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NHS: Fracture Liaison Services

Volume 835: debated on Monday 5 February 2024


Asked by

To ask His Majesty’s Government what plans they have to invest in NHS Fracture Liaison Services in England.

My Lords, I beg leave to ask the Question standing in my name on the Order Paper, and I declare my interest as co-chairman of the APPG on Osteoporosis.

The Government recognise the value of the quality-assured secondary fracture prevention services, including the fracture liaison services, or FLS. More than 500,000 fragility fractures occur annually in the UK, and up to 40% of fracture patients will suffer from another. FLS are commissioned by integrated care boards, which are well placed to make decisions according to local need. The Major Conditions Strategy: A Case for Change and Strategic Framework outlines that, with NHS England, we will explore supporting the additional provision of FLS.

My Lords, I thank my noble friend for that Answer, but all we ever seem to get are warm words and then broken promises. We were promised money for FLS in the elective recovery plan by the Chancellor himself, with announcements on FLS before the end of last year. A package of measures was promised in the Autumn Statement, as well as a national specialty adviser on osteoporosis. None of those promises has been kept.

To go back to basics, can my noble friend tell me whether he accepts that the 90,000 people who need anti-osteoporosis medication are missing out on it because of no access to FLS; that universal coverage of FLS in England could prevent 31,000 hip fractures over five years; and that investment in FLS would pay for itself in just 18 months? If he does accept those points, can he tell us why on earth these promises have not been honoured, and why the needless suffering of tens of thousands of people has not been brought to an end? When will words finally become deeds?

First, I thank my noble friend for his tireless campaigning in this space. I agree that there is a very good case to be made. Many of us will know the advantage of the fracture liaison services. A lot of studies show that you are at least 10% less likely to suffer from another fracture, so it is a vital part of the prevention programme. There is a very strong case behind it, and my noble friend can rest assured that it is something that we are really looking to progress.

My Lords, would the Government agree to a temporary transformation fund to pump-prime the fracture liaison services? If everyone over 50 had access to a quality fracture liaison service, it would prevent 74,000 fractures, which would help people to stay in work and help to take pressure off hospital beds. Would the Minister agree that this would be investing to save?

As I mentioned, I agree with the noble Baroness that the FLS has shown many cases of prevention. There is a good argument in terms of investment and the return on it all. That is something that we are working towards and, as the noble Baroness will know, it is part of the major conditions strategy for musculoskeletal. So it is something that we are looking to expand.

My Lords, do the Government regret dropping the commitment that they gave in a debate in this House in September to expand financial provision for fracture liaison services? Is the health department considering the introduction of a best-practice tariff to reward those trusts that establish and maintain these vital services?

I think that the statement made previously has been corrected on this, but, as I mentioned, we accept that these services are very effective in what they do. That is why we have musculoskeletal as part of the major conditions strategy. It was something that we put £400 million behind last year, in terms of a workforce package. We are looking at the effectiveness of FLS and, in ICBs that are not doing it, whether there is a case to expand them further.

My Lords, I thank the noble Lord, Lord Black, for his dedicated work in bringing this important topic to the attention of the House. Around this time a year ago, the noble Lord asked another Question on the early detection of osteoporosis, which is the leading cause of fractures in those aged over 50, particularly women. In his answer, the Minister, who is answering the Question again today, noted that

“a fractured femur is the second biggest reason for intake into hospitals, in terms of beds”—[Official Report, 19/1/23; col. 1926]

and that he would be happy to report on progress on this to the House. Will he tell us whether any progress has been made since he gave that answer one year ago?

Yes. Again, I did more research into this and, similar to the point just made, for women over 45 more hospital days are spent with osteoporosis than with conditions such as diabetes, heart problems or breast cancer, so it is recognised that FLS have a very strong part to play. We are trying to pursue a prevention agenda; there is a good cost-benefit argument around it, so we are making a strong case for their expansion.

My Lords, the noble Lord, Lord Black, and the Better Bones campaign have done an excellent job in raising the public profile of fracture liaison services, so I was a little surprised that searching for them on the NHS website returned some general articles about fractures and advice about the Patient Advice and Liaison Service but nothing about fracture liaison services as such. Will the Minister look into this to ensure that people trying to find information about FLSs are given it and directed to their local service?

I thank the noble Lord. His interventions around the communications side are always welcome, because we recognise that it is one thing having a service and another thing making sure that the world knows about it. I will go and find out more and write to the noble Lord.

My Lords, the fracture liaison service originally started in Glasgow, with the particular intention of identifying mostly women who had a higher risk of fractures from osteoporosis. In England and Wales, a fracture liaison service audit has been established now for several years. How do the Government receive the learning from those audits and how do they implement the learning that they receive?

The noble Lord is correct; there has been some good evidence gained. As I mentioned previously, it shows that the probability of suffering from a fracture if you have been in a clinic is 10%—some studies have shown as much as 30% to 40%. It also shows, as my noble friend Lord Black was saying, that there is actually a good cost saving: it is thought that £65 million per annum will give a return of more than £100 million. There are some very good statistics around this, and I assure noble Lords that we are making a strong case for their expansion.

My Lords, the Minister has previously confirmed in your Lordships’ House that just 51% of ICBs have a fracture liaison service, and that the rest of the country has what he described as “different versions of it”. Will he explain what is meant by this, so that it can be understood whether this means a full fracture liaison service or not in the remaining 49%? When will Minister Caulfield’s promise to establish more fracture liaison services actually be delivered?

I believe that the latest number is 57%, but the general point stands that that leaves 43% which are making other types of provision. The work we are doing right now is trying to understand the success of those versus what we see as prudent with that 57%. That is the case we are making and the case that Minister Caulfield was referring to as well. I believe personally that it is a strong case, so it is something that, as I say, we are looking to work further on.

My Lords, I apologise for adding to the pressure on my noble friend, but half of all over-50s women will suffer fractures due to osteoporosis, and this affects 50,000 working-age women each year, yet too often this disease is just stereotyped as affecting old women. The menopause increases fracture risks for women in their 50s, when many are in the prime of their life. Might such mistaken stereotyping about old women explain the near total absence of osteoporosis from the Government’s laudable women’s health strategy? Will we perhaps see women’s health hubs referring women to fracture liaison services, with further progress in the forthcoming Budget?

Again, the use of hubs and their importance for getting people back to work is recognised. That is why in 2023, in the major conditions strategy, we announced the £400 million workforce programme to get 100,000 people with employee support back into work. It is absolutely recognised that what we can do with fracture liaison clinics is a major help. We are also looking at digital therapeutics—the app is close to my heart—that can help with MSK as well. There are a range of measures.

My Lords, I declare my role as president of the Chartered Society of Physiotherapy. Will the Government undertake to work with the physios and Public Health England to look at prevention? This is a public health issue because people have trip hazards in their homes, and a decrease in exercise means that people’s balance generally is not as good, and therefore they are more likely to have a fall. When people do have a fall when they are older, they are more likely to sustain a fracture. Avoiding trip hazards and increasing people’s mobility can be a very important preventive measure.

The noble Baroness is correct. As well as using a physio to strengthen people’s use of their limbs, there is a strong investment case behind home improvements because of the payback from them. This is all part of the prevention agenda, and we are looking to see if we can put a package of measures together because our feeling is that prevention is the best way to go.