Osteoporosis and fracture liaison services: Reducing future fracture risk

Eve Collyer Merritt

Image shows a person with a broken arm in a cast

1. Osteoporosis and fragility fractures

The National Institute for Health and Care Excellence (NICE) explains that “osteoporosis is a disease characterized by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture”.

Osteoporosis is asymptomatic until ‘fragility fractures’ occur. Fragility fractures are bone breaks from an impact that would not cause a fracture in someone without a decline in bone density, for example a fall from standing height. NICE estimates that in England and Wales, around 180,000 of the fractures presenting each year are the result of osteoporosis. NICE notes that the figure does not include all vertebral fractures: fractures to the vertebrae in the spine, usually sustained from lifting or bending. Vertebral fractures present as back pain, which can be misdiagnosed, often as a muscular issue.

The ROS explains that fractures are painful, can be challenging to recover from and may lead to social isolation, loss of mobility and independence, and depression.

Clinical guidance for osteoporosis is provided by the National Osteoporosis Guideline Group.

2. Osteoporosis risk factors

The NHS details who is at risk of osteoporosis. Osteoporosis is more common in older people, as bone density declines after around 35 years of age. NICE also notes that the prevalence of osteoporosis increases markedly with age, from approximately 2% at 50 years of age to almost 50% at 80 years of age. Other factors can accelerate the decline. 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. 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 2 million women in England and Wales have osteoporosis. For men, low testosterone levels are associated with an increased risk of osteoporosis. Other risk factors include:

thyroid and parathyroid disorders
a family history of osteoporosis or hip fracture
a body mass index (BMI) of 19 or less
medication which affects hormone levels or long-term use of high-dose steroid tablets
having an eating disorder, such as anorexia or bulimia
heavy drinking or smoking
rheumatoid arthritis
malabsorption-related conditions, such as coeliac disease and Crohn’s disease
long periods of inactivity, such as long-term bed rest

Health professionals often use the FRAX fracture risk assessment tool to help identify osteoporosis risk, using personal details such as height and weight, medication history, smoking history and family history.

The Royal College of Physicians also highlights that patients from households with lower incomes are more likely to have a hip fracture and have poorer outcomes after a hip fracture.

3. 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. 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 highlights that around 50% of people who experience a hip fracture have previously broken a bone.

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

4. Quality and coverage of services

ROS figures from August 2021 show that 63 out of 123 NHS trusts (51%) in England were able to confirm they had an FLS. In comparison, coverage is 100% in Scotland and Northern Ireland, though trusts in these parts of the UK do not report on quality in the same way as trusts in England and Wales.

The Royal College of Physicians maintains the FLS database, which monitors the performance of FLSs in England and Wales. The latest collated figures, referring to 2021, highlight “a signification variation between FLSs […] with a negative impact on patient safety”. For example, the average percentage of patients recorded as identified by the local FLS compared to the expected instance in the population was 43%, but at a service level the range was between 4% and 103%.

One of the challenges FLSs face is staffing. The ROS recommends one whole time equivalent (WTE) nurse with 0.5 administrators to serve an over 50s population of between 40,000 and 46,000. In 2021, an average of 1.59 WTE nurses and 0.45 WTE administrators served an average population of 494,945 over 50s in England and Wales.

The FLS database also includes a dashboard, as part of the ‘Falls and fragility fracture audit programme’, indicating latest available statistics against key performance indicators. Will Quince, minister of state at the Department of Health and Social Care, describes the aims of the audit programme as “to benchmark services and drive quality improvement”.

The ROS states that “most trusts fall consistently short of the national standards, which involve identifying and seeing at least 80% of patients in a timely way, and then following up at agreed intervals to ensure, amongst other things, that patients are supported to stay on treatment—which needs to be taken for five or more years to work”.

There are known concerns about patient adherence to treatment for osteoporosis. For example, patients report finding it challenging to keep taking bisphosphonates, which are commonly prescribed to counter decline in bone density, because they must be taken in a particular way and can cause side effects. In addition, patients do not feel ‘better’ from taking them: they reduce long-term fracture risk rather than addressing any current symptoms. The FLS database reports that poor patient experience is correlated with poor adherence to treatment.

The ROS has also evaluated patient experience data. In August 2021, it reported that 38% of over 3,000 respondents had to wait over a year for an osteoporosis diagnosis after their first broken bone, 28% more than two years and 17% more than five years. The ROS also flagged concerns that less empowered patients were missing out on treatment as 29% of osteoporosis patients prompted their own health assessment.

Access to diagnostic services also varies by region. The APPG on osteoporosis and bone health attributes this to a national shortage of DEXA bone density scanners and radiographers. In the latest available NHS England figures, from May 2023, 66,469 patients were waiting for a DEXA scan: 11.2% more people than in May 2022. Figures also show 33.5% of patients had been waiting more than the targeted six weeks.

5. Campaign for improvements

The ROS and the Sunday Express newspaper have launched the ‘Better Bones’ campaign. The campaign is calling for 100% FLS coverage for England, to match the situation in Scotland and Northern Ireland and a recent pledge by the Welsh government for the same level of coverage in Wales by September 2024. It is also calling for £30mn a year in additional investment to fill gaps in coverage and quality as well as the appointment of a national clinical director to lead the improvement programme.

The campaign follows two inquiry reports by the APPG: ‘How to end the postcode lottery for access to a quality fracture liaison service’ (2021) and ‘Fracture prevention and osteoporosis in primary care’ (2022).

The 2022 report on fracture prevention found that:

Despite national guidance outlining the responsibility on primary care to identify and manage people at high risk of fracture, we found 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.

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 England in the NHS long term plan. The national screening committee decided against screening for osteoporosis in all post-menopausal women in 2019.

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.

6. Government responses and plans

In a written answer on the government’s assessment of the APPG’s 2022 report published in December 2022, Helen Whately, minister of state at the Department of Health and Social Care, said:

The report’s recommendations are predominately being addressed through the women’s health strategy and National Institute for Health and Care Excellence’s guidance on assessing and managing the risk of fragility fractures in people aged 18 years old and over. NHS England’s ‘Getting it right first time’ programme aims to improve access to secondary fracture prevention services to supplement the ‘Best MSK [musculoskeletal] health’ programme.

In the government’s ‘Women’s health strategy for England’, first published in July 2022 and republished a month later, there is a commitment to “a greater focus on identifying those at particular risk, and on both primary and secondary prevention, thereby addressing the treatment ‘gap’ that exists currently”. It also pointed to £3mn of funding for a national ‘reconditioning programme’, which aims to support older people to build strength and resume their pre-pandemic activities, and the health promotion taskforce, which will “identify opportunities to take action across government to improve health and reduce health disparities”.

The NHS ‘Best MSK health’ programme, part of the ‘Pathways to better health’ programme, has published pathway templates and key performance indicators for osteoporosis management. The guidance was described as supporting “the recovery and transformation of MSK services” by the Chartered Society of Physiotherapy. However, the ROS reports that responsibility and increased expectations in implementation sit with primary care but that this is without accompanying increases in funding.

On the question of appointing a national clinical director, the government has stated that Andrew Bennett, NHS England’s national clinical director for musculoskeletal conditions, holds the portfolio for osteoporosis and fracture prevention.

Lord Markham, parliamentary under secretary of state at the Department of Health and Social Care, responded to a written question on FLSs on 16 June 2023. He said a forthcoming strategy would contain more detail on improving MSK treatment and prevention:

The government recognises the value of quality assured secondary fracture prevention services, including fracture liaison services. NHS England is working with commissioners to support the mobilisation and implementation of fracture liaison services in each area and establish a greater number of clinics. […] The forthcoming major conditions strategy will set out a clear vision for musculoskeletal conditions, covering treatment and prevention, alongside other major conditions.

The government’s call for evidence for the ‘Major conditions strategy’ closed on 27 June 2023. 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.

7. Read more

Timothy J S Chesser et al, ‘Overview of fracture liaison services in the UK and Europe: Standards, model of care, funding, and challenges’, OTA International: The Open Access Journal of Orthopaedic Trauma, 2022, vol 5, issue 3S

Cover image by ronnachaipark on Freerange Stock.

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