Quality statement for osteoporosis and bone health

This quality statement is an aspirational description of what good looks like for children, young people and adults receiving osteoporosis and bone healthcare services throughout their life course. It is also for people who are at high risk of sustaining a fragility fracture, for example those with:

• previous fracture history
• dementia
• frailty
• underlying risk factors for osteoporosis

It also seeks to connect with, and advocate for, health improvement action which supports good bone health and prevents osteoporosis, throughout the life course for people in Wales.

Fragility fractures occur worldwide and are estimated to affect 1 in 3 women over the age of 50, and 1 in 5 men, and can cause significant impacts for a person’s quality of life, including psychological, social and economic factors. In addition, following a first fracture, there is a 1 in 3 chance of sustaining another fracture within 12 months. The high incidence of fragility fractures can result from lack of primary preventative measures that improve and maintain good bone health; poor identification of and untreated osteoporosis. Fragility fractures not only increase pressure on NHS services but can have an immeasurable cost to individuals and their family.

In 2020, there were 20,565 fractures across Wales, of which 4,113 were hip fractures. Within 2 years, 2,468 people had a refracture, of which 987 were hip fractures which accounted for 31,094 hospital bed days. Half of these people were unable to walk unaided, there was a 20% mortality rate within 12 months and 15% were discharged from hospital to care homes.

Vertebral (spine) fractures can cause chronic back pain in two-thirds of people and can lead to an average 14 GP visits per year following a fracture.

The cost to health services for each hip fracture in Wales is estimated to be:

• £17,857 per person for acute care
• £448 for community and primary care
• £8,237 in social care

This brings the total cost to £26,272 per person. The annual cost for hip fractures is more than £81 million. When we add the costs of non-hip inpatient and outpatient fractures and clinical vertebral fractures, the total costs per year are more than £133 million. And this does not include the personal cost in terms of quality of life and independence.

Osteoporosis is often diagnosed when a fragility fracture occurs, but subsequent fractures lead to accumulation of fracture-specific morbidity over time. This is described as the fracture cascade.

Fragility fracture prevention is aligned to the vision set out in the written statement on building capacity through community care - further faster. Bone health services will be developed in line with the aims set out in a healthier Wales, focusing on prevention and early intervention and providing seamless care and support for people when they need it.

Good bone health and osteoporosis care will be delivered by targeting 5 key groups, with an initial focus on subsequent fracture prevention in the most vulnerable and those with unmet needs. These key groups are:

• fragility fracture in those 50 and over: subsequent fracture prevention (secondary prevention)
• primary fracture prevention in frailty and dementia
• bone health in high-risk groups: people with chronic conditions, severe and chronic eating disorders, those who are prescribed certain drugs (such as steroids and oestrogen-lowering drugs), those at high risk of falls and those with a parental hip fracture
• bone health in post-menopausal women: women’s health focus, including education, awareness, diet, exercise and HRT treatment and close collaboration with the women’s health clinical network (aligned with the women’s health plan)
• bone health in Wales: primary prevention to improve and maintain good bone health across the life-course, including a focus on physical activity, obesity, nutrition and healthy lifestyle

Fracture liaison services have been established in the 6 university health board areas across Wales. Mutual agreements are in place between Powys teaching health board and adjacent district general hospitals to ensure access to services for people living in Powys.

The Welsh fracture liaison model has 3 priorities, all underpinned by quality:

• planning
• improvement
• management and assurance

The 3 priorities are based on quality principles to promote health by:

• raising awareness and education on bone health and osteoporosis
• provide care by integration and partnership leading to co-production
• protect re-fracture by improving identification, management and care based on the national standards

The bone health clinical implementation network (CIN) will sit under the musculoskeletal (MSK) strategic clinical network (SCN) within the NHS Executive. It will use the national clinical framework to guide progression of osteoporosis and bone health services to achieve the aims of a healthier Wales and the Wellbeing of Future Generations (Wales) Act 2015. The network will develop national leadership, local engagement and collaborative partnerships working to ensure there is a long-term and consistent approach to improving bone health in the population whilst supporting the prevention and management of bone health conditions throughout the life course.

The introduction of quality statements was signalled in a healthier Wales, and has been described in the national clinical framework as the next level of national planning for specific clinical services. Quality statements form part of the enhanced focus on quality and will be integral to the future planning and accountability arrangements for the NHS in Wales.

There is a need to ensure that equity of access and health outcomes is provided for those people who face inequity, such as, deprivation, ethnic minority, rural, LGBTQ+ communities, other protected characteristics. The same is true for people who experience health exclusion, for example, people experiencing homelessness and people in contact with the justice system. Pathways will need to be flexible and proportionate to meet the varied needs.

The more than just words strategy to strengthen Welsh language in health and care services through the ‘active offer’ principle should become an integral part of service provision. Service providers should build on current best practice and plan, commission and provide care based on this principle.

This approach aligns with the national clinical framework, which places specific emphasis on the development of high value national clinical pathways that meet population need. It also aligns with the quality safety framework, which emphasises the importance of systemic local use of the quality management system. It also enables a focus on co-production and cross-working with other groups to address areas such as:

• prevention
• rehabilitation
• pain management
• care for those who are critically ill or at end of life
• collaboration with other conditions

A system-wide approach to quality requires a culture that embeds continuous learning and improvement at its heart. This should be underpinned by a clear definition and understanding of what good quality looks like, utilising national and benchmarked standards, peer review and audit.

The duty of quality requires Welsh ministers and NHS bodies to ensure quality-driven decision-making and planning is in place to ultimately deliver better outcomes for all people who require health services. Quality needs to be system-wide and applied across all clinical and non-clinical services within the context of the wellbeing and health needs of the population.

There are 12 health and care quality standards for people with osteoporosis and bone health conditions.

Safe

This means:

• Effective integrated care with appropriate clinical governance, multi-professional involvement, communication, monitoring and follow up to meet individual needs.
• Decisions relating to care are appropriately documented showing the shared decisions that were made and the rationale behind them, including consideration of risk, benefits and potential outcomes of considered interventions.
• Evidenced safety improvement programmes are embedded using the all-Wales incident reporting system to identify themes and share collective learning points.

Timely

This means:

• Timely access to fracture liaison services (FLS) and continued receipt of osteoporosis care by specialist multi-disciplinary teams for those who sustain fragility fractures in line with the UK national standards.
• Prompt identification, investigation and osteoporosis treatment are delivered in line with latest evidence, national standards, Welsh Health Circulars (WHC) and National Institute for Health and Care Excellence (NICE) guidance, including access to DXA scanner as part of the FLS Database (FLS-DB) standards, diagnostics using artificial intelligence and specialist medications including anabolic drugs.

Effective

This means:

• Promotion of good bone health, across the life-course, through provision of advice on healthy lifestyle (including health and wellbeing checks), good dietary calcium intake, regular weight bearing exercise, smoking cessation and alcohol consumption within national guidelines.
• Awareness raising of bone health for community and healthcare staff. Development of an effective osteoporosis prevention, early identification and management, education programme to enable delivery of a high quality, evidenced based care.
• Consideration of specialised bone health clinic assessments for those who sustain a fracture while on treatment, have a very high fracture risk or have an inadequate response to osteoporosis treatment and younger adults with very low bone mass or undiagnosed secondary causes.
• Addressing falls risk factors, particularly nutrition and hydration, and promoting muscle strengthening and balance training exercises.
• Dedicated FLS quality improvement teams to influence prudent use of resources and provide high quality care. Efforts should be made to involve local influencer and patient or carer for service feedback and co-produce the change with patients. Improvement teams should review FLS data bi-monthly (shorter-frequent meeting) and annual reviews of the FLS should be presented to the health board clinical standards and effectiveness group.

Efficient

This means:

• Building on and expanding new ways of working which improve efficiency, including artificial intelligence.
• Training and developing bone health clinical nurse specialists, therapists, pharmacists or other key clinicians to act as accountable role models and take autonomous responsibility for the provision of effective, efficient and appropriate high quality bone care.
• Osteoporosis risk should be determined through use of a fracture risk assessment tool (for example, FRAX), following the national guidelines, such as the national osteoporosis guideline group guidance for requesting a bone density (DXA) scan.

Equitable

This means:

• Co-produced regional and local services that utilise local needs assessment to understand and actively work to meet needs of the local population not being addressed by existing services.
• National pathways implemented at a local level to ensure transparency, support equity of access, promote consistency in standards of care and address unwarranted variation.
• Health boards to collaborate with FLS-DQA board to support equity of access for everyone over 50 and promote mandatory national audit participation to ensure consistency in standards of care (that meet agreed national clinical standard KPIs as set out by the Royal College of Physicians FLS-DB) whilst highlighting unwarranted variation regardless of their postcode, ethnic origin or gender (or gender identity).

Person centred

This means:

• Communication is kind, empathetic, accurate, effective and accessible.
• People are signposted to, or provided with, accurate and approved evidence-based information (including voluntary organisations) that aligns with pathway recommendations in a format that meets their individual needs.
• People and their carers are engaged in "what matters" conversations where their values, preferences and wishes are understood and included in shared decision making.
• Promotion of comprehensive person-centred delivery of care closer to home and partnership working with primary and community care.

Enablers

Leadership

This means:

• A nationally led approach through the bone health clinical implementation network to support health boards to empower local clinical leads, to deliver equitable regional and local services.
• National leadership and promotion of the delivery of high-quality and equally accessible services for patients with osteoporosis, previous fragility fracture and those at higher risk of fragility fracture.

Workforce

This means:

• A transformed, multi-professional, whole system workforce to better meet future needs of people with osteoporosis and bone health conditions.
• A workforce that is supported, developed, and trained to meet current and future needs, address recruitment and retention challenges and which is sustainable and equitably distributed.

Culture

This means:

• Embedding a culture of quality improvement through engagement of professional teams in appropriate, regular, timely and constructive discussion at multi-disciplinary clinical governance meetings and collaboration to deliver joined up, person-centred, outcome focused, services.
• A culture that utilises a whole system approach including social, education, employment, and peer support.
• A culture that enables supported self-management as locally as possible.

Information

This means:

• A national approach to informatics systems and data that enables greater integration of care and provides relevant, high quality, standardised data to drive service improvement.
• The digital enablers or solutions for improved and efficient care to be explored and developed.

Learning, improvement and research

This means:

• A value based healthcare (VBHC) dashboard for osteoporosis prevention and care to be developed to capture people’s experience and outcomes (PREM and PROM), adherence with medications and quality of life.
• Newer biochemical techniques to measure bone markers and radiological treatments (for example, vertebroplasty where appropriate) to be explored and developed. Vertebroplasty to be considered if severe ongoing pain for unhealed spinal fracture as per NICE guidance.
• Audit and monitoring of osteoporosis and bone health services delivered by health boards to improve quality of patient care and outcomes. To be achieved via the continued participation in the Royal College of Physicians’ "FLS-DB" audit. A continuous focus on achieving all key performance indicators (KPIs) particularly aiming to identify 80% of the expected fragility fractures, commencing treatment for 50% and monitoring 80% of those who have commenced on bone treatment at 16 weeks and 52 weeks.

Whole-systems approach

This means:

• Multi-professional teams will work with local partners to build and sustainably support and optimise bone health across the life course in the community.
• Fracture liaison services (FLS) will work in partnership with other clinical strategic, implementation and operational delivery networks and where possible join up services for those with multiple interacting co-morbidities. 
• Integration with primary and community care to ensure effective prevention and early identification of people with osteoporosis, transfer of care from FLS and conduct annual bone health reviews and use of FRAX/NOGG guidance to plan long-term osteoporosis care including referral for a new DXA scan or specialised bone health clinic.

Quality statement

High-level statement of intent for what “best” looks like for services for people with osteoporosis and bone health conditions.

Co-production

A way of working in partnership, by sharing power between health professionals and people who draw on care and support, carers, families and citizens.

Dual energy x-ray absorptiometry (DXA) or Bone density scan 

A bone density scan is used to measure bone mineral density (BMD) using low radiation x-ray.

Fracture liaison services (FLS)

A fracture liaison service ensures people aged 50 and over with a broken bone after a fall have their bone health and falls risked checked and managed to lower their risk of any further fractures in the future. The service features a team of healthcare professionals and has been shown to benefit individuals and be both a clinically and cost-effective form of early intervention, which helps to avoid future hospital admissions.

Hormone Replacement Therapy (HRT)

Hormone replacement therapy (HRT) is a treatment used to help menopause symptoms. It replaces the hormones oestrogen and progestogen, which fall to low levels as women approach the menopause.

National Institute for Health and Care Excellence (NICE)

A non-departmental public body that develops and provides national guidance and advice to improve health and social care in England and Wales.

Patient reported experience measures (PREM)

Assesses the quality of healthcare experiences focusing on patients.

Patient reported outcome measures (PROM)

Assesses the quality of care delivered to NHS patients from the patient perspective.

Value based health care (VBHC)

Improving the health outcomes in both a financially sustainable and patient value centred way.

Welsh Health Circular (WHC)

Health guidance issued to health boards and professionals as a circular and sets the standard required to the NHS.