1. Dr Neil Gittoes & Sr Alison Doyle University Hospitals Birmingham October 2010 Fracture Liaison Service Provision – Local Perspective

2. Local Historical Context - Birmingham Decades of ‘osteoporosis’ nihilism –Influence throughout primary & secondary care –Inertia ++ Excellent DXA scanning service with capacity++ No DXA access for most secondary care specialties Open access GP DXA –~500 from SBPCT (383,000) –Anticipated ~5 000 (NOS Facts & Figures) –Interested GP providing reporting No osteoporosis/metabolic bone clinics National view of Birmingham bone…

3. Understand your Environment Are you pushing on an open/closed door? Who has the power/influence? What are the local drivers? –Know everyone’s agenda X

4. Early Days – Doing the Groundwork Seek out allies –Critical mass DXA unit & other secondary care colleagues PCT Promote awareness locally –Facilitators GP educational days, grand rounds Media, MPs Pharmaceutical companies –Bring in outside help People who have done it before Make yourself/your service indispensable

5. Vision Phased Deliverable Sustainable Fracture liaison service –Demonstrate need in primary care –Business case development in secondary care

6. Demonstrating Need to Primary Care Positive and high profile in PCT –Education lead - Governance lead –Medical director - Public health –Primary/secondary care interface groups –Falls groups/community geriatric services Ammunition –Uncontroversial National documents MSF – FLS, NICE - FLS NSF Older People Std 6, National audits –Peer review of services

7. Develop Shared Guidelines with Primary Care What type of service are you aiming for? –Possible to drive agenda Agreed interface with primary care Falls friendly Pulls in influential players locally Don’t reinvent wheel Determines rules of engagement with primary care –‘Protocolise’ where appropriate –‘Poaching patients’…

8. Pushing PCT Buttons? Awareness of their agendas –Strategic plan (5 years) –Local delivery plan (LDP) National and local audit data Locally commissioned reports (Public Health) Need to get onto this Has money attached –Need for compliance with NICE –DES (directed enhanced services) Funding attached –LES (locally enhanced services) Needs to find funding Falls tick more boxes than do fractures!

9. SBPCT strategic planning 1. Reducing premature death 2. Reducing avoidable risks 3. Maternity services 4. Children’s health 5. Urgent care 6. End of life care 7. Support for people with long term conditions 8. Mental health 9. Moving from hospital closer to home 10. Integrating services and social care Mortality after # Falls/fracture prevention Diet – Public health #NOF pathway/FLS Osteoporosis as chronic disease, etc. Service development, infusion service NH/RH falls/fracture services

10. Secondary Care – Going it Alone! Business case for appointment of Fracture Liaison Nurse (and service) –Self funding for secondary care –Successful Primary care ‘resistant’ to pay for associated additional DXAs –Long negotiations Yes right thing to do Yes NICE, etc –Not on agenda/radar –Change in reimbursement of OPD investigations!

11. The Primary Care Catalyst Public health commissioned report –Falls (and fracture) services –Result indicated ‘deficiencies’ Incorporated into LDP –Recurring funding Joint primary and secondary care negotiations –Senior nurse coordinators + support staff Primary & secondary care –‘FLS’ …Alison Doyle

12. Timeline to Progress % Desired model Years 0 1 2 3 4 5 6 7

13. DXA Bone genetics Complex GI/ bone Metabolic bone MEN-1 Transition Ambulatory care infusion service Physio screening Research Falls service NOS Gate keeping HCD OP MBC Community clinics Research Primary care Secondary care Orthogeriatric Service # NOF Nurse led Bone Clinics FLN Acute FLN Primary

14. Utilising existing Resources Who are your key contacts primary or acute care What forums currently exist? In south – Falls Network Regional groups Link to other initiatives How do you use existing technology?

15. Are there any other sources of funding that you can secure Locality bid - posts/project Business case - SPA Optimal care – New ways of looking at the funding streams Planning for winter – collaborative working The `NEW` NHS – G.P. Federations and the Consortia – Who?

16. What is Happening Across the Midlands? RCP-CEEU national organisational audit 2009 Do you have a fracture liaison nurse or similar post?

17. RCP-CEEU national organisational audit 2009 Do you have a fracture liaison nurse or similar post? Organisations answering “Yes”: –East Midlands SHA: 8/19 –West Midlands SHA:7/31

18. FLS in the Midlands What you told us 22 respondents For Inpatients: –8 delegates have a funded service that provides routine post fracture assessment of future fracture risk in inpatients –4 have a nurse-led service –These services look at men and women, mainly over the age of 50 –Reasons for no service: lack of funding or delegates are community-based.

19. FLS in the Midlands What you told us For outpatients: –5 delegates have a funded service that provides routine post fracture assessment of future fracture risk in outpatients –4 are nurse-led services –Again, men and women are assessed, but age ranges included over 50s, over 65s and over 75s. –Reasons for no service: lack of funding and support or delegates are community-based

20. FLS in the Midlands What you told us The majority of respondents said that responsibility for identifying low trauma fractures lay in fracture clinic, on orthopaedic wards or in A&E 5/9 have consultant orthogeriatricians 9/9 have access to DXA 4/7 have an auditable database for fracture care (other than NHFD) 2/6 have agreed protocols between primary and secondary care

21. Summary Know what you want your service to look like Ensure deliverable and sustainable Be aware of and sensitive to drivers in primary care Find allies in primary care and work with them Don’t neglect falls (more weight in primary care) Don’t reinvent wheel Tenacity

22. Personal Attributes to Succeed Tenacity Opportunism Infiltration Innovation Networking Motivation Credible –Local –Beyond