Commissioning hip fracture care – the NICE way

Dr Karthik Kayan is onsultant orthogeriatrician at Stockport NHS Foundation NHS Trust.

Prof Opinder Sahota is consultant in elderly medicine at Nottingham University Hospitals NHS Trust and Joint Chairman of the Falls and Bones SIG at the BGS.mobility

It is well known in geriatric medicine circles that hip fractures are the most common osteoporotic fracture affecting predominantly older people.

Currently, the incidence of hip fracture emergency admission is around 70,000 in the UK and will continue to increase as the population ages. The projected incidence for hip fracture in the UK is 101,000 by 2020. The crippling effects of hip fracture are significant for the patient as independence is affected and a number of them die within a year of sustaining a fracture. The cost of managing osteoporotic fractures is £1.7 billion and over 90 per cent of this is due to health and social care costs associated with the fracture.

NICE clinical guidelines (CG 124), published in 2011, offers evidence-based counsel on the management of hip fracture from admission to secondary care and through to final return to the community and discharge from specific follow up. This was followed by the NICE Quality Standards (QS 16), published in March 2012, which defines clinical best practice. QS 16 provides specific, concise quality statements, measures and audience descriptors with a view to defining high quality care for the public, health and social care professionals, commissioners and service providers.

Making commissioning decisions based on the best available evidence such as NICE or NICE accredited guidance, as well as other trusted sources accessed via NHS Evidence, can help commissioners ensure that they are using their resources effectively. Commissioners should bear all the NICE guidance and quality standards when commissioning a programme of care for hip fracture, although it is recognised these are very clinically focused. Therefore NICE has produced a further resource, specifically to support commissioners, clinicians and managers to commission high-quality and evidence-based hip fracture care across England. Called, Commissioning Guidance (CMG 46): Management of Hip Fracture in Adults, this guide for commissioners provides advice on commissioning services for people with hip fracture until discharge from the Hip Fracture Programme (4-6 weeks post hospital discharge), and ongoing secondary prevention of further hip fracture/fragility fractures.

CMG 46 does not include advice on commissioning services for the primary prevention of hip fracture, longer term rehabilitation post-fracture, or the commissioning of services for people with hip fracture from causes other than osteoporosis or osteopenia. It highlights any recommendations supporting cases for disinvestment or decommissioning by identifying treatments and interventions that do not add value, enabling commissioners to release resources or generate savings where appropriate. Implementation of the guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement this guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity.

The main components of the guidance are :

  • Section 1 makes the case for commissioning services for the management of hip fracture in adults
  • Section 2 is a pathways approach to commissioning high-quality integrated care for hip fracture
  • Section 3 helps one assess local service levels
  • Section 4 describes service components
  • Section 5 makes suggestions for contract specification
  • Section 6 explains more about the cost impact of service redesign
  • Section 7 signposts to further information

Section 1
It was the consensus of the topic advisory group that commissioning service for hip fracture will achieve some of the national outcomes set out in the NHS outcomes framework 2012/13, Public health outcomes framework for England 2013-16, Adult social care outcomes, commissioning outcomes framework and quality and outcomes framework.

Section 2
The guidance emphasises that Commissioners should work with a range of partners and stakeholders, including emerging clinical commissioning groups, health and wellbeing boards, social care, service users and carers, when planning services for people with hip fracture. Partners should develop an effective and integrated local pathway that takes into account patient safety, patient experience, and timely access to assessment and treatment. The guidance states that an important function of the Hip Fracture Programme is to ensure the required liaison with related services, particularly mental health, falls prevention, bone health, primary care and social services.

Commissioners should work with service providers to carry out baseline assessment and clinical audit using NICE implementation support for hip fracture and NICE CG 124. This will enable commissioners to identify where recommendations from the NICE clinical guideline on hip fracture have been implemented and highlight areas for improvement.

Section 3 
Commissioners and their partners should conduct a local needs assessment to know the epidemiology of hip fracture, patient outcomes after hip fractures and quality measures. This will assist to estimate local service need, plan sufficient capacity and develop plans to improve the accessibility and inclusivity of services.

The outcomes after hip fracture are:

  • return to usual place of residence after hospital treatment for an acute hip fracture episode
  • mobility change after acute hip fracture episode
  • mortality after acute hip fracture episode.

The guidance states that commissioners should use NICE QS16 and the Department of Health’s Best Practice Tariff to achieve high quality care and these are likely to improve outcomes for people with acute hip fracture. Commissioners should work with providers to encourage them to submit accurate and full data to the National Hip Fracture Database (NHFD), and to use local data to monitor the quality and performance of the service. The hip fracture commissioning and bench marking tool can be used by commissioners to determine the level of service that might be needed locally and to calculate the cost of commissioning the service using the indicative benchmark and/or your own local data.

Section 4
Commissioners should specify that upon admission, people with hip fracture are offered a formal, acute orthogeriatric or orthopaedic ward-based Hip Fracture Programme (HFP) that includes all of the following:

  • orthogeriatric assessment
  • rapid optimisation of fitness for surgery.
  • Commissioners should ensure that all providers identify and treat comorbidities immediately so that surgery is not delayed by correctable conditions
  • early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term wellbeing
  • continued, coordinated, orthogeriatric and multidisciplinary review
  • liaison or integration with related services, particularly mental health, falls prevention, bone health, primary care and social services
  • clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those delivered in the community.

Commissioners should ensure that providers assess all people admitted to hospital where hip fracture is suspected for pain, cognitive impairment and venous thromboembolism. They should therefore ensure that providers work with service user groups to develop appropriate information for patients (or, as appropriate, their carer and/or family) about treatment and care. They may also specify that the HFP team provides patient advocacy services and supports patients, their families or their carers and ensure the local secondary care provider has processes in place to support the HFP team to develop effective working relationships with associated services across the local area. This includes nominating a local GP champion for hip fracture, who should be invited to attend the HFP team meetings. Commissioners may also wish to specify that the HFP team is effectively able to support the discharge of patients across neighbouring local authority areas and that staff are aware of local differences in eligibility criteria for social care support.

When developing the local HFP, commissioners may decide to review the eligibility criteria for intermediate care and they should be aware of the recommendation in the NICE clinical guideline on hip fracture for intermediate care. They should ensure that providers have appropriate policies in place for lone working, community-based working child protection and protection/safeguarding of vulnerable adults and risk management. Commissioners should ensure that providers have processes in place for regular scheduled clinical team meetings which are attended by all members of the multidisciplinary HFP team. They should also work with the HFP team to establish procedures for ensuring that discharge information is promptly available to all relevant providers, including intermediate care providers.

Section 5
Commissioners should collaborate with clinicians, local stakeholders and service users when determining what is needed from services for people with hip fracture in order to meet local needs. The care pathway should be person-centred and integrated with other elements of care for people with hip fracture. They should ensure that the services they commission represent value for money and offer the best possible outcomes for their service users.

Section 6
Commissioners are able to download commissioning and bench marking tools for hip fracture to enable them to determine the level of service that might be needed locally and to calculate the cost of commissioning the service.

Section 7 
All the national drivers relevant to hip fracture are summarised for the commissioners to use and includes suggestions to address one or two for local service redesign.

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