The need for fully joined up patient services to improve hip fracture care

The National Hip Fracture Database (NHFD), which has been recording hip fracture care data for almost 10 years, has been a crucial driver for improvement in patient care and outcomes for people following admission to hospital with a hip fracture. Professor Finbarr Martin, the Falls and Fragility Fracture Audit Programme (FFFAP) clinical lead, discusses the need for fully joined up patient services.

This year’s NHFD annual report – taken from the records of 64,864 hip fracture patients in 2015 across 177 hospitals in England, Wales and Northern Ireland – indicates that, thanks to commitment to quality improvement from clinicians, most patients received good care while in hospital and nearly two-thirds of them received ‘best practice’ care. For example, they had surgery on their first or second day in hospital and were able to get out of bed by the day after their operation.

The NHFD report found many instances where the hip fracture programme teams are unable to determine what has happened to their patients after they leave the acute unit.

Finbarr Martin, FFFAP clinical lead

However, the report also reveals that after leaving hospital information about the standard of rehabilitation care patients received and their recovery was patchy. Pockets of excellent practice do exist, and where found they are highlighted, but these are in the minority. The NHFD report found many instances where the hip fracture programme teams are unable to determine what has happened to their patients after they leave the acute unit.

A patient's story

The experience of Iona Price, who struggled to get physiotherapy rehabilitation for her 88-year-old mother Alice following her discharge to a nursing home after hip fracture surgery, is a prime example of this. Her mother was both elderly and frail but when she finally received rehabilitation services, after a delay of several months, her mobility greatly improved. It is unlikely that Mrs Price would ever have been able to return to full independence after her surgery but she may well have recovered quicker, and to a higher level of mobility, if she had received physiotherapy services sooner.

To enable quality improvement HFPs must reach into community elements of the patient pathway too.

Finbarr Martin, FFFAP clinical lead

NICE recommends all patients undergoing hip fracture surgery are cared for, supported and monitored through a hip fracture programme (HFP) covering the whole pathway of care, from acute services through to community-based rehabilitation. The NFHD report found that, though hospitals do have HFPs in place, too many programmes are focused entirely on acute care. To enable quality improvement HFPs must reach into community elements of the patient pathway too.

Some programmes, such as those cited in the report at the Royal Berkshire Hospital and St Peter’s Hospital, where partnerships linking hospital and community services are improving outcomes and reducing hospital bed occupation, are achieving this. If they are not already doing so, all hospitals need to follow this example by developing their own local partnership model.

Joining up patient services

The NHFD report calls for:

  • multidisciplinary hospital teams and community service providers to be included in the governance of HFPs
  • local joint strategies and shared targets across pathways devised around the patient’s needs
  • a clinician-led 120-day follow-up review for all patients to determine success of rehabilitation models and ensure adherence with therapies to prevent future fractures.

Emergency hip fracture surgery represents a huge cost to the NHS and length of hospital stay represents the largest portion of this cost. Improved patient outcomes from a truly joined up patient recovery pathway across health, community services and social care can significantly improve the experience and outcome for older people. It can also provide a much needed cost saving for the NHS.

The focus on hip fracture that has developed alongside NHFD has resulted in significant improvement in both length of hospital stay and patient 30-day mortality rates. However, outcomes which matter most to patients – mid- to long-term recovery of mobility – now need to be a priority in hip fracture care as NHFD moves into its 10th year.