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Hip fracture care still improving, but two in five patients still not receiving best practice care

The National Hip Fracture Database's (NHFD's) ninth annual report shows that while more patients are receiving early surgery and surviving a hip fracture, two in five are not receiving all of the recommended elements of a hip fracture programme that represent ‘best practice’.

Key findings

The NHFD report analyses the process and outcomes of care of nearly 65,000 people who presented with a hip fracture across 177 hospitals. It reports much good practice within inpatient care, with the majority of patients getting prompt surgery, specialist geriatric assessment and consideration of their nutritional status.

But, across the country nearly 40% of patients are still not receiving the full package of care that represents best practice and are missing out on important clinical assessments that will improve their rehabilitation and recovery after this serious injury. In addition, in England, the full package attracts the £1,335 additional payment of Best Practice Tariff (BPT), so hospitals are missing out on potential income.

Some of the other key findings of the latest report include:

  • A rise in length of hospital stays of 1 day in English hospitals, equivalent to the use of an extra 160 inpatient beds across NHS services in England.
  • Over 85% of patients now receive surgery appropriate to the type of their hip fracture, but almost 4,000 patients that NICE recommend should be offered a Total Hip Replacement were not able to have that operation.
  • An examination of patient outcomes at 120 days shows that from the 18,141 patients for whom the audit has this data, 9% (1,545) remain completely immobile 4 months after their injury.

    Antony Johansen, geriatrician clinical lead for the NHFD said:

    The elements of care that define best practice in England are designed to encourage teams to deliver key elements of a hip fracture programme – a multidisciplinary, patient-centred approach that considers the wider health of frail people with this potentially life-changing injury.

    If 40% of patients are not receiving this care – usually because they miss out on just one or two elements, this could compromise their rehabilitation and recovery. If this figure could be halved then a typical unit seeing 360 cases a year would attract an additional £100,000 in BPT each year – an obvious target in financially challenging times.

    What is NHFD?

    NHFD is an NHS quality improvement programme that has dramatically improved the care of elderly people admitted to hospital with a hip fracture. Now in its tenth year, the database has continuously collected data on all over 60 year olds with a hip fracture in England, Wales and Northern Ireland. During this time, more than half a million patient records have been submitted, enabling comprehensive monitoring of patient care from admission to hospital through to post-discharge follow-up.

    NHFD data

    Reporting on NHFD data has contributed to major improvements in patient treatment and care, including:

    • The number of hospitals participating in the NHFD has increased from 11 in 2007 to 177 in 2017 – every acute hip fracture unit in England, Wales and Northern Ireland
    • The rate of early surgery has increased from 55% in 2007 to 71% in 2016 meaning that more patients than ever are promptly relieved of pain and so able to commence rehabilitation
    • Improved 30-day mortality after hip fracture, from 10.9% in 2007 to 6.7% in 2016 means that this year over 2,700 more patients survived the injury than did so in 2007
    • Hip fracture services nationwide are able to monitor their services and implement continuous quality improvement using real-time online performance charts.

    Notes to editors

    Media contact

    Joanna Morgan, CQID communications manager, Royal College of Physicians

    List of best practice indicators

    1. Time to surgery within 36 hours from arrival in an emergency department, or time of diagnosis if an inpatient, to the start of anaesthesia
    2. Admitted under the joint care of a consultant geriatrician and a consultant orthopaedic surgeon
    3. Admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia
    4. Assessed by a geriatrician in the preoperative period: within 72 hours of admission.
    5. Postoperative geriatrician-directed multi-professional rehabilitation team
    6. Fracture prevention assessments (falls and bone health)
    7. Pre- and post- operative cognitive assessment using the Abbreviated Mental Test Score

    About the National Hip Fracture Database (NHFD)

    The National Hip Fracture Database (NHFD) documents major innovations in collaborative working between orthopaedic surgeons and geriatricians which drive improved care for patients requiring emergency hip fracture surgery. Its annual report collates this data.

    The NHFD is a clinically led, web-based quality improvement initiative commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by the Royal College of Physicians (RCP). The NHFD was founded by the British Orthopaedic Association and the British Geriatrics Society between 2004 and 2007. It has collected data since 2007. In 2012 the NHFD moved to be managed as part of the Falls and Fragility Fracture Audit Programme (FFFAP) within RCP London.

    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, 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.

    More information, including audit reports, can be found at the NHFD website.