Lord Black of Brentwood
To ask His Majesty’s Government what plans they have to improve access to, and quality of, services in England for people with osteoporosis and those at risk of fractures, including Fracture Liaison Services.
Lord Black of Brentwood (Con)
My Lords, I note my interest as co-chair of the APPG on osteoporosis. I am incredibly grateful to all colleagues who have stayed late today to take part in this important debate. Osteoporosis is an urgent public health crisis; half of women over 50 and a fifth of men will suffer fractures due to the condition. Osteoporosis weakens bones, so they break after simple everyday occurrences: a cough, a fall, even a hug from grandchildren can be enough to cause a debilitating fracture with often life-changing consequences. I saw this at close hand with my own mother, the last years of whose life were blighted by this cruel disease. It was diagnosed and treated too late, robbing her of her independence and, above all, quality of life because of multiple fractures.
Such fractures are no minor inconvenience; they are the fourth-worst cause of premature death and disability in the UK. As many people die of fracture-related causes as of lung cancer or diabetes. Fractures are also the second-highest driver of bed occupancy in the NHS. Today, they cost the health and social care system £4.6 billion. By 2030, this will edge towards £6 billion as we all live longer. Furthermore, fractures account for 2.62 million sick days annually in the UK, and spinal fractures in particular are a significant cause of older workers exiting the workforce in their 50s and 60s—figures of which the Treasury should take careful note.
But it need not be that way, as osteoporosis is treatable with safe, effective therapies that are highly affordable for the NHS. We do not need a miracle cure; the medicines already exist to halt the progress of the condition. The newest therapy can even rebuild bones. The stark problem is simply that we are overlooking 90,000 people every year who desperately need these drugs, because we are falling behind the rest of the world on modern diagnostics. The key to all of this is fracture liaison services—or FLS—which are the world standard for diagnosing osteoporosis early, straight after the first break, so that life-changing spine and hip fractures can be prevented.
In our 2021 inquiry, the APPG found that FLS have an unrivalled record in identifying people who need treatment. That is up to 95% of at-risk patients in a local population being put on a treatment plan and monitored so that they stay on their medication. Yet, incredibly, only half of NHS trusts in England have them. In areas without FLS, people are fixed up in A&E and forgotten about. They have their first break mended, but no one assesses them for osteoporosis and the disease is left to continue its deadly path. These are the people who present later with devastating hip and spinal fractures.
That is why 88 Members of this House have endorsed the better bones campaign that has run for the last two months in the Sunday Express. Week by week, in partnership with the Royal Osteoporosis Society, the paper has been setting out the enormous opportunities FLS can deliver. I take this opportunity to thank the Sunday Express and praise it for its fantastic coverage. The campaign calls for all areas to have quality FLS, for the provision of a very modest amount of funding to set them up and for a new national specialty adviser in the NHS to drive the step change we need. The level of support for the campaign has been staggering, demonstrating the public, professional and political demand for FLS. As noble Lords know, it is rare that such a wide coalition comes together in full and passionate agreement.
Already, 240 parliamentarians across the UK have backed the campaign, along with seven royal medical colleges. Their president spoke powerfully as part of the campaign on the role FLS can play in reducing waiting lists, freeing up operating theatres and releasing terrible pressure on A&E. The representative bodies for care home providers and ambulance workers have joined the call, along with 42 other charities and organisations, and business leaders and trade unions have joined forces because they know that FLS can help keep people in work.
The stark truth is that 31,000 hip fractures can be prevented over the next five years if we make FLS universal and high quality. We would stop treating the symptoms and prevent the damage in the first place. Today, we are spending money the wrong way around, managing the costs of failure rather than preventing harm in the first place. To coin a phrase, that is voodoo economics. Hip fractures are the most costly fragility fractures to treat: the average length of stay in hospital is three weeks, and a million acute hospital bed days are taken up by patients every year. Yet half the people with a hip fracture have suffered a previous fracture, which could have flagged them as being at risk and led to prevention. But, of course, they needed an FLS to do the flagging.
That can all change. If we front-end just 1.5% of our current spend on fixing hip fractures into setting up an FLS in every area, we can prevent a tenth of hip fractures happening. That is 31,000 people’s lives changed for the better, around 8,000 of whom would otherwise have died shortly after injury. Ending the postcode lottery for FLS would cost just £27 million per year in additional funding but have a total benefit of £440 million over five years. FLS, which break even in just 18 to 24 months—another point that the Treasury should note—deliver return on investment of roughly £3.26 for every pound invested. Is £27 million not just a rounding error in the grand scheme of NHS budgets compared with the £4.6 billion cost of unprevented fractures today?
For the population, the benefits of FLS would be vast, with 74,000 fractures prevented by 2028. It would also release 750,000 hospital bed days, which must be worth doing. If the Prime Minister wants to meet his pledge to reduce hospital waiting lists, this would be an easy win. In fact, I doubt he can do so without it. It would be a win for patients and their families, who have to care for so many of those suffering, for the hard-pressed NHS and for the taxpayer.
I know that the Government support the FLS model: NHS England has signalled to integrated care boards that they are a good thing. But there is nothing holding ICBs and trusts accountable for their delivery. That is why we are flatlining. The hard power of NHS England KPIs in 63 other areas is crowding out fracture prevention. Why would a commissioner spend £1 on something that the Government say may be a good idea when that pound is pulled away from 63 other areas in which they are publicly held accountable by NHS England and Ministers? These stubborn factors have led to fracture prevention flatlining since the APPG—I am pleased to see so many members of it here—published its report in 2021. There has not been a single percentage point of improvement: 90,000 people are missing out, which is 90,000 lives at risk.
The current approach has failed, and we need a step change in leadership from Ministers. A very modest, simple policy change, backed by limited investment, can deliver huge savings for the NHS and a significant boost for economic productivity among people in their 50s and 60s. We all want to see this, and it is of real importance to the Government. It can be a real demonstration that they are committed to the prevention elements of the long-term plan. That is vital. As our population continues to live longer, which is fantastic, broken bones caused by osteoporosis are a demographic time bomb. Without urgent action, a longer life will not be a better life.
This is a big strategic challenge for the whole of our society. Bold, visionary leadership from the Government could change the terms of the game, improving the lives of tens of thousands, relieving pressure on our beloved NHS and saving money for the taxpayer. We have such a huge opportunity here to save and change lives. I implore the Government to take that opportunity.
Baroness Donaghy (Lab)
My Lords, it is a real pleasure to follow the noble Lord, Lord Black of Brentwood. I thank him for all his work in this important area.
I have been a member of the Royal Osteoporosis Society for about 13 years, not because I had any family association with osteoporosis—at least, that is what I thought until March this year, when a close family member was diagnosed—but because I thought that it was a good organisation, which deserved support.
When I was a non-executive director at King’s College Hospital in the 1990s, I was asked to be the older persons’ champion. I spent considerable time looking at hospital processes and staff awareness to identify the needs of older people. The impact of falls, and the cost not only to the health services but to individual quality of life, was and is immense. That impact has to be multiplied several times if the faller has osteoporosis or is subsequently diagnosed with it.
Too often overlooked is the loss of confidence, an unwillingness to go out and an increase in fearfulness. We cannot assume that sufferers will want treatment or welcome attention, which is why it is so easy to neglect this disease and why two-thirds of people needing medication miss out.
I want to ask some questions about the Government’s women’s health strategy. In a Written Answer to the APPG’s report on the undertreatment of osteoporosis, which was referred to, the Minister Helen Whately indicated:
“The report’s recommendations are predominately being addressed through the women’s health strategy and National Institute for Health and Care Excellence’s guidance”.
However, osteoporosis is mentioned only 12 times in the 128-page women’s health strategy report, with no actionable plan for addressing bone health for women throughout their lives. NICE guidance is of course important, but it cannot address the need for leadership that the noble Lord, Lord Black, called for.
On 6 June, Minister Maria Caulfield said:
“NHS England is expanding fracture services for high-risk women with osteoporosis, and it is working to prevent falls”.—[Official Report, Commons, 6/6/23; col. 668.]
Can the Minister give any examples of an area where fracture services are being expanded for high-risk women? How many of the new women’s health hubs will have arrangements for density scanning and referral to fracture liaison services?
I conclude by thanking the Sunday Express for its Better Bones campaign and the noble Lord, Lord Black of Brentwood, for initiating this debate.
Lord Alderdice (LD)
My Lords, I also thank the noble Lord, Lord Black of Brentwood, for obtaining this debate and for his work on the APPG on Osteoporosis and Bone Health.
Osteoporosis has a huge impact, especially on women and not least as they get older. As we have heard from the noble Lord, Lord Black, fractures caused by osteoporosis affect 50% of women aged over 50 and a fifth of men. It is one of the most consequential health conditions if measured in disability and premature death. It is, in many ways, a hidden condition, since even those suffering from it may not be aware that it is the cause of some of their problems. When anyone sustains a broken bone and the trauma that caused it does not seem severe enough to have warranted a fracture, underlying osteoporosis should be considered as a vulnerability factor and addressed before more fractures and disability arise.
A friend of mine in her 60s took a relatively minor tumble during a 10-pin bowling game, yet sustained a fracture. As a doctor, she was alert to the possibility of osteoporosis and appropriate investigations showed that she was indeed suffering from the condition. This is not an unusual story and I have no doubt that many other noble Lords in this debate will rightly flag up the high incidence, especially among older women.
However, a theme that I suspect may receive a little less attention is how spinal fractures from osteoporosis affect people of working age, contrary to the misconception that it is just about hip fractures in older people. The first time I came across the situation of a spinal fracture was when I was working in Belfast in the 1970s, in what was then Northern Ireland’s only psychosexual clinic. One day, one of my patients, who in those days we described as transsexual—we would now call them transgender—arrived in a wheelchair. A previous clinician had prescribed steroids as part of their gender transition process, and the consequence was a crumbling of some of their spinal bones from the resulting steroid-induced osteoporosis. My patient was now coming to see me in a wheelchair with spinal fractures.
More recent decades have seen a massive increase—we are not really sure why—in the number of people suffering from a whole range of autoimmune diseases. These often require treatment with steroids. Both patients and their healthcare professionals need to be constantly aware not just of the symptoms of the disorders, but of the potential sequelae of their medical treatment. One of those is steroid-induced osteoporosis, resulting in fractures that lead to disability and problems in employment.
The Treasury is currently looking for ways to keep older workers in the workforce, and recently committed £400 million for the same. Apart from looking to the health budget to address osteoporosis, will the Minister explore whether some of this £400 million could be devoted to investment in diagnostics and treatment for osteoporosis, so having a significant impact on keeping people at work by raising the alert level on osteoporosis?
Baroness Finlay of Llandaff (CB)
My Lords, I declare that I am president of the Chartered Society of Physiotherapy and that I chair the Commission on Alcohol Harm.
We must all appreciate the noble Lord, Lord Black of Brentwood, for having secured this very important debate. Osteoporosis is predicted to cost the UK health service £2.2 billion by 2025, so I want to focus on the very early part of the prevention pathway. With age, fragility fractures become more common, particularly in the long bones of the arms and legs and in the vertebrae. These bones are made up of a scaffolding of less dense and trabecular, and therefore less heavy, bone, where about 26% of bone is remodelled every year. Old bone is gobbled up by osteoclasts, and osteoblasts, under the influence of signalling cells, lay down a scaffolding of unmineralised osteoid, which then becomes fragilely mineralised as the new bone solidifies. As we have just heard, many hormones—proteins, vitamin D, calcium—all influence this process. When imbalanced, prolonged osteoclast activity gobbles up more bone and the bone becomes increasingly fragile.
In osteoporosis, this bone loss in the long bones and the vertebrae is particularly evident. Bone mass declines over time, accelerated by smoking and moderate to high alcohol intake, as well as by illness and its treatment, such as some cancer treatments and treatments with steroids, as we have heard. Gut disease, diabetes and chronic kidney disease all impair absorption of calcium and magnesium, as do some of the indigestion drugs so commonly taken across the population and anti-epileptic drugs, which impede the absorption of nutrients required for bone growth.
No one would advocate not treating this serious condition, but all is worsened by physical inactivity. Preserving skeletal muscle with exercise increases bone strength and slows the development of osteoporosis, as well as improving balance, thereby reducing the risk of falls. A diet rich in fruit and vegetables, with an increased protein intake, helps maintain muscle mass and bone strength.
Yet, we are a nation of inactivity, with 36% of the adult population physically inactive. Our healthcare costs related to inactivity are the third highest across 15 nations in western Europe, running at £20.53 per person in the UK, compared to £5.11 in Finland or £12.25 in France, which is near the middle of group. When bone has become fragile, early treatments, as we have heard, can lessen the chance of fragility fractures and prove cost effective, but prevention through exercise and healthy eating is essential. It is never too late to start.
Baroness Chisholm of Owlpen (Non-Afl)
My Lords, I thank the noble Lord, Lord Black, for initiating this debate. I have long been involved with the Royal Osteoporosis Society and, in the short time available to me, I am going to have to gallop through what I want to say.
As has been part of the campaign in the Sunday Express, I am going to set out the reasons why a national leadership on osteoporosis and fracture prevention within the NHS is essential. Either a national clinical director or, at the very least, a national speciality adviser will enable us to have a strong, visible leadership. There is already a long list of 41 leadership roles within NHS England for virtually every condition—from long Covid to flu, from tobacco addition to eye care—and it seems to me the fact that fracture prevention is not mentioned on that list sends a clear message to local commissioners that it is not a priority.
Surely that is wrong. When you consider—as the noble Lords, Lord Black and Lord Alderdice, mentioned—that half of women over 50 will have a fracture due to osteoporosis and that these fractures are the fourth worst cause of disability and premature death in the UK today, it is a no-brainer that osteoporosis and fracture prevention should be represented with national leadership. I am aware that it is felt that the present NHS national director for musculoskeletal conditions includes osteoporosis in the portfolio, but the existing leadership bandwidth is extremely stretched, and osteoporosis is such a distinct specialism, so even if it continues in the MSK basket, in my book there is still a very strong case for a national speciality adviser.
From what I have learnt, good intentions at national level are failing to filter down across ICSs, leading to commissioners’ awareness being extremely low when it comes to the financial benefits brought by increasing FLSs. We need a specialistic leader in NHS England, properly resourced to get the job done. For over a year, the ROS has indicated that it will part fund such a role, surely an offer that NHS England should embrace. Rumours are that there is a freeze on recruitment, but that appears to have been lifted, as there is a recent advert for two new clinical director roles—so a place for us. On what possible NHS England criterion can a condition which affects so many people and costs so many years of healthy life and creates such a strain on public services possibly be allowed to continue?
Baroness Hayter of Kentish Town (Lab)
I, too, thank the noble Lord, Lord Black, for introducing this debate. As has been clear, the Government have simply passed the buck on this. The Written Answer from the noble Lord, Lord Markham, told me that:
“NHS England does not have a specific budget … The Department continues to work with NHS England on the consideration and implementation of musculoskeletal policy, including Fracture Liaison Services”.
That means no national action, and it is not good enough.
It is not enough just to highlight NICE guidelines and the Getting It Right First Time programme which has led to huge gaps in coverage. As we have heard, only half of English trusts have fracture liaison services and chronic underinvestment means that, even where services exist, performance is below par. High-quality services can identify 95% of at-risk patients, compared to a quarter using other non-specialist services. The Government need to take concrete, immediate action. All involved, including professionals, know we need these specialist services, with bodies representing over 650,000 doctors and nurses supporting the Better Bones campaign.
But, as we heard, locally, commissioners have poor awareness of osteoporosis and the benefits of fracture prevention. As we heard, they often wrongly think that investment in these services takes time to pay off; in fact, they break even within two years. However, the catch is that the savings occur in a different part of the health service from where the money is spent. So, without a government mandate, money simply will not be ring-fenced and allocated.
In Wales, the Health Minister, our former colleague my noble friend Lady Morgan of Ely, mandated all seven Welsh health boards to ensure 100% coverage of fracture liaison services by this time next year, and she set up a government-led taskforce to help meet that deadline. That shows how strong leadership can improve and save the lives of tens of thousands of people, particularly older women—I had better declare an interest.
The Royal Osteoporosis Society does an amazing job, as do thousands of clinicians and carers, but this urgent issue needs government resolve and leadership. Yes, it needs resources, but it also needs investment to save not just money but pain, discomfort and the diminished quality of life that fractures cause. As the noble Lord, Lord Black, said, these are no minor inconveniences. We live longer, which is great, but we need to live longer healthier, and this issue can make a difference. A clear mandate from Westminster is needed for English ICSs to prioritise fracture liaison services.
Baroness Bloomfield of Hinton Waldrist (Con)
My Lords, it is a pleasure to follow the noble Baroness, Lady Hayter, and I applaud my noble friend Lord Black for securing this important debate and for his work in the APPG. Like many noble Lords, I suspect—indeed like my own mother, who suffered from this pernicious disease for decades, causing her much pain, misery and distress—I speak as someone who has this inherited condition as well.
The example of my mother was actually a benefit, in that I was diagnosed very early. Spending 10 years on HRT did little, and alendronic acid has done much, although I am out of time on that, so, for now, I am successfully keeping my density levels stable with load-bearing exercise and vitamin D. However, not everyone is so lucky: osteoporosis is asymptomatic—I never suffered from any breaks—so, until fragility fractures occur, it is often not diagnosed. So I am fully supportive of any mechanism by which fellow sufferers can be identified as early as possible.
Today, we heard of the need for, and the clear benefits of, fracture liaison services. I welcome Minister Maria Caulfield’s recent commitment, in the Sunday Express, to explore setting up more fracture liaison services and to say more before the end of this year.
According to the ROS, the amount of money needed to fill the gaps in population coverage and the quality of FLS in England is very modest: just £27 million per annum. This is out of a total annual spend in the NHS of £180 billion. We can give everyone over 50 access to an FLS, and it will improve the quality of all these bodies so that they can deliver well against the quality standards monitored by the Royal College of Physicians.
We all recognise the difficult economic environment, but there is a clear need for a national catalyst to get things moving. The Royal Osteoporosis Society suggested a capped two-year transformation budget of £54 million to pump-prime FLSs to become universal across England. This will light the spark so that we can have change. Then, after those first two years, the services can be absorbed into ICSs as “business as usual” within conventional funding channels, overseen by ICBs, when the benefits materialise. This offers a pragmatic way for the Government and NHS England to catalyse the change in an affordable way. It reflects perfectly the principles in the long-term plan, replacing cash badly spent on fixing avoidable injuries with sensible investment in prevention.
The ROS also suggested several other approaches, and there are many ways to create change in this area, with a quicker pay-off than officials might expect. The Better Bones campaign has shown that the national support for FLS is only growing. Rather than going round in circles, can we now take action to make it happen? Will the Minister please meet with the ROS to discuss these proposals?
Lord Bilimoria (CB)
My Lords, my 87 year-old mother Yasmin lives in Dehradun in north India, in the foothills of the Himalayas. She has had severe osteoporosis and osteoarthritis—a point that has not been made is that many sufferers of osteoporosis also suffer from osteoarthritis. In India, of the hundreds of millions of Indians over the age of 50, it is estimated that at least 20% are women with osteoporosis, so it is a major public health problem with Indian women.
As the noble Baroness, Lady Bloomfield, has said, osteoporosis-related fractures are associated with substantial pain and suffering. My mother, fortunately, was diagnosed very early. The gold-standard diagnosis is the dual-energy x-ray absorptiometry DXA. However, very few of these machines are found in India.
This is a global phenomenon: 54 million people in the United States have osteoporosis; women are four times more likely to develop it than men; in Italy, its expense is €10 billion, and in Spain the burden of fragility fractures was estimated at €3 billion; in the Netherlands, the burden of fractures will increase by 30% to over €1 billion.
I thank the noble Lord, Lord Black, for initiating this debate. As he noted, the condition is asymptomatic until fragility fractures take place. It is estimated that there are around 180,000 fractures presenting each year as a result of osteoporosis. This is a huge number. There are GPs who spot it, and, of course, fracture liaison services. I was shocked to discover that only 63 out of 123 NHS trusts—just over 50%—were able to confirm that they have an FLS, whereas 100% in Scotland and Northern Ireland do. Could the Minister confirm why 100% of NHS trusts do not have these FLS services?
There seems to be a lack of the DXA scanners, which I mentioned earlier. From May 2023, 66,469 patients were waiting for these scans, which is 11.2% more than in May 2022. Why can we not have more of these scanners available throughout? Why can there not be a public health campaign about bone health—far more than is taking place now—to make people aware of it? The noble Baroness, Lady Finlay, made the very important point that there should be much more awareness and encouragement of physical activity and access to physiotherapy. I have seen this first-hand with my mother, who suffers so much pain that she has access to physiotherapy. Do we give enough access to physiotherapy? The conclusion is that detection and prevention have to be the way ahead.
Lord Shinkwin (Con)
My Lords, I join other noble Lords in congratulating my noble friend Lord Black of Brentwood on securing this debate on an issue very close to my heart, as someone who lives with the bone condition osteogenesis imperfecta, to give brittle bones its medical term, which forced me to spend much of my childhood in a hospital bed. The cost-effective proposal that my noble friend highlighted constitutes a win-win for people faced with my condition, OI, and osteoporosis.
Sticking with my condition for a moment, I understand from bone expert Professor Kassim Javaid, that there were 16,245 hospital admissions for OI patients between 2014 and 2018, with a total cost to the NHS of £24,052,451. Yet, incredibly, OI is not listed as a condition on the NHS website. You can be in hospital and get a diagnosis, go home and look at the NHS list of conditions and see that the condition you have just been diagnosed with supposedly does not exist. How unhelpful for patients and their families looking to manage the condition and reduce fracture risk. I would be really grateful if my noble friend could have that simple but cost-effective anomaly corrected.
I turn specifically to osteoporosis, which people with my condition often go on to develop. I am not going to rehearse the arguments that have been so excellently and eloquently made by my noble friend and others. The key point for me, as for my noble friend, is value for money, so I ask the Minister to give one example of bigger bangs for bucks than investing £27 million in the urgent rollout of fracture liaison services, when the ROI is £3.26 in savings made for every £1 spent. To its credit, Mid and South Essex Integrated Care System has shown what can be done at the working level; now we need it in Government. As the Royal Osteoporosis Society has made clear in its excellent campaign with the Sunday Express, 41—that is, all other—health authorities have yet to act, so we urgently need that top-down mandate.
I finish with this question to the Minister: it may not be a medical term, but does he agree with me and my noble friend Lady Chisholm that this is a classic case of a no-brainer?
Lord Allan of Hallam (LD)
My Lords, I am grateful to the noble Lord, Lord Black of Brentwood, for securing the debate and to the Royal Osteoporosis Society for meeting me recently.
In the short time available, I shall focus on an aspect that many speakers have already raised: fracture liaison services. I was struck by looking at the Royal College of Physicians database of fracture liaison services, which has a map showing vividly just how variable the provision is across England. We have a protocol that we know both improves patient outcomes and is ultimately less expensive for the NHS, as the noble Lord, Lord Black, and the noble Baroness, Lady Hayter, have pointed out to us, and we have it working well in some areas—the noble Lord, Lord Shinkwin, has just given us an example of places where it is—but we do not seeing it rolling out everywhere in a timely way.
I wonder how the Minister feels about those areas of England where it is not rolling out. Is he disappointed, frustrated, irritated or all of the above? We should be frustrated, irritated and disappointed that people in England are not getting the service that will mean that they have fewer negative health outcomes and that we will all save on the NHS budget as they get cheaper care, rather than more expensive care further down the track.
I turn to the potential fixes, and we have discussed some of those today. How long will it be before the department intervenes more directly? I hope the Minister can talk about the kind of interventions that it is thinking of. My understanding is that the provision of a fracture liaison service is relatively straightforward in health terms. It requires trained nurses, administrators, access to systems and some tools, such as the scanners that the noble Lord, Lord Bilimoria, referred to, but these are not at the cutting edge or at least the most expensive end of what is needed in the health service, so it is certainly achievable.
Building on the point made by the noble Baroness, Lady Chisholm, about a national specialist leader, that seems to be essential. I would perhaps be even more aggressive: there needs to be someone whose responsibility is to get us from 51% to 100%. All they should think about when they wake up in the morning is, “How do I get to 100% coverage of fracture liaison services?” They should praise the best and make the worst feel very uncomfortable for not doing their job. They should help to build business cases for ICBs that, for whatever reason, have not built their own business case, to demonstrate to them how they would be stupid not to do so—and, if the ICBs still do not do it, make sure that everyone knows they are not doing it, because the evidence is there. They should look at creative ways to unblock any barriers and quite simply not accept no for an answer.
I hope the Minister can say that the department is thinking creatively about how it can put that kind of structure in place, where incentives exist to get from 51% to 100% in the shortest time possible.
Baroness Wheeler (Lab)
My Lords, I thank the noble Lord for this important debate, for his excellent introduction and for his work with the APPG. We have heard a number of speakers who are very active in the group, so ably co-chaired by the noble Lord and my colleague in the Commons, Judith Cummins MP. She has led the charge in the Commons campaign for improved access and quality of services, as has the noble Lord here in this House.
The APPG’s two reports, on the FLS postcode lottery and setting out the role that primary care needs to play in identification, treatment and care, have been landmark reports in raising awareness among parliamentarians and NHS leaders about osteoporosis and the importance of bone health. We look forward to its further report later this year on bone density scanning, following the public evidence-taking session.
I also thank the Royal Osteoporosis Society for its very succinct key facts briefing for today. It makes for pretty stark reading, as we heard from noble Lords. It includes the fracture treatment gap, which leads to thousands of people each year missing out on anti-osteoporosis medications; the patching up of people in existing fracture clinics without underlying osteoporosis being diagnosed; and the enormous burden of preventable fractures on the NHS, which mean that half of hospitalised hip fracture patients who have had a previous fracture could have been flagged up as being at risk.
On the absolutely key issue of why only 51% of NHS trusts provide FLS, I note the response from the noble Lord, Lord Markham, to the Oral Question on osteoporosis early detection on 19 January, in which he emphasised strongly that all ICBs have the responsibility to roll out these services “or their equivalent”, and that the others—the 49% that have not done so—had “different versions of it”. I look forward to the Minister’s explanation today of exactly what those different equivalent versions comprise and how their outputs are measured and assessed for fracture treatment and prevention. Why is the treatment gap so wide and shocking?
For the record, the ROS warns of the barriers to ICSs in seizing the missed opportunities. It notes a lack of a central directive through the standard NHS contracts in emphasising fracture prevention; a general lack of awareness of the impact of fractures and the cost benefits of secondary fracture prevention; the patchy clinical leadership in drafting business cases; and the short-termism in business planning, including the break-even issue that has been mentioned. I would be interested to hear what steps the Government are taking to address those issues.
On 19 January, noting the impact of osteoporosis affecting half of women over 50, my noble friend Lady Merron drew attention to the UK primary care base trial on screening for osteoporosis for older people. It examined a systematic approach to identifying older women in fracture prevention, leading to a 28% reduction in hip fracture risk, thereby significantly reducing costs and seeing increased adherence to treatment. It is an exciting trial, and I would welcome further information on it from the Minister.
Finally, I will briefly follow up on a previous issue I raised about research on osteoporosis. Can the Minister say what support the Government have provided to the ROS’s research academy and its potentially game-changing road map, which charts the key steps for researching a cure for this extremely debilitating disease?
Lord Evans of Rainow (Con)
My Lords, I thank my noble friend Lord Black of Brentwood for bringing forward this Question for Short Debate. As chair of the All-Party Parliamentary Group on Osteoporosis and Bone Health, he has long been a champion for those with osteoporosis. I thank him for sharing his experience of looking after his own mother over many years.
My noble friend is absolutely right that osteoporosis represents a growing challenge, particularly for older people. In the UK, it is estimated that over 3 million people have osteoporosis and over 500,000 fragility fractures occur every year. People of all ages want to enjoy good health for as long as possible, but remaining independent often depends on health and social care services being effective enough to support them wherever they live. Many people of working age also suffer preventable fractures, with an estimated 2.6 million sick days taken every year in the UK due to osteoporotic fractures. Studies show that over 22% of the population aged 50 to 64 will suffer from a fracture at some stage.
To that end, this year’s spring Budget announced a package of measures to support individuals at risk of, or experiencing, musculoskeletal conditions, including by making best use of digital health technologies to support people to manage symptoms better and to increase mobility, and by designing and scaling-up musculoskeletal community hubs, thereby expanding access to community-based services and delivering physical activity interventions. These will be effective as exercising regularly reduces the rate of bone loss, lowering the risk of fractures and falls. Given that good work improves health and well-being, the spring Budget also announced measures to support people with musculoskeletal conditions to remain in or return to work, including by integrating employment advisers into musculoskeletal pathways, building on the success of the NHS talking therapies programme, and piloting the WorkWell partnerships programme to support disabled people and people with health conditions who want to work.
The Government are also undertaking two consultations to understand how best to increase employer use of occupational health services. Osteoporosis disproportionately affects women, who often face a one-size-fits-all health system that does not consider their specific health needs. The women’s health strategy for England set out plans to achieve the 10-year ambition for women to have improved outcomes with musculoskeletal conditions, including through increasing early identification and treatment of those at risk, which many noble Lords pointed to in the debate.
The noble Baroness, Lady Donaghy, asked what the Government are doing. We are proposing to announce, in the forthcoming Autumn Statement, a package of prioritised measures to expand the provision of fracture liaison services and improve their current quality. NHS England is also setting up a fracture liaison service expert steering group to explore the expansion and improvement in quality of services for people with osteoporosis and those potentially at risk of fractures. We also have the major conditions strategy. I assure noble Lords that we are committed to making sure that people get the best care, no matter what condition they have.
Last month, we set out our initial plans for the major conditions strategy, with the case for change and strategic framework. This report identifies actions to improve outcomes for individuals across six major conditions groups, including musculoskeletal conditions. It includes exploring how best to support musculoskeletal service improvement and leadership—for example, through improving collection of data. Joining up patient experiences across datasets will enable more effective commissioning of support for those with musculoskeletal conditions. It is also includes, together with NHS England, exploring further support in the provision of fracture liaison services, which many noble Lords mentioned here today. This could include identifying people at risk of further osteoporotic fragility fractures, and implementing strategies to reduce risk of future fracture, including falls, and mortality.
Fracture liaison services are key to prompt diagnosis of osteoporosis and are acknowledged as the world standard for secondary fracture prevention. According to the Royal Osteoporosis Society, for every £1 spent on fracture liaison services in the UK, the taxpayer can expect to save £3.28. By levelling up provision to cover everyone over the age of 50, we could prevent just under 5,700 fragility fractures every year, a point very well made by my noble friend Lord Black.
As noble Lords will be aware, fracture liaison services are commissioned by integrated care boards, and while we expect musculoskeletal fragility fracture and fall services to be fully incorporated into planning and decision-making, coverage is not universal, with only 50% of the country able to access services. The noble Lord, Lord Allan of Hallam, always gives very demanding targets, 100%, and he is absolutely right to demand that. It will take time, but it is the intention to be able to do that across the way. I have noted the 100% and I look forward to discussing that in future debates.
NHS England is already working with commissioners to support the mobilisation and implementation of fracture liaison services in each area and to establish a greater number of clinics. It has provided local health systems. My noble friend Lord Black talked about leadership, and I will certainly make sure that colleagues in the department are fully aware of what he is talking about: it will certainly be considered by Ministers.
NHS England’s “getting it right first time” programme has a specific workstream on musculoskeletal health and is exploring how best to support integrated care systems in the diagnosis and treatment of osteoporosis. As part of this work, NHS England is reviewing pathways for secondary prevention of fragility fractures. Systematic vertebral fragility fractures and non-ambulatory fractures feature, and we will publish guidance to support local health systems to implement these pathways. The programme has also produced a draft adult orthopaedic trauma national speciality report, which includes recommendations on adopting fraction liaison services.
I turn to some specific questions. My noble friends Baroness Chisholm and Lord Shinkwin asked about having a dedicated fracture tsar. As the noble Lords will be aware, the role of the NCD as speciality adviser is to provide specialist clinical advice, and leadership to drive transformation of services for patients and support the commissioning of services. I think it is an important point to have somebody focused day in, day out, whose waking worry is to take it from 57% to 100%. I certainly will feed that one back.
The noble Lord, Lord Bilimoria, talked about DEXA scanners. Unfortunately, I have not got precise detail on that so I will write to the noble Lord on the specific details of that particular question.
I pay tribute to the noble Baroness, Lady Finlay, and her colleagues for the work that she does on this. She reminded us that prevention is better than cure, and that physical exercise and diet throughout one’s life helps with this. I didn’t realise “gobbling up” was a technical, clinical term, but we know exactly what you mean; that is the importance of diet and exercise to keep that bone mass and muscle mass there. As the Minister always says, in one week in hospital for patients, you lose 10% of your body mass, which is a sobering thought.
I do not underestimate how painful and debilitating this silent disease is, but I am confident that real advances have been made and will continue to be made. I assure noble Lords that the Government is determined to support improving access to, and quality of, services for those with osteoporosis.
In answer to my noble friend Baroness Bloomfield, I am very happy to meet with the ROS at a time convenient, and I extend my thanks once again to noble Lords for securing this debate and for the thoughtful comments and questions.
I note, on this particular date and others, the fact that noble Lords have actually cared for, and looked after, family relatives, which gives you first-hand experience of the challenges for family and friends of people living with this difficult disease. As a noble Lord mentioned—I do not know who—the good news is we are all living longer, but the bad news is that, at some stage, we may all suffer from this terrible disease.
Baroness Wheeler (Lab)
Can I ask if the noble Lord is going to follow up with a letter on the questions he did not cover please? Thank you.
Lord Evans of Rainow (Con)
Do forgive me, apologies. I have not got that information in my notes, I am afraid, so I will write to you and the noble Lords on that specific question.