Welsh Fracture Liaison Service (FLS) Model

Dr Inderpal Singh, Consultant Geriatrician, Aneurin Bevan University Health Board, National Clinical Lead, Bone Health, Wales

Fracture Liasion Service (FLS)

Strategic Case for Adoption:

Between 2011 and 2021, Wales saw a significant demographic shift, with a 17.7% increase in the population aged 65 and over. This ageing population is particularly vulnerable to osteoporotic fractures, a condition that affects 1 in 2 women and 1 in 5 men over the age of 50, primarily impacting the hip, spine, arm, and forearm.

Notably, the incidence of fractures has risen, with a fragility fracture occurring every minute, compared to every two minutes in 2013. Across the UK, over 300,000 fragility fractures occur annually, costing an estimated £2 billion. In Wales alone, 20,000 fractures are expected each year as a consequence of osteoporosis, which now affects 3.8 million people across the UK.

The scale of the problem: only 9.3% of individuals in Wales who experienced a fragility fracture were identified in 2020 and only 64% received specialist care within 90 days, despite these fractures being a key indicator of increased risk for future breaks. Additionally, only 5.3% of those identified were commenced on treatment and only 20% of these patients were followed up at 52 weeks. This means that only 3.3% (n=222) of patients identified in 2020 received the recommended treatment to guidance (taken from the FLS database).

A 2004 study on fracture risk following an initial osteoporotic fracture found that 34% of individuals aged 60 to 80 years experienced a subsequent hip, clinical vertebral, forearm, or shoulder fracture within the first year. Over a five-year follow-up period, this risk gradually declined to 9% by the fifth year (Johnell O et. Al. 2004).

A study conducted in 2019 among women aged 65 and older found that, in the absence of appropriate secondary prevention, the risk of refracture remained alarmingly high—reaching 10% at one year, 18% at two years, and 31% at five years (Balasubramanian A et. Al. 2019).

A more recent systematic review and meta-analysis in 2024 assessing the effectiveness of FLS in adults aged 50 and older found moderate-certainty evidence that FLS significantly reduces the risk of secondary fragility fractures at follow-up periods of two years or more. Hence stronger partnership and collaboration with Primary Care for an extended follow-up is particularly beneficial due to the time required for bone remodelling as a result of osteoporosis medications (Danazumi MS et. al. 2024).

Proactive care can prevent many fragility fractures, yet the consequences of fractures remain severe and often unmeasurable. Hip fractures are associated with a 20% mortality rate within one year, 50% are unable to walk unaided and 15% require discharge to nursing homes. Additionally, 66% of patients with vertebral fractures develop chronic back pain with 20% risk of dying within five years. Beyond the physical impacts, these fractures also contribute to a loss of confidence, fear of falling, loneliness, and depression.

The economic burden of all fragility fractures in Wales is substantial, amounting to £133,062,444 annually. This figure underscores the importance of addressing osteoporosis and fragility fractures on a national level through preventative strategies and timely interventions.

New Service Approach:

The Fracture Liaison Service (FLS) aims to deliver ROS 80% identification/50% treatment/80% monitoring model for preventable osteoporotic re-fractures. The approach is scalable to all health boards and meets national guidelines.

Methodology:

Digital identification: An administrator completes an initial triage of a live digital record, identifying patients over 65 years who have sustained a fragility fracture, (the FLS ultimate aim is to identify patients over 50 years). A bone health nurse practitioner/ advanced clinical practitioner (ACP) completes the next review to identify patients who would benefit from a specialist bone health review, whereby patients are referred to a consultant geriatrician.

Treatment: Suitable patients are contacted for a bone health assessment which includes falls risk and community care. Bone therapy is recommended for suitable patients.

Adherence to Treatment: Patients will be monitored in their understanding of the risk of osteoporosis, lifestyle modification requirements and their adherence to bone therapy at 16 and 52 weeks.

The service is integrated with radiology, rheumatology, emergency and trauma and patients are seen by the FLS team within days rather than the traditional referral model of weeks to months before their first clinical review.

Clinic & Systems Impact:

As a result of the service transformation in Aneurin Bevan UHB, fracture case identification improved from 25% (2021) to 44% (2022). Identification of fracture cases increased further to 53% in 2023, reaching 70% in 2024 (National benchmark=36%).
64% patients were treated to guidance (national benchmark=55%). Treatment and monitoring achievement in AB-FLS is now higher than the national average.
These advancements have ensured that more patients receive timely, high-quality osteoporosis care, preventing missed treatment opportunities.
FLS is spreading across all parts of Wales and there is an observed increase in case identification of 46.5%, from 16.8% (3,537 cases) in 2023 to 25% (5,200 cases) in 2024.

Economic Impact – Local to National Transformation:

The FLS has been communicated as a ministerial priority and has received £1,000,000 funding for national roll out based on its evidence in providing high-value, high-quality patient care. Health boards are expected to consider formal FLS business case to ensure the sustainability of the prudent value based service.

To date, the FLS has recruited an additional 13 ACP/ bone health nurses and 11 administrators/ FLS coordinators.

The FLS has demonstrated a best return of value for services, with expected annual cost benefits of £11,047,324 across Wales.

Key Requirements:

The ROS recommends 1 WTE nurse/ ACP with 0.5 administrator to serve a population between 40,000-46,000.

Key team members:

FLS administrators/ co-ordinators
Clinical specialist nurses/ ACPs
Booking clerks and directorate support officers
Radiographers
Consultants (bone health specialists and radiologists)

Benefits:

Reduced risk and rate of fragility fractures for Wales
Reduced rate of post fracture mortality and complications that would usually occur in the frailer population
Reduced demand for primary and secondary services
Improved patient self management, outcomes and quality of life in older years
National equitable value-based service with significant return on investment through resource release
Meeting national standards of care
Political support for adoption, scale and spread (quality statement and national mandate)

Resources for Health Boards

Relevant Policy/ Strategic Alignment

Quality statement for osteoporosis and bone health [HTML] | GOV.WALES

Our Programme for transforming and modernising planned care and reducing waiting lists in Wales (2022).

Goals:

Effective referral (most clinical needs seen in the right setting)
Advice and guidance (to aid informed decision making by secondary and primary care)
Treat accordingly (right place, right time)
Follow up accordingly
Measure what’s important

Priorities: