“For us, working with the AHSN is superb because we have aligned agendas.  We are both focussed on how we can make a tangible difference to the Healthcare system across sectors and geographies with the patient at the heart of it.”
Phil Crane, Kyowa Kirin International plc

NENC hip fracture image 1 220 dpiOverview

In collaboration with Clinical Commissioning Groups (CCGs), GP practices, Interface Clinical Services, Kyowa Kirin and AMGEN we are using a population based approach to assess routine GP practice data to identify patients at risk of fracture across the North East and North Cumbria.

The Bone Health initiative looks at identifying ‘at risk’ patients at GP practice level and starts them on the correct patient pathway in line with local and national guidance. The project expanded on this and also looked at reviewing patients on bisphosphonates.

Since the start of the project in 2014, we have completed audits in 60 GP Practices across the region, screened a total population of 389,662, case reviewed 126,027 and made 12,684 interventions, which may have included medication initiation, change of medication, education/information on a healthier lifestyle and or compliance advice. The cost saving model (based on the Cochrane Review 2008) conservatively indicates that treatment of 1500 patients with bone sparing drugs could potentially avoid 59 hip fractures, giving a saving of £960,000 over 4 years (against a cost of bone sparing treatment for four years of £60,900).

Challenge/problem identified

Approximately 65,000 hip fractures occur in the UK each year, expected to rise to over 75,000 by 2020; with an annual cost of over £2 billion (this includes medical and social care). In 2012, the National Institute for Health and Care Excellence (NICE) issued guidelines on the assessment of risk of fragility fracture (NICE CG146) recommending “opportunistic case finding” and the Quality and Outcomes Framework (QoF) for primary care in England and Wales to support the identification and treatment of fragility fracture. However, while fracture risk assessment and “secondary” prevention treatment of fragility fracture are now recommended in general practice, targeted treatment of other patients at risk is not. This programme aims to target those ‘other patients at risk’ across the North East and North Cumbria.

The overall aim is to support the region’s reputation in leading innovation by targeting fracture risk assessment in Primary Care by identifying patients at high risk of fracture, evaluate, educate and treat them with the aim of future fracture prevention.

Actions taken

Using routine GP practice data on age, gender, weight, height, smoking status, alcohol consumption, Glucocorticoid use, rheumatoid arthritis and other diseases such as diabetes, malnutrition, liver disease and early menopause, individual patient risk of fracture can be estimated.  With a 10-year hip fracture threshold of 10% or greater, an average size GP practice will identify approximately 200 patients.  For this group a reined estimate of fracture risk is required.  A process of stratifying risk into categories of Red, Amber and Green assists with agreed patient interventions.

The National Osteoporosis Guideline Group (NOGG) interpretation graph indicates that patients within the red category are at high risk or osteoporotic fracture and should be provided with preventative therapy, those in the green category are at low risk and health promotion advice can be offered. Patients categorised into the amber category (medium risk) require further information, which can be provided through a face-to-face or telephone consultation or referral for DXA scan.

NENC NOGG interpretation graph low res png

Interface Clinical Services working with Sheffield University have developed a systematic audit programme approach which was used in GP practices across North East and North Cumbria.  This approach has GP practices working together in a systematic way to achieve population-based outcomes. It standardises the approach to care and reduces variation between practices.


The benefits for patients include education on: the risk of osteoporosis, the importance of a healthy diet, exercise and (if required) bone health therapies/treatments, in reducing fracture risk. The programme optimises osteoporosis treatment and supports primary and secondary fracture prevention.

The benefits for GP Practices/Surgeries include:

  • QOF Prevalence and Value (Osteoporosis QOF points, potential inclusion of 41 patients added for an average sized practice)
  • Care Quality Commission (CQC) – recurring audits and re-audits (towards CQC accreditation)
  • A Personal Development Plan (PDP) revalidation.

The overall outcomes can include:

  • Strong Bones – Fracture Prevention
  • Patient Education on the importance of a Healthy Diet and Exercise
  • Patient care optimised within clinical therapy area
  • Funded GP Practice support at a time when resources are stretched

“As an organisation we strongly believe effective partnership and collaborative working that delivers proactive, preventative, patient focused healthcare, is vital to overcoming the current challenges facing local NHS organisations. It has therefore been fantastic to have been involved in an excellent example of a partnership that has been successful in tackling the significant issues faced within bone health and fragility fracture incidence. The ASHN deserve immense credit for their bone health and fracture prevention programme.”
Omar Patel, Clinical Director, Interface Clinical Services

“At Amgen we strive to put patients at the centre of everything we do, and the opportunity to work in partnership with the AHSN enables this by helping to improve the patient experience both now and in the future.” Andy Ruczenczyn, NHS Value Solutions Manager, Amgen UK & Ireland

NENC Bone Health (002)

Plans for the future

Bone health is an often overlooked condition that affects millions of people across the UK with high rates of morbidity and mortality associated with fractures in the elderly population.  The aim of the bone health programme is to improve the health outcomes for patients at risk of sustaining a fragility fracture and promote improvements in bone health through targeted case finding, effective treatment and medication compliance. The Bone Health Programme through the support of the AHSN NENC is being rolled out across the North East and North Cumbria and by other AHSN’s across the country including North West Coast, Greater Manchester, Yorkshire & Humber, Oxford and East Midlands to ensure this condition is not overlooked.

The Bone Health Programme has expanded to reviewing patients on bisphosphonates. To Support the Proactive Review of Current Prescribing and Identification of GAPs in Care.

Which national clinical or policy priorities does this example address?

The Bone Health Programme addresses priority areas;

  • Care and Quality
  • Funding and Efficiency
  • Health and Well Being.

And uses the following national guidelines to support our work;

  • NICE clinical guideline CG146
  • SIGN guideline (56)
  • NICE Guidelines (160 and 161) (2011)
  • RCP Guideline
  • The National Osteoporosis Guideline Group (NOGG) Guideline (2010).

Start and end date

Work on this project started in 2014 as a pilot and is now being rolled out across the North East and North Cumbria and adopted by other AHSNs across the country.

Contact us for help and advice

Helen Ridley, AHSN Falls and Fracture Programme Lead
E: h.ridley@ahsn-nenc.org.uk

Donna Smith, Comms Team , AHSN NENC
E: donna.smith@ahsn-nenc.org.uk