House of Commons - Health Committee

Commissioning - Health Committee Contents

Memorandum by the National Osteoporosis Society (COM 111)

COMMISSIONING

EXECUTIVE SUMMARY

1. Osteoporosis causes fragile bones and can lead to painful and disabling fractures. Bone protecting treatments, recommended by NICE and available on the NHS, have been shown to reduce a person's chances of fracture by up to 50%. Fracture Liaison Services (FLSs) ensure that those at risk are identified and offered treatment. However, only a third of local areas in England offer access to an FLS, leaving many patients without NICE recommended treatments. This is putting them at risk of unnecessary fractures and without access to follow-up services which may be necessary to reduce their risk of falls.

2. At present, the commissioning process is not working effectively enough for patients with or at risk of fractures. Guidance on commissioning comprehensive falls and fracture services has been produced by the Department of Health (DH) for PCTs and local authorities as part of the Prevention Package for Older People. The guidance must now be implemented. PCTs and local authorities should also review their falls and fracture services, to stimulate best practice. This process could be led by Strategic Health Authorities (SHAs).

OSTEOPOROSIS AND FRAGILITY FRACTURES

3. Osteoporosis causes fragile bones, which can lead to painful and disabling fractures. It is a long-term condition which affects 2.3 million people in England[2],[3],[4]. In the UK, one in two women and one in five men will fracture at some point after the age of 50, mainly because of poor bone health. 300,000 fragility fractures (fractures which result from a fall from standing height or less) occur every year in the UK.

4. Hip fractures which result from osteoporosis are extremely serious: 10% of patients die within one month of their injury; 30% die within a year. 78,000 hip fractures occur annually in the UK. £2 billion is spent every year treating and caring for UK hip fractures[5],[6],[7],[8].

5. Yet fractures which result from osteoporosis are not inevitable. Bone protecting treatments, recommended by NICE and available on the NHS, have been shown to reduce a person's chances of fracture by up to 50%.

FRACTURE LIAISON SERVICES (FLS)

6. The occurrence of a fragility fracture is often the first sign that an individual has osteoporosis and is at a higher risk of sustaining a future fracture. It is a fact that half of all hip fracture patients have suffered previous fragility fractures[9],[10],[11],[12].

7. It is, therefore, vital that every person who suffers a fragility fracture in any part of their skeleton is identified. This should be following presentation at a hospital or through their GP. Each fragility fracture patient should also be offered a future fracture risk assessment. Where appropriate, this should lead to advice and treatment to ensure that their future risk of falling and fracturing is reduced.

8. These important steps are recognised in a number of national policy documents in place for England, which advocate osteoporosis and falls assessment for older people who suffer fragility fractures:

— National Service Framework for Older People, Section 6: Falls. March 2001.

— NICE Clinical Guideline 21, November 2004.

— NICE Technology Appraisal 161, October 2008.

— Directed Enhanced Service (DES) on osteoporosis and fragility fracture prevention, 2008-10.

9. Despite this, a number of recent studies show that, worryingly, the majority of patients with fragility fractures are simply slipping through the net. Most are not receiving the assessment and treatment they need to prevent a further (or "secondary") fracture, as recommended by NICE.[13],[14]

10. As such, the most readily identifiable patients at high risk of future hip fracture are being consistently missed by the NHS. This is leaving those who are most vulnerable to hip fracture without the treatment they need.

11. The way to ensure that every fragility fracture patient receives the assessment and treatment they need is through the implementation of FLSs throughout England, linked to every hospital that receives fracture patients.

12. FLSs are usually provided by a dedicated nurse specialist, working under the guidance of a specialist in bone health. The nurse specialist is responsible for establishing systems of care to ensure that every fracture patient over 50 years (excluding high trauma and road traffic accident victims, whose fractures are unlikely to have been caused by osteoporosis) is identified, recorded and offered a "one-stop-shop" fracture risk assessment.

13. The FLS bridges the existing care gap between different areas of health and social care and provides seamless and efficient patient care. It also ensures that the patient does not have to manage all the different parts of the NHS themselves—the presence of an FLS means that the NHS does this on behalf of the patient.

14. Different areas of health and social care and FLSs are extremely effective in identifying those individuals with fragility fracture who may otherwise have slipped through the net. They have been found to assess over 95% of fragility fracture patients presenting at hospital, compared to just 25% at hospitals with other service configurations.[15]

15. There are some excellent examples of FLSs operating in the NHS in England. The Ipswich FLS team have published on practical aspects of setting up and running their service with a view to support like-minded colleagues wanting to establish an FLS in their own areas.[16] Other exemplary services include the Newcastle Fracture Clinic Service and the falls and fracture service in Greenwich, London.

16. Despite this compelling evidence, the proportion of hospitals in England with access to an FLS is shockingly low. An organisational audit of falls and fracture services by The Royal College of Physicians and the Healthcare Quality Improvement Partnership (HQIP)[17] published in 2009, found that:

— just 24% of NHS and Health and Social Care Trusts in England, Wales and Northern Ireland employ a Fracture Liaison Nurse

— 31% of Trusts have the assessment and management of fracture patients co-ordinated by a Fracture Liaison Nurse

— just 23% of Trusts have a written local commissioning strategy for bone health.

These results highlight a significant health inequality in terms of the future fracture risk that those patients who have and have not had their care co-ordinated by an FLS are exposed to.

17. High Quality Care for All: NHS Next Stage Review states that variations in the quality of care provided across England must be tackled if the visions of all 10 of the NHS regions are to be realised.

COMMISSIONING FRACTURE SERVICES

18. The majority of patients do not have access to services which would ensure that they receive NICE recommended treatments for fracture prevention. This shows that, for the majority of those at risk of fractures, the commissioning process is not operating correctly across England.

19. Commissioning strategies are vital to the provision of comprehensive services. All parties involved in a local falls and fracture service must be jointly involved in drafting a strategy. As an example, these should include:

— commissioners;

— health professionals (working in both primary and secondary care);

— managers at acute NHS trusts;

— intermediate care;

— local authority social care services;

— the local ambulance trust; and

— patient representatives (through a local National Osteoporosis Society support group).

20. Reviewing current service provision is an important part of the commissioning cycle. PCTs and local authorities should audit their falls and fracture care against that provided by comparator services within their SHA region. This approach has been piloted by DH the local SHA with the NHS South West region.[18] It should now be applied across England.

THE PREVENTION PACKAGE FOR OLDER PEOPLE

21. In July 2009, DH published the Prevention Package for Older People. This provides guidance for PCTs and local authorities on commissioning comprehensive falls and fracture services. The Package includes:

— a template care pathway;

— assistance on conducting a Joint Strategic Needs Assessment (JSNA);

— guidance on exercise training to prevent falls;

— a financial impact assessment, providing projections of:

— the financial costs and savings associated with a comprehensive falls and fracture service for a PCT and local authority(s); this shows that such a service will be cost-neutral for local areas to provide over a five-year period; and

— the fractures prevented by a comprehensive FLS for a population-size typically served by a PCT.

22. The guidance is based upon peer-reviewed evidence and provides local areas with the tools they need to provide patients with access to NICE-recommended treatments and care. It is consistent with DH's World Class Commissioning initiative. Though its implementation, PCTs can also deliver evidence-based, patient-centred services, helping them to meet the demands set out in the NHS Constitution and High Quality Care for All: NHS Next Stage Review.

23. The Charity was represented on the expert task group which advised the DH on the content of the Prevention Package. We are working with the Department to encourage its implementation; this includes taking part in a regional meetings held in each SHA region in 2009, led by the National Clinical Directors for Older People and Trauma Care.

About us

24. The National Osteoporosis Society is the only charity dedicated to improving the diagnosis, prevention and treatment of osteoporosis across the UK. The organisation was established in 1986 and is a well respected charity with approximately 25,000 members.

November 2009

2 Calculated using mid-2007 population data2 and osteoporosis incidence from3 Back

3 National Statistics Online, 2007. Available for download from: http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15106. Accessed on 19 January 2009. Back

4 Kanis JA, Johnell O, Oden A, Jonsson B, De Laet C, and Dawson A, 2000. Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000; 27, pp. 585-590. Back

5 Figures in5 updated using mid-2007 population data6 and the Hospital and Community Health Services (HCHS) pay and price inflation 06-077. Back

6 Torgerson D, Iglesias C and Reid DM, 2001. The economics of fracture prevention. In-The Effective Management of Osteoporosis. Edited by DH Barlow, RM Francis and A Miles, pp. 111-121. Back

7 National Statistics Online, 2007. Available for download from: http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15106. Accessed on 19 January 2009. Back

8 NHS Finance Manual, 2009. Available for download from: http://www.info.doh.gov.uk/doh/finman.nsf/Newsletters. Accessed on 19 January 2009. Back

9 Gallagher JC, Melton LJ, Riggs BL, Bergstrath E, 1980. Epidemiology of fractures of the proximal femur in Rochester, Minnesota. Clin Orthop Relat Res;150: pp.163-171. Back

10 Lyles KW, Colon-Emeric CS, Pieper C et al, 2006. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. Abstracts of the 28th Annual Meeting of the American Society for Bone and Mineral Research. 2006, ASBMR 28th Annual Meeting in Philadelphia, Pennsylvania, USA. Abstract SA405. Available for download from: http://www.abstractsonline.com/viewer/?mkey=%7BFC197A55%2DD8DD%2D4F3D%2D9994%2D290B64584CCB%7D. Accessed on 14 October 2008. Back

11 Edwards BJ, Bunta AD, Simonelli C, Bolander M, Fitzpatrick LA, 2007. Prior fractures are common in patients with subsequent hip fractures. Clin Orthop Relat Res;461: pp. 226-230. Back

12 McLellan AR, Reid DM, Forbes K, Reid R, Campbell C et al., 2004. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland. Available for download from: http://www.nhshealthquality.org/nhsqis/qis_display_findings.jsp?pContentID=2755&p_applic=CCC&pElementID=0&pMenuId=0&pservice=Content.show&. Accessed on 14 October 2008. Back