Cost Efficacious Hip Fracture Care: preventing the fracture transforming the care

1. Cost Efficacious Hip Fracture Care:preventing the fracturetransforming the care Prof. Keith Willett National Clinical Director for Trauma Care SHA Guidance Day 2009

2. Hip Fractures: national perspective Hip fractures – 87% of total cost of all fragility fractures – top 10 HRGs 1.2 million NHS bed days per year £426 million per year acute care £13 million per PCT acute care £50 million on-going care £2.0 billion total care cost FRAGILITY FRACTURES 2

3. Quality Improvement and Cost Effectiveness International published evidence supports a 4-7 day reduction in length of stay Every pre-op day compounds to 2-3 days Reduced mobility and muscle strength Faster and enhanced rehabilitation Fewer medical problems chest / urinary infections Earlier, more appropriate referral to Social Care Supported by UK experience (NHS Institute) Inexplicable variation in length of spell and superspell FRAGILITY FRACTURES 3

4. What the NHFD told us in 2008? Inexplicable range for time to surgery from 36% to 92% within 48 hours “I don’t believe the sun should set twice on a hip fracture”

5. What the NHFD told us in 2008? Medical preoperative assessments vary from zero to 100% 25% of patients have none

6. What the NHFD told us in 2008? Bone Health Falls Secondary prevention is generally POOR

7. Length of stay – Spell variation SUPERSPELL median 28 days Range 17 – 40 days

8. BEDS RELEASED IF LIKE TOP 25% £75,000,000 300,000 £493,665

9. DH Health Economic Assessment 2008/9 £17,688,000 per NHS day saved nationally Excludes any effect of improved outcomes on social care dependency costs FRAGILITY FRACTURES 9

10. Improved Quality of Care . . . . . . . . . . . . . . . . and it just happens to be cheaper!

11. Commissioning the Integrated Hip Fracture Care Pathway, joint PCT, PBC, Acute Trust workshop: The Strategic Commissioner for Social Care Commissioning Manager and Lead Commissioner for Older Peoples Services in the PCTs Directorate Manager and Lead Clinicians for the Orthopaedics and Geriatric Services Primary Care Practice Based Commissioners NCDs for Older People and Trauma Care NHS Institute, RCP Audit, PbR, NHFD FRAGILITY FRACTURES 11

12. Deriving the Integrated Hip Fracture Care Pathwayjoint PCT / Social Care + Acute Trust workshops: Pre-hospital Emergency Department Pre-operative medical and surgical assessment Anaesthesia Surgery – timing and capacity Peri-operative care Assessment of rehabilitation potential Bone health assessment and Falls risk MDT link for secondary and primary care Social Care . . . . . . . . . . . . . . form an FOFFF group FRAGILITY FRACTURES 12

13. DH Systematic approach to falls and fracture care & prevention: four key objectives Hip fracture patients Stepwise implementation Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards Hip fracture patients Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care Non-hip fragility fracture patients Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention Individuals at high risk of 1st fragility fracture or other injurious falls Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards Older people 15 September 2014

14. Fracture Prevention : the economic case Each hip fracture NHS treatment cost - £9000 Average Acute Trust treats 350 hip fractures 16% reduction in hip fractures over 3 years: 6% from previous hip fractures 10% from non-hip fractures What would you pay for a fracture prevention programme? . . . . . . . . . . . . . . . . 25% of that

15. Phase II: prevention . . . . . accept financial (political) return will be in the medium to long-term Hang the prevention strategies on the hip fracture initiative Integrate Falls and Bone Health (osteoporosis) assessments 1st fracture clinic follow-up appointment Falls services linked to primary care / residential care / ambulance services / patient discharge Objective 2: Respond to the first fracture, preven the second – through Fractur Liaison Services in acute and primary care Non-hip fragility fracture patients FRAGILITY FRACTURES 15

16. But it’s held my weight for years