Audit of fragility fracture prevention services calls for improvements in patient care

A report published today by the Royal College of Physicians (RCP) finds that while more fracture patients are receiving a bone health check by a Fracture Liaison Service (FLS), a greater standard of care for all ‘fragility’ fracture patients is required.

This echoes estimations that implementing effective secondary fracture prevention within the NHS could help prevent over 50,000 fractures over the next 5 years.[1]

The report, Leading FLS improvement: Secondary fracture prevention in the NHS, from the RCP’s Falls, Fragility and Fracture Audit Programme (FFFAP)  finds that despite fracture liaison services (FLSs) being an effective way to prevent further fragility fractures,  access to an FLS and the quality of care provided depends too much on where a patient lives.

There are more than half a million fragility fractures in the UK each year, including around 79,000 hip fractures, at a cost to the NHS of £4.3 billion a year.[2] Individuals over the age of 50 who experience fragility fractures, the majority of whom are post-menopausal women, are more likely to go on to suffer more serious bone breaks, such as hip fractures, as they age.

Nearly half of all fracture patients identified are seen by an FLS, although this also remains very variable depending on each service.

The audit found that 67% of patients were assessed by an FLS within 90 days. This, however, varies widely depending on the NHS Trust, with less than a quarter of FLSs able to assess over 95% of patients within 90 days. In comparison, a similar number (28%) of FLSs saw less than half of patients in the same time frame.

The report’s findings and recommendations include:

  • There is a marked variability in the proportion of patients receiving recognised standards of care:
    • some FLSs are seeing a lower number of patients than elsewhere in the country, as well as identifying less vertebral fractures than elsewhere.
  • More patients are receiving a falls assessment, now at 40% compared to the previous figure of 32%.
  • Only 41% of patients who were prescribed anti-osteoporosis medication were monitored by 12-16 weeks post fracture. The report recommends that that more work should be done to improve monitoring of fracture patients.
  • National coverage of secondary fracture prevention using FLS remains low with around just a third of all acute trusts participating. The majority of trusts that did not provide data do not have a FLS, contributing further to the regional variance in care a patient can receive.
  • CCGs and LHBs without an FLS should actively work with their local NHS staff to develop fund and implement a service.[3]

Dr Kassim Javaid, FLS-DB clinical lead said:

Fragility fractures are very common in those over the age of 50, with the number of older people projected to experience a hip fracture expected to rise by 65% over the next 20 years. These fractures can be a potentially life-changing experience for those who suffer them and it is therefore hugely important that patients receive effective treatment and care to help ensure they do not suffer further fractures later on in life.

Being able to potentially reduce the number of preventable fractures by over 50,000 would represent a substantial reduction in emergency admissions to our already overstretched hospitals and help to lessen the demand on social care at a time when these services have never been so pressured. It would also provide a huge benefit for patients and their families and carers in reducing the stress and suffering that fractures so often cause. We have an opportunity to close this gap in bone health care and we should work together to achieve it.

Claire Severgini, National Osteoporosis Society chief executive said:

We hear far too often from people with osteoporosis about the devastating effects fractures have on their lives and their families, and it is vital that we place the prevention of fragility fractures as an absolute priority for all health services.

The work of the FLS-DB is very important in showing the many benefits of having a properly integrated fracture liaison service. Receiving great care should not depend on where you live and more work needs to be done in extending coverage of FLSs across the country.

The Fracture Liaison Services Database (FLS-DB) is the only national patient-level audit of the quality of FLSs in the world. The report is the first annual review of services provided by FLSs covering the identification, assessment, treatment and monitoring of people over 50, who have suffered a bone fragility fracture from a low, standing height fall.

The audit measures primarily against NICE technology assessments and guidance on osteoporosis, and the National Osteoporosis Society (NOS) clinical standards for FLSs.

Notes to editors


[1] National Osteoporosis Society. Benefits calculator 2016. Bath: NOS, 2016. [Accessed 27 February 2017].

[2] Freemantle N, Cooper C, Diez-Perez A et al. Results of indirect and mixed treatment compariso2n of fracture efficacy for osteoporosis treatments: a meta-analysis. Osteoporos Int 2013;24:209–17.

[3] The FLS Toolkit has been developed by The National Osteoporosis Society in conjunction with partners in the NHS to aid the commissioning of services that improve care of people with osteoporosis and fragility fractures:


  1. A ‘fragility’ fracture is a fracture that occurs as result of normal activities, such as a fall from standing height or less. They are fractures of the large bones, generally vertebrae, neck of femur or wrist.
  2. The Department of Health recommends that all patients who suffer a fragility fracture should have access to a local Fracture Liaison Service for assessment (DH Fracture Prevention services: an economic evaluation. London:DH, 2009) and, if required, received treatment to strengthen their bones. NICE clinical guideline 146 and NICE  TA161, TA204

About Fracture Liaison Services

Fracture Liaison Services, commonly known as FLSs, are coordinator-based, secondary fracture prevention services. The services are commissioned to be provided by either primary or secondary care Trusts. Anyone over 50 years of age, who may have suffered a fragility fracture, should be referred to an FLS for assessment and possible treatment. One in two women and one in five men break a bone after the age of 50. Despite strong evidence supporting the treatment, in 2013 fewer than one in five patients who experienced a fragility fracture requiring therapy were on the therapy within a year (QOF achievement, prevalence and exceptions data 2012/13).

Fracture Liaison Services Database

In 2016 the RCP published the project’s first report, a review of the provision of Fragility Liaison Services. This called for better commissioning of FLSs and better access to fragility fracture prevention services for patients. In April 2017 the RCP published the first report using patient data. This called for better data quality and improvements to patient care.

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 over 34,000 fellows and members worldwide, the RCP advises and works with government, patients, allied healthcare professionals and the public to improve health and healthcare.