Capture the Fracture, a Global View, with some focus on UK

1. Capture the Fracture, a Global View, with
some focus on UK
MK Javaid
Associate Professor in Metabolic Bone Disease, University of Oxford
Hon Consultant Rheumatologist, Nuffield Orthopaedic Centre, OUHFT

2. Declarations
In the last five years I have received honoraria, travel and/or subsistence
expenses from:
• Amgen, Eli Lilly, Medtronic, Novartis, Proctor and Gamble, Servier, Shire, Internis,
Consilient Health, Stirling Anglia Pharmaceuticals, Mereo Biopharma, UCB, Kyowa
Kirin Hakin, Optasia, Zebra Medical vision
Clinical lead for the United Kingdom Royal College of Physicians FLS
database audit
Co-Chair of the International Osteoporosis Foundation Capture the
Fracture working group

3. More than 80% of patients
after a seeing a doctor with
a fragility fracture receive
inadequate care.
Pharmacological
therapy reduce
fracture risk
from 20 to 80%

4. What is success?
What did the UK do differently?

5. Maps

6. Maps

7. Netherlands
17.08 million

8. Aim:
• Become local champions for FLS
Learn from the experiences and expertise
Speed up how to set up an effective and efficient FLS

9. Imminent fracture risk: pooled analysis
Klotzbuecher JBMR 2000

10. European level 1 trauma
2419 (1745 females) patients aged 50 years
Excluded RTC/ pathological
Radiology reports in same hospital for 2yrs
~ 11.9% absolute fracture risk
Imminent fracture risk: Dutch experience 1
van helden OI 2006

11. n=924 fractures
31.7% fractures within 2 years
~ 7.6% absolute fracture risk
Van Geel 2009
4140 PMO primary care questionnaire
10 year traceable women
Invited to another questionnaire
83% 2372 of the 2847 alive answered
Clinically validated fractures
Imminent fracture risk: Dutch experience 2
> Dead and non responder bias> underestimate risk

12. Living in Dubbo Australia
n=4005 60 years and over
Radiology report review
Hip,
Major: spine, pelvis, distal femur, proximal tibia
multiple rib, proximal humerus
Minor but not fingers / toes
Center JAMA 2007
1242 index fractures
324 re-fractured
~13.2% absolute fracture risk
Imminent fracture risk: Australian experience

13. n=2364 women humerus
Men and women
48.9% re fracture within 2 years
~ 23.2% absolute fracture risk
Kanis OI 2018
30, 794 residents of Reykjavik
Born 1907 – 1935
18,872 recruited 1967-91
Medical record review
excluded fracture avulsions, cancer, stress fractures
ICD10: humeral, vertebral, forearm and hip fracture
Subsequent fractures excluded ankle, face, skull, hand,
patella, foot & tibia in men
30 day washout
Imminent fracture risk: Icelandic experience

14. Imminent fracture risk
100 1 2 3 4 5 6 7 8 9
0
5
10
15
20
25
30
35
40
Time (years)
Fracturerisk
2% fracture risk expected by 2 years
Low fracture rate
Low number of avoided fractures

15. Imminent fracture risk
100 1 2 3 4 5 6 7 8 9
0
5
10
15
20
25
30
35
40
Time (years)
Fracturerisk
Much higher two year rate
 More patients above treatment threshold
 More fracture avoided

16. FLS pathway
Effective
anti-osteoporosis
management
for 5 years
Recent fracture
Rapid treatment initiation
Treatment rapid onset of fracture benefit
Treatment adherence for at least 2 years

17. Step 5: Become a mentor for other sites
Step 4: How to get an FLS working better
Step 3: How to start an FLS?
Step 2: What does a good FLS look like?
Step 1: Funding FLS: why now?

18. Step 5: Become a mentor for other sites
Step 4: How to get an FLS working better
Step 3: How to start an FLS?
Step 2: What does a good FLS look like?
Step 1: Funding FLS: why now?
Experience
Expertise
Tools

19. What is a Fracture Liaison Services?
FLS is a clinically and cost- effective
model of care

20. Identify
Investigate
Initiate
Monitor
Not leaflets
Not Education
Fracture Liaison Services
Not Referring or asking others
to do extra work
Sale OI 2011

21. Identify
Investigate
Initiate
Monitor
Specialist nurses
Administrators
Small core specialist service
Champion
Responsible for
delivering pathway
Patient pathways
DXA/ Laboratory tests
Treatment / referrals
Fracture Liaison Services

22. Complex clinical pathway
Fewer patients in
emergency room
Fewer operations
Fewer patients needing
family support
Health Care
system

23. • A global flagship programme by the
International Osteoporosis
Foundation (IOF)
• Launched in 2012
• Mission: facilitating the
implementation of FLS to prevent
secondary fractures
CAPTURE THE FRACTURE®

24. Prof. Kassim Javaid
Co-chair, CTF
Oxford University,
UK
Prof. Serge Ferrari
Chair, CSA
Geneva University
Hospital,
Switzerland
Prof. Kristina Åkesson
Co-chair, CTF
Malmo Skåne Hospital,
Sweden
Prof. Willem Lems
VU University
medical centre,
The Netherlands
Prof. Thierry Thomas
University Hospital of
St-Etienne, France
Dr. Donncha
O’Gradaigh
Waterford Hospital,
Ireland
Prof. Stefan
Goemaere
Ghent University
Hospital, Belgium
Dr. Paul Mitchell
Synthesis Medical
Ltd, New Zealand
CTF STEERING COMMITTEE MEMBERS
Prof. Cyrus C. Cooper
President, IOF
University of Southampton
Medical School, UK

25. KEY AIMS
Be the global voice
Drive national/international policy
Ensure quality
Provide support for FLS implementation,
getting started & improving & sustaining

26. Ensuring Quality
How do we evaluate the effectiveness of
an FLS?
→ By creating standards

27. AIM:
1. Set the standard for FLS (13 criteria)
2. Guidance
3. Benchmarking and Quality improvement
 Available in 11 different languages
BEST PRACTICE FRAMEWORK
HEALTH CARE QUALITY

28. 13 Criteria and Standards
1. Patient Identification
2. Patient Evaluation
3. Post Fracture Assessment Timing
4. Vertebral Fracture (VF) ID
5. Assessment Guidelines
6. Secondary Causes of OP
7. Falls Prevention Services
8. Multifaceted Assessment
9. Medication Initiation
10. Medication Review
11. Communication Strategy
12. Long-term Management
13. Database
Standard 1 definition:
Fracture patients are identified to enable
delivery of secondary fracture prevention
Standard Bronze Silver Gold
Patient
Identification
Patients
identified, not
tracked
Patients
identified, are
tracked
Patients
identified,
tracked &
independentl
y reviewed

29. SCORING: 5 domains
Hip fracture
Other
inpatient
Outpatient
Vertebral
Organizational
(Falls/database)

30. 300+ FLS, 38 countries, 6 continents
August, 2018

31. 2-4
1
10- 20
5- 9
20 +
April 2018: 247 FLS, 38 COUNTRIES, 6 CONTINENTS

32. Highest score per country: Growing FLSs to GOLD
Silver (61)
Bronze (46)
Gold (56)
Under evaluation (24)

33. Maximum vertebral star per country: n=41
+ VFA
Clinical
+ Radiological
Under evaluation

34. Running an FLS?
Join the Capture the Fracture® Programme
Why join?
• Showcase your achievements
• Learn from the BPF to improve your service
• Get international recognition with a Gold, Silver,
or Bronze star
• Be part of a global invitiative to prevent
secondary fractures
Who can participate?
• Coordinator-based models of care
• All type of facilities
• At any stage in development
• Any size worldwide

35. How to get mapped - The Process
Step 1
FLS submits online
application
Step 2
FLS marked in green
on the map while
being reviewed
Step 3
BPF achievement
level assigned
Step 4
FLS is scored and
recognized on the
map
https://youtu.be/gpAAvvukjQw VIDEO!

36. Tools to Help you Implement an FLS
FLS
Implementation
Tools
Mentorship
programme
Best Practice
Framework
Slide kits
Toolkit
Webinars
Global
Patient
Charter
FLS
Implementation
Tools
Mentorship
programme
Best Practice
Framework
Slide kits
Toolkit
Webinars
Global
Patient
Charter

37. National Toolkits – under ‘ Resources’

38. EDUCATIONAL PROGRAMME (Webinars) Webinars
2017
5 new CTF webinars on
specific topics
 > 275 attendees
 > 270 videos + slides
downloaded
 > 2520 webinar page views
 Survey rating for all webinars
= >80%
2016
Webinars on FLS and BPF in 8
different languages
> 300 attendees

39. Barriers: why have we not got there yet
• Reduced fracture cases
• Effectiveness of therapy
• Fracture Healing
• Rare fractures

40. Too old?
18, 872 residents of Reykjavik Iceland
6895 Inpatient and outpatient fractures
Johannsson OI 2017; Khalid Esceo 2017
Newer bone agents rapidly
reduce fracture risk
1611 denosumab vs. 16,025 matched alendronate users
2yr follow-up
Spain

41. • Good rating for your hospital – focused on patient outcomes
• Our focus is surgery not the osteoporosis
• Non-elective admissions burden on hospitals/ hospital beds
• Unplanned/ A&E waits
• Long length of stay (>20 days)
• Dependent on social care/ Blocking beds
• Physiotherapy / Rehabilitation
• FLS will allow space for elective admissions/ work
“If we put in an FLS then we would have fewer fracture admissions and lose money”
“Purposefully not treating high risk patients so they can fracture again?”
Aging
Population
Increasing
Number of
Fragility
Fractures

42. Barriers
• Reduced fracture cases
• Effectiveness of therapy
• Fracture Healing
• Rare fractures
No effect on fracture healing
Increased callus size
Reduced remodelling

43. Results
• 101 responses
Sweden 13
UK 11
Australia 10
Norway 9
Canada 7
Denmark 7
Ireland 4
Italy 4
Nederland 4
Greece 3
India 3
New Zealand 3
Chile 2
France 2
Germany 2
Japan 2
Spain 2
Austria 1
Brazil 1
England 1
Estonia 1
Iceland 1
Lebanon 1
Lebanon 1
Mexico 1
Nepal 1
Portugal 1
Russia 1
United States 1
0%
10%
20%
30%

44. Not enough time…to?
• Alert patient
• This could happen again, you need a bone check
• Integrated pathway with protocols
• Normal labs, no other risks = treat after hip or spine or > 75 years
• Setup service for more complex patients – FLS
• Abnormal labs, need to risk stratify

45. National Health Service: July 5 1948
45

46. UK health service
Hospitals
200 Clinical
Commissioning
Groups/ 14 health
boards
Spec
Service
NHS England £101.1 billion
Clinics
Drugs
Procedures
8000
Independent
Primary care
contractors
98.8%
general taxation
1.2% patient
charges

47. Fall from standing height or less
Exclude digits, scaphoid, face, skull
500,000
Fragility Fractures
68,000 / yr
20% 1yr mortality
50% care home
Chronic pain
+14 GP visits
50% poor outcome
Predict future fracture
£4.3 billion/ year
More bed days
MI/CVA
Dolan P and Torgerson DJ. OI 1998;8:611–617. NHFD 2015

48. UK focus
All patients over 50 have 4 steps
Champion: work out how much and how to do this for the locality
Identify
Investigate
BOTTOM
TOP
Initiate
Monitor

49. Focus of osteoporosis care:
Department of Health Prevention Package for Older People: Falls and
Fractures - Effective interventions in health and social care, 2009
Hip
Fracture
Secondary
Fracture prevention
High risk
Primary prevention
Healthy
aging
Priority
for
delivery
50%
50%
Hip fractures
26% population
74%
population

50. Political Prioritization: Everyone had same message
Department of Health Prevention Package for Older People: Falls and Fractures - Effective
interventions in health and social care, 2009
Professional
Societies
Patient
Societies
Government

51. Political Prioritization: Everyone had same message
Department of Health Prevention Package for Older People: Falls and Fractures - Effective
interventions in health and social care, 2009
Positive
Benefit vs costs at
national level
Quality framework

52. https://benefits.nos.org.uk/

53. National Osteoporosis Society. Effective Secondary Prevention of Fragility
Fractures: Clinical Standards for Fracture Liaison Services. NOS 2015.
National standards

54. FLS should perform FLS does perform

55. Marsh OI 2011, Eisman JBMR 2012
National Hip Fracture Database
Inpatient Falls Audit
FFFAP
FLS Database

57. Key performance indicators
• Meaningful
• Measurable
• Fracture rates
• Re-fracture rates
• Time to first monitoring visit
• Number and % on anti-osteoporosis medication at 4 and 12 months
…...from date fracture diagnosed in NHS

59. Achievements
Numberofcases
NumberofFLSs
137,959 cases entered from 65 FLSs

60. National audit
60

61. 61
How well is your FLS doing now?

62. The next step: Sustainable FLSs
Without working FLSs then
> How to show others the benefit and get more funded?
Every FLS should be
improving
FLS looks at
performance
Identifies
Highest
priority
Develops
service
improvement
plan
Implements
plan
Re-checks
performance

63. > 80%> Good
> 50 - 79%> OK
< 50 %> Bad
FLSDB clinical report 2017
I have an FLS commissioned
and it is working well
Do we need to audit?
FLS name
Numberofcasessubmitted
Numberoffields(outof29)with20%
orgreatermissingdata–n
Hipcaseascertainment–%
Non-hipcaseascertainment–%
Within90days(diagnosisto
assessment)–%
Within90days(diagnosistoDXA)–%
Bonetherapymissing–%
Fallsassessmentdoneorreferred–%
Patientsfollowedup(ofthose
prescribedbonetherapyorreferredfor
furtherclinicalopinion/GP)–%
Barnet Hospital Fracture Liaison Service 156 3 * 17.8 93.6 77.1 20.5 91.7 83.3
Bromley Healthcare Falls and Fracture Prevention Service 283 2 6.9 38.7 100 92.4 31.1 100 78.2
Broomfield Hospital 382 9 27.5 30.9 93.7 15.9 5 1.6 0
Dorset County Hospital 536 20 81.3 59.8 90.9 63 36.2 0.9 0
East Lancashire Hospitals NHS Trust 273 3 * 26.3 96 72.5 33.3 8.4 62.5
East Surrey Hospital 233 2 * 22.6 5.2 6.1 * 99.6 0
FLS West Berkshire 358 3 5.1 43.8 96.6 81.2 * 18.2 63.1
Guys and St Thomas’ NHS Foundation Trust 284 21 15.0 62.4 4.9 * 98.7 9.5 0
King’s College Hospital – Denmark Hill site 79 7 * 24.3 98.7 * 100 2.5 0
Medway NHS Foundation Trust 436 12 59.0 53.2 0 * 70.9 0.9 2.2
Milton Keynes University Hospital Foundation Trust 134 12 6.0 22.2 95.5 34.1 44 47 60
Musgrove Park Hospital 811 0 106.5 74.8 77.2 80.5 3.3 65.8 73.7
North Bristol NHS Trust 1,111 9 94.3 81.5 74.9 57.9 2.3 55.1 49.3
North Tees and Hartlepool NHS Foundation Trust 553 9 52.9 53.4 99.8 53.3 14.5 53.9 0
Nottingham University Hospitals 1,250 11 77.2 63.6 99.4 0 82.2 33 0
Oxfordshire Fracture Prevention Service 1,210 7 54.7 70.7 73.8 53.7 0.8 24.9 26.9
Peterborough and Stamford Hospitals NHS Foundation
Trust
260 2 5.6 28.5 92.3 67.8 100 95.8 0
Poole General Hospital 69 15 * 3.5 0 0 95.8 40.6 0
Portsmouth and Southeast Hampshire 936 16 11.9 57.0 91.1 72.5 1.6 0.2 0
Queen Elizabeth Hospital, Woolwich 109 7 7.1 13.8 * 0 0 1.8 5.3
Royal Surrey County Hospital 251 1 7.9 38.7 92.8 74.3 13.9 93.2 59.6
Royal Wolverhampton Hospital NHS Trust 285 16 7.8 26.9 96.1 * 60.7 1.1 0
Sandwell and West Birmingham Hospitals NHS Trust 86 11 2.6 1.2 51.2 18.5 69.8 90.7 0
St George’s Hospital 725 15 127.0 131.3 43.7 68.7 51.6 46.9 15.7
Sunderland Royal Hospital 584 2 63.6 49.2 99.1 56.6 90.5 67 30.2
The Haywood Hospital Burslem Stoke-on-Trent 644 0 15.8 38.8 84 83.6 15.1 2.6 45.5
The Hillingdon Hospitals NHS Foundation Trust 110 0 5.0 24.8 90.9 70.8 0 5.5 50
The Ipswich Hospital NHS Trust 944 14 87.2 80.7 35.2 25.9 10.9 52.1 19.3
The Rotherham NHS Foundation Trust 109 8 * 20.6 86.2 86.1 31.8 16.5 0
United Lincolnshire Trust 1,218 13 56.1 63.0 0 86.8 0 0 0
University Hospital Lewisham 191 11 43.2 52.0 74.3 74.5 27.7 31.9 36
University Hospital Llandough 344 10 2.4 32.2 86.6 * 18.9 3.5 13.2
University Hospital of North Durham and Darlington
Memorial Hospital
835 14 47.4 46.4 76.2 43.1 22.2 2.2 48.1
University Hospitals Birmingham NHS Foundation Trust 643 4 45.4 58.3 72.3 21.3 20.3 57.4 68.1
University Hospitals Bristol NHS Foundation Trust 679 12 100.6 81.1 20 63.9 0.3 0.6 38.9
West Suffolk Fracture Liaison Service 219 3 29.4 22.4 63.5 74.7 6.4 57.1 76.3
Wye Valley NHS Trust 231 4 * 33.9 98.3 0 0.9 97 0.8
Yeovil Hospital 795 6 97.5 98.3 46.2 * 12.6 30.8 71.8
Overall (Average)
18,35
6
– 35.6 45.5 66.9 46.5 33.2 32.3 36.4

65. FLS name
Numberofcasessubmitted
Numberoffields(outof29)with20%
orgreatermissingdata–n
Hipcaseascertainment–%
Non-hipcaseascertainment–%
Within90days(diagnosisto
assessment)–%
Within90days(diagnosistoDXA)–%
Bonetherapymissing–%
Fallsassessmentdoneorreferred–%
Patientsfollowedup(ofthose
prescribedbonetherapyorreferred
forfurtherclinicalopinion/GP)–%
Barnet Hospital Fracture Liaison Service 156 3 * 17.8 93.6 77.1 20.5 91.7 83.3
Bromley Healthcare Falls and Fracture Prevention
Service
283 2 6.9 38.7 100 92.4 31.1 100 78.2
Broomfield Hospital 382 9 27.5 30.9 93.7 15.9 5 1.6 0
Dorset County Hospital 536 20 81.3 59.8 90.9 63 36.2 0.9 0
East Lancashire Hospitals NHS Trust 273 3 * 26.3 96 72.5 33.3 8.4 62.5
East Surrey Hospital 233 2 * 22.6 5.2 6.1 * 99.6 0
FLS West Berkshire 358 3 5.1 43.8 96.6 81.2 * 18.2 63.1
Guys and St Thomas’ NHS Foundation Trust 284 21 15.0 62.4 4.9 * 98.7 9.5 0
King’s College Hospital – Denmark Hill site 79 7 * 24.3 98.7 * 100 2.5 0
Medway NHS Foundation Trust 436 12 59.0 53.2 0 * 70.9 0.9 2.2
Milton Keynes University Hospital Foundation Trust 134 12 6.0 22.2 95.5 34.1 44 47 60
Musgrove Park Hospital 811 0 106.5 74.8 77.2 80.5 3.3 65.8 73.7
North Bristol NHS Trust 1,111 9 94.3 81.5 74.9 57.9 2.3 55.1 49.3
North Tees and Hartlepool NHS Foundation Trust 553 9 52.9 53.4 99.8 53.3 14.5 53.9 0
Nottingham University Hospitals 1,250 11 77.2 63.6 99.4 0 82.2 33 0
Oxfordshire Fracture Prevention Service 1,210 7 54.7 70.7 73.8 53.7 0.8 24.9 26.9
Peterborough and Stamford Hospitals NHS Foundation
Trust
260 2 5.6 28.5 92.3 67.8 100 95.8 0
Poole General Hospital 69 15 * 3.5 0 0 95.8 40.6 0
Portsmouth and Southeast Hampshire 936 16 11.9 57.0 91.1 72.5 1.6 0.2 0
Queen Elizabeth Hospital, Woolwich 109 7 7.1 13.8 * 0 0 1.8 5.3
Royal Surrey County Hospital 251 1 7.9 38.7 92.8 74.3 13.9 93.2 59.6
Royal Wolverhampton Hospital NHS Trust 285 16 7.8 26.9 96.1 * 60.7 1.1 0
Sandwell and West Birmingham Hospitals NHS Trust 86 11 2.6 1.2 51.2 18.5 69.8 90.7 0
St George’s Hospital 725 15 127.0 131.3 43.7 68.7 51.6 46.9 15.7
Sunderland Royal Hospital 584 2 63.6 49.2 99.1 56.6 90.5 67 30.2
The Haywood Hospital Burslem Stoke-on-Trent 644 0 15.8 38.8 84 83.6 15.1 2.6 45.5
The Hillingdon Hospitals NHS Foundation Trust 110 0 5.0 24.8 90.9 70.8 0 5.5 50
The Ipswich Hospital NHS Trust 944 14 87.2 80.7 35.2 25.9 10.9 52.1 19.3
The Rotherham NHS Foundation Trust 109 8 * 20.6 86.2 86.1 31.8 16.5 0
United Lincolnshire Trust 1,218 13 56.1 63.0 0 86.8 0 0 0
University Hospital Lewisham 191 11 43.2 52.0 74.3 74.5 27.7 31.9 36
University Hospital Llandough 344 10 2.4 32.2 86.6 * 18.9 3.5 13.2
University Hospital of North Durham and Darlington
Memorial Hospital
835 14 47.4 46.4 76.2 43.1 22.2 2.2 48.1
University Hospitals Birmingham NHS Foundation Trust 643 4 45.4 58.3 72.3 21.3 20.3 57.4 68.1
University Hospitals Bristol NHS Foundation Trust 679 12 100.6 81.1 20 63.9 0.3 0.6 38.9
West Suffolk Fracture Liaison Service 219 3 29.4 22.4 63.5 74.7 6.4 57.1 76.3
Wye Valley NHS Trust 231 4 * 33.9 98.3 0 0.9 97 0.8
Yeovil Hospital 795 6 97.5 98.3 46.2 * 12.6 30.8 71.8
18,35
Potential patient impact over 5 years
If all patients in England received a
comparable service to the highest
treating FLS:
21,848 fractures would be prevented
- including 9157 hip fractures.
Saving £151 million from just hip
fractures

66. Marked variation in FLS
across all quality indicators
Highlights need for ongoing
audit to improve quality of FLSs
Great opportunity to address variation and improve population health
Target clinical area for Local Health Economies
to concentrate their improvement efforts on

67. Berwick: triple aim
1. Effective
2. Efficient
3. Patient Experience
FLS name
Numberofcasessubmitted
Numberoffields(outof29)with20%or
greatermissingdata–n
Hipcaseascertainment–%
Non-hipcaseascertainment–%
Within90days(diagnosistoassessment)
–%
Within90days(diagnosistoDXA)–%
Bonetherapymissing–%
Fallsassessmentdoneorreferred–%
Patientsfollowedup(ofthoseprescribed
bonetherapyorreferredforfurther
clinicalopinion/GP)–%
Barnet Hospital Fracture Liaison Service 156 3 * 17.8 93.6 77.1 20.5 91.7 83.3
Bromley Healthcare Falls and Fracture Prevention Service 283 2 6.9 38.7 100 92.4 31.1 100 78.2
Broomfield Hospital 382 9 27.5 30.9 93.7 15.9 5 1.6 0
Dorset County Hospital 536 20 81.3 59.8 90.9 63 36.2 0.9 0
East Lancashire Hospitals NHS Trust 273 3 * 26.3 96 72.5 33.3 8.4 62.5
East Surrey Hospital 233 2 * 22.6 5.2 6.1 * 99.6 0
FLS West Berkshire 358 3 5.1 43.8 96.6 81.2 * 18.2 63.1
Guys and St Thomas’ NHS Foundation Trust 284 21 15.0 62.4 4.9 * 98.7 9.5 0
King’s College Hospital – Denmark Hill site 79 7 * 24.3 98.7 * 100 2.5 0
Medway NHS Foundation Trust 436 12 59.0 53.2 0 * 70.9 0.9 2.2
Milton Keynes University Hospital Foundation Trust 134 12 6.0 22.2 95.5 34.1 44 47 60
Musgrove Park Hospital 811 0 106.5 74.8 77.2 80.5 3.3 65.8 73.7
North Bristol NHS Trust 1,111 9 94.3 81.5 74.9 57.9 2.3 55.1 49.3
North Tees and Hartlepool NHS Foundation Trust 553 9 52.9 53.4 99.8 53.3 14.5 53.9 0
Nottingham University Hospitals 1,250 11 77.2 63.6 99.4 0 82.2 33 0
Oxfordshire Fracture Prevention Service 1,210 7 54.7 70.7 73.8 53.7 0.8 24.9 26.9
Peterborough and Stamford Hospitals NHS Foundation
Trust
260 2 5.6 28.5 92.3 67.8 100 95.8 0
Poole General Hospital 69 15 * 3.5 0 0 95.8 40.6 0
Portsmouth and Southeast Hampshire 936 16 11.9 57.0 91.1 72.5 1.6 0.2 0
Queen Elizabeth Hospital, Woolwich 109 7 7.1 13.8 * 0 0 1.8 5.3
Royal Surrey County Hospital 251 1 7.9 38.7 92.8 74.3 13.9 93.2 59.6
Royal Wolverhampton Hospital NHS Trust 285 16 7.8 26.9 96.1 * 60.7 1.1 0
Sandwell and West Birmingham Hospitals NHS Trust 86 11 2.6 1.2 51.2 18.5 69.8 90.7 0
St George’s Hospital 725 15 127.0 131.3 43.7 68.7 51.6 46.9 15.7
Sunderland Royal Hospital 584 2 63.6 49.2 99.1 56.6 90.5 67 30.2
The Haywood Hospital Burslem Stoke-on-Trent 644 0 15.8 38.8 84 83.6 15.1 2.6 45.5
The Hillingdon Hospitals NHS Foundation Trust 110 0 5.0 24.8 90.9 70.8 0 5.5 50
The Ipswich Hospital NHS Trust 944 14 87.2 80.7 35.2 25.9 10.9 52.1 19.3
The Rotherham NHS Foundation Trust 109 8 * 20.6 86.2 86.1 31.8 16.5 0
United Lincolnshire Trust 1,218 13 56.1 63.0 0 86.8 0 0 0
University Hospital Lewisham 191 11 43.2 52.0 74.3 74.5 27.7 31.9 36
University Hospital Llandough 344 10 2.4 32.2 86.6 * 18.9 3.5 13.2
University Hospital of North Durham and Darlington
Memorial Hospital
835 14 47.4 46.4 76.2 43.1 22.2 2.2 48.1
University Hospitals Birmingham NHS Foundation Trust 643 4 45.4 58.3 72.3 21.3 20.3 57.4 68.1
University Hospitals Bristol NHS Foundation Trust 679 12 100.6 81.1 20 63.9 0.3 0.6 38.9
West Suffolk Fracture Liaison Service 219 3 29.4 22.4 63.5 74.7 6.4 57.1 76.3
Wye Valley NHS Trust 231 4 * 33.9 98.3 0 0.9 97 0.8
Yeovil Hospital 795 6 97.5 98.3 46.2 * 12.6 30.8 71.8
Overall (Average)
18,35
6
– 35.6 45.5 66.9 46.5 33.2 32.3 36.4
1. Identify priority
2. Develop improvement plan
3. Deploy improvement plan
4. Re-Measure
Most change is
unhelpful or bad…..
but can not Improve
without change
Balancing measures

68. Bottom up approach
Local /
Regional bone
clubs
Cluster of
Practice
Behaviour change
Ownership
Use national
data

69. 1st step: find a champion
• Overall leadership
• Responsibility for management
• Drive process
• Sustain the service
Clinical knowledge
How to write a business case
Negotiating skills
Time to deliver
Drew BMC Muscul Dis 2015

70. Stakeholder map
Stakeholder map
Primary care
Drs/ nurses
District, practice, advisor
Physio/ OT
Pharmacy
Payer
Board- decision
Clinical representatives
Aligned projects
Hospital
Departments
Finance
Coding/ Activity
Estates/ IT
Orthopaedics
Rheumatology
Endocrinology
Radiology
Emergency
Patients
Carer
Patient society

71. Champion Plan
Data
Implement
Hip fractures
How many per month/ year
Length of stay
Fractures in last 2 years
On bone treatment at time of fracture
Fracture pathways
How many per month/ year
Location & Timing
DXA & Laboratory tests
Primary care
FLS structure and cost
Identification
Investigation
Initiation
Monitoring
Share FLS groups Local, regional and national
Effective
Efficient
Good patient experience
Prioritisation policy document
Benefits / cost business case
Recruit, contracts and training
Service improvement

72. Maps

73. Champion Plan
Data
Implement
Hip fractures
How many per month/ year
Length of stay
Fractures in last 2 years
On bone treatment at time of fracture
Fracture pathways
How many per month/ year
Location & Timing
DXA & Laboratory tests
Primary care
FLS structure and cost
Identification
Investigation
Initiation
Monitoring
Share FLS groups Local, regional and national
Effective
Efficient
Good patient experience
Prioritisation policy document
Benefits / cost business case
Recruit, contracts and training
Service improvement
Champion
Team