Health: Osteoporosis and Fractures

Baroness Wheeler Excerpts

Thursday 14th September 2023 Grand Committee

[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.