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Achieving effective service: FLS Database Annual report 2018

The FLS Database Annual report 2018 provides the second national benchmark for the performance of FLSs at the patient level and shows that there has been an improvement in most key performance indicators (KPIs) but further work is needed for effective and efficient service delivery.

Key recommendations

  • 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 NICE and 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.


There are over 300,000 fragility fractures in England and Wales every year in patients aged 50 years and over. This includes 66,668 hip fractures and 70% survive at least a year with one in two needing to start using walking aids and one in five having to move to a care home setting. This has a life-changing impact on the patient and their family, as well as presenting a burden to health and social care. 
Having a fragility fracture identifies a patient at risk of another fracture and each patient needs to be assessed for their risk of osteoporosis and falling. Those assessed to be at high risk must be offered effective interventions to reduce their risk of future fractures. This post-fracture care requires joint working between specialties in hospitals, GP surgeries and community services. FLSs were recommended by the Department of Health in 2009 to provide this vital link, guiding patients through the different parts of the NHS to ensure the patient gets the right treatment at the right time. FLSs need to deliver effective care at scale to realise the potential benefits of secondary fracture prevention for their communities. 
The FLS-DB began collecting patient level data on a continuous basis from 1 January 2016. There has been tremendous engagement from the FLS community and to date 65 FLSs have submitted patient data from over 135,000 patients across the NHS in England and Wales. The FLS-DB is the only national secondary fracture prevention patient-level audit in the world.

Key findings

We congratulate the achievement of the 55 FLSs across England and Wales that submitted data which contributed towards this report. 52,731 patient records were included in 2017, an increase from 42,589 in 2016:

  • Identification – In 2017 identification of all fractures had improved to 43% compared with 40% in 2016.
  • Identification – On average 6% of patients had a spine fracture in 2017, compared with 4% in 2016.
  • Treatment recommendation  – The percentage of patients being recommended anti-osteoporosis medication increased to 43% in 2017 from 38% in 2016.
  • Falls assessment – 46% of patients received (or were referred for) a falls assessment compared with 40% in 2016.
  • Monitoring contact –  There was a decline in monitoring in 2017 with only 38% of patients recommended anti-osteoporosis medication being contacted at 12–16 weeks post fracture compared with 41% in 2016.