Working in urgent and emergency care, both as an operational manager and more recently as a commissioner, I have always been conscious of the lack of awareness around falls and the link between bone health and fractures. And there has been a lack of interest to a degree that would be unacceptable were we talking about heart or stroke issues. What cannot be denied is that hip fracture is now becoming a major health issue due to an increasingly elderly population.
There are around 60,000i emergency hospital admissions for hip fracture in England each year and demographic projections suggest this is set to rise significantly over the next decadeii. Outcomes for patients with broken hips can be poor, with only around half of patients discharged to their usual place of residence within 30 days and one in three dying within 12 months. Although most of these deaths are not due to the fracture itself, it is an indication of the high prevalence of pre-existing illnesses in these patients. In addition, around half of all hip fracture patients do not regain their previous level of mobility and people who have had a previous hip fracture are more likely to experience a further hip fracture in the future.
Evidence from national audits of falls and bone health show the fundamental assessment and treatment of patients in line with NICE recommendations is too frequently not delivered– again in a way which would be intolerable in equally common and costly conditions such as heart disease or stroke. The latest audit, published in May 2011, identifies an unacceptable variation in the quality of falls and fracture services in England. Worryingly, it also finds a major gap between what organisations report and the actual care provided. Furthermore, the National Hip fracture Database (NHFD), 2012 National Report has recently found a concerning reduction in both the number of patients admitted to an orthopaedic ward within four hours and the number of patients receiving surgery within 48 hours. This is particularly alarming as it suggests patients who have missed the 36 hour standard for best practice tariff are being further delayed and taking lesser priority than patients still eligible for best practice tariff.[iii]
Effective management of hip fracture needs the coordinated application of medical, surgical, anaesthetic and multidisciplinary rehabilitation skills together with a comprehensive approach covering the full course of the condition from presentation to follow-up, including transition from hospital to community.
Commissioners have a vital role to play in improving hip fracture services and to support them to meet this challenge NICE has produced a guide for commissioners on the management of hip fracture in adultsiv. The NICE commissioning guidance draws on the NICE clinical guidelinev and accompanying qualityvi standard for hip fracture, to highlight evidenced-based interventions that can help improve outcomes for people who have fractured their hip.
The guide for commissioners focuses on a number of key areas of care for people with hip fracture where evidence demonstrates these can significantly improve outcomes for patients, reduce the length of hospital stays, help patients recover their mobility faster and reduce the number of follow-up procedures. These include specifying:
· the development of a local Hip Fracture Programme
· services for the rapid optimisation of fitness for surgery
· services for post-surgery rehabilitation and hospital discharge
· services for the secondary prevention of fragility fractures.
As well as practical examples of service models for hip fracture, the guide also includes a commissioning and benchmarking tool to help users determine the level of service that might be needed locally. It provides a baseline against which improvements can be measured and rewarded, enabling commissioners to address gaps in service provision, support best practice and encourage evidence-based treatments and care.
As we move from PCTs to the clinically driven CCGs there will need to be a stronger emphasis on quality improvement and financial stability. The joined up care of patients will be particularly important ensuring that their journey through the system is as simple and seamless as possible. At a time where QIPP is omnipresent, commissioners should be focusing on stopping silo working and encouraging integration, working innovatively across pathways, improving the quality of care for patients, and providing the best value for tax payers. This NICE guide for commissioners is the support we need to enable this to happen for patients who have suffered a hip fracture.
JoAnne Panitzke-Jones is senior commissioning manager for South Devon and Torbay Clinical Commissioning Group and a member of the NICE hip fracture topic advisory group
iHospital episode statistics, 2010/11. The number of emergency admissions where the episode was first episode of spell, primary diagnosis (ICD 10 codes: S72.0, S72.1, S72.2), The Information Centre for health and social care, Leeds.
iiOffice for national statistics, Interim 2011-based subnational population projections for England, 2012, London
iiiNational Hip Fracture Database (2012) National Report
ivNational Institute for Health and Clinical Excellence (2012) Commissioning services for the management of hip fracture. NICE guide for commissioners. London (UK)
vThe National Clinical Guideline Centre (2011) The management of hip fracture in adults. NICE clinical guideline 124. London (UK): The Royal College of Physicians.
viNational Institute for Health and Clinical Excellence (2012) Hip fracture in adults. NICE quality standard 16. London (UK)