Effective Secondary Preventionof Fragility Fractures:
Clinical Standards for
Fracture Liaison Services

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services
Osteoporosis is the fragile bone diseaseassociated with an increased risk of fragility (lowimpact) fractures, the consequences of which aresignificant. Fragility fractures are:• Common: One in two women and one in fivemen break a bone after the age of 501.
• Costly to the NHS: The hospital costs of hip
fractures alone are estimated at £1.1 billion2.
• Life-changing to the individual: The impact offractures may lead to loss of mobility andindependence, social isolation and depression3.
Many fragility fractures could be prevented bytimely interventions to reduce fracture risk. A
Fracture Liaison Service (FLS) systematically
identifies, treats and refers to appropriate services
all eligible patients aged over 50 within a local
population who have suffered a fragility fracture,with the aim of reducing their risk of subsequent
fractures.
As around 50% of people who experience a hip
fracture have broken a bone in the past4, FLS
represents an ideal opportunity for intervention in
the journey to avert that hip fracture.
FLSs are underpinned by evidence demonstratingthat they are clinically and cost effective. The
principles of evidence-based FLS are presented
in the 5IQ model described in this document.
By adopting these standards, evidence-based
best practice can be implemented and replicatedeffectively across the UK to reduce the futureburden of fractures, improving outcomes forpatients and ensuring efficient and appropriate
use of NHS resources.

2

Population: These standards apply to adults in
the UK aged 50 or older who have had a fragility
fracture.
Audience: These standards have been prepared
for the following audiences:• Adults aged 50 or older who have had afragility fracture, their carers and families.
• Healthcare professionals who deliver or wish todevelop an FLS.
• Healthcare professionals who are involvedin any part of the fragility fracture prevention
pathway.
• Commissioners/funders of FLS.
• Managers involved with service provision.

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Reviewed by (authors and affiliate organisations):

Supported by:

Stephen Gallacher

Chair, Consultant Endocrinologist,
Queen Elizabeth University Hospital,
Glasgow
Swapna Alexander Consultant Geriatrician, Llandudno
Hospital
Natalie Beswetherick Chartered Society of Physiotherapy
Will Carr
Head of Service Delivery, Royal
Osteoporosis Society (ROS)
Amanda Durber
Osteoporosis Specialist Nurse,
Betsi Cadwaladr University Health
Board
Neil Gittoes
Society for Endocrinology
Andy Gray
British Orthopaedic Association
Kassim Javaid
Clinical Lead, FLS-DB, Royal College ofPhysicians
Denise Kendrick
Royal College of General Practitioners
John Lindsey
Consultant Endocrinologist, Belfast
Trust
Terence Ong
British Geriatrics Society
Alison Smith
Patient representative
Mike Stone
Consultant Physician and Director of
Bone Research, University Hospital
LlandoughNuttan Tanna
Royal Pharmaceutical Society
Anne Thurston
Head of Quality Improvement, ROS
Fiona Wardell
NHS Healthcare Improvement Scotland
Publication date: August 2019
Date for review: August 2022
Version: 2
Acknowledgements: With thanks to the authors who
contributed to the previous version of this guidance: Alastair
McLellan, Alun Cooper, Frances Dockery, Graham Davenport,
Victoria Goodwin, Anthony Hui, Zoe Long, Paul Mitchell, Pravin
Jha, Susan Poulton and Sonya Stephenson.
Funding: The development and printing of this document was
funded by the ROS. We are grateful to the authoring group forgiving their time without renumeration.
Please send any comments on this practical guide to:clinical@theros.org.uk
3

4

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Contents
Summary of Clinical Standards for Fracture Liaison Services (FLS)

6

Introduction

8

Using these standards as a patient, carer or family member

10

Identify

12

Investigate

16

Inform20

Intervene

23

Integrate

28

Quality32

Implementing the FLS standards

36

References

38

Appendix 1: Primary care coding

40

Appendix 2: Abbreviations and definition of terms

425

Summary of Clinical Standards for
Fracture Liaison Services (FLS)The six standards described in this document are summarised below. Please refer to the relevant
section for context and further information.
FLSs are underpinned by evidence demonstrating that they are clinically and cost effective. The
principles of evidence-based FLS are presented in the 5IQ model. All principles will be adhered to inorder to achieve benefits shown in the evidence base.
Standard

Criteria

1 Identify:

1.1 The FLS identifies people aged 50 years or older with a new fragility fracture
which also includes:

People aged 50
years and over with afragility fracture aresystematically identified.

2 Investigate:
Investigations toassess risk of fragility
fractures and falls andpossible underlying
secondary causes
for osteoporosis areoffered to people
identified by the FLS.

• Newly identified vertebral fracture.
• A new fracture occurring whilst a patient is taking an osteoporosis drug
treatment.
2.1. People identified as being at increased risk of another fragility fracture areoffered an assessment which will include:• A fracture risk assessment including use of FRAX or QFracture and qualityassured axial DXA including a vertebral fracture assessment (VFA) whereindicated.
• An assessment of falls risk in people aged 65 or over.
• Relevant laboratory and imaging investigations to identify any underlying
secondary causes of osteoporosis and help inform drug treatment decisions.
2.2. Assessment will be completed within 12 weeks of fracture diagnosis.

3 Inform:

3.1. People are offered information according to their needs about:

Information andsupport are offeredto people (and where
relevant their carers)
using the FLS.

• Osteoporosis and risk factors for fracture.
• Lifestyle interventions aimed at reducing fracture risk including nutrition andexercise.
• Coping with pain and any disability associated with their fracture.
• Drug treatment options for osteoporosis - including information on benefits
and side effects.
• Reducing falls risk.
• Next steps in their care plan including follow-up appointments.
3.2. Information is available in a range of formats and languages, appropriate to the
population covered by the service.
3.3. People and their carers understand where to get further information about
osteoporosis and support following their appointment.
3.4. Communications from the FLS are written in a style that can be understood by the
person and their carers. Communications are copied to the person who has had afracture as well as the healthcare professionals involved in their care, including their GP.
People feel supported and empowered to make informed choices and reachshared decisions about their management plan.

6

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Standard

Criteria

4 Intervene:

4.1. People at high risk of fragility fracture are initiated on an appropriate
osteoporosis drug treatment within 16 weeks of fracture diagnosis (i.e. within
4 weeks of the assessment being completed).

Interventions to
reduce the risk offragility fractures areoffered to people as
required.

4.2. People at high risk of falling are referred to falls prevention services andoffered interventions within 16 weeks of their fracture to maximise balance
and mobility.
4.3. People who are recommended interventions to reduce risk of fracture will be
reviewed by the FLS within 16 weeks of fracture and at 52 weeks to ensure:• Treatment has been started and taken appropriately.
• Referral to falls reduction programmes has been actioned.
5 Integrate:
The FLS will integratewith the wider
healthcare system tofacilitate an inclusive
patient pathway;
ensuring effective
case-finding, onward
referrals and longterm management of
osteoporosis.

5.1. Clear management plans are prepared to facilitate transfer of patient care
into primary care, enabling the long-term management of osteoporosis.
5.2. The FLS staff maintain relationships with relevant in-hospital services.
5.3. The FLS staff have a good understanding of the available out-of-hospital
services and how people using the FLS can access these.
5.4. Referral pathways between the FLS and relevant services are agreed.
5.5. People who are recommended interventions to reduce risk of fracture will be
reviewed annually to monitor adherence, tolerability and unwanted effects of
their treatment plan.
5.6. Staff participate in a local multidisciplinary fracture prevention interest groupwhich meets regularly to co-ordinate, plan and develop the FLS.

6 Quality:

6.1. A designated lead clinician is accountable for all components of the service.

The FLS demonstrates
clinical accountability,
ongoing quality
improvement,
effective governanceand funded accessto continuing
professional
development for allpractitioners.

6.2. The FLS is developed in line with a local falls and fracture prevention
strategy.
6.3. Core data from people identified by the FLS is recorded on an operational
database.
6.4. A quality assurance framework is in place that includes:• A programme of continuous improvement including regular audit.
• Participation in national audits such as the FLS-DB in England and Walesor the Hip Fracture Audit in Scotland.
• Peer review.
• Patient and carer experience measures.
6.5. All members of the FLS team have assessment of professional
competencies and demonstrate continuing professional development.
6.6. Staff are active participants in a regional clinical or professional network.
7

Introduction
Osteoporosis and fragility fractures
Osteoporosis is the most common chronicbone disease5. It affects men and women andleads to fragile bones, which can then lead to‘fragility fractures’. These broken bones occur
after low trauma, such as a minor bump or fallthat would not normally cause a bone to break.
These fractures are the consequence of lowbone density and structural deterioration of bone
tissue. The World Health Organization (WHO) has
defined a fragilty fracture as one which occurs
due to forces equivalent to a fall from a standingheight or less.
One in two women and one in five men will breaka bone after the age of 50 years1. An estimated500,000 fragility fractures occur in the UK every
year6. At any one time, hip fractures accountfor occupation of over 3,600 hospital beds
across England, Wales and Northern Ireland7.
Hip fracture accounts for the majority of hospitaland outpatient costs related to all osteoporotic
fractures. The hospital costs of hip fractures
alone are estimated at £1.1 billion2. This figure
excludes the high cost of social care, which adds
significantly to this cost.
As well as the significant burden on health andsocial care resources, the impact of fractures on
individuals can be devastating, leading to lossof independence, mobility and capacity to carryout everyday tasks. In a survey conducted by
the ROS of more than 3,000 people living withosteoporosis, 42% felt socially isolated by theirosteoporosis, one in three reported difficulty withdomestic chores and more than 40% of those
who had fractured said they were in long-term
pain they did not think would ever go away3.
People who have had one fracture remain at
a two- to three-fold greater risk of sustaining
another (known as a ‘secondary fracture’)8 and
23% of secondary fractures in women aged over
50 occur within one year of the first event9.

8

Preventing fractures with Fracture Liaison
Services
An FLS systematically identifies, treats andrefers to appropriate services all eligible patients
aged 50 and older within a local population who
have suffered fragility fractures, with the aim of
reducing their risk of subsequent fractures.
An FLS is an essential component of acomprehensive and integrated approach topreventing falls and fractures among people over
the age of 50 years. Assessment within an FLS
should be part of the pathway for all patients witha fragility fracture.
An FLS is centred around a dedicated coordinator (often a Clinical Nurse Specialist) who
works to pre-agreed protocols to case-find andthen assess patients who have had a fracture. The
service may be based in any healthcare setting,either in-hospital or out-of-hospital, and requires
support from a medically qualified practitioner(typically a hospital doctor or a GP with expertisein osteoporosis and fragility fracture prevention).

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Implementing the standards

Working with national guidance and policies

An estimated 59% of the UK population currently
has access to an FLS, but service provision varies
across the country; Scotland has 100% coverage,
and Northern Ireland is close to achieving the same,
while in England coverage is 53%. Consequently,
implementation of these standards will range
from those needing to start new services, to wellestablished services looking for ways improve.

These standards have been developed to be usedalongside national guidance for the prevention of
falls and fractures produced by National Instituteof Health and Care Excellence10–15, Scottish
Intercollegiate Guidelines Network16 and the
National Osteoporosis Guideline Group17. Clinicalprotocols will be developed locally, based on
relevant national guidelines.

In order to effectively prevent fractures, an FLS will
deliver all six standards outlined in this document.
The methods used for doing so will vary according
to staffing and resources available locally. Tools
and support in developing or improving an FLS areavailable from the ROS (see page 36 for further
details).

The standards also align with the principles ofRealistic Medicine18, Prudent Healthcare19 andMaking Every Contact Count20, and with quality
improvement programmes delivered by ‘Getting It
Right First Time’21 and NHS RightCare22.

Assessing service performance
Participation in national audits facilitatesassessment of performance as well as a benchmark
against national levels of achievement.
Services can also be assessed at a local level.
Examples of audit and evidence of achievement
are given for each standard. Additionally, use the‘what this means to a member of staff and theorganisation’ sections to assess your practice andprocesses.
A list of key performance indicators is included in
the FLS Implementation Toolkit (see implementing
the FLS standards on page 36).

9

Using these standards as a patient,carer or family member
As well as helping health services understand how to deliver high-quality, evidence-based care,
this document can be used by patients and their carers, family and friends. Each section explains
what each standard means to people over the age of 50 who have broken a bone. It can help
you to check whether you’ve received care that meets these standards and to have informed
conversations with your healthcare team.
The checklist can be used by patients, their carers and families to make sure they are getting
everything they should, and at the right time1.

Day 1

The date your broken bone was identified as a ‘fragility fracture’ in the NHS.

By 12 weeks

You should be assessed by an FLS and, if necessary, have had a DXA scan tomeasure your bone density as part of your assessment.

By 16 weeks

If prescribed a drug treatment to protect you from further broken bones, you
should be contacted to ensure you have started taking the drug treatment
and have no side effects.

By 16 weeks

You should be asked if you have started your strength and balance exerciseclasses, if you were referred to one.

By 52 weeks

If prescribed osteoprosis drug treatment to improve your bone health, you
should be contacted to find out how you are and ensure you are continuing totake the drug treatment.

By 3-5 years

Most osteoporosis drug treatments need to be taken for at least 3-5 years
to protect your bones. Your doctor will review your bone health and discuss
the next steps with you. This may be continuing the treatment you’re alreadytaking, switching to another treatment or pausing treatment for a short period.

1 Adapted from Strong bones after 50: FLS explained 44.

10Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Understanding what the Clinical Standards mean to healthcare professionals
This diagram summarises the components of an FLS outlined in this document.

Standard 1:
Identify
peopleat risk

Standard 2:
Investigate
to assessrisk of falls
and fractures

Standard 3:
Inform andsupportIn-patient
non-hip
fracturesHip
fractures

Newly identifiedvertebralfractures

Initial falls risk
assessment in
adults over 65

Bone healthassessment

Low risk

Referrals

Risk of falling

By 12
weeks

Information to inform
care decisions and on
self management

By 16
weeks

Osteoporosis drug treatment
Falls prevention
interventions

Standard 4:
Intervene
to reducerisk of falls
and fractures

Standard 5: Integrate for long-term management
and holistic patient careStandard 6: Quality through leadership,
governance and development

99 Patient-centred management plans

99 Leadership
99 Fracture prevention strategy
99 Data collection
99 Quality assurance
99 Continued professional development
99 Regional clinical network

99 Relationships with in-hospital services
99 Relationships with out-of-hospital services
99 Fracture prevention interest group

By 16
weeks

Follow-up contact at 16 weeks

Follow-up contact at 52 weeks

99 Referral pathways

Day 1

Falls Prevention
ServiceHigh risk

Bone healthand lifestyle
information

Outpatient
fractures

By 52
weeks

11

IdentifyStandard 1: People aged 50 years and over with a fragility fracture are systematically
identified.
Rationale

In practice

People aged 50 years and over who have had afragility fracture need to be identified by the FLS
to ensure they undergo investigations to assess
their need for intervention. Deploying a range ofcase finding strategies will yield the best results.
Strategies used will depend upon local service
models and pathways.

Identifying people aged 50 years or older witha new clinical fracture is a core responsibilityof an FLS. This is undertaken by the ‘FLS coordinator’ who is typically a dedicated ClinicalNurse Specialist, although this role may also be
undertaken by Allied Health Professionals (AHPs)
or competent non-clinical personnel.

Criteria
1.1 The FLS identifies people aged 50 years orolder with a new fragility fracture which also
includes:• Newly identified vertebral fracture.
• A new fracture occurring whilst a patientis taking an osteoporosis drug treatment.

FLSs will include for assessment all people aged
50 years or older who have sustained a new
fracture or radiological fragility fracture at any
skeletal site; though an exception is justified for
fractures of skull, facial, digit and scaphoid bones
that are typically caused by a traumatic injury. A
pragmatic approach to the definition of a fragility
fracture is encouraged and exclusions might bemade in the case of a road traffic collision (orother clearly significant trauma) or where a fall
has clearly been from above standing height.
Identification of new clinical fracture presentations
is achieved most readily by an in-hospital FLS.
In addition to using hospital IT systems, the FLS
co-ordinator can facilitate the identification ofpatients with new fractures through engagement
in orthopaedic ward rounds, trauma teammeetings and attending fracture clinics. All ofthese approaches provide the opportunity to meetpatients personally to educate, persuade and invite
them to attend for further investigation. Patients are
more likely to respond to direct personal invitation.
An out-of-hospital FLS will rely on reporting fromfracture clinic and/or radiology departments, soclose liaison with local secondary care centre(s)needs to be established at the outset to enable
seamless, continuous capture of all relevantcases. Out-of-hospital FLSs are well-placed to
identify patients with prior fragility fracture history(prevalent fractures) from GP systems, whereas
these will remain a challenge for in-hospital FLSs.

12

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

It is unlikely that any single approach will identify all
patients with a new fracture and the FLS co-ordinator
will customise screening methods as per local
systems; it is recommended that multiple strategies
are used for identification to maximise yield.

A fall during a hospital stay may result in a fracture.
These will be identifiable via incident reporting
systems (such as Datix), seen in fracture clinic ortransferred to orthopaedics. It is important that thesepatients are identified and assessed by the FLS.

An FLS will aim to identify all patients from thefollowing groups:

Outpatient fractures• Managed as inpatients on acute orthopaedic/
trauma wards.
• Managed as inpatients on general medical/careof the older person wards not requiring surgicalfixation (e.g. pelvic, upper limb, acute vertebral
fracture presentations).
• Presenting acutely and not requiring hospital
admission but managed as outpatients via
orthopaedic / emergency medicine fracture clinics.
• Presenting acutely but not requiring hospital
admission or fracture clinic follow-up.
• Vertebral fractures newly identified on radiology
reports (incidental or anticipated).
• New fractures as a result of a fall during ahospital stay.
• Patients who fracture whilst away from homeand present later to local orthopaedic or primarycare services.
Some examples of how patients may be identified
are described below.

Inpatient fractures
People who need to stay in hospital after their fracture
are not only at highest future fracture risk23,24, but also areamong the easiest to identify in a hospital-based FLS.
Identify these patients by:
99 Liaising with orthopaedics, orthogeriatricians
and trauma nurses
99 Attending trauma meetings
99 Using IT/informatics systems
Liaison with local orthopaedic and trauma teams isessential in order to agree roles and responsibilities
for identifying people aged 50 or older who have
had a fragility fracture, and to agree access to the
FLS for people under the care of orthopaedic or
emergency departments.

People who have a fracture and are managed in
fracture clinics are another readily recognisable group.
Identify these patients by:
99 Reviewing emergency department lists
99 Screening fracture clinic notes
99 Reviewing primary care records
99 Linking with virtual fracture clinics

Vertebral fractures
Vertebral fractures are amongst the most common
osteoporotic fractures. A vertebral fracture is a
powerful predictor of further fracture, yet theyoften account for less than 5% of clinical fracture
presentations to FLS.
Identify these patients by:
99 Liaising with radiology to identify vertebral
fractures which are incidental findings on images
99 Carrying out vertebral fracture assessment(VFA)25,26 (see Investigations)
99 Liaising with physiotherapy-led musculoskeletalback pain services or other interface services
where people present with back pain
Vertebral fractures are often identified incidentallyon plain X-rays, CT and MRI scans. Guidance on
identification and reporting of vertebral fractures isgiven by the ROS27. This recommends that radiology:• Review the spine in all images of the chest,
abdomen and pelvis.
• Report vertebral fractures clearly using the term‘vertebral fracture’.
• Recommend further assessment andmanagement to reduce fracture risk.

Referral into FLS
Referrals should also be encouraged into the FLS
from other services, such as GPs, pain clinics,
interface services and falls services.
13

What this standard means to:
A person receiving care
You will be identified by the FLS if:• You are aged 50 years or older and you have broken a bone more easily than you’d expect (known
as a ‘fragility fracture’).
• A healthcare professional finds you have had a vertebral fracture (a broken bone in your spine).
Some people can have a vertebral fracture without realising and with no obvious symptoms but
they could benefit from medication to protect them from further broken bones in the future.
A member of staff
You will:• Follow agreed protocols to ensure that people with fragility fractures are identified by the service.
• Use imaging reports to identify people with vertebral fractures.
• Work with colleagues in other departments and specialties to establish protocols to maximise theidentification of people at risk of osteoporosis.
The organisation
The organisation will:• Allow access for FLS practitioners to relevant IT systems that will support identification of patients
presenting with a fracture. This may require cross-organisational collaboration.
• Support services such as orthopaedics, emergency departments and imaging to come together tosupport the work of FLS practitioners• Have procedures in place to ensure that all inpatients and outpatients with fragility fractures are
identified by the FLS.
• Have procedures in place to ensure that all images which include the spine are scrutinised for thepresence of vertebral fractures and these are reported clearly with signposting to the FLS.
• Put in place adequate resources to meet the demand of its population.

14

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Examples of audit and evidence
Identification (all fragility fractures)
Percentage of patients identified compared with thelocal estimated case load.
Numerator – number of people with fragility
fractures identitifed by the service.
Denominator – estimated total number of fragility
fractures for the service (estimated by multiplying
total hip fractures in patients aged over 50 by afactor of five or use FLS benefits calculator).
Identification (vertebral fractures)
Percentage of patients with a spine fracture as theirindex fracture site.
Numerator – number of people with vertebral
fractures identified by the service.
Denominator – total number of people with fragility
fractures identitifed by the service.
Repeat fractures
Number of patients identified with a fracture alreadyon an osteoporosis drug treatment.
Numerator – number of people with a fracture
already taking an osteoporosis drug treatment.
Denominator – total number of people with fragility
fractures identified by the service.
Vertebral fracture reporting
Audit standards for identification and reporting ofincidental vertebral fractures are outlined in ‘Clinical
Guidance for the Effective Identification of Vertebral
Fractures’27. Audit of vertebral fracture reports willquantify the diagnostic gap and inform service
development, including the case for funding thevertebral fracture identification pathway.

15

Investigate
Standard 2: Investigations to assess risks of fragility fractures and falls and possible
underlying secondary causes for osteoporosis are offered to people identified by the FLS.
Rationale

In practice

A comprehensive multifactorial assessment will
ensure that interventions to prevent secondary
fractures are appropriately targeted to the people
that need them.

Assessing fracture risk
There are two components to a bone healthassessment; evaluation of risk factors using afracture risk assessment tool and a dual X-ray
absorptiometry (DXA) scan to measure bonemineral density (BMD).

Prompt assessment and intervention is needed as
the risk of having a further (secondary) fracture is highin the first year following a fracture. Investigations will
occur as soon as feasible after the fracture so thatinterventions are not delayed. Investigations, results
and reports will be completed within 12 weeks of thefracture diagnosis.
FRAX and QFracture are the recommended fracturerisk assessment tools in the UK. They will be used inconjunction with bone mineral density (BMD) resultsfrom axial DXA. BMD measurement is an importantpart of clinical decision-making. It quantifies theseverity of osteoporosis and establishes a baseline
for future evaluation of treatment performance. BMD
measurement is recommended before osteoporosis
drug treatment begins, wherever feasible. A falls risk
assessment is also important as most fractures will
result from a fall.

Criteria
2.1. People identified as being at increased riskof another fragility fracture are offered anassessment which will include:• A fracture risk assessment including useof FRAX or QFracture and quality-assured
axial DXA including a vertebral fractureassessment (VFA) where indicated.
• An assessment of falls risk in people aged
65 or over.
• Relevant laboratory and imaging
investigations to identify any underlying
secondary causes of osteoporosis and help
inform drug treatment decisions.
2.2. Assessment will be completed within 12
weeks of fracture diagnosis.
16

Fracture risk assessment
Bone mineral density, a prior fracture, age andgender are the most powerful contributors tofuture fracture risk. These and other key risk
factors have been used to develop tools that allow
assessment of fracture risk.
There are several fracture risk assessment
tools, including FRAX and QFracture, which havebeen assessed by NICE13 and SIGN16. National
guidance makes recommendations about
how to use FRAX or QFracture in fracture risk
assessment and should be used to develop local
protocols.
As with any assessment tool or guidance, clinicaljudgement should always be used. Users need
to be aware of limitiations of these risk tools
to understand when to amend the calculated
fracture risk scores. These limitations include
differences in fracture risk by differences infracture site, number of fractures and recency of
fracture as well as prevalence of other medical
conditions such as diabetes mellitus, or drug
therapies such as androgen deprivation therapy.
DXA scans
Osteoporosis is diagnosed by measuring BMD
using axial DXA. BMD measurement serves
as a means to quantify fracture risk and is an
important aid to treatment decision-making.
Although a DXA scan should be measured inmost situations after fracture, exceptions may beconsidered in the following instances where antifracture effects of osteoporosis drug treatments

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

have been demonstrated in patients who do nothave osteoporosis as defined by a bone density
measurement:• In the presence of two or more vertebral fractures(where other causes of multiple vertebral
fractures have been excluded16).
• After hip fracture.
NICE guidance suggests that treatment may beoffered to patients over the age of 75 without a DXA
scan where the responsible clinician considers it to
be clinically inappropriate or unfeasible11,14,15.
Vertebral Fracture Assessment (VFA)As well as providing a BMD measurement, DXA
can be used to assess for vertebral fractures. Quickto perform and with very low additional X-ray
exposure, VFA avoids the substantially greater costs
and radiation exposure of conventional plain spine
radiology and can reliably identify the presenceof vertebral fractures. Guidelines produced by theInternational Society for Clinical Densitometry25 canbe used to develop local protocols.
Other investigations
Patients believed to be at increased risk of fracture
will have investigations to guide treatment selectionand ensure treatment safety. From the point ofview of safe prescribing, where a bisphosphonate
treatment is recommended, urea & electrolytes(U&Es) with estimated glomerular filtration rate(eGFR) and bone profile tests (adjusted calcium,
albumin and alkaline phosphatase) will be carriedout as a minimum in all cases.
Laboratory tests should not be more than threemonths old at the point of making treatment
decisions. It is important to recognise that clinicalconditions can change rapidly and, in some situations,contemporary blood test results may be required.
Other procedures may be appropriate for individual
patients depending on the clinical presentation andlocal protocols in order to assess for underlying
secondary causes of osteoporosis and high fracturerisk. These may include (adapted from NOGG 2017:
Clinical Guideline for the prevention and Treatmentof Osteoporosis17):• Full blood count (FBC).
• Erythrocyte sedimentation rate (ESR).
• C-reactive protein.
• Liver function tests (LFTs).
• Thyroid function tests (TFTs).
• Serum protein immunoelectrophoresis, serum
free light chains and urinary Bence Jones protein.
• Serum 25-hydroxyvitamin D, especially ifplanning parenteral treatment.
• Plasma parathyroid hormone.
• Serum testosterone, sex hormone binding
globulin, follicle stimulating hormone, luteinizing
hormone (in males).
• Serum prolactin.
• 24-hour urinary free cortisol/overnight
dexamethasone suppression test.
• Endomysial and/or tissue transglutaminase
antibodies.
• Markers of bone turnover.
• Urinary calcium excretion.
Falls risk assessment
In line with NICE guidance on preventing falls inolder adults10, FLS staff should routinely ask people
aged 65 years and older whether they have fallen
in the past year and about the frequency, context
and characteristics of their fall/s. Older people
reporting a fall or considered at risk of fallingshould be observed for balance and gait deficits
and considered for their ability to benefit frominterventions to improve strength and balance.
This may also be appropriate in people aged 5064 seen by the FLS who have risk factors for falls.
FLS co-ordinators will need adequate training andexpertise in these initial assessment techniques.
An FLS will work closely with local falls services,to determine access to appropriate pathways toensure early falls risk assessment and intervention
post-fracture. The responsibility for any subsequentmultifactorial falls assessment and targeted intervention
will lie primarily with local falls services but, dependingon local arrangements, elements of this assessment
may be conducted by an FLS with relevant skills. In thissituation, there must be clear and timely referral to
the necessary intervention pathways (see Integrate).
17

What this standard means to:
A person receiving care
You will:• Be asked about your medical history and may have a DXA scan (like an X-ray) and blood tests.
The information gathered will be discussed between you and your healthcare professionals so you
can make decisions about what can be done to help reduce your risk of breaking a bone in the
future.
• Be asked about whether you have fallen in the past year and your healthcare professional will
look at how you walk. If you have fallen two or more times, or your balance and the way you
walk suggest you would benefit from specialist help, you will be invited to meet other specialist
healthcare professionals who will be able to assess your risk of falling in the future.
• Receive a copy of the final FLS report prepared by the healthcare professionals who assess you.
This will include your bone density scan results and whether you will benefit from an osteoporosis
drug treatment to strengthen your bones.
A member of staff
You will:• Carry out a comprehensive assessment considering all aspects of bone health. This may include
fracture risk assessment using FRAX or QFracture, DXA, VFA, blood tests and review of imaging as
appropriate.
• Ask whether the person has fallen in the past year, observe their gait and balance, and refer them
to falls prevention services for further assessment where indicated.
• Share final FLS reports (including DXA scan and tests results, as well as treatment and intervention
recommendations) with relevant healthcare professionals and the person who has been assessed.
The organisation
The organisation will:• Support two-way referral processes between the FLS and the falls prevention service.
• Ensure sufficient quality-assured DXA scanning and reporting is available in a timely manner forthe population it serves.
• Ensure there are appropriate staff to run the FLS within waiting time requirements and FLS standards.

18

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Examples of audit and evidence
Time to FLS assessment
Percentage of patients who were assessed by the
FLS within 12 weeks of their fracture:
Numerator – people who have had an assessment
within 12 weeks.
Denominator – total number of people identified
by the FLS.

Clarity of correspondence
Proportion of respondents to the patient satisfaction
survey who found copies of correspondence fromthe FLS easy to understand.
Numerator – number of people who felt that
correspondence was easy to understand.
Denominator – total number of people who
responded to the patient satisfaction survey.

Waiting time to FLS assessment
Average waiting time to FLS assessment.
Time to DXA
Percentage of patients who had a DXA ordered orrecommended and were scanned within 12 weeks
of fracture.
Numerator – number of people who were scanned
within 12 weeks.
Denominator – number of patients who had a DXA
ordered or recommended.
Falls assessment
Percentage of patients who received a falls
assessment or were referred or recommended for afalls risk assessment.
Numerator – number of people who receive or werereferred for a falls risk assessment.
Denominator – total number of people seen by
the FLS.
Correspondence to people
Percentage of people who were sent copies ofcorrespondence.
Numerator – number of people who were sent a
copy of correspondence from the FLS.
Denominator – total number of people seen by
the FLS.

19

Inform
Standard 3: Information and support are offered to people coming into contact with the
FLS, and, where appropriate, their carers.
Rationale

In practice

By giving people and, where appropriate, theircarers, information in formats that meet theirneeds, interests and concerns, people canbe effectively supported to understand theircondition and the importance of adhering to theirtreatments and interventions.

Patient education is an important componentof an FLS. The priorities are to cover simple
key points and back this up with information
resources in appropriate formats.

Criteria
3.1. People are offered information according totheir needs about:• Osteoporosis and risk factors for fracture.
• Lifestyle interventions aimed at reducing
fracture risk including nutrition and exercise.
• Coping with pain and any disability
associated with their fracture.
• Drug treatment options for osteoporosis
management - including information on
benefits and side effects.
• Reducing falls risk.
• Next steps in their care plan and follow-up
appointments.
3.2. Information is available in a range of formats
and languages, appropriate to the population
served by the service.
3.3. People and their carers understand where to
get further information about osteoporosis
and support following their appointment.
3.4. Communications from the FLS are written ina style that can be understood by the person.
They are copied to the person who has had afracture as well as the healthcare professionals
involved in their care, including their GP.
3.5. People feel supported and empowered tomake informed choices and reach shareddecisions about their management plan.

20

The FLS will cover the areas outlined in
criteria 3.1 and will allow sufficient time within
the appointment to encourage people to ask
questions, provide information about otherservices they will be referring people to (such as
falls prevention, physiotherapy, pain clinics etc.)
and explain the next steps in their care. Where apatient lacks mental capacity to make decisions,appropriate carers, family or friends will be
involved in discussions and decisions.
Giving someone a diagnosis can be overwhelming
for the person concerned and people may notabsorb or understand all that is explained tothem during their appointment. A summary of
key information in an appropriate format will beoffered and people will be signposted as to how
to get further information following their FLS
appointment. This may include useful websites,by contacting staff at the FLS or through an
information helpline such as the nurse-led
Helpline run by the ROS.
If resources are available, group education
sessions are popular and ensure that there isa range of options to suit different preferences.
These can be led by either peers or healthcare
professionals and be offered as a series of groupsessions or individual meetings.
All written communications and materials need
to be easily understood by the person who has
had a fracture, or their carer. It is good practice toensure the person receives a copy of reports andletters from the FLS to facilitate their on-going
management28.

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

What this standard means to:
A person receiving care
You will:• Feel informed and supported.
• Be given opportunities to ask questions, discuss options and participate in decisions about your care.
• Understand your bone health and what you can do to keep your bones strong.
• Understand your diagnosis and your risk factors for broken bones (bone density etc.)• Understand the benefits and side effects of treatments recommended for you.
• Understand how to take treatments recommended for you and what to do if you have any difficulty
taking your treatment.
• Receive contact information for your local osteoporosis service and/or regional and national charities,
including the ROS, which can give you more information and support whenever you need it.
• Be given information in the format that best suits you.
A member of staff
You will:• Ensure the information and support needs of people aged 50 and older (and where appropriate theircarers) are considered at each stage of the FLS pathway.
• Tailor the information you give to meet the needs of the individual.
• Allow time for people to ask questions, discuss options and participate in decision-making.
• Reinforce the information you give verbally with other formats where appropriate.
• Provide information on bone health to everyone coming through the service.
• Provide information about the individual’s risk factors for fracture including BMD.
• Provide information on treatment options, including their benefits and side effects where appropriate.
• Ensure that people have contact information for the service and/or regional and national charities,
including the ROS, which can offer further information and support.
• Run group education sessions.
The organisation
The organisation will:• Hold information in a range of formats and languages suitable for the population it serves.
• Provide sufficient time in appointments to enable discussion between people and their healthcare
professionals.
• Provide resources for regular patient education sessions to give information and support to people atrisk of fragility fractures.

21

Examples of audit and evidence
Understanding of where to get more information
Percentage of patients who respond to patient
survey indicating that they understand where to
get further information.
Numerator – number of people who understood
where to get further information.
Denominator – total number of people who
responded to the patient satisfaction survey.
Involvement in management plan
Percentage of patients who respond to patient
survey and agreed they felt they were jointly
involved in agreeing their management plan.
Numerator – number of people who felt they were
jointly involved in agreeing their management plan.
Denominator – total number of people who
responded to the patient satisfaction survey.
Group education sessions
Proportion of people seen by the service who
were invited to attend a patient education session.
Numerator – number of people invited to attend apatient education session.
Denominator – total number of people seen by
the FLS.
Proportion of people invited by the service who
attended a patient education session.
Numerator – number of people who attended apatient education session.
Denominator – total number of people invited toattend a patient educuation session.

22

Proportion of people who found the patient
education session useful.
Numerator – number of people who responded
that they found the education session useful.
Denominator – total number of people who
attended a patient education session.
Providing targeted information to meet an
individual’s needs
Various techniques can be used to evalutate
how information is given and gain feedback tohelp staff reflect on and improve practice. These
include pathway feedback, shadowing by peers
or expert patients, focus groups and case studies.
Feedback can form part of an annual appraisal
process as well as on-going team meetings.

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Intervene
Standard 4: Interventions to reduce the risk of fragility fractures are offered to people as
required.
Rationale

Criteria

Intervention following FLS assessment willcomprise a tailored package of care that addresses
modifiable fracture risk factors that have been
identified for each person.

4.1. People at high risk of fragility fracture are
initiated on an appropriate drug treatment within
16 weeks of fracture diagnosis (i.e. within fourweeks of the assessment being completed).

There is a range of effective osteoporosis drug
treatments available and national guidance gives
advice about how these will be used11,14–17,29. Local
protocols will be developed using appropriate
national guidance.

4.2. People at high risk of falling are referred to falls
prevention services and offered interventions
within 16 weeks of their fracture to maximisebalance and mobility.

Many fragility fractures occur as a result of a fall,
and many of the risk factors contributing to falls are
modifiable with appropriate interventions. Thoughclinical trials of falls interventions have not to datedemonstrated an effect upon fracture risk reduction,common sense should be adopted in promoting
these proven interventions to reduce future falls
risk30,31. Exercise can also reduce fear of falling andimprove confidence32. It may help to promote bonestrength as well as help with the symptoms caused
by vertebral fractures, especially postural changes
and back pain33.
Following-up with people to check that theirosteoporosis drug treatment has been started and isbeing correctly taken is an essential component for
an FLS to be effective. Attention from a healthcare
professional can increase treatment adherence
significantly34. In population terms, adherence of atleast 80% is required to achieve significant fracturerisk reduction35.

4.3. People who are recommended interventions
to reduce risk of fracture will be reviewed by
the FLS within 16 weeks of fracture and at 52
weeks to ensure:a. Treatment has been started and taken
appropriately.
b. Referral to falls reduction programmes
have been actioned.

In practiceDecisions about treatment interventions will bebased on information gathered through clinicalassessment, and local protocols derived fromnational evidence-based guidance.

23

Osteoporosis drug treatments

Onset of effect

The most appropriate osteoporosis drug
treatment will be selected according to theindividual’s needs. Treatment choice will take into
account patient preference and an analysis ofbenefit versus risk (side effects). The person who
has had a fragility fracture will be included in thisdecision-making process.

Different osteoporosis drug treatments are likely
to have different speed of onset to achieve
greatest fracture risk reduction. In clinicalstudies, non-vertebral fracture risk reduction
has been shown with 12–18 months of oral drug
treatment39. One meta-analysis suggests risk
reduction may occur as early as six months after
starting treatment40. However long an individual
treatment takes to reach fracture risk reduction,
it is likely to require at least several months oftherapy, during which time non-pharmacologicalinterventions such as falls risk-reduction
strategies assume significant importance.

An optimal treatment choice should be supported
by a strong evidence-base and should havedemonstated benefits in terms of reducing
vertebral and non-vertebral (including hip
fracture) fracture risk 11,14–17. Treatment decisions
will also take into account the individual’s
circumstances (physical, social, comorbidities,
phobias (e.g. needles)) and preferences.
A generic oral bisphosphonate will berecommended as the first treatment choice forthe majority of people14. These treatments are
effective at reducing fracture risk at low cost.
A number of licensed injectable treatments
are available and feature among second- andthird-line options. These offer some potential
advantages over oral treatments, including faster
onset of action, no reliance on gastrointestinal
absorption, no direct upper gastrointestinal side
effects, reduced frequency of administration andbetter assured adherence with therapy. Patientswith complex comorbidities, cognitive impairment,
multiple drug intolerances or severe fracture risk
may benefit from parenteral treatment.

Supplementary treatment

Falls prevention
The FLS will link closely with falls prevention
services and ensure that people assessed as
being at risk of falls are referred for appropriate
interventions. In most cases, the development of
an individualised multifactorial intervention will be
undertaken by the falls prevention service, which
may comprise:• Muscle strength and balance training.
• Home hazard assessment and intervention.
• Vision assessment and onward referral if required.
• Medication review with modification/withdrawal.
Direct exercise programs and/or referrals forhome hazard modification may take place insome FLSs following initial triage assessmentby the FLS. This depends on local falls service
arrangements and will be agreed locally.

Regular balance exercises are recommended for
Vitamin D and calcium are generally
recommended concurrently with a drug treatment anyone who is unsteady, or older than 65 years
and not doing regular active leisure or sports33.
for osteoporosis. There is some evidence thatcombined calcium and vitamin D supplementation
alone may reduce fracture risk in frail older women
living in care homes36. A calcium calculator,
such as the one developed by the University of
Edinburgh37 can help review dietary calcium intake.
Where calcium intake is adequate, a vitamin D
supplement alone can suffice. Further guidance onmanaging vitamin D deficiency in people with or at
risk of bone disease is given by the ROS38.
24

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Exercise to promote bone strength
Weight-bearing exercise interventions have a benefit
on both hip and spine BMD16. Combining weightbearing and impact exercise interventions withmuscle strengthening exercise, ideally incorporating
progressive resistance training, is recommended.
Further advice is given in Strong, Steady andStraight: An expert consensus statement on
Physical Activity and Exercise for osteoporosis33.

Effective follow-up
The effectiveness of an FLS is critically dependanton sufficient long-term adherence to interventions.
Many clinical reviews have shown long-term
treatment concordance with oral bisphosphonate
drug therapy to be poor. Maintaining patientson treatment is critically important in achieving
reductions in future fracture risk. Most studies
suggest that, where there is a problem with drug
treatment, the person taking the medication willstop taking this within the first six months or so.

Follow-up will allow people to express any doubts
and concerns about their treatment. It will also
include tools to reinforce the importance of thetreatment, an assessment of correct understandingof the administration of the treatment andsuggestions of how to remember to take thetreatment as directed.
This 16-week follow-up should also be used
to make sure that referrals to other associatedservices (such as falls services) have been actioned.
52-week follow-up: Follow-up contact describedabove will be repeated at 52 weeks from fractureby the FLS where adherence with recommended
osteoporosis drug treatments will be checked.
Following this, long-term management will betransferred to primary care (see Integrate on
page 28).

In order to improve long-term treatment rates,
patients should be advised to contact their GP or
local FLS team should they have any problems orconcerns about their treatment so that alternatives
can be considered as required.
Furthermore, an FLS will proactively check thatpatients are started on the treatment recommended
and agreed (see 16-week follow-up below). A
further check of longer-term treatment adherence
is required at around 52 weeks from fracture (seeannual follow-up below).
16-week follow-up: An initial follow-up contact will
be carried out by the FLS within 16 weeks fromfracture to check that recommended interventions
have commenced, and if so, to check that
osteoporosis drug treatments are taken as directed
and for side effects. This is also a good opportunity
to check adherence to lifestyle measures, calcium,
vitamin D, and to ask whether the person has fallenor fractured again.

25

What this standard means to:
A person receiving care
You will:• Be offered an osteoporosis drug treatment within 16 weeks of your fracture if required.
• Understand the importance of taking your treatment regularly and as directed, and understand thereasons these instructions are important.
• Take treatments as directed by your healthcare professional and speak to your GP, pharmacist or
local FLS team if you have any difficulties or concerns.
• Understand when and where you will have your next dose if you have been recommended an
injectable osteoporosis treatment.
• Be invited to meet healthcare professionals who can help you stay strong, steady and independent
if you have fallen more than twice in the past 12 months, have injured yourself by falling, or yourbalance and the way you walk suggest you would benefit from specialist help.
• Understand when you next need to speak to a healthcare professional to review the osteoporosis
drug treatment recommended for you.
• Be asked how you are taking your osteoporosis drug treatment, if you have any side effects orother problems taking it within 16, weeks and again within a year after your broken bone.
A member of staff
You will:• Discuss osteoporosis drug treatment options with the individual and provide information about thebenefits and side effects to inform decision-making.
• Explain how the recommended treatment is taken and why these instructions are important.
• Explain when treatment will be reviewed and anticipated initial treatment duration.
• Explain what the person with osteoporosis should do if they have any difficulties or concerns about
their medication• Refer to falls prevention services where appropriate.
• Follow-up with people within 16 weeks to check recommended treatment has been started.
• Follow-up with people at 52 weeks to check adherence to treatment.
The organisation
The organisation will:• Have robust systems to ensure that people initiated on an injectable treatment receive the next
dose at the right time.
• Ensure that the osteoporosis service has strong links and two-way referral protocols with the falls
prevention services.
• Support processes to ensure patients on long-term therapy have treatment reviews in place.

26

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Examples of audit and evidence

Monitoring contact at 52 weeks post fracture

Bone therapy recommended

The percentage of patients who were followed
up at 52 weeks following their fracture.

Percentage of patients who were recommended
an osteoporosis drug treatment.
Numerator – number of people recommended
an osteoporosis treatment.
Denominator – total number of people seenby the FLS.

Monitoring contact within 16 weeks post
fracture
The percentage of patients who were followed
up within 16 weeks following their fracture.
Numerator – number of people followed-upby the FLS within 16 weeks of their fracture.
Denominator – total number of people seenby the FLS.

Commenced osteoporosis drug treatment by
first follow-up
The percentage of patients who had commenced(or were continuing) an osteoporosis drug treatment.

Numerator – number of people followed-upby the FLS at 52 weeks of their fracture.
Denominator – total number of people seenby the FLS.

Adherence to prescribed anti-osteoporosis
medication at 52 weeks post fracture
The percentage of patients who had confirmed
adherence to a prescribed osteoporosis drug
treatment at 52 weeks post fracture.
Numerator – number of people indicating that they
are taking treatment correctly as prescribed during
their 52-week follow-up.
Denominator – total number of people seen by the
FLS, or number of people followed-up by the FLS by
16 weeks.
Rate of prescribed medicines in primary careper 1,000 people aged 50 and over.

Numerator – number of people indicating thattreatment had started during their 16-week follow-up.
Denominator – total number of people seen by the
FLS/ or number of people followed-up by the FLS
by 16 weeks.

Strength and balance training
The percentage of non-hip fracture patients who
had attended a strength and balance class within
16 weeks of their fracture
Numerator – number of people who had attended
a strength and balance class within 16 weeks of
their fracture
Denominator – number of non-hip fracture patientsseen by the FLS/ or number of people followedup by the FLS by 16 weeks/ or number of non-hip
fracture patients referred to the falls prevention
service.

27

IntegrateStandard 5: The FLS will integrate with the wider healthcare system to facilitate an
inclusive patient pathway; ensuring effective case finding, onward referrals and long-term
management of osteoporosis.
Rationale

In Practice

An FLS can be based either in-hospital or out-ofhospital. Regardless of healthcare setting, in order
to be effective, the FLS will be integrated withother services and the wider fracture prevention
care pathway. This enables an FLS to maximisecase finding, refer to appropriate services to meeta patient’s needs and ensure transfer of care tofacilitate long-term management of osteoporosis.

Case finding
In order to identify people aged 50 years or older,an FLS will maintain relationships with relevant
in-hospital services. As a minimum, the FLS
should establish ways of working with:

Osteoporosis drug treatments need to betaken correctly for long periods in order to gain
maximum benefit. Ensuring good communication
amongst healthcare professionals delivering
fracture preventative care enables long-term
support for patients to maximise treatment
adherence and benefits.

• Orthopaedic and trauma department

Criteria
5.1. Clear management plans are prepared tofacilitate transfer of care enabling the longterm management of osteoporosis in primarycare.
5.2. The FLS staff maintain relationships with
relevant in-hospital services.
5.3. The FLS staff have a good understanding of
the available out-of-hospital services andhow people using the FLS can access these.
5.4. Referral pathways between the FLS andrelevant services are agreed.
5.5. Staff participate in a local multidisciplinary
fracture prevention interest group that meetsregularly to co-ordinate, plan and develop the
FLS.

28

• Emergency department• Fracture clinic• Radiology department
Where the FLS identifies a person who has
fractured while away from their normal place ofresidence (known as ‘out of area’), processes will
be put in place to ensure that the person’s GP and
the FLS in their area are informed.
Referrals to meet patients’ needs
Contact with an FLS presents an opportunity for
associated health needs to be considered. Thisshould be tailored for the individual and may
include referral to other services such as falls
prevention, pain management, rehabilitation,
mental health, and support with lifestyle changes.
Management plans and long-term managementof osteoporosisLong-term treatment of osteoporosis will be
managed by the GP. Clear management plansfrom the FLS will outline the recommendations
for treatment and review timescales. The FLS
report will support transfer of care and long-term
management of osteoporosis to the patient’s
primary care team. A report template will becreated with input from GPs and patients, andfeedback should be invited to ensure the report
meets their needs. Inclusion of the following
information is recommended:Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services• Personal information and unique identifier.
• Details of fragility fracture(s).
• Current osteoporosis drug treatment.
• Results of assessments including fracture risk
assessment, BMD results and laboratory tests.
• Management recommendations including
treatment changes, recommended review dates
and circumstances for re-referral.
• Appropriate primary care codes including
the fracture site and type of fracture (e.g.
osteoporotic). See Appendix 2 for suggested
codes.
While the FLS will carry out initial follow-up contact
by 16 weeks and at 52 weeks, further annual
reviews should be completed outside of the FLS.
How this is done in practice will depend on local
capability and capacity. Examples include via a GP
or another member of the primary care team, ora community pharmacist. It can be carried out aspart of a medication usage review, at a face-toface appointment, by questionnaires or over the
telephone41.

When a drug holiday is used as part of thetreatment schedule for bisphosphonates, it isimportant that people have sufficient calcium andvitamin D and, at the end of this break, they either
automatically restart osteoporosis drug treatment or
are reassessed to determine whether osteoporosis
drug treatment should be reinstated. A fragility
fracture during this treatment holiday will beconsidered an indication to restart treatment.
Fracture prevention interest group
Regular virtual or face-to-face meetings of afracture prevention interest group are used to plan
service development, provide peer support andfacilitate the sharing of standardised, high-qualitycare. The group will be multidisciplinary and ideallymulti-organisational, with representatives fromall stakeholders in falls, bone health and fracture
prevention and will include patient representatives.
This will include commissioners and service
managers as well as healthcare professionals fromin-hospital and out-of-hospital services.

A reassessment of fracture risk will be carried out
by the GP or by referral to the osteoporosis service
at three years (for intravenous zoledronic acid or
denosumab) or five years (for oral bisphosphonate)
to determine whether it is appropriate to continue
osteoporosis drug treatment or take a ‘drug holiday’.
Denosumab treatment should only be discontinued
after advice from a specialist in bone metabolism.
A description of the process around this is given in
NOGG guidance17 and adapted into a flowchart by
the ROS42.

29

What this standard means to:
A person receiving care
You will:• Be seen within an integrated FLS which has good links to other relevant services based in hospitaland in the community.
• Experience seamless services for bone health and falls prevention.
• If appropriate, be invited to meet other healthcare professionals who can help you, for example aphysiotherapist or pain relief specialist.
• Be referred by FLS to other clinical services (either in primary or secondary care) depending upon
your clinical need.
• Have your response to treatment (including your risk of breaking a bone) reassessed after three orfive years to check that your treatment is still right for you.
A member of staff
You will:• Prepare management plans that can be understood by the person who has fractured and facilitatetransfer of their care to their primary care team.
• Have knowledge of local services that will support the person to recover from their fracture andreduce their risk of future fractures.
• Ensure that the FLS has effective communication links with relevant in-hospital and out-ofhospital services so that people can access other services that they might need.
The organisation
The organisation will:• Support processes that allow seamless referrals across different services and healthcare settings.

30

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Examples of audit and evidence
In-hospital case finding
Percentage of patients identified through liaison
with each relevant in-hospital department.
Numerator – number of patients identified fromeach in-hospital department.
Denominator – total number of patients identified.
Number of onward referrals
Percentage of patients referred by the FLS to otherrelevant services in line with patients’ needs.
Numerator – number of patients referred by the
FLS to each other relevant service.
Denominator – total number of patients identified.

Three to five year osteoporosis treatment review
Percentage of people seen by the service who are
already taking an osteoporosis drug treatment but
have not had a treatment review at three to five
years.
Numerator – number of people who have exceeded
three or five years of osteoporosis drug treatment
without a treatment review.
Denominator –number of people seen by theservice who are already taking an osteoporosis
drug treatment.
Fracture prevention interest group
Evidence of membership, attendance, agendas
and minutes.

FLS reports
Percentage of GPs who are satisfied that the FLS
reports meet their needs.
Numerator – number of GPs who are satistifed
with the FLS report.
Denominator – number of GPs consulted.
Also consider compliments, complaints and queries.

31

QualityStandard 6: The FLS demonstrates clinical accountability, effective governance,
professional development and ongoing service improvement.
Rationale

In practice

Leadership, governance, professional accountability
and staff development are essential to providing
an efficient, coordinated and consistent service thatmeets the needs of its patients.

Accountability and governance
Clear lines of responsibility support effective
delivery of complex healthcare systems for the
benefit of patients. Within the FLS, a designatedclinical lead will be responsible for improvement
and ensuring that all components of the service
are connected. Agreed indicators will be monitored
regularly and reported to commissioners orservice managers. It is advisable to establish arisk register for the FLS and ensure that risks
are managed or escalated according to local risk
management protocols.

In order to deliver high-quality care, staff
will demonstrate the necessary professional
competencies and will participate in CPD to
maintain their knowledge.
Service improvement involves individual staff,
work teams and organisations looking at how
making changes to the way they work can help
improve patient care by making services better.
Regional variation in care is minimised throughaudit and peer support.

Criteria
6.1. A designated lead clinician is accountable forall components of the service.
6.2. The FLS is developed in line with a local falls
and fracture prevention strategy.
6.3. Core data from people identified by the FLS
is recorded on an operational database.
6.4. A quality assurance framework is in place
which includes:• A programme of continuous improvement
including regular audit.
• Participation in national audits such as the
FLS-DB in England and Wales, or the Hip
Fracture Audit in Scotland.
• Peer review.
• Patient and carer experience measures.

32

Service improvement
The following elements of a quality assurance
framework will be put in place in order tocontinually improve the FLS.
Strategy: Working with the fracture prevention
interest group (see Integrate on page 28),
a fracture prevention strategy will provide aroad-map for development and improvementof the service.
Operational database: An operational databaseis a necessity for any FLS. Efficient databases
reduce the administration burden and store data
in a form that can be exported for audit andreporting purposes. The database should record:• Patient identification.
• Investigation of bone health.
• DXA.
• Falls risk.

6.5. All members of the FLS team have assessmentof professional competencies and demonstratecontinuing professional development (CPD).

• Treatment initiation/recommendation.

6.6. Staff are active participants in a regional
clinical or professional network.

• Monitoring treatment concordance at 16- and
52-weeks post-fracture.

• Referrals to other services, e.g. falls prevention.

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Any data collection tool may potentially be usedas the basis of the database. Whatever IT solution
is put in place, it must work in line with local NHS
e-Health strategies and integrate with other clinical
IT applications (such as patient administration, DXA
scanning and laboratories). It is also helpful if data
can be extracted for the national audit purposes(see below) where applicable.
Audit: The service will put in place an audit programme
which is incorporated in local goverance processes tomeasure its performance against these standards.
For sites in England and Wales, detailed datasetof core questions is provided by the Fracture
Liaison Service Database (FLS-DB). The FLSDB provides site specific feedback to inform
service improvement and national benchmarking.
The dataset within the FLS-DB is based onnationally assured documents such as NICE
and SIGN guidance as well as these standards.
Through engagement in national audit, a greater
understanding of secondary fracture prevention
can be achieved, and standards improved to ensure
consistently high quality of care.
Key performance indicators: Commisioners andservice planners will work with proivders to identify
key performance indicators (KPI) by which to monitor
the quality and impact of the FLS. Aligning local
quantitative measures of performance with the national
audit dataset is recommended. This means data canbe captured once and effectively used for multiple
purposes. A list of recommended KPIs is included in the
FLS Toolkit (see page 36 for more information).
Peer review: Peer review is offered by some
professional bodies or it may be organised
informally between sites with FLS. Regardless of theapproach used, it should bring stakeholders together
to assess clinical care against agreed standards
and ensure that clinical teams’ voices are heard
and help shape the future delivery of the service.

Peer review is beneficial to all participants, allowing
time for reflection, problem solving and sharing of
good practice. It also addresses agendas of clinicalgovernance and revalidation.
Professional development
The Competency Framework for HealthProfessionals Working in Fracture Prevention43
provides pragmatic competencies and is a practicalworking document for all healthcare professionals
regardless of where the FLS is based. It can be used
for facilitating CPD, aiding performance appraisal,
identifying gaps in competency, highlighting specifictraining needs and providing a framework to help
recruitment and selection procedures.
In order to provide safe and clinically effective
care and management, it is recommended that
all healthcare professionals within the FLS teamwill maintain appropriate CPD. Various courses,
conferences and meetings exist across the UK andbeyond, which provide evidence-based knowledge
on osteoporosis and secondary fracture prevention.
Participation in a regional clinical or professional
network is also a valuable tool for professional
development and sharing of good practice.
The ROS has developed an online Fracture
Prevention Practitioner (FPP) course which aims
to provide accredited, easily accessible training
to establish a knowledge quality standard andcertification at a basic and advanced level.
Content includes modules on epidemiology ofosteoporosis, fracture risk assessment, osteoporosis
management, falls assessment and management
and complex cases.
The ROS hosts a biennial conference, a biennial FLS
champions’ summit in Scotland and annual FLS
champions’ summits in England. These meetings
provide the latest updates for FLS practitioners
and an environment to share experiences andknowledge between FLSs.

33

What this standard means to:
A person receiving care
You will:• Receive good quality care that meets current guidance and reflects up-to-date practice from all thehealthcare professionals you come into contact with.
• Receive care from motivated staff with the right knowledge and skills for their role.
• Be able to make informed decisions about your care.
A member of staff
You will:• Feel supported and motivated.
• Be able to demonstrate competencies relevant to your role.
• Have formal and informal opportunities to develop your knowledge and skills.
• Carry out audits relevant to your area of work.
• Contribute to the local fracture prevention interest group by either:-- Becoming a member, actively communicating with your colleagues to represent their views andkeep them informed; or-- Working with your representative.
• Be an active member of a regional clinical/professional network.
• Be an active member of national networks/meetings.
• Be able to question practice and discuss different approaches to care.
The organisation
The organisation will:• Have networks in place to support the development of services and sharing of knowledge.
• Allow access to and support for a database that is specifically set up for the purposes of the FLS• Have an inclusive multidisciplinary fracture prevention interest group.
• Have a fracture prevention strategy that includes falls and bone health.
• Carry out regular audits, review the results and seek to continually develop and improve.
• For England and Wales, provide administrative support for upload to national audits.
• Have a professional accountability framework with clear lines of responsibility.
• Benchmark the service locally and nationally through engagement with national audit.

34

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Examples of audit and evidence
Professional development
Percentage of FLS staff who have completed
an accredited course or learning programmeappropriate to their role.
Numerator – Number of FLS staff who havecompleted an accredited learning programmeappropriate to their role in the last 52 weeks.
Denominator – Total number of FLS staff.
Percentage of FLS staff who have attended at least
one regional or national meeting or workshop.
Numerator – Number of FLS staff who haveattended at least one regional or national meetingor workshop in the last 52 weeks.
Denominator – Total number of FLS staff.
Patient Satisfaction with FLS
Annual patient satisfaction completed. Use as abaseline in year one and develop action plan withcommissioners and service planners to address any
issues.
Recording data
Data is recorded for local audit purposes anduploaded to national audit (where available).
Continuous improvement
Examples include plan of audit cycles, completed
audit cycles show improvement, and detailsof patient and public involvement in service
improvement.

35

Implementing the FLS standards
There are many variations in the models ofprovision of FLS dependent on local assets,existing service pathways and local health system
priorities. However, by adopting these standards,
the principles of evidenced-based best practice canbe replicated effectively across the UK.

In addition to the online resources, the ROS offers:

Establishment of any new service requires timeand dedication. Since 2015, the ROS has been
supporting the development of FLS acrossthe UK. A team of specialist Service Delivery
Leads (SDLs) with clinical and commissioning
experience works with sites to support newservice development or quality improvementof existing services. The SDLs work regionallyin partnership with their Development Manager
colleagues. This team is particularly experienced
in volunteer and event management, andsupports the provision of information to people
affected by the condition i.e. patient educationor newly diagnosed sessions. As a combined
regional team, they are able to provide a holisticoffer of support to health services, people affectedby osteoporosis and healthcare professionals.

• Bespoke and expert support from inception
to launch of an FLS, including development of
the business case, service specification, andresource and capacity planning.

Operating in an economic climate where healthbudgets are tightly constrained, investment in
new services must demonstrate both a solid
evidence base and a strong business case.
The ROS has produced a suite of evidencebased resources and templates to support FLS
development and improvement. A comprehensive
FLS Implementation Toolkit supports providers
and payers in the commissioning and service
improvement process. Users can create acompelling, evidence-based business casewithout the need for advanced skills in costing,modelling or other health economic techniques.

36• Facilitation of engagement with stakeholders,
including commissioners and NHS
management to generate commitment to FLS
and ensure that services are sustained.

• Assistance with induction and training of the
FLS coordinator.
• Advice regarding relevant protocols and carepathways for the service.
• Support for quality improvement to enable
the development of an FLS to meet the UK
FLS Clinical Standards, including periodic gap
analysis and networking with peers.
• Advice regarding data collection and methodsof analysis, reporting and evaluation.
These services and resources are provided freeof charge.
The FLS Implementation Toolkit is online at:https://theros.org.uk/healthcare-professionals/
fracture-liaison-services/
Contact us:
Email: fls@theros.org.uk
Phone: 01761 471771

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

37

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National Osteoporosis Guideline Group (NOGG).
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18. Calderwood C. Realising Realistic Medicine: Chief
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39Appendix 1:
Primary care coding
Fragility fracture
Read 2CTV3SNOMED

Fragility fractureN331N

XaNSP%

306171000000106

Osteoporosis

N330.%

N330.%<<64859006

DXA results
Ideally a report of a DXA result will contain both the relevant qualitative and the quantitative findings
for at least one of the osteoporotic sites, as follows:
Read 2CTV3SNOMED

58EM.

XaITb

391075000

Femoral neck DXA scan result osteoporotic 58EV.

XaPE2

440100002

Hip DXA scan result osteoporotic

58EG.

XaITW

391070005

Hip DXA scan T score

58EE.

XaITU

391068001

Lumbar spine DXA scan T score

58EK.

XaITZ

1083701000000107

Femoral neck DXA scan T score

58ES.

XaPDy

440050006

Lumbar DXA scan result osteoporotic40Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

Drug treatments
Prescribed agents are automatically coded by the issue of a prescription through the GP system. An
exception would be long interval agents prescribed in hospital such as PTH, ibandronate, zoledronate anddenosumab. Where this is the case, the following codes can be added to primary care systems:
Read 2CTV3SNOMED

Teriparatide therapy

8BP1.

XaKb0

416362002

Denosumab therapy

8BPW.

Xaagz

700139004

Zoledronic acid therapy

8BPY.

Xaah1

700105003

Ibandronic acid therapy

8BPX.

Xaah0

700106002

Hospital dispensed

Falls
Falls assessments and interventions are important to consider in patients who have sustained a fracture
following a fall. They are not included in QOF, but some suitable codes are as follows:
Read 2CTV3SNOMED

Referral to falls service

8Hk1.

XaLqJ

247541000000106

Refer for falls assessment

66aF.

XaISu

717091000000109

Falls risk assessment referral

9Og0.

XaJ9V

717091000000109

Multidisciplinary falls assessment done

9Og6.

XaJLD

408555007

Group exercise programme

8E7A.

XaItq

401167006

41

Appendix 2:
Abbreviations and definition of terms

42

DXA

Dual energy X-ray absorptiometry: The technique used to measure bonedensity and diagnose osteoporosis.

FLS

Fracture Liaison Service: A service which systematically identifies, treats
and refers to appropriate services all eligible patients aged 50 and older
within a local population who have suffered fragility fractures, with the aimof reducing their risk of subsequent fractures.

Fragility Fracture

A broken bone (fracture) resulting from a low impact, such as a fall fromstanding height or less.

VFA

Vertebral Fracture Assessment: The technique used to assess for thepresence of prevalent vertebral fractures as performed as part of a DXA
assessment.

NICE

National Institute for Health and Care Excellence

SIGN

Scottish Intercollegiate Guidelines Network

FRAX

An online diagnostic tool used to evaluate the 10-year probability offracture risk.

QFracture

An online calculator used to estimate an individual’s risk of developing hip
fracture or osteoporotic fracture (hip, spine, wrist or shoulder) over 10 years

In-hospital services

Healthcare provided in a hospital setting.

Out-of-hospital
services

Any healthcare provided in a setting other than a hospital.

Community care

Health services you receive close to your home or in your home, forexample, health visiting, physiotherapy or speech and language therapy.

Primary care

The advice and treatment you receive from your local GP.

Effective Secondary Prevention of Fragility Fractures:
Clinical Standards for Fracture Liaison Services

43About us

Professional Membership

The Royal Osteoporosis Society is the only UKwide charity dedicated to ending the pain andsuffering caused by osteoporosis. The Charity
works tirelessly to help and support people withthe condition as well as promoting good bonehealth to prevent osteoporosis. We do this by:Professional membership of the Royal
Osteoporosis Society will ensure you become
better informed and able to deliver the best carepossible to people with osteoporosis or fractures.

• Providing a range of information resources
covering all aspects of osteoporosis forhealthcare professionals and the public• Providing a free helpline staffed by nurses withspecialist knowledge of osteoporosis
and bone health• Investing in research to ensure future
generations are freed from the burdenof osteoporosis

As a professional member, you’ll have all theinformation you need at your fingertips and will
stay up to date on best practice, care, delivery,
new treatments and the latest news on
osteoporosis research findings.
You’ll also feel proud to be part of an organisation
working hard to help those affected by osteoporosis.
To join a growing network of professional
members like you, call our membership team on
01761 473287 or visit theros.org.uk/HCPs• Influencing government and campaigning
to improve and maintain essential services• Educating healthcare professionals to ensure
they are kept up to date about osteoporosis– through events, accredited training courses
and our leading conference on osteoporosis
and bone health• Working in partnership with the NHS to set up
and improve Fracture Liaison Services which
can reduce the number of fractures caused byosteoporosis
To find out more about our information, supportand services, visit our website: theros.org.uk@RoyalOsteoPro
01761 471771 (General Enquiries)
0808 800 0035 (specialist nurse Helpline)
theros.org.uk
Camerton, Bath BA2 0PJ

President: HRH The Duchess of Cornwall
Royal Osteoporosis Society is a registered charity no. 1102712 in England and Wales, no. SC039755 in Scotland, no. (pending)in Guernsey and no. (pending) in Isle of Man. Registered as a company limited by guarantee in England and Wales no. 4995013,
and no. (pending) in Isle of Man. Registered address: Camerton, Bath BA2 0PJ.
Formerly the National Osteoporosis Society.
Published August 2019.