti-slipping devices for shoes and personal protection devices like hip padding could also play an important preventative role . Research conducted in the USA on all falls among people aged 65 and over, demonstrated that fall related medical expenditure is two to three times higher for a woman than a man, with authors hypothesising that this discrepancy was due to higher costs of osteoporotic fractures, which disproportionately affect women .
Here we show that the costs for hospital trusts in England of treating emergency admissions due to falls on snow and ice during this three month period was 42 million GBP. The total cost of these accidents to the health services is likely to be much higher. Firstly, the costs presented here do not include the cost of treating people who attended Accident and Emergency departments but who were not admitted to hospital, nor the costs of people who contacted primary care services like their GP, pharmacist or 'walk in' centre for treatment. Secondly, the costs detailed here do not include longer term health and social care costs. Among older people, for example, falls are often associated with hip fractures which frequently lead to loss of independence and disability requiring extensive rehabilitation (in NHS outpatient departments) and nursing home admission [13, 14]. Indeed a study in the UK estimated that the healthcare costs associated with a typical hip fracture in 2000 were approximately 25,000 GBP with long stay residential care accounting for 80% of this cost . Finally, the costs do not include falls on snow and ice that occurred outside of December to February, nor do they include wider societal costs as a result of sickness absence from work.
Worldwide, falls are the second leading cause of deaths from accidental or unintentional injury , but snow and ice injuries are different from other major accidents in that they are predictable and preventable. A key aspect of fall prevention strategies is creating safe environments  and the most important aspect for preventing falls involving snow and ice is clearing pavements . Following the 2009/10 winter, much discussion ensued about the wisdom of stockpiling large amounts of salt to clear roads from snow and ice and the cost of this if it was not used. Discussions also focused on the costs to the economy of lost revenue from business which had to close because employees could either not make it to work or because of childcare issues due to school closures. The financial cost of falling on snow and ice received little attention.
Within the context of Government proposals for massive changes to the way in which the health service is delivered in England, responsibility for health improvement will be transferred from primary care trusts to local authorities , with local authority based health and wellbeing boards taking on the responsibility of joining up health and social care commissioning and partnership working . Consequently, in the future, local authorities will need to balance the costs of public health prevention measures, such as gritting the roads and pavements, and indeed the costs of stockpiling salt in preparation of this, with the economic and healthcare costs associated with falls due to snow and ice. Such decisions will be made all the more difficult in the coming winters because Council Tax is frozen for at least a year and possibly even longer .
A significant focus of the new UK coalition Government is to encourage social responsibility and volunteering and people coming together to help one another and improve their communities . The Local Government Association has reiterated these sentiments, believing that a joined up approach to snow clearing that encourages the public to take a more active role would help to ensure that more footpaths and cycle paths remain clear . Indeed a newspaper report suggests that Knowsley council in Merseyside, in the North West of England, has already suggested that they will advocate that the public and businesses keep pavements clear of ice . In other European countries, like Germany, Austria and Switzerland, regulation is already in place that requires citizens to keep their pavements clear of snow. In the US state of Minneapolis, snow must be removed within 24 hours of the snow fall ending, while in Boston, fines can reach up to $250 for every day that the snow remains . While such initiatives seem sensible, a significant obstacle to this approach in the UK is public concern about litigation should an injury occur on an area that they have cleared . In response to these concerns, and wider unease about the growth of a compensation culture in the UK, a recent Government review of the operation of health and safety laws identified the publication of snow clearing guidelines as a key milestone for immediate consideration . However, clarifying the legal position may not be enough to encourage the public to act altruistically towards other members of their community; of the 14,800 excess deaths in Paris during the heat wave of 2003, 19% occurred at home , suggesting a lack of family or community support for those in high risk populations.
The UK population is ageing and the cost of falls to the NHS is expected to rise , while the cost of hip fractures is predicted to double between 2007 and 2050 . The economic burden of falls underscores the need for effective prevention interventions, including those that focus upon preventing falls due to snow and ice. The media (for example meteorological forecasts) can be effective in communicating health protection messages to the public  but the information must be meaningful and presented in a manner which supports those people most at risk to make sensible decisions.