House of Commons - Health Committee

Commissioning - Health Committee Contents

Written evidence from the National Osteoporosis Society (COM 37)

EXECUTIVE SUMMARY

— Osteoporosis causes fragile bones and can lead to painful and disabling fractures. Bone protecting treatments, recommended by NICE and available on the NHS, have been shown to reduce a person's chances of fracture by up to 50%. Fracture Liaison Services (FLSs) ensure that those at risk are identified and offered treatment. However, only a third of local areas in England offer access to an FLS, leaving many patients without NICE recommended treatments. This is putting them at risk of unnecessary fractures and without access to follow-up services which may be necessary to reduce their risk of falls.

Prevention Package for Older People

— The NHS, the public health service and social care must all work closely together to ensure that comprehensive, integrated care is commissioned and provided. Ideally, a single health outcomes framework, applicable to all three, should be put in place. Patients and the public must be empowered to provide their views on how services are organised. The newly proposed structures, including health and wellbeing boards and HealthWatches, have potential to ensure that this occurs.

OSTEOPOROSIS AND FRAGILITY FRACTURES

1. Osteoporosis causes fragile bones, which can lead to painful and disabling fractures. It is a long-term condition which affects 2.3 million people in England.[49], [50], [51] In the UK, 1 in 2 women and 1 in 5 men will fracture at some point after the age of 50, mainly because of poor bone health. 300,000 fragility fractures (fractures which result from a fall from standing height or less) occur every year in the UK.

2. Hip fractures which result from osteoporosis are extremely serious: 10% of patients die within one month of their injury; 30% die within a year. Over 80,000 hip fractures occur annually in the UK. £2 billion is spent every year treating and caring for UK hip fractures.[52], [53], [54], [55]

3. Yet fractures which result from osteoporosis are not inevitable. Bone protecting treatments, recommended by NICE and available on the NHS, have been shown to reduce a person's chances of fracture by up to 50%.

FRACTURE LIAISON SERVICES (FLS)

4. The occurrence of a fragility fracture is often the first sign that an individual has osteoporosis and is at a higher risk of sustaining a future fracture. It is a fact that half of all hip fracture patients have suffered previous fragility fractures.[56], [57], [58], [59]

5. It is, therefore, vital that every person who suffers a fragility fracture in any part of their skeleton is identified. This should be following presentation at a hospital or through their GP. Each fragility fracture patient should also be offered a future fracture risk assessment. Where appropriate, this should lead to advice and treatment to ensure that their future risk of falling and fracturing is reduced.

6. These important steps are recognised in a number of national policy documents in place for England, which advocate osteoporosis and falls assessment for older people who suffer fragility fractures:

— National Service Framework for Older People, Section 6: Falls. March 2001.

— NICE Clinical Guideline 21, November 2004.

— NICE Technology Appraisal 161, October 2008.

— Directed Enhanced Service (DES) on osteoporosis and fragility fracture prevention, 2008-10.

— The Prevention Package for Older People, July 2009.

7. Despite this, a number of recent studies show that, worryingly, the majority of patients with fragility fractures are simply slipping through the net. Most are not receiving the assessment and treatment they need to prevent a further (or "secondary") fracture, as recommended by NICE.[60], [61]Assessment rates are better amongst hip fracture cases (75% of hip fracture patients in England, Wales and Northern Ireland are currently prescribed bone-strengthening medication, are being assessed or are awaiting assessment).[62] However, further work is still needed to ensure that fragility fracture patients over the age of 50 receive appropriate investigations and treatments for osteoporosis where necessary.

8. Overall, most of the readily identifiable patients at high risk of future hip fracture are being consistently missed by the NHS. This is leaving those who are most vulnerable to hip fracture without the treatment they need.

9. The way to ensure that every fragility fracture patient over the age of 50 receives the assessment and treatment they need is through the implementation of FLSs throughout England. These should be linked to every hospital that receives fracture patients.

10. FLSs are usually provided by a dedicated nurse specialist, working under the guidance of a specialist in bone health. The nurse specialist is responsible for establishing systems of care to ensure that every fracture patient over 50 years (excluding high trauma and road traffic accident victims, whose fractures are unlikely to have been caused by osteoporosis) is identified, recorded and offered a "one-stop-shop" fracture risk assessment.

11. The FLS bridges the existing care gap between different areas of health and social care and provides seamless and efficient patient care. It also ensures that the patient does not have to manage all the different parts of the NHS themselves—the presence of an FLS means that the NHS does this on behalf of the patient.

12. FLSs are proven to be effective in UK settings. Glasgow has had a city-wide FLS since 2002, which has operated in parallel a falls prevention service. The FLS was expanded to include the neighbouring Clyde region in 2009. Studies on hip fracture incidence in the Greater Glasgow area show that between 1998 and 2008, the number of recorded hip fractures in the region decreased by 7.3% from 1,377 to 1,276.[63] In comparison, hospital admissions for hip fracture in those aged 65 and over in England have increased by approximately 2% per year during the years 1998-99 to 2008-09.[64] The Glasgow data provides an indication of the outcomes that can be achieved when a comprehensive secondary fracture prevention service is put in place in a UK setting.

13. The case for FLSs is further strengthened by data which shows the success of the Kaiser SCAL system in the United States. In 2009, the actual number of cases of hip fracture sustained by individuals aged 60 and over was recorded as 47.8% lower than the number that would have been expected, had the system not been in place.[65]

14. There are some excellent examples of FLSs operating in the NHS in England. The Ipswich FLS team have published on practical aspects of setting up and running their service with a view to support like-minded colleagues wanting to establish an FLS in their own areas.[66] Other exemplary services include the Newcastle Fracture Clinic Service and the falls and fracture service in Greenwich, London.

15. Despite this compelling evidence, the proportion of hospitals in England with access to an FLS is shockingly low. An organisational audit of falls and fracture services by The Royal College of Physicians and the Healthcare Quality Improvement Partnership (HQIP)[67] published in 2009, found that:

— just 24% of NHS and Health and Social Care Trusts in England, Wales and Northern Ireland employ a Fracture Liaison Nurse;

— 31% of Trusts have the assessment and management of fracture patients co-ordinated by a Fracture Liaison Nurse; and

— just 23% of Trusts have a written local commissioning strategy for bone health.

16. These results highlight a significant health inequality in terms of the future fracture risk that those patients who have and have not had their care co-ordinated by an FLS are exposed to.

17. Under the proposals contained in the Health White Paper, the NHS Board will need to ensure that it retains an overview of national audit data. This will be necessary in order for it to decide how to focus its resources on tackling variations in clinical practice and health inequalities. Where GP consortia are not meeting their obligations to reduce inequalities, the board should hold the power to intervene to improve GP commissioning activity where necessary.

18. In order to make informed decisions about commissioning comprehensive and integrated falls and fracture services, GPs consortia will need to take account of local results derived from national audit data such as that described above.

THE PREVENTION PACKAGE FOR OLDER PEOPLE

19. In July 2009, DH published the Prevention Package for Older People. This provides guidance for PCTs and local authorities on commissioning comprehensive falls and fracture services. The Package includes:

— a template care pathway;

— assistance on conducting a Joint Strategic Needs Assessment (JSNA);

— guidance on exercise training to prevent falls; and

— a health-economic impact assessment, providing projections of:

— the financial costs and savings associated with a comprehensive falls and fracture service for a PCT and local authority(s); over a five-year period, an FLS will cost £234,181 to set up and maintain; in the same period, it will save £290,708 in treatment and care costs from averted fractures; this represents a net saving of £56,527;

— the fractures prevented by a comprehensive FLS for a population-size typically served by a PCT: a comprehensive FLS serving a PCT population of approximately 320,000 people will prevent 33 fragility fractures over a five-year period.

20. The guidance is based upon peer-reviewed evidence and provides local areas with the tools they need to provide patients with access to NICE-recommended treatments and care. Though its implementation, local communities can deliver evidence-based, patient-centred services, helping them to meet the demands set out in the NHS Constitution.

21. The charity was represented on the expert task group which advised the DH on the content of the Prevention Package.

22. The NHS Board should use resources which have already been produced (such as the Prevention Package) to form the national framework of quality standards, model contracts, tariffs and commissioning networks to assist GP commissioners. The board should also share examples of commissioning best practice. The overall framework of support must be maintained and kept up to date as new data becomes available and new models of service provision are developed.

23. When facing difficult choices, we call upon commissioners to prioritise those services which evidence shows will have the greatest health and economic benefits for both patients and the NHS. Integrated falls and fracture services are proven to be both effective at preventing fractures, in addition to being cost-saving. They should be put in place in every local community in England.

COMMISSIONING FRACTURE SERVICES

24. The majority of patients do not have access to services which would ensure that they receive NICE recommended treatments for fracture prevention. This shows that, for the majority of those at risk of fractures, the commissioning process is not operating correctly across England.

25. Commissioning strategies are vital to the provision of comprehensive services. All parties involved in a local falls and fracture service must be jointly involved in drafting a strategy. As an example, these should include:

— commissioners;

— health professionals (working in both primary and secondary care);

— managers at acute NHS trusts;

— intermediate care;

— local authority social care services;

— the local ambulance trust; and

— patient representatives (through a local National Osteoporosis Society support group).

26. The National Osteoporosis Society would ideally prefer an outcomes framework which spans public health, the NHS and social care to be put in place. Achieving a reduction in fragility fractures requires intervention from all three, and we do not believe that the NHS can commission in isolation to achieve this outcome.

27. The we hope that the local Health and Wellbeing boards, proposed in the White Paper, facilitate integrated commissioning between public health, the NHS and social care. GP consortia should be bound by law to ensure that they engage with these bodies.

28. The National Osteoporosis Society believes that GP consortia should only include practices which cover a geographically discrete area. We feel that this is necessary to ensure that effective patient care pathways are commissioned and provided across each community.

29. The Royal College of General Practitioners (RCGP) states that consortia will need to be of sufficient size.[68] This is to:

— pool risk;

— create economies of scale; and

— communicate on an equal level with large NHS Trusts and external bodies.

30. RCGP anticipates that each consortium should cover a population of at least 500,000, rather than the 100,000 suggested in the White paper. The National Osteoporosis Society agrees with this position. Evidence has shown that local health and social care communities in the UK provide populations of this size with effective care for falls and fracture.[69] The Glasgow Fracture Liaison Service expanded to incorporate the larger NHS Greater Glasgow and Clyde board area in 2005. It serves as an example of how the expansion of a primary care organisation can reduce health inequalities among a population for which it has not previously held responsibility.

31. Ideally, we would like GP consortia to demonstrate coterminosity by covering the same geographical areas as local authorities and NHS Trust catchment areas. This will provide the best opportunity for the design and delivery of integrated, high quality care.

PUBLIC AND PATIENT INVOLVEMENT

32. GP consortia must take account of patient views through local HealthWatch organisations. In turn, HealthWatches must be involved in commissioning decisions through local Health and wellbeing boards. Elected members of local authorities should represent patients and the public on the proposed health and wellbeing boards. Elected members should also be empowered to hold the work of GP consortia and the health and wellbeing boards account though overview and scrutiny committees.

33. Third sector organisations are often best-placed to act as a conduit between the NHS and patients, their carers and the general public. The sector must be supported and provided with the capacity to encourage these groups become involved in local commissioning decisions.

DURING THE TRANSITION

34. PCTs, Care Trusts and shadow GP consortia, in addition to health and social care professionals, must work closely during the transition period. This will be vital in ensuring that successfully commissioned and/or provided patient care pathways currently in place are not adversely affected by the new arrangements.

ABOUT US

35. The National Osteoporosis Society is the only charity dedicated to improving the diagnosis, prevention and treatment of osteoporosis across the UK. The organisation was established in 1986 and is a well respected charity with approximately 25,000 members.

October 2010

49 Calculated using mid-2007 population data59 and osteoporosis incidence from60 Back

50 National Statistics Online, 2007. Available for download from: http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15106. Accessed on 19 January 2009. Back

51 Kanis J A, Johnell O, Oden A, Jonsson B, De Laet C, and Dawson A, 2000. Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000; 27, pp 585-590. Back

52 Figures in62 updated using mid-2007 population data63 and the Hospital and Community Health Services (HCHS) pay and price inflation 06-077. Back

53 Torgerson D, Iglesias C and Reid D M, 2001. The economics of fracture prevention. In-The Effective Management of Osteoporosis. Edited by D H Barlow, R M Francis and A Miles, pp 111-121. Back

54 National Statistics Online, 2007. Available for download from: http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15106. Accessed on 19 January 2009. Back

55 NHS Finance Manual, 2009. Available for download from: http://www.info.doh.gov.uk/doh/finman.nsf/Newsletters. Accessed on 19 January 2009. Back

56 Gallagher J C, Melton L J, Riggs B L, Bergstrath E, 1980. Epidemiology of fractures of the proximal femur in Rochester, Minnesota. Clin Orthop Relat Res;150: pp 163-171. Back

57 Lyles K W, Colon-Emeric C S, Pieper C et al, 2006. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. Abstracts of the 28th Annual Meeting of the American Society for Bone and Mineral Research. 2006, ASBMR 28th Annual Meeting in Philadelphia, Pennsylvania, USA. Abstract SA405. Available for download from: http://www.abstractsonline.com/viewer/?mkey=%7BFC197A55%2DD8DD%2D4F3D%2D9994%2D290B64584CCB%7D. Accessed on 14 October 2008. Back

58 Edwards B J, Bunta A D, Simonelli C, Bolander M, Fitzpatrick L A, 2007. Prior fractures are common in patients with subsequent hip fractures. Clin Orthop Relat Res;461: pp 226-230. Back

59 McLellan A R, Reid D M, Forbes K, Reid R, Campbell C et al, 2004. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland. Available for download from: http://www.nhshealthquality.org/nhsqis/qis_display_findings.jsp?pContentID=2755&p_applic=CCC&pElementID=0&p MenuId=0&p service=Content.show&. Accessed on 14 October 2008. Back