Written evidence submitted Royal Osteoporosis Society

Every Integrated Care System (ICS) should enable its population to have access to a fully funded and staffed Fracture Liaison Service (FLS) for the prevention of secondary fractures.  This is an urgent priority since only 51% of NHS trusts currently have a FLS. Osteoporosis affects 3.5 million people in the UK and costs the NHS over £4.6bn per year.  It is a pivotal issue for women’s health in particular – affecting half of women over 50 (and a fifth of men at similar age). Osteoporosis affects people from lower-income families even more severely than the norm, so universal access to FLS would also serve to accelerate the Government’s Levelling Up programme.

FLS is the world standard for preventing secondary fractures.  People who have had one fragility fracture are five times more likely to sustain another fracture within the next two years - 10% re-fracture within a year, 18% within two years, and 31% within five years.  FLS is the world standard for identifying these patients and giving them a personalised treatment plan to reduce secondary fractures.  

The model was invented by British scientists and clinicians, before being copied around the world.  It is a bitter irony that there is such uneven access to FLS in this country – with a postcode lottery for both population coverage and quality. Ensuring everyone over 50 has access to a quality-assured FLS would end the current unfairness and make a major contribution to the recovering FLS. 

Osteoporotic fractures currently account for over £4.6bn of direct costs to the NHS, forecast to rise to c.£6bn by 2030 as the population ages.  As many people die of fracture-related causes as from lung cancer and diabetes.  The right therapies already exist for osteoporosis – safe, effective medication that’s highly affordable for the NHS.  But the lack of FLS coverage across ICSs has given rise to staggering rates of under-diagnosis and under-treatment.  Putting just 1% of the of the current hip fracture spend into FLS provision can facilitate early intervention and leverage major reductions in pressure on the system.  This measure would reduce demand on ambulances, beds and relieve the wider elective care backlog.

Osteoporosis is a common but under-diagnosed condition. Too many people consider falls, broken bones, curved backs and height shrinkage as ‘part of getting older’. Low awareness amongst the public and healthcare professionals has led to a sizeable treatment gap – two-thirds of people were missing out on the interventions they need even before the pandemic. In particular, ROS’s research has shown that the condition is not fully understood by clinicians and many GPs have neither the knowledge or support to properly diagnose osteoporosis and initiate effective treatment.

As a result, we see systemic missed opportunities to prevent the pain of life-changing fractures.  A quarter of women currently endure more than three fractures before they finally get the diagnosis they need. The presence of an FLS allows identification, assessment and treatment to be delivered after the first fracture, dramatically reducing the incidence of further fractures, including debilitating and life-threatening hip fractures.

An illustration of the missed opportunities is that two-thirds of people with spinal fractures - some 2.2 million people in the UKare undiagnosed.  70-80% of these tell-tale fractures never come to medical attention.  Spinal fractures increase subsequent fracture risk more than fractures at any other site.  If undiagnosed and untreated, spinal fracture patients have a 1 in 5 chance of a further spine fracture over the next 12 months and are three times more likely to sustain a hip fracture. Hip fractures are the injury which does more than any to undermine dignity and independence, with a 25% mortality rate after 12 months – and a cost to the NHS of £2bn per year

Hip fractures are also the most common serious injury in older people and the most frequent reason for older people to require emergency anaesthesia and surgery.  In 2019, 61,402 hip fractures occurred in England, accounting for 1.1m bed days and 123,000 hrs of operating theatre time. 

Social deprivation is also associated with higher mortality in the year following hip fracture amongst both men and women, with longer hospital stays and greater risk of subsequent emergency readmission.  Those living in areas of socioeconomic deprivation are therefore disproportionately impacted by the current inequitable access to Fracture Liaison Services.

There is a clear financial argument for the implementation of a universal FLS service across all ICSs. Ending the current postcode lottery will release pressure on the £2bn annual hip fracture spend, as well as myriad indirect costs such as social care. ROS modelling shows that Government and NHS leaders can expect £3.28 back for every £1 invested in FLS.  The services will pay for themselves within two years, with a full 3:1 ROI within the lifetime of a Parliament.

Examples like the operation in Sheffield show what a properly funded and staffed FLS can do. GPs feel empowered because they have accurate and concise information which they can then pass on to their patients. Modest investment in improved services can unlock major savings.  If we get fracture prevention right, we can transform people’s experience of later life in this country and significantly reduce backlogs for care.


October 2022