Crawley Primary Care Centre

Primary care-based fracture liaison service

  • - £218k: The cost-savings of reducing hip fractures alone, over three years

  • - 34%: The reduction in fractures in the first year of the fracture liaison service

The development of a fracture liaison service by Crawley Primary Care Service has reduced the cost of hip fractures by £218,000 over three years through identification and management of high risk patients to reduce their long-term risk of fracture, thereby avoiding costly hospitalisations.

Download a printable pdf of the Crawley fracture liaison service case study

The challenge

- The Department of Health had identified that a disproportionately high number of patients with hip fractures had previously had a fracture. The service therefore wanted to address this issue by increasing the quality of care for those at highest risk of future fracture in order to reduce fractures, unscheduled admissions, morbidity and mortality.

The solution

- A fracture liaison service was established to identify high-risk patients and ensure that appropriate therapy is initiated and compliance is monitored
- The service uses IT, information sharing with secondary care (radiology) and outreach to care homes to case-find patients who it can then provide with systematic assessment, monitoring and long-term support in the community at nurse-led clinics within each of the 13 General Practices
- The nurse-led clinics are overseen by a medical clinical lead and are used to request tests and investigations, prescribe and administer medications, and organise referrals when appropriate
- The service also provides its patients with regular follow up to monitor medicines and compliance
- Originally a three year pilot study, the service was deemed so successful it was permanently implemented after evaluation by the North West Sussex Commissioning Association

Service performance and outcomes

- The new fracture liaison service began in September 2009. Since then, the service has identified 2,400 high-risk patients, and it has registered a drop in fractures of 34% in the first year of  implementation and a further 22% decrease in the second year
- The service has seen an increase in the prescription of second-line treatments, indicative of improved follow up with respect to medicines management and compliance

Patient focus and satisfaction

- In the service, patients are seen closer to home (in their own practice) and fewer blood tests are required, as previous results are available immediately from practice patient records
- In a patient satisfaction survey, 96% of patients found the new service “very helpful”

Financial performance and outcomes

- The service costs are estimated at £92,000 per annum, covering expenditure on training, supervision and non-pay costs.
- Since the fracture liaison service began in September 2009, the cost of hip fractures alone has decreased, resulting in a saving of £218,000 over three years due to the introduction of the service

Commissioning priorities

The Crawley primary care-based fracture liaison service is an example of commissioning best practice in rheumatology and meets a number of the priorities for commissioners as outlined by the King’s Fund in 2013:
- Primary and secondary prevention – through predictive risk modelling to identify high-risk patients, and management of these patients, the service helps to reduce the risk of future fractures
- Managing ambulatory conditions and managing urgent and emergency activity – by following up patients with history of fracture, the service aims to reduce unscheduled admissions to hospital
• Care co-ordination – information sharing between secondary care and primary care facilitate the identification of high-risk patients, and the nurse-led fracture clinics allow patients to receive medications in their local practice rather than as an inpatient in secondary care
• Medicines management – through follow up and treatment changes, medicines compliance can be monitored and adjusted as necessary
• The service addresses all elements of the QIPP agenda and the overarching objective of the NHS Outcomes Framework. The service also meets national guidelines on reducing fracture rates in the elderly, (NICE Clinical Guideline 21) and better use of secondary therapy to reduce the risk of osteoporotic fragility fractures (NICE Technology Appraisal 161)

Sponsorship statement

This best practice case study project has been sponsored by UCB and supported by a medical education grant from Pfizer.
UCB and Pfizer have not had any influence over content: editorial control remained with the British Society of Rheumatology.

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We gratefully acknowledge the generous support of our sponsors, which enabled the case study project to take place.