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FLS-DB annual report 2023

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The sixth annual report for the Fracture Liaison Service Database (FLS-DB), 'Rebuilding FLSs to meet local patient need', provides national benchmark performance for the care of people with fragility fractures in 2021.

Key recommendations

The report recommends the 80/50/80 model for service improvement

  • Given that the percentage of patient records submitted compared with the local estimated caseload has decreased from 49% in 2019 to 43% in 2021, fracture liaison services (FLSs) submitting less than 80% of their expected caseload to the FLS-DB should review the underlying causes for this and agree an action plan to improve identification rates.
  • All FLSs with less than 50% treatment recommendation should review their pathways in line with NICE technology appraisals and guidance (NICE CG146, QS86, TA161, TA204, TA464, TA791), NOGG 2021: Clinical guideline for the prevention and treatment of osteoporosis and the Royal Osteoporosis Society clinical standards for FLSs.
  • FLSs should continue to aim for monitoring performance for at least 80% patients who are recommended or referred for therapy. This includes patients who receive injectable therapies after referral to other clinical teams, to ensure the treatment recommendations have been actioned.

The full report has recommendations for a range of audiences including services, commissioners, and executive teams.

Map of England and Wales showing expected size of local fragility fracture population and achievement of case identification in 2021. The size of the circle relates to the expected local fragility fracture caseload.

Full report

The Fracture Liaison Service Database (FLS-DB) began collecting patient data in 2016. To date, 75 FLSs have submitted patient data from over 400,000 patients across the NHS in England and Wales.

This annual report presents the results of analysis on secondary fracture prevention care received by patients aged 50 and older in England and Wales in 2021, using the 11 FLS-DB key performance indicators (KPIs). These are complemented by the data from the benchmark tables and run charts which are publicly available on the FLS-DB website. The findings have been presented against data from 2019 to compare the current performance of FLSs with pre-COVID-19 level performance. For the first time in the FLS-DB audit, results have been presented for the KPIs by age, gender, care home status and geography.

The report encourages services to focus on KPI 2 and KPI 3 (identification), KPI 7 (bone therapy recommended) and KPIs 9, 10 and11 (monitoring, follow-up and adherence) for service improvement goals (80/50/80 model).

Local commissioners and FLSs should use this report to improve the effectiveness in post-fracture care delivery from existing FLSs through service improvement and additional commissioning to reduce the number of preventable fragility fractures in this high-risk patient group.

If your organisation (hospital, primary care practice, network and/or other community service) treats fractures you need to participate in the FLS-DB.

If you, or someone you know has suffered a fragility fracture we have a number of resources available to view online in the FLS-DB resource repository.

Who's involved


We would like to acknowledge and thank members of the FLS-DB advisory group who contributed to this report;

Alison Smith, FFFAP patient and carer panel

Antony Johansen, FFFAP senior clinical lead

Clare Cockill, Royal College of Nursing

David Stephens, Royal College of General Practitioners

Gavin Clunie, British Society for Rheumatology

Kathleen Briers,  FFFAP patient and carer panel

Michael Stone, Cardiff and Vale University Health Board

Neil Gittoes, Society for Endocrinology

Nimalini Ajith, AGILE, Chartered Society of Physiotherapy

Opinder Sahota, British Geriatrics Society

Rachael Thornton, MRPhramS MFRPSII, Royal Pharmaceutical Society

Rachel Bradley, British Geriatrics Society

Steven Rowntree, Royal Osteoporosis Society

Teena Chowdhury , operations director of Audit and Accreditation, Royal College of Physicians

Xavier Griffin, British Orthopaedic Association