Fracture liaison services: Towards 100% coverage in England

Approximate read time: 11 minutes 

 On 4 December 2024, the House of Lords will debate a question for short debate on progress towards universal provision of fracture liaison services in England by 2030. The debate has been tabled by Lord Black of Brentwood (Conservative).  

1. Osteoporosis and fragility fractures   

  Osteoporosis is characterised by low bone mass and structural deterioration of bone tissue.^[1] This causes bones to be more fragile and susceptible to fracture.   

  Osteoporosis is asymptomatic until ‘fragility fractures’ occur. Fragility fractures are bone breaks that would be very unlikely in someone without a decline in bone density. The National Institute for Health and Care Excellence (NICE) estimated that in England and Wales, around 180,000 fractures each year are the result of osteoporosis.^[2] NICE notes that the figure does not include all vertebral fractures: fractures in the spine, usually sustained from lifting or bending. Vertebral fractures present as back pain, which is often misdiagnosed as muscular.   

The Royal Osteoporosis Society (ROS) has explained that fractures are painful and can be challenging to recover from.^[3] Fractures can lead to social isolation, loss of mobility and independence, and depression.   

Osteoporosis is more common in older people. Bone density declines after around 35 years of age, with a steep decrease in the oldest age groups.^[4] Other factors can accelerate the decline in bone density, including smoking, diet and some illnesses. The risk of fragility fractures is increased for people who are at greater risk of falling. This can include people with visual impairments, muscular weakness, cognitive impairment and issues with coordination and balance.  

Women are more at risk than men.^[5] For women, oestrogen levels are key for bone health, and a decline in oestrogen, for example after menopause, increases the risk of developing osteoporosis. NICE states that more than two million women in England and Wales have osteoporosis. For men, low testosterone levels are associated with an increased risk of osteoporosis.  

2. Functions and operation of fracture liaison services  

In addition to some patients being identified in primary care settings, like GP surgeries, fracture liaison services (FLSs) proactively identify people with a risk of osteoporosis.^[6] FLSs are commissioned by local integrated care boards.   

An FLS contacts patients aged 50 and over with a fragility fracture to check their bone health and falls risk, with the goal of lowering their risk of a subsequent fracture. The ROS has highlighted that around 50% of people who experience a hip fracture have previously broken a bone.^[7]     

Services are usually led by specialist nurses or other health professionals who provide a clinical assessment, often including a bone density scan, and then provide treatment options and information to patients.^[8]   

3. Quality and coverage of fracture liaison services  

ROS figures from a freedom of information request in August 2021 showed that 63 out of 123 NHS trusts (51%) in England were able to confirm they had an FLS.^[9] Coverage is 100% in Scotland, Northern Ireland and Wales.^[10]  

The Royal College of Physicians maintains the FLS database, which has monitored the performance of FLSs since 2016.^[11] Looking at data for 2022, the 2024 annual report found “a major improvement in identification of patients and falls assessment”.^[12] However, it found little improvement in waiting times for bone density scans or for monitoring.  

The ROS has highlighted that monitoring and follow up are key to patients staying on treatments.^[13] Patients report finding it challenging to keep taking common osteoporosis medications, because they must be taken in a particular way and can cause side effects. At the same time, patients do not feel ‘better’ from taking them: they reduce long-term fracture risk rather than addressing any current symptoms.^[14]   

The FLS database 2024 annual report also noted that there remained poor governance and inequity of care by region and whether a patient was in a care home.^[15] It assessed that the number of patients not being identified would mean further fractures:  

There were 99,220 patients who were not identified, and we expect this will lead to 2,100 avoidable fractures over the next 2 years, including 596 hip fractures with significant increased mortality, morbidity, health and social care services use and costs. 

The FLS database also includes a dashboard, as part of the ‘Falls and fragility fracture audit programme’, including the latest available statistics against key performance indicators.^[16] In England for 2024, the dashboard estimates that 35.8% of potential patients are being reached.   

Access to diagnostic services also varies by region. The All-Party Parliamentary Group (APPG) on Osteoporosis and Bone Health attributed this to a shortage of DEXA (dual energy X-ray absorptiometry) bone density scanners and radiographers.^[17] In the latest NHS England figures, for September 2024, 56,366 patients were waiting for a DEXA scan: 18.5% had been waiting more than the targeted six weeks.^[18] This is an improvement on 33.6% in September 2023.   

4. Campaign for improvements to and increased provision of fracture liaison services  

The ROS, the Express and the Mail on Sunday have all been campaigning for 100% coverage of FLSs in England.^[19]   

The ROS has estimated that £30mn investment in fracture liaison services could prevent 74,000 fractures, including 31,000 hip fractures, over five years.^[20] ROS said, “This would save the NHS £665mn and release 750,000 bed days”. It is also calling for improvements in quality and the appointment of a national clinical director to lead the improvement programme.   

The campaigns follow two inquiry reports by the APPG on Osteoporosis and Bone Health:^[21] ‘How to end the postcode lottery for access to a quality fracture liaison service’ (2021) and ‘Fracture prevention and osteoporosis in primary care’ (2022).   

As well as advocating for 100% FLS coverage, the 2022 report concluded that people were having to “battle to access the care they needed”:   

People struggled to access GP appointments, investigations, scans and specialist advice. Many reported having to go private to get the provision they expected from primary care.^[22]  

The report recommended that the national screening committee reconsider the case for a targeted national screening programme to detect high fracture risk, citing the focus on prevention in the NHS long term plan.^[23] The national screening committee decided against screening for osteoporosis in all post-menopausal women in 2019.^[24]   

Other recommendations in the APPG’s 2022 report on fracture prevention included a public health campaign about bone health, expansion of DEXA services to tackle current backlogs and future-proof services, and personalised ‘bone health management plans’ for identified patients, with a specified timescale for reviews.^[25]  

5. Previous government policy  

In the 2022 ‘Women’s health strategy for England’ there was a commitment to “a greater focus on identifying those at particular risk [of osteoporosis and fragility fractures], and on both primary and secondary prevention, thereby addressing the treatment ‘gap’ that exists currently”. In a January 2024 statement about progress implementing the women’s health strategy, the government said osteoporosis would be factored in to the major conditions strategy.^[26]  

The government’s call for evidence for the major conditions strategy closed on 27 June 2023.^[27] It sought views on “how best to prevent, diagnose, treat and manage six major groups of conditions that contribute to disease in England”, including musculoskeletal disorders.   

The House of Lords held a debate about FLSs tabled by Lord Black in 2023. Lord Evans of Rainow responded for the government:  

We are proposing to announce, in the forthcoming autumn statement, a package of measures to expand the provision of fracture liaison services and improve their current quality. NHS England is also setting up a fracture liaison service expert steering group.^[28] 

However, no mention of FLSs was made in the autumn statement, or in the spring budget 2024. In May 2024, Secretary of State for Health and Social Care Victoria Atkins committed to action: 

I have listened to the tireless campaigning of the Royal Osteoporosis Society and the campaigns of the Express and the Mail on Sunday, so today I want to confirm that this government have the ambition to expand the use of fracture liaison services to every integrated care board in England and achieve 100% coverage by 2030.^[29] 

6. Current government policy 

In June 2024, Wes Streeting (then shadow health secretary) told the Mail on Sunday that Labour would also aim for 100% coverage by 2030.^[30] Mr Streeting committed to “FLSs right across the country”. He said, “All the evidence shows earlier diagnosis means faster treatment and better outcomes for patients”. At a September 2024 party conference fringe event, he said: “We’ve made the promise, and now we will keep the promise”.^[31]  

The government has repeated its commitment to the expansion of FLSs in written answers.^[32] The government has said it is “working closely with NHS England to develop rollout plans to end the postcode lottery”.^[33] In a written answer in October 2024, the government said that FLSs are a “key priority”.^[34]   

The government paused work on the previous government’s major conditions strategy, instead working on its own plans for the NHS.^[35] The government has launched a public engagement exercise to help shape its 10-year health plan, expected in spring 2025, which will be underpinned by three big shifts in healthcare:^[36]   

• from hospital to community 

• from analogue to digital 

• from sickness to prevention.^[37] 

The ROS argued that improving osteoporosis diagnostics would deliver on each of those shifts:^[38] 

• from hospital to community: early diagnosis and medication can keep treatment in the community and prevent hospital visits 

• from analogue to digital: databases facilitate proactive, systematic identification of people for osteoporosis assessments 

• from sickness to prevention: diagnosis after a first fracture and early access to medication reduces re-fracture rates 

In the autumn 2024 budget, the government pledged funding for NHS technology and digital improvements, as well as diagnostic tests.^[39] Craig Jones, CEO of the ROS said that the additional funding meant there is now “no excuse for Mr Streeting not to honour his commitment to roll-out these life-saving osteoporosis services nationally”.^[40] The society also highlighted that “a medical steering group including Age UK and eight expert societies has convened to support ministers and officials in making the roll-out as speedy and effective as possible”. 

---

Photo by Harlie Raethel on Unsplash