A comparison of the Most Successful Fracture Liaison Services in the UK: Glasgow Royal Infirmary and Oxford University Hospitals NHS Trust.

Osteoporosis is the most common bone disease in humans both affecting women and men; the clinical manifestation of this disease is fragility fracture (National Osteoporosis Society, 2013). Fragility fractures usually result from a fall in older patients that have compromised bone strength (Fracture Fragility Network, 2013). Hip fracture is all too often the final destination of a thirty year journey fuelled by decreasing bone strength and increasing fall risk (National Hip Fracture Database, 2013). The 2007 British Orthopaedic Association and the British Geriatric’s Society’s Blue Book Standards on care of patients with fragility fracture states “the most practical option available to the NHS to attenuate the rising incidence of hip fractures is to ensure that every patient presenting today with any fragility fracture receives effective secondary preventative care”. The Blue Book advocates the establishment of a Fracture Liaison Service in every UK hospital as a means to achieve this objective. Many UK studies established that routine provision of secondary fracture prevention is occurring for a maximum of 30% of fragility fractures in the absence of a systematic approach to healthcare delivery (Nixon, 2007).

In 2007, the first national evaluation of standards of care for osteoporosis and falls in primary care was commissioned (BOA/BGS, 2007). The Department of Health had introduced the National Hip Fracture Database in 2009 as a means of driving up the standards of care by all patients who had hip fractures. Best Practice Tariffs were introduced as a means of incentives for all NHS Trusts in the UK to reward those hospitals whose standards of care for their hip fractures are high (DOH, 2009). One of the standards was effective secondary prevention of hip fracture or any fragility fracture by specialist fall assessment and bone health (DOH, 2009). These can be more effectively coordinated by the fracture Liaison Service (NHFD, 2009; Fracture Fragility Network, 2013; National Osteoporosis Society, 2013).

The Fracture Liaison Service (FLS) model was originally developed within the Glasgow university teaching Hospitals, described in details in 2 peer-reviewed publications (DOH Prevention Package for Older People, 2009; National Osteoporosis Society, 2013). In summary, the FLS relies upon a dedicated nurse specialist working within the orthopaedic environment under the guidance of an expert in metabolic bone disease. They maybe a geriatrician, orthopaedic surgeon or rheumatologist. The specialist nurse is responsible for establishing systems of care in the particular hospital to ensure that every fracture patient over 50 years receives a “one-stop-shop” osteoporosis assessment, with DEXA Scan where appropriate, by the nurse working towards protocols devised by clinicians (National Osteoporosis Society Manifesto, 2009). The FLS will integrate with local falls services and other agencies. This model has been recognized by the Department of Health and BOA-BGS as an example of best practice to implement NICE TA 87 (2007).

Glasgow and Oxford Fracture Liaison Services were visited and best practices were identified to be adapted for the establishment of our first Fracture Liaison Services in Salisbury which has seen annual rise of fragility fractures including hip fractures. A business case has been drawn up by a consultant rheumatologist colleague and is expected to be approved by Wiltshire CCG and Public Health England at the end of this month. Systems to be able to capture all fragility fracture patients-both in-patients and out-patients, had to be in place to have the maximum impact on fracture prevention. Software systems like the GISMO and Elphin will have to be considered as these seemed to have worked for both Glasgow and Oxford FLS. A fragility fracture pathway has to be developed to incorporate falls prevention, case finding, assessments, treatment initiations and monitoring of compliance with treatments. The over-all aim will be to reduce the incidence of fragility fractures especially hip fractures by as much as 15% in the next 3 years. Other objectives will be to reduce patients’ burden, integrate services-trauma case finding and community monitoring, transfer care from high costs specialist settings to lower cost community settings and integrated care which is cost-effective, safe and has resulted in a positive experience for the patients (NHS England, 2013).