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Falling standards, broken promises: report of the national audit of falls and bone health

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The Falling standards, broken promises report is based on the findings of the national audit of falls and bone health in older people 2010.

Key recommendations

  • Local NHS services should commission a fracture liaison service (FLS) in line with best evidence for fracture prevention.
  • Health and local authority commissioners should ensure adequate local provision of therapeutic exercise programmes for falls prevention.
  • Local NHS services should ensure that there is adequate provision of falls clinics, or similar, particularly for those older people who have fallen and fractured or who are at risk of fracture.
  • Emergency departments and minor injury units should introduce routine screening for falls risk and osteoporosis for all older people presenting with falls and fractures.
  • Local health commissioners should ensure that care home residents receive regular medication reviews, including treatment of osteoporosis, and, where appropriate, have access to therapeutic exercise for falls prevention.
  • Acute hospitals should review and improve their procedures for admission and care of hip fracture patients, with particular regard to pain relief, pressure sore prevention and intravenous fluids.


The audit was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and carried out by the Royal College of Physicians’ Clinical Effectiveness and Evaluation Unit (CEEU) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). Information on nearly 10,000 patients came from all NHS acute trusts, or equivalent, in England, Wales and Northern Ireland, as well as primary care organisations, mental health trusts and a sample of care homes.

The findings are significant given the scale of the problem:

  • Every year, over 500,000 older people attend UK emergency departments following a fall and 200,000 suffer fractures due to osteoporosis.
  • Falls and fractures in the over-65s account for over 4 million bed days per year in England alone, at an estimated cost of £2 billion.
  • Falls and fractures often lead to disability and loss of independence, and are the leading cause of accidental death in this age group.

There is real urgency to ensure effective assessment and management for people who fall and in the very least to ensure evidence-based fracture liaison services are established in all trusts.

Dr Jonathan Potter, clinical director at the Royal College of Physicians’ Clinical Effectiveness and Evaluation Unit

Report overview

  • Only 37% of local health services provide any kind of FLS, which is recommended as the best way to organise care to prevent future fractures.
  • Despite 94% of sites stating they use a tool that includes gait, balance and mobility assessment, only 34% of patients with non-hip fractures (ie fractures of wrist, arm, pelvis or spine) and 72% of hip fracture patients received an assessment.
  • 86% of services report that they provide supervised strength and balance exercise training, however only 19% of non-hip fracture patients participated in any form of exercise for falls prevention within 12 weeks of the fracture.
  • Many hip fracture patients do not receive adequate acute assessment and care: a third of hip fracture patients had not received pain relief within 1 hour of arriving in hospital. There was also inadequate attention to prevention of pressure sores or to early provision of intravenous fluids.
  • Many healthcare providers are failing in their responsibility to provide adequate services to reduce falls and fractures in care home residents, despite this being a high-risk group.
  • Despite modest improvements since the last audit in 2007, osteoporosis treatment remains substandard for the majority of patients. Only 33% of non-hip fracture and 60% of hip fracture patients received appropriate treatment for osteoporosis.
  • Neither emergency departments nor fracture clinics are assessing falls risk or bone health in most patients, which suggests that accident and trauma services are focused on treating the injury and not the cause of the injury or reducing the chances of further serious injury.