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FLS-DB facilities audit - FLS breakpoint: opportunities for improving patient care following a fragility fracture

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The Fracture Liaison Service Database (FLS-DB) facilities audit - FLS breakpoint: opportunities for improving patient care following a fragility fracture audit report provides the first detailed mapping of current service provision for secondary fracture prevention within the NHS in England and Wales. The FLS-DB is delivered as part of the Falls and Fragility Fracture Audit Programme (FFFAP), which aims to improve the delivery of care for patients who have falls or sustain fractures through effective measurement against standards, feedback to providers and quality improvement initiatives.

Key recommendations

Service providers and commissioners (or local health boards (LHBs)) should use the data in this report to review local performance and inform quality improvement. This will require collaboration and these data should form a basis for discussion to inform and improve services. The report makes recommendations for commissioners and local health boards, existing FLS providers and potential new FLS providers. These recommendations include:

For commissioners and LHBs

  • Commissioning – clinical commissioning groups (CCGs) and LHBs should ensure that aneffective FLS is part of its care pathway for secondary prevention of all fragility fracture groups.
  • Caseload – CCGs and LHBs should ensure that FLSs are commissioned to identify and treatall fracture groups such as hip fracture inpatients, other (non-hip) fracture inpatients, outpatient-treated fracture patients and vertebral fractures.

For existing FLS providers
Services should review their current service to identify any gaps and variations in secondary fracture prevention and then take the necessary steps to address these issues.

  • Identification – FLSs should ensure that there is a process to identify all patients aged 50years and over with a new fragility fracture, including hip fracture patients and those with newly reported vertebral fractures.
  • Bone health – FLSs should ensure that all fragility fracture patients are assessed andreceive treatment for bone health in line with NICE guidance.
  • Falls assessments – FLSs should link with local falls prevention services to ensure that fallsassessments are performed in line with NICE guidance, and ensure rapid access to strength and balance classes that deliver the evidence-based 50 hours of supervised exercise.7,8
  • Information – FLSs should ensure that core items (such as risk factors for bone health andfalls and fracture risk score) are included in communications within different parts of the NHS, including primary care, and with patients.
  • Monitoring – FLSs should ensure that there are clear local arrangements for monitoringpatients who are recommended drug therapy; these should occur within 4 months of the fracture to check successful uptake, and every 12 months to check and encourage adherence to the treatment plan. Pathways for monitoring should be agreed and responsibility for ongoing review should be specified and audited.

This report sets the scene in England and Wales regarding the organisation of FLSs. It also identifies gaps in commissioning to encourage future FLS development and to improve the quality of care to patients.

Every acute NHS trust in England and Wales, regardless of whether it has an FLS, was contacted and eligible to participate. Eighty-two sites participated in this audit (this is estimated to be just under half of eligible sites).

Dr Kassim Javaid, FLS-DB clinical lead said:

This is the first time there has been a national audit on the provision of services in fragility fracture prevention across England and Wales. The FLS-DB results show that although there are pockets of really good care, many services are not meeting the needs of their local patients. I hope this inaugural facilities audit is the first step to help services work towards reducing the number of fragility fractures currently happening in England and Wales.