If there aren’t really good connections made between a fracture liaison service and primary care providers, follow-up can be less effective and people can fall through the gaps. ANNE THURSTON, ROYAL OSTEOPOROSIS SOCIETY 

A national audit and hospital incentives have contributed to improved outcomes for hip fracture patients.¹⁸ In-hospital management of hip fractures has seen annual improvements, leading to better outcomes such as consistently declining rates of death within a month of the fracture.¹³ In England, hospitals receive a best practice tariff (BPT) if they meet eight best-practice standards when managing a person with a hip fracture.¹ A similar scheme is being implemented in Scotland.⁷ Care that meets these standards is associated with significantly improved patient outcomes,^{19 20} and in order to achieve them, many hospitals have adopted integrated orthogeriatric models of care.¹⁸ In contrast, best-practice care standards are reached far less frequently in Wales and Northern Ireland, where this type of incentive scheme is not in place.¹³ However, there is still considerable variation between hospitals across England in achievement of key best practice tariff standards, such as orthogeriatric assessment, which ranges from 1% to 100% of hip fractures.¹³ While the tariff has certainly had an impact, some experts argue that the development of the National Hip Fracture Database has been the primary driver of improved management of hip fractures in hospitals in England.^{3 21}

Fracture liaison services (FLS) are well-established in the UK, although there is wide variation in access. Since FLS were first developed in Scotland,²² implementation has expanded across the UK and it is estimated that 55% of the UK population now has access to an FLS.² While this is higher than in many other European countries, thousands of people still lack access.²³ FLS are unevenly distributed across the UK, with better coverage in some areas than others.^{3 24} Every health board in Scotland, for example, operates an FLS.²⁵ In England, there is notable variation, with experts identifying a range of barriers to implementation including limited funding, staff capacity and variations in commissioning decisions at a local level.⁵ It has also been suggested that local champions are instrumental in pushing for investment in new services.³

FLS programmes in the UK are supporting improved identification and management of osteoporosis, although challenges remain. While there are some gaps in service provision and reporting, annual audit data show continuous improvement. In 2017, identification of fragility fractures increased from 40% to 43%.²⁴ While osteoporosis medication was recommended to 43% of people seen by an FLS – up from 38% the previous year – only 38% of these people had their medication monitored by a healthcare professional during follow-up.¹ To improve prevention of subsequent fractures, an expert commentator has stated that optimisation of existing FLS should be prioritised so that examples of best practice can be used to inform the implementation of additional FLS across the UK.³

Limited integration of services may pose a barrier to long-term follow-up and treatment review. Clinical guidance states that osteoporosis treatment should be reviewed 16 weeks after initiation and annually thereafter.²⁶ While treatment is generally initiated by a specialist or through an FLS, long-term monitoring and management must usually be facilitated in primary care.^{5 26} However, communication gaps and suboptimal collaboration between secondary and primary care can mean that treatment plans are not adequately monitored and people may not be supported to adhere to treatment in the long term.⁵