This document outlines the National Osteoporosis Society's plans to implement Fracture Liaison Services (FLS) across the UK. FLS aim to systematically identify, assess, and treat patients over 50 who have experienced fragility fractures to reduce their risk of future fractures. The document discusses establishing an FLS Implementation Group to provide strategic leadership. It also outlines developing UK FLS Clinical Standards, an FLS Implementation Toolkit, and training to help establish high quality FLS nationally. The goal is to have every person over 50 who breaks a bone assessed for osteoporosis and managed appropriately through an FLS approach.

1. FLS Implementation –
A National Approach
Friday 4 September 2015
Hilary Arden, Head of Service Delivery
Sonya Stephenson, Service Development Manager
Tim Jones, Commissioning Advisor

2. The National Osteoporosis Society
• The only UK-wide charity dedicated to
improving the prevention, diagnosis and
treatment of osteoporosis
• Vision: A future without fragility fractures
• Mission: Working together for a brighter
future for people with or at risk of
osteoporosis and fragility fractures across
the UK, putting an end to preventable
broken bones and helping people to live
without pain and disability

7. • 300,000 fragility #
• 85,000 are hip #
• 1.8M hospital bed days
• 20% die in 4 months
• 33% become totally
dependent
• £1.9B in hospital costs
Impact of Fractures in the UK

8. What is the solution?

9. A Fracture Liaison Service (FLS)
• A proven model for fragility fracture prevention
• All patients > 50 years who fracture are targeted
• 50% of hip fracture patients have had a prior
fragility fracture
• Where treatment is initiated, up to 50% hip
fractures could be avoided in future
• Clinically and cost effective
Find
them
Assess
them
Treat where
appropriate
Follow-
up

10. National Osteoporosis Society
Priorities and Plans for 2015
Aim 1:
Every person aged over 50 who breaks a
bone is assessed for osteoporosis and
managed appropriately.
Priority 1:
Extend coverage of Fracture Liaison
Services
Priority 2:
Improve quality of Fracture Liaison
Services and osteoporosis services

11. • FLS Implementation Group
• UK FLS Clinical Standards
• FLS Implementation Toolkit
• FLS Implementation Workshops
• Fracture Prevention Practitioner (FPP)
Training
• Peer Review
• Service Delivery Team
A National Approach to FLS

12. FLS Implementation Group
• National stakeholders & Government
• Provide strategic leadership and coordination
across projects
• Ensure good communication and partnership
across FLS stakeholders
• Plan and deliver agreed actions and
milestones
• Ensure delivery of high quality, efficient and
cost-effective FLS

13. Definition of an FLS
‘‘A Fracture Liaison Service (FLS) systematically
identifies, treats and refers to appropriate services
all eligible patients aged over 50 years within a
local population who have suffered a fragility
fracture, with the aim of reducing their risk of
subsequent fractures.’’

14. • FLS Implementation Group
• UK FLS Clinical Standards
• FLS Implementation Toolkit
• FLS Implementation Workshops
• Fracture Prevention Practitioner (FPP)
Training
• Peer Review
• Service Delivery Team
A National Approach to FLS

15. Service Delivery Team
Sonya Stephenson
Service Development
Project Manager
Will Carr
Service Development
Project Manager
Hilary Arden
Head of
Service Delivery
Tim Jones
Commissioning
Advisor
Mayrine Fraser
Service Development
Project Manager
Debbie Stone
Service Development
Project Manager
Fiona Gardner
Operation Projects
Officer
Henry Mace
Professional
Development Lead

16. • Facilitate stakeholder engagement
• Help establish patient/care pathway
• Project manage commissioning/funding:
o The economic and business case
o Service specification
o Resource and capacity planning
• Work with commissioners to ensure
services are sustained.
How We Help

17. • Provide input to enable the development of
an FLS meets the UK FLS Clinical Standards
• Help establish data collection, analysis,
evaluation and reporting
• Identify gaps in service provision, put in
place improvement plans and monitor
against agreed actions
• Peer review
How We Help

18. FLS: Some Localities

19. UK FLS Clinical Standards
The 5IQ approach describes the key objectives of an FLS:
• Identification
• Investigation
• Information
• Intervention
• Integration
• Quality www.nos.org.uk/fls

20. UK FLS Clinical Standards
Summary of Standards
CRITERIA RATIONALE MEASURES OUTCOMES
Identification
1 All patients aged 50 years and over with a new fragility
fracture or a newly reported vertebral fracture, whether
managed as inpatients or outpatients, will be systematically
and proactively identified.
Patients who have sustained a
fracture are at higher relative risk of
fracture than those who have not.
Targeted interventions in this
population will have most impact on
reducing future fracture burden.
Proportion of fracture patients aged
over 50 years identified by the FLS.
Denominator for all fragility fractures
can be best estimated by multiplying
total hip fractures in over 50 year
olds by 5 (1).
Systematic identification of at
risk patient population who
would benefit from investigation.
Investigation
2 Patients will have a bone health assessment and their need
for a comprehensive falls risk assessment will be evaluated
within 3 months of the incident fracture.
Assessments need to be conducted
promptly as the risk of having a further
fracture is increased in the first year.
% of identified patients who have a
bone health assessment within 3
months of incident fracture.
% of identified patients who have
their need for a falls risk assessment
evaluated within 3 months of
incident fracture.
Improved identification of the
population who will benefit from
interventions leading to
appropriate targeting of
resources.
Information
3 All patients identified will be offered written information about
bone health, lifestyle, nutrition and bone-protection
treatments.
Anyone aged over 50 years who has
had a fracture needs to be aware of
the steps they can take to maintain
healthy bones.
% of identified patients given
information.
Improved patient understanding
leading to confident self-
management and engagement
with recommended
interventions.
Intervention
4 Patients at risk of further fracture will be offered appropriate
bone-protection treatments.
Appropriately targeted interventions
reduce future fracture risk.
% of assessed patients offered
bone-protection treatment.
The right people receive the
right interventions for bone
health and falls leading to
reduced fracture risk and fewer
fractures.
Patient mobility and
independence is maintained.
5 Patients at risk of further falls will be offered appropriate
assessment or interventions to reduce future falls.
Evidence-based falls interventions are
effective at reducing falls risk.
% of assessed patients offered
referral for assessment or an
intervention.

21. Integration
6 Management plans will be patient centred and integrated between
primary and secondary care.
Effective communication is essential to
ensure that long-term management is
achieved and that patients are supported
to engage with recommended
interventions.
Measure of communication – patients
copied in/discharge letters
Written/verbal.
Patient feels supported.
Issues with treatment compliance
and adherence are identified
promptly.
Adherence to treatments is
improved leading to greater patient
benefit.
7 Patients who are recommended a drug to reduce risk of fracture
will be reviewed within 4 months to ensure appropriate
treatment has been started; and every 12 months to monitor
concordance with the treatment plan.
Treatments must be taken consistently
and appropriately over many years to be
effective. Follow-up allows early
identification of issues (side effects,
compliance) with prescribed medications,
reinforces need to take treatments and
supports long-term concordance. Long-
term management and follow-up should
be carried out in primary care.
% of patients on treatment who are
reviewed within 4 months
% of patients on treatment who are
assessed annually.
Quality
8 Core clinical data from patients identified by the FLS will be
recorded on a database. Regular audit and patient experience
measures will be performed and the FLS will participate in any
national audits undertaken.
Data recorded will allow the FLS to audit
and improve the service they provide
ensuring that high standards are met and
maintained. Initial data will provide a
baseline from which improvements can be
assessed.
Date of last audit against FLS
standards.
Date of last patient satisfaction survey.
Excellent quality of care is provided
and best practice is shared.
9 The FLS team will have appropriate competencies in secondary
fracture prevention and supported to maintain relevant CPD.
All staff need appropriate knowledge,
skills and experience to fulfil their role.
Engagement with relevant CPD activities
ensures that these are up to date.
Review of competencies and training
needs in annual appraisals.
Assessment of CPD attained.
10 The FLS should engage in a regular peer-review process of
quality assurance.
Clinical peer review facilitates quality
standard assurance, equitable access to
services and provides a means of
benchmarking and sharing best practice.
Date of last peer review and progress
against an agreed action plan.
UK FLS Clinical Standards

22. UK - Gap analysis
All patients aged 50 years and over with a new
fragility fracture or a newly reported vertebral
fracture will be systematically and proactively
identified.
outline process for identifying (include numbers seen where able)
In-Patient hip fractures
50-75
75+
Outline process for identifying (include numbers seen
where able)
In-Patient hip fractures
50-75
75+
In-patient non-hip fracture
50-75
75+
Out-patient fractures
50-75
75+
Spinal fractures

23. Assist with Stakeholder Meetings
• Lead clinician/local
champion
• Consultants:
o Endocrinologist
o Rheumatologist
o Geriatrician
o Radiologist
o Orthopaedic surgeon
• Osteoporosis nurse
specialists
• DXA radiographers
• Service manager/s
• Pharmacist
• Prescribing advisors
• Physiotherapist
• GPs/Primary care
• CCGs
• Commissioners
• Health & Wellbeing
Board/s
• Public Health
• IT
• Site services
• Patient rep (NOS!)

24. Assist with FLS Pathway
FALLS RISK
ASSESSMENT
NEW
CLINICAL FRACTURE
NEW
VERTEBRAL
FRACTURE
(RADIOLOGY REPORT)
PREVIOUS FRACTURE OR
FRACTURE NOT PRESENTING
TO ACUTE CARE
ORTHO
IP
Virtual/
#
CLINIC
‘CASE-FINDING’ BY FLS‘CASE-FINDING’
BY COTE
‘CASE-FINDING’
BY GP/SEC CARE/CH
FLS
RISK ASSESSMENT
ONE-STOP CLINIC
WITH DXA
EXERCISE
CLASSES
Rx FOR FRACTURE
2Y PREVENTION
EDUCATION
PROGRAMME
CARE OF
THE
ELDERLY
4 & 12 MONTH
FOLLOW UP
CLINIC
COMPLEX
CLINIC
(IF REQUIRED)

25. 25
FLS Implementation Toolkit
1. Promotes commissioning of effective high-quality
services that are integrated within a system-wide
approach
2. Ensures services are in accord with the evidence
base and able to demonstrate outcomes
3. Stimulates provision of services that are
sustainable
4. Make implementation easier, cheaper and more
effective for commissioners and providers.

26. Contents
Name Description Format
UK FLS Standards Clinical standards for FLS PDF
Call to action A summary of evidence for providers and commissioners PDF
Service Specification A part populated service specification suitable for use with
NHS Standard Contracts
MS Word
Benefits Calculator A financial model demonstrating potential cost savings Web
Cost Calculator A financial model to calculate the service requirements Web
Service Improvement Guide A descriptive guide setting out step-by-step actions for
providers to achieve a service improvement
PDF
Outcome and Performance
Indicators
Practical, evidence-based indicators to demonstrate service
improvement
MS Excel
Improvement Project Plan A list of tasks and activities for a development project MS Excel
Business Case Part populated case for investment in FLS MS Word

27. An FLS is both clinically and cost effective

28. FLS Benefits Calculator
• Additional resource within the
FLS-IT
• Designed for use by hospitals, community
services and commissioning organisations
to help develop an FLS
• Estimates the benefits in terms of reduced
fragility fracture incidence and cost savings
that can be realised in a local health
economy as a result of implementing an
effective FLS.

29. What is the Impact of an FLS?
Economic benefits in the UK:
• Reduction in hip fractures
• Hip fractures cost £1.9 billion/year
• For every 1000 FLS patients assessed in
FLS
• 18 fractures are prevented
• 11 of those are hip fractures

30. What Investment is Required?
• Cost of staff required:
• Consultant
• Nurse specialist
• Clerical/admin
• Set up costs – FLS accommodation, IT, DXA
scanner and other associated costs:
• DXA scans/reporting
• Other diagnostics
• Drug costs

31. FLS Mapping
Area Population
Salisbury 278,000
Stoke on Trent 215,000
Vale of York 348,000
Rotherham 255,000
TOTAL 1,096,000

32. Activity in 2015
Aim 1:
Every person aged over 50 who breaks a bone is assessed for
osteoporosis and managed appropriately.
Priority 1:
Extend coverage of Fracture Liaison Services
Priority 2:
Improve quality of Fracture Liaison Services and
osteoporosis services
Contact
made
Implementation
from no service
Quality improvement Intervention
concluded
Total
sites
Peer support Commissioning
35 34 30 12 6 117

33. How Good is Your FLS?

34. “You must be the
change you wish
to see in the
world.”
Mahatma Gandhi

35. Hilary Arden
+44 (0)1761 473112
h.arden@nos.org.uk