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FLS-DB clinical audit: Identifying high-quality care in the NHS for secondary fracture prevention

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FLS forward: Identifying high-quality care in the NHS for secondary fracture prevention is the RCP's Fracture Liaison Service Database (FLS-DB) clinical audit report. It provides the first ever benchmark for the performance of fracture liaison services at the patient level and is the next step in understanding current secondary fracture prevention care in England and Wales.

Key recommendations

FLSs that participated in the report should:

  • be congratulated for their wish to evaluate and improve the patient service that they offer
  • review their own service’s performance within this report and develop effective quality improvement plans to improve quality and efficiency of patient care or of service
  • ensure that patients presenting with a hip fracture are included in the FLS-DB, as they are at very high risk of another fracture and current audits have limited measures for the quality of bone assessment9
  • develop closer working between primary, community and secondary care services to help facilitate effective management plans and to support patients to understand the importance of ongoing steps to minimise fracture risk, including adherence to anti-osteoporosis medication
  • review their performance using their own live run charts, which are available on the FLS-DB webtool
  • participate in the FLS-DB audit continuously to measure key quality aspects of their service
  • provide constructive feedback to the FLS-DB audit team by email at flsdb@rcplondon.ac.uk, so that we can improve the audit over the years to come
  • ensure that, as a minimum, they collect the audit dataset within their local pathway and then work to improve FLS-DB data submission by the next data cut-off of June 2017.

FLSs that did not participate in the report and services without an FLS should:

  • review opportunities regarding data entry options, and discuss approaches with other, well-performing fracture liaison services
  • contact FLSs that did participate and NOS for advice on how to develop and improve the services offered by an fracture liaison services.

Chief executives and hospital trust boards should:

  • support their FLS’s work for quality improvement to develop and improve the FLS’s services and engagement with the audit
  • recognise that secondary fracture prevention provides a great opportunity to improve integration across clinical service areas to provide a genuinely patient-centred approach.

Commissioners and local health boards should:

  • review the audit’s findings. Those clinical commissioning groups (CCGs) without an FLS should actively support a project plan so that they can implement a service in 2017/18
  • contact other CCGs with effective fracture liaison services and the NOS for support in developing strategies to establish new FLSs
  • consider aligning the key performance indicators for their fracture liaison service(s) with those of the audit run charts to reduce duplication and improve transparency.

Dissemination of local results

Generic PowerPoint slides which contain national audit data are available to download. Sites are encouraged to use this template, enter their individual data, and share their service’s audit results.


There has been a fantastic response, with over 18,356 patients entered from 38 fracture liaison services. The audit demonstrates clear areas for improvement in order for FLSs to develop greater effectiveness and efficiency, leading to sustainable funding.  However, national coverage of secondary fracture prevention using fracture liaison services is still low.

We are grateful for the hard work of many NHS professionals in England and Wales who have contributed to a very high return rate for the audit, and recognise that the findings of this audit will be challenging for many fracture liaison services. The aim of this audit is to stimulate quality improvement to ensure that each FLS in the NHS is effective and delivers its service efficiently.


Please contact us by email at flsdb@rcplondon.ac.uk or by phone on +44 (0)20 3075 1619 if you have any questions about the report.


Who's involved


  • British Geriatrics Society
  • British Orthopaedic Association
  • National Osteoporosis Society
  • Public Health England
  • The Royal College of Surgeons
  • Healthcare Quality Improvement Partnership (HQIP)