Development of policy on falls and fracture prevention in the United Kingdom provides a useful case study for policymakers in New Zealand to consider.
Falls and fracture policy development
In 2008, the Department of Health in England (DH) established a falls and fractures policy working group. In 2009, the policy was published – Falls and fractures: Effective interventions in health and social care – which described four key objectives for specific populations:
- Hip fracture patients: Improve outcomes and improve efficiency of care after hip fractures by following the six British Orthopaedic Association ‘Blue Book’ standards
- Non-hip fragility fracture patients: Respond to the first fracture, prevent the second through Fracture Liaison Services in acute and primary care
- Individuals at high risk of 1st fragility fracture or other injurious falls: Early intervention to restore independence through falls care pathway linking acute and urgent care services to secondary falls prevention
- (All) Older people: Prevent frailty, preserve bone health, reduce accidents through preserving physical activity, healthy lifestyles, and reducing environmental hazards
DH subsequently published an economic evaluation of FLS to support implementation of the second policy objective.
Quality incentive payments
In April 2010, the Best Practice Tariff (BPT) for fragility hip fracture was introduced for hospitals in England. The BPT offered an uplift in reimbursement for provision of hip fracture care at the individual patient level (made possible by the NHFD). The payment differential for delivering best practice was initially set at £445 (NZ$872) for 2010–11, which was subsequently increased to £890 (NZ$1,744) for 2011–12 and £1335 (NZ$2,616) for 2012–13, and 2013–14. In order to receive the BPT uplift, all of the following criteria needed to be met during 2010–11 and 2011–12:
- Time to surgery within 36 hours from arrival in an emergency department, or time of diagnosis if an inpatient, to the start of anaesthesia
- Involvement of an (ortho) geriatrician:
i. Admitted under the joint care of a consultant geriatrician and a consultant orthopaedic surgeon
ii. Admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia
iii. Assessed by a geriatrician (as defined by a consultant, non-consultant career grade (NCCG), or specialist trainee ST3+) in the perioperative period (defined as within 72 hours of admission)
iv. Postoperative geriatrician-directed:
- Multi-professional rehabilitation team
- Fracture prevention assessments (falls and bone health)
From April 2012, an additional BPT criterion was added, which required pre- and postoperative cognitive assessments to be completed.
In April 2012, secondary fracture prevention was included in the General Practice Quality and Outcomes Framework (QOF). The QOF is a system for performance management and payment of general practitioners (GPs) in the NHS throughout the UK. The secondary fracture prevention indicators introduced were:
- OST1. The practice can produce a register of patients:
i. Aged 50–74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan, and;
ii. Aged 75 years and over with a record of a fragility fracture after 1 April 2012
- OST2. The percentage of patients aged between 50 and 74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, who are currently treated with an appropriate bone-sparing agent
- OST3. The percentage of patients aged 75 years and over with a fragility fracture, who are currently treated with an appropriate bone-sparing agent.
The QOF indicators were retained for 2013–14 and some changes have been made to the indicators for 2014-15.