Section 11: Recommendations for commissioners of healthcare
In 2017, the National Falls Prevention Coordination Group with Public Health England (PHE) produced a falls and fracture consensus statement and resource pack with the aim of reducing falls and fracture risk and improving management of fractures, including secondary prevention ( https://www.gov.uk/government/publications/falls-and-fractures-consensus-statement). The guidance is aimed at local commissioning and strategic leads in England with a remit for falls, bone health and healthy ageing. Following this, NHS RightCare, working with PHE and the Royal Osteoporosis Society (ROS), developed a Falls and Fragility Fractures Pathway ( https://www.england.nhs.uk/rightcare/products/pathways/falls-and-fragility-fractures-pathway/) which defines three priorities that commissioners responsible for falls and fragility fractures should optimise as a priority:
- Falls prevention
- Detecting and managing osteoporosis
- Optimal support after a fragility fracture.
The ROS has developed an online Fracture Liaison Service Implementation Toolkit (https://theros.org.uk/healthcare-professionals/fracture-liaison-services/implementation-toolkit/) designed to enable FLS Commissioning.
In England, the move to Integrated Care Systems (ICS) provides an opportunity to embed enhanced pathways of care for patients at risk of fragility fracture, including imminent fracture risk 310, as part of routine service delivery, for example enabling direct referrals between different secondary care services to streamline patient care pathways.
Where healthcare funding is not delivered through a commissioning structure the recommendations below apply to bodies providing healthcare funding and to local health boards. Thus, in Wales these recommendations apply to the Welsh Government and to local health boards (that are funded directly from the Welsh Government) when setting their Integrated Medium-Term Plans (IMTPs). In Northern Ireland health and social care are integrated and are the responsibility of the Department of Health. Health services are commissioned by the Health and Social Care Board (HSCB) through local commissioning groups from the five Health and Social Care Trusts. Thus, in Northern Ireland these recommendations apply to the HSCB and to the five local commissioning groups.
Based upon the evidence presented in this guideline the NOGG makes the following recommendations to service leaders and/or commissioners of healthcare who:
- Should recognise that fractures due to osteoporosis are a significant and growing public health issue with consequent high health and social care costs and ensure that fragility fractures are addressed explicitly in their local healthcare programmes (Strong recommendation).
- Should ensure that local healthcare programmes address approaches to reduce the prevalence of avoidable risk factors for osteoporosis and fractures related to falls and poor bone health and, in so doing, makes explicit the roles of both the NHS and other agencies (Strong recommendation).
- Should ensure electronic patient health record systems have FRAX, and the link to the NOGG website, integrated to aid identification and treatment of those at risk of fragility fracture, and that electronic patient health record systems enable clear, and where possible automated, electronic communication between FLS and primary care teams (Strong recommendation).
- Should put arrangements in place so that those at risk of osteoporotic fractures have the opportunity to receive appropriate investigation (e.g., fracture risk assessment, falls risk assessment, bone density measurement), lifestyle advice (e.g., about diet, exercise, and smoking) and bone protective drug therapy [NICE Quality Standards 149, 2017]. The latter includes the availability of parenteral drug therapies in primary care and community healthcare settings (Strong recommendation).
- Should ensure that accurate, up-to-date consistent information about pharmacological drug interventions is widely available to postmenopausal women, and men age ≥50 years, their healthcare advocates and professional advisers, so that patients can make informed decisions about treatment and treatment adherence (Strong recommendation).
- Integrated Care Systems (ICS) should specifically address the burden of fragility fractures on the local economy and ensure that Fracture Liaison Services ( see Section 9) are available for all patients who sustain a fragility fracture (Strong recommendation).
- ICS should bring together local specialists, generalists and other stakeholders, including patient representatives, to agree local treatment practices and referral pathways for the management of osteoporosis and prevention of fragility fractures. It is often helpful to identify a lead clinician in both primary and secondary care. The recommendations of this group should take account of local resources and relevant cost-effectiveness data. Local guidelines should be consistent with the evidence presented in this document. Once local guidelines have been agreed, they should be widely disseminated to relevant professionals and potential patients, and the necessary service changes made to allow the guidelines to be implemented. Implementation should be audited and appropriate changes in practice should be instituted where standards are not met with appropriate monitoring of compliance to guidelines thereafter (Strong recommendation).