Last month, the RCP Falls and Fragility Fracture Audit Programme (FFFAP) published its 2019 commissioner's report on fracture liaison services (FLS-DB) across England and Wales. Dr Gareth Llewelyn, our vice president for Wales, takes a look at the findings, and looks ahead to implementing the recommendations in Wales.
'The financial implications of failure to provide universal access to secondary fracture prevention are significant, and will only worsen as our population ages.'
Osteoporosis currently affects over three million people in the UK. It is a condition that weakens bones, making them fragile and more likely to break – especially those of the spine, wrists and hips. They are known as ‘fragility fractures’ if they are caused by a fall from a standing height or less.
People who have suffered a fragility fracture are at higher risk of breaking another bone, and many break a number of bones before they are diagnosed with osteoporosis. According to the Royal Osteoporosis Society (formerly the National Osteoporosis Society), a fifth of women who have broken a bone will sustain three or more fractures before being diagnosed.
This is not merely a statistic in an academic paper, these numbers represent individuals. For many, these injuries will have been traumatic with far-reaching consequences.
Last year, over 300,000 fragility fractures were sustained by patients aged over 50 across England and Wales. As Iona Price, chair of the FFFAP patient panel explains, 'this is not merely a statistic in an academic paper, these numbers represent individuals. For many, these injuries will have been traumatic with far-reaching consequences.' Many patients will need to start using walking aids, and some will have to move to a care home setting after a fracture.
Indeed, the National Hip Fracture Database reports that hip fractures alone account for 4,000 hospital admissions in Wales and over 120,000 bed days in Welsh hospitals. They cost the Welsh NHS at least £100 million a year, excluding the impact on social care services.
But the good news is that thousands of fractures could be avoided if more patients were to undergo rapid assessment and timely treatment post-fracture. That’s why the RCP has been working to persuade health boards and NHS bodies across Wales that we need more fracture liaison services (FLS) in our hospitals and communities.
These multi-disciplinary teams are made up of nurses, doctors, therapists and administrative staff who are able to identify and treat people aged 50 and over who have suffered a fragility fracture. The aim is to reduce their risk of subsequent fractures; crucially, an FLS is also able to refer people to other services to improve their bone health and reduce their risk of falling.
This requires joint working between specialties in hospitals, GP surgeries and community services. Something we should be in an excellent position to achieve, given our integrated health system here in Wales.
- FLSs should ensure identification is above 50% of their expected caseload.
- FLSs with >10% of all submitted patients presenting with a spine fracture should work together to define the best practice pathways for spinal fracture identification.
- FLSs should ensure their services meet with Sefydliad Cenedlaethol dros Iechyd a Rhagoriaeth Gofal (NICE) and Grŵp Canllaw Osteoporosis Cenedlaethol (NOGG) guidelines for treatment.
- FLSs that are not routinely recommending or referring their patients for falls assessment should pilot an agreed falls pathway in their FLS.
- FLSs with >50% identification of their expected fracture caseload are advised to prioritise improving monitoring over improving identification.
The Welsh government should now take these recommendations seriously. Dr Antony Johansen, the RCP’s clinical lead for the National Hip Fracture Database (NHFD) and a consultant ortho-geriatrician at the trauma unit at the University Hospital of Wales (UHW) in Cardiff, says that while some hospitals in Wales, including Bronglais Hospital in Aberystwyth, are beacons of good practice, many others are lagging behind.
Ideally, each health board should be considering its performance against several key performance indicators (KPIs) on a monthly basis and the Welsh government should be asking them why they are not performing if they are not meeting 75% of their KPIs on a regular basis. None of it is unachievable because it’s all happening somewhere in Wales.
'Ideally, each health board should be considering its performance against several key performance indicators (KPIs) on a monthly basis and the Welsh government should be asking them why they are not performing if they are not meeting 75% of their KPIs on a regular basis. None of it is unachievable because it’s all happening somewhere in Wales,’ explains Dr Johansen.
So what do the findings from the 2018 FLS-DB annual report tell us? Well, we know that the identification of fractures is improving, and more patients than ever are being referred for a falls assessment. However, broadly speaking, there is an overall decline in post-fracture monitoring.
The chief executive of the Royal Osteoporosis Society, Claire Severgnini says she is ‘confident that the focus this year on several key performance indicators will continue to drive progress in standards of care in a targeted fashion. There is still more work to be done, but [this report] shows us where improvements are required and how to achieve them.’
‘Fragility fractures should be understood as the canary down the mineshaft of healthcare,’ Dr Johansen says. ‘For example, a patient with a hip fracture often bounces between different hospital departments, with little to no cooperation or collaboration between teams, and worse still, no mechanism to measure cooperation. In an ideal world,’ he adds, ‘we need to use independent audits like the FLS-DB and the National Hip Fracture Database to improve care.’
The RCP Cymru Wales team will continue to collaborate with our colleagues at the FFFAP team in London to influence change and improve patient care for those who need fracture liaison services.
For more information, please contact the Fracture Liaison Service Database by telephone on +44 (0)20 3075 1511 or email at FLSDB@rcplondon.ac.uk.