The solution: fracture liaison services
I want to set up a fracture liaison service: what next?



Osteoporosis is the most common chronic bone disease,1 affecting an estimated three million people in the UK.2 The condition—which doesn’t show any outward symptoms, but causes low bone density and structural deterioration of bone tissue—clinically manifests itself as fragility fractures. These are broken bones resulting from mechanical forces that wouldn’t usually cause fracture, such as a fall from standing height or less. Common fracture sites include the wrists, hips and spine.

The consequences of fragility fractures are wide-reaching and significant. Half of women and 20% of men over the age of 50 will break a bone due to osteoporosis,3 with an estimated 500,000 fragility fractures occurring in the UK each year2—that’s one every minute.

The impact of these fractures can be devastating for those affected, including loss of independence and mobility. But broken bones due to osteoporosis also place a significant burden on health and social care resources; treating these fractures, including the cost of social care, is estimated at around £4.4 billion each year.4 This figure will only increase as our population continues to age.

Thankfully, fracture risk in individuals with osteoporosis can be minimised and broken bones prevented. But how do we identify and manage those at risk?


The solution: fracture liaison services

People who have broken a bone due to low bone strength are two to three times more likely to suffer further fractures.3 This presents an ideal opportunity for intervention, which is where Fracture Liaison Services (FLSs) come in.

FLSs systematically identify patients over the age of 50 who have suffered a fragility fracture, assess them for osteoporosis, and arrange effective management to improve their bone health and reduce their risk of future broken bones. By identifying patients in this way, it is estimated that up to 25% of hip fractures—around 20,000 a year —could be prevented.5

There are now 110 FLSs in operation across the UK in hospitals and community settings, providing access for around 55% of the current population. Of these, 22 sites are newly established since 2015. The National Osteoporosis Society (NOS) estimates that these new sites alone will save the NHS £49 million over the next five years.6

Recognising that these services are hugely beneficial for patients and make good financial sense for the NHS, Public Health England (PHE) recommends FLSs as an effective method of fragility fracture prevention.7 So, when it comes to looking after the bone health of your local population in the most cost-effective way, having a FLS is key.


There are now 110 FLSs in operation across the UK in hospitals and community settings


I want to set up a fracture liaison service: what next?

The establishment of any new service, or improvement of an existing one, requires time and dedication. To take some of the hard work out of the process, the NOS has developed on online FLS Toolkit with templates and resources to help you with the following stages:

1. Drawing up a case for your service

You’ll need to convince service providers and commissioners that there’s a case for establishing an FLS by putting together a summary of evidence.

2. Developing a project plan

Establishing or improving a service can be complex, involving many stakeholders and decision-makers. Approaching the project using a proper plan will help you to ensure that all essential tasks are completed.

3. Calculating the benefits

Use the charity’s Benefits Calculator to estimate the potential benefits of establishing an FLS in your area. This tool gives a predicted number of fragility fractures prevented over a five-year period, based on a given population, and potential savings to the local health economy.

4. Writing a business case

Use the toolkit and support from the charity’s Service Delivery team to help you write up a formal proposal for your FLS.

5. Presenting to commissioners and service providers

See tips from Tim Jones, NHS Commissioner and Service Improvement Advisor for the National Osteoporosis Society, to increase the chances of having your FLS commissioned. Learn about how to effectively communicate your business case to commissioners and avoid common pitfalls.

6. Monitoring your service

Once established, you’ll need to demonstrate your FLS is achieving good outcomes and providing an excellent standard of care. The charity’s toolkit includes a framework with outcome and performance indicators, which can be used to submit and collate data. You can learn more about evidence-based best practice in the National Osteoporosis Society’s Clinical Standards for Fracture Liaison Services.8

Will Carr, Head of Service Delivery at the National Osteoporosis Society, said: “Establishing or improving an FLS can be a daunting task, but the charity is here to help. Our Service Delivery team can offer bespoke support with everything from advice around staffing levels and patient pathways, to evaluating your service’s performance. Our expertise can give your FLS the best chance of getting up and running and ensure it’s an ongoing success with improved outcomes for your patients.”



National Osteoporosis Society FLS Toolkit resources are freely available at

You can view the Clinical Standards for Fracture Liaison Services and other National Osteoporosis Society resources for healthcare professionals at


The National Osteoporosis Society will be holding its annual conference Osteoporosis 2018 at the Birmingham ICC on 2–4 December.

See the programme and book tickets at


Rachael McKie, National Osteoporosis Society
Conflict of interest: none declared



1. Mauck KF, Clarke BL (2006). Diagnosis, screening, prevention, and treatment of osteoporosis. Mayo Clin Proc  2006; 81(5): 662–72

2. Svedbom A, Hernlund E, Ivergård M, et al, EU Review Panel of IOF. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 2013; 8(1-2): 137

3. van Staa TP, Dennison EM, Leufkens HG, Cooper C. Epidemiology of fractures in England and Wales. Bone 2001; 29(6): 517–22

4. Svedbom A, Hernlund E, Ivergård M, et al, EU Review Panel of IOF. (2013). Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 2013; 8(1-2): 137

5. National Institute for Health and Care Excellence (2018). NICEimpact: falls and fragility fractures.

6. National Osteoporosis Society (2015). Benefits calculator:

7. Public Health England (2017). Falls and fractures consensus statement: Supporting commissioning for prevention.

8. National Osteoporosis Society (2017). Effective Secondary Prevention of Fragility Fractures: Clinical Standards for Fracture Liaison Services