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25 March 2009: The second national clinical audit to investigate the organisation of services for patients who have fallen and fractured bones (hip, wrist, arm, pelvis or spine) shows that commissioning of falls services is very variable, rarely providing a co-ordinated falls and fracture strategy. Many NHS Trusts do not comply with NICE guidance on fracture prevention services, despite PCOs (Primary Care Trusts and Local Health Boards) claiming that they are compliant.

The findings, showing serious gaps in the provision of care, are significant given the scale of the problem. Every year over 700,000 older people in the UK attend A&E following a fall. Falls and fractures in the over-65s account for over 4 million bed days per year in England alone.

The audit was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and carried out by the Royal College of Physicians' Clinical Effectiveness and Evaluation Unit (CEEU). Results came from 158 NHS Acute Trusts, 7 Combined Health and Social Care Trusts, 44 Mental Healthcare Trusts, 150 Primary Care Organisations, and 73 care homes.

Significant findings include:

Opportunities to prevent recurrent falls and fractures are being missed:

• Risk assessments in Emergency Departments and Fracture Services are inadequate
• Services with Falls Coordinators and Fracture Liaison Nurses have better case finding systems in place to identify high risk fallers than those without, but many services lack these key people
• Most Trusts have developed inpatient falls policies, but only a third know how many patients have fallen or fractured while in hospital.

Commissioning is patchy, rarely providing a coordinated falls and fracture strategy:

• Important public health information on fracture rates is inadequate or not collated
• Only 39% of commissioning Trusts report being compliant with the NICE technology appraisal on secondary prevention of osteoporotic fragility fractures. This figure contrasts with the results of 2007/8 Healthcare Commission annual health check on NHS Trusts, in which the great majority of PCOs in England self-reported as compliant, as reflected in Core Standard 5a. This public reassurance about fracture prevention services turns out to be misleading, since only 24% (40/169) of PCOs have audited local bone health prescribing and only 9 know their local fragility fracture rates.

Many clinical services are not adhering to the NICE guideline-based treatments to prevent falls and fractures (CG21 and TAG87*):

• Patients with first fractures are not identified to be started on treatment to reduce the risk of future fractures
• Many of the exercise programmes being provided are not evidence based for falls prevention
• Too few services used patient-agreed treatment plans
• Assessments for safety at home using a validated approach could be better.

Dr Jonathan Treml, Associate Director of the National Falls and Bone Health Audit Programme, said: "This audit demonstrates that the services provided for older people at risk of falls and fractures fall short of the services that the evidence supports, that national guidelines dictate, and that older people deserve."

Robin Burgess, Chief Executive of HQIP, said: "This audit really highlights the need to address the shortfalls in aftercare services being offered to patients who have fallen and fractured bones. A fall can have serious consequences for both the physical and emotional well being of older people and access to the right aftercare services and support can both help rehabilitation and prevent recurrent falls. As with many HQIP commissioned national clinical audits, implementation of the practice changes identified means that patients can continue to lead active and fulfilling lives after a fall."

Nick Rijke, The National Osteoporosis Society's Public and External Affairs Director, said: "The incredible numbers of people suffering fragility fractures is not a mere statistic. Fractures have a profound impact on quality of life, greatly diminishing mobility and independence. 80% of older women would rather die than experience the reduced quality of life and subsequent admission to a nursing home that follows a serious hip fracture. By correctly identifying those at risk, NHS trusts could save time, money and most importantly, lives."

Main recommendations of the report

Primary care organisations (PCOs) should develop commissioning strategies that include:

• A "fracture liaison service" - using the current evidence based model
• Clinical leaders including a consultant with a job plan commitment to falls prevention
• Case finding systems in hospital and community settings to identify high risk fallers
• Adherence to NICE treatment guidelines with monitoring by local audit
• Widespread and accessible evidence-based exercise programmes
• Targeted use of validated home safety assessments

The Department of Health should review how it can best support these developments by:

• Provision of advice on commissioning
• Strengthening incentives for commissioning and provision of falls and bone health services
• Provision of metrics, some of which can be derived fro this audit, for falls prevention, fractures and osteoporosis treatments.

For more information, or to view the full report, click here.

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