The Royal College of Physicians Falls and Fragility Fracture Audit Programme (FFFAP) Fracture Liaison Services Database (FLS-DB) for the first time reviews the provision of NHS services to prevent further fragility fractures in England and Wales.
FLS breakpoint: opportunities for improving patient care following a fragility fracture sets the scene in England and Wales regarding the organisation of fracture liaison services (FLSs).
It also identifies gaps in commissioning to encourage future FLS development and to improve the quality of care to patients. Every acute NHS trust in England and Wales, regardless of whether it has an FLS, was contacted and eligible to participate. Eighty-two sites participated in this audit (this is estimated to be just under half of eligible sites).
A well organised and appropriately funded FLS is an effective way to prevent further fragility fractures and requires an integrated approach between various health care providers in hospitals, primary and community care settings. The National Osteoporosis Society (NOS) estimated that effective secondary fracture prevention within the NHS would prevent over 46,000 avoidable fragility fractures over 5 years in the UK.
However, the report reveals that most services are not funded to match the level of patient need with variation in how patients with a fragility fracture are identified, investigated, treated and subsequently monitored.
Other key findings include:
- There is wide variation in the types of clinical investigations routinely offered to fragility fracture patients meaning that nationally fragility fracture patients may not be offered a consistent standard of care.
- Nearly half of FLSs delegated their monitoring to primary care providers. This means that there may be no way of identifying whether the patient has continued with their treatment. This is important because poor persistence to osteoporosis medications is common.
- Where a falls assessment was carried out by the FLS, there was a wide variation in types of questions asked.
We recommend that FLSs review their current service to identify any gaps and variations in secondary fracture prevention and then start to take the necessary steps to address these issues.
Other key recommendations include:
- Commissioning – clinical commissioning groups (CCGs) and local health boards (LHBs) should ensure that FLSs are commissioned to identity and treat all fracture groups.
- Identification - FLSs should ensure there is a process to identify all patients aged 50 years and over with a new fragility fracture including hip fracture patients and those with newly reported vertebral fractures.
- Bone health - FLSs should ensure that all fragility fracture patients are assessed and received treatment for bone health in line with NICE guidance.
- Falls assessments - FLSs should link with local falls prevention services to ensure that falls assessments are performed and, in line with NICE guidance.
- Monitoring– patients who are recommended medication to reduce risk fracture should be reviewed within four months of the fracture to ensure appropriate bone and falls interventions have been initiated.
Dr Kassim Javaid, FLS-DB clinical lead said:
This is the first time there has been a national audit on the provision of services in fragility fracture prevention across England and Wales. The FLS-DB results show that although there are pockets of really good care, many services are not meeting the needs of their local patients. I hope this inaugural facilities audit is the first step to help services work towards reducing the number of fragility fractures currently happening in England and Wales.
1 in 2 women and 1 in 5 men break a bone after the age of 50 and most fractures occurring in older people are related to falls to the ground, known as a fragility fracture. Fragility fractures are related both to the risk of falling and bone health and, are potentially life changing. Those individuals who suffer a fracture can experience ‘loss of mobility and independence, social isolation and depression’ and may be at risk of future fractures. The current hospital cost of hip fractures is approximately £1.9 billion, excluding any social care costs.
Critically, one fragility fracture significantly increases the risk of another fracture for the patient. Routine delivery of evidence-based secondary preventive care to patients presenting with fragility fractures provides an opportunity to learn about the underlying cause of the fracture and receive treatment to prevent it from happening again.
The FLS-DB is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP)*. The FLS-DB is managed by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians, as part of the Falls and Fragility Fracture Audit Programme.
For more information or to arrange an interview, please contact Jessica Smith, communications manager, RCP Care Quality Improvement Department on 020 3075 1354.
Fracture Liaison Service Database (FLS-DB) Facilities Audit
The overarching aim of the facilities audit is to appraise the national situation on the organisation of FLSs. The audit provides an important first step in building a more comprehensive national picture of fragility fracture secondary prevention, as well as a comparison of service models and associated outcomes at the patient level for different NHS organisations. This will identify gaps and shortfalls in commissioning of FLSs and assist the sharing of best practice, which in turn will generate improvements in outcomes for this patient group. This work strongly serves the public interest as it aims to improve the health of many individuals, improve the quality and consistency of care and reduce pressure on the NHS both in financial terms and in hospital admissions.
The Royal College of Physicians
The Royal College of Physicians (RCP) plays a leading role in the delivery of high‐quality patient care by setting standards of medical practice and promoting clinical excellence. The RCP provides physicians in over 30 medical specialties with education, training and support throughout their careers. As an independent charity representing 32,000 fellows and members worldwide, the RCP advises and works with government, patients, allied healthcare professionals and the public to improve health and healthcare.
The Clinical Effectiveness and Evaluation Unit (CEEU) delivers an ambitious programme of work that supports the RCP’s strategic aim to improve care for patients via its national clinical audit, healthcare quality improvement and patient safety.
*About HQIP, the National Clinical Audit Programme and how it is funded
The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the National Clinical Audit Programme (NCA), comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands.