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Quality care for everybody – Fracture Liaison Service: an all-Wales approach

In a blog written to mark World Osteoporosis Day on 20 October 2023, Dr Inder Singh, the Welsh government’s national clinical lead for falls and frailty, reflects on the importance of fracture liaison services for improving patient outcomes and reducing the pressure on NHS services with his new video: ‘Osteoporosis: what you need to know.’

Fragility fractures affect half of women over the age of 50, and one fifth of men, but not everyone in Wales has equal access to fracture prevention services. COVID-19 had a significant direct and indirect negative impact on healthcare services in general, and particularly on those treating the most vulnerable and older people.

The 2023 National Hip Fracture Database report on the year 2022 observed over 72,000 hip fractures, compared with 66,000 in the year 2020 and 2021. This is about 10% higher incidence of hip fractures in comparison with pre-pandemic years. In addition, following a first fracture, there's a one-in-three chance of sustaining another fracture within 12 months. The high incidence of fragility fractures is the result of a lack of active case finding and untreated osteoporosis. Fragility fractures not only increase NHS pressures but have an immeasurable cost to the person and their family.

The most effective way to reduce the re-fracture risk is to have Fracture Liaison Services (FLS) in Wales. FLS systematically identify and investigate causes for osteoporosis and treat eligible patients aged 50 and older within a local population who have suffered a fragility fracture. FLS is a cost-effective way to reduce the risk by 30% for any re-fractures and by 40% for major re-fractures.

To overcome the enormous variability in fragility fracture care, the Welsh government has set out a top-down mandate to deliver the Falls and Fragility Fracture Audit Programme (FFFAP) recommendations. The FFFAP is a national clinical audit run by the RCP designed to audit the care that patients with fragility fractures and inpatient falls receive in hospital and to facilitate improvement initiatives. I was appointed as a national clinical lead by the Welsh government in 2020 to provide stronger clinical leadership.

The FLS Development and Quality Assurance Board (Wales), which is accountable to the minister for health and social services, has been established for delivering national standardised equitable access to FLS. A wider integration and partnership work has been introduced to ensure high-quality fracture care for everyone over the past two years across Wales. This includes undertaking a national review of services, working closely with the RCP in Wales to raise osteoporosis awareness, and engaging with Welsh health boards to assess their business case approaches and provide support. The Royal Osteoporosis Society (ROS) has supported the FLS network team to help shape policy by using cost-benefit analysis regarding the benefits of FLS.

Wales held the inaugural Fracture Liaison Service National Conference in 2022 to celebrate World Osteoporosis Day. The minister for health and social services issued a written statement, setting out clear expectations that everyone in Wales must have access to an FLS and that health boards must take ownership of delivering these services. The minister’s ambition of full national coverage and improved services should be achieved by September 2024 – after all, Welsh teams are now following the national recommended model – we have committed to identify 80% of fragility fractures, start treatment for 50% of those identified, and monitor 80% of those on a treatment pathway.

However, in 2022, Wales only identified 1,120 additional patients, compared with 2,030 patients in the year 2021. To achieve the target of 80% identification of fragility fractures by 2024, and implement FLS consistently across Wales, we need further investment, so we are exploring funding options. The FLS network in Wales continues to work with community teams and the third sector to raise education and awareness of osteoporosis. Our joint objective is to provide excellent FLS for everyone in Wales, to help identify first fractures and to achieve equitable outcomes.

To raise awareness on osteoporosis, we have created a video in collaboration with Lynne Hughes-Williams (professional visual journalist and content creator). Find out more by contacting Inder.Singh@wales.nhs.uk.

Dr Inder Singh
National clinical lead, falls and frailty
Consultant physician and geriatrician with interest in falls and bone health