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NHS: Osteoporosis Services

My Lords, it is extraordinary that this is the first time in over 10 years—I have checked this—that the House has had a full-scale debate on this extremely important subject, so the noble Baroness should be congratulated doubly for having tabled her Question. She was, of course, right in all that she said. The messages are stark: brittle bones and bone fractures are the source of immense amounts of pain and distress among older people, and the cost to the NHS and to the country is commensurately huge and rising. The combined cost of hospital and social care for patients with osteoporotic fractures is reported as being more than £1.8 billion a year, a figure that the noble Baroness mentioned. One in two women and one in five men is likely to suffer such a fracture after the age of 50. Out of every five orthopaedic beds, one is occupied by someone who has had a hip fracture. Twenty per cent of those patients die within a year as a consequence; another 20 per cent end up in a nursing home. In fact, the suffering that arises from a fall and a hip fracture in old age cannot really be measured. So great is the dread of immobility arising from a serious hip fracture that, as my noble friend mentioned, over 80 per cent of older women said in a survey that they would rather be dead than experience the reduced quality of life that that would bring. As with so many issues in the public health arena, we know what we should be doing about all this but the evidence, unfortunately, is that we are just not doing it. There have been improvements in NHS provision over the years; we have the NSF for Older People, and we have recognised preventive treatments. But as the British Orthopaedic Society reported last month, most eligible patients miss out. A recent UK audit showed that fewer than 5 per cent of women with a history of fracture underwent a DEXA scan for bone density, and fewer than 10 per cent were treated with drugs to reduce the risk of further fractures. The sobering part is that we know it is possible to predict a great many of the hip fractures that occur in the elderly, and therefore to prevent them. The biggest predictor is a fracture that has happened to someone previously. In fact as many as half to two-thirds of patients who present with a hip fracture have broken a bone before. The unpleasant conclusion is that many people at risk are not being looked after properly by their doctors. That brings us to the whole question of the quality and outcomes framework. GPs are perfectly placed to be targeting those patients at risk of brittle bone fractures, but all the evidence is that this kind of proactive, preventive doctoring is not happening nearly enough. Doctors are well aware that there is a range of a priori risk factors for osteoporosis: being white and female; having had an early menopause; having a low body mass index; being a smoker or a drinker; leading a sedentary lifestyle; being on steroids—all these are predisposing factors. The QOF provided a golden opportunity to bring uniformity to the way in which fragile bone disease is targeted throughout the country, but the opportunity was not seized. It would be very helpful if the Minister could bring us up to date on this. What representations have been received on the subject by her department, and is she aware of any plans for osteoporosis to be included in the framework in future? Part of the problem, so I understand, is that many of the signs or symptoms that might otherwise sound the necessary warning bells are not always recorded. For example, the fact that someone has been on a long-term course of steroids is very seldom flagged up on computer recordings, and older patients who have had a history of falls are very unlikely to have that fact recorded. The same applies to the investigations associated with a previous fracture: the patient record often does not highlight them. One of the main conclusions from the report published in the summer by QResearch was that computer recording of diagnoses of osteoporosis needs to be improved so that patients at risk of fracture can be more easily identified. There needs to be better recording of the interventions and treatments delivered to those at risk. In particular, there need to be much better systems in place to prevent bone fractures among older people living in residential care homes, where it was found that only one-third of such people are receiving the very basic and extremely cheap therapy of extra calcium and vitamin D. So there are a number of very simple indicators, which the QOF could include, that would make a huge difference to the burden on secondary care arising from bone fractures and an equal difference to the workload of falls services. Falls services are extremely important. A couple of years ago, the Royal College of Physicians discovered in an audit exercise that, although about three-quarters of trusts in England are part of a co-ordinated falls service, there were key parts of hospitals, such as A&E and fracture units, where falls and bone health are not adequately addressed. The amount of actual clinical activity in these areas was surprisingly low, and it was noticeable that public health strategies often failed to make mention of either falls or bone health. Part of the problem that the Royal College identified was that trusts found it difficult to get the necessary information from PCTs relating to either issue. It would be useful if the Minister were able to tell us whether things have improved over the past two years since the royal college audit was done. The gold standard nowadays is for every trust to be part of an integrated, multi-agency, multi-professional service for falls; and that a quarter of trusts should not be is clearly unacceptable. The noble Baroness, Lady Quin, rightly referred to the guidance published by NICE. I have spoken to two doctors about this, who both echoed the concerns that have been expressed recently by the National Osteoporosis Society and the Nuffield Department of Orthopaedic Surgery, among others. A decision to rule out NHS funding for all but one of the generic first-line treatments will leave doctors without any ability to exercise their clinical judgment to prescribe something else, if the patient cannot tolerate that particular treatment. Alendronate is known to cause nasty side effects, which some patients find intolerable. I do not as a rule criticise NICE’s decision-making, because it is an organisation of which I approve, but I very much hope that it will listen to the representations made to it on this subject and that it does not leave doctors in a position in which they can choose from a menu of only one. Prevention is one part of this equation and treatment is the other part. I was encouraged to see that a new audit is currently under way to improve the care of patients who have suffered hip fractures. The aim of this is to audit hospitals against six standards that are set out in a guide to best practice published by the British Orthopaedic Association and the British Geriatrics Society. The two key standards are that patients with hip fractures should be admitted to an acute orthopaedic ward within four hours of presentation and that surgery should be performed within 48 hours on all those who are medically fit. Some 75,000 people every year break a hip. Sadly, the evidence is that at least half those people wait more than 48 hours for an operation; and a delay beyond that period means that you are more likely to die or suffer permanent disability. I very much hope that this audit process will lead to faster response times and a general raising of standards. The Minister has been given a lot of food for thought in this debate—at least I hope so. She will need no convincing of how important it is that we tackle this awful condition in a systematic and co-ordinated way across the country. The good news is that it is well within our capability to do it. All we need are the systems, the incentives and, of course, the will.