My Lords, it is a privilege to introduce this important debate, in which I declare an interest as co-chair of the All-Party Parliamentary Group on Osteoporosis and Bone Health. I am very grateful to all those taking part. I hope that, together, we will again demonstrate the strength of feeling on this issue across all parties in the House, and our determination to ensure action. It is a particular pleasure to welcome the noble Baroness, Lady Merron, to her place for her first debate on osteoporosis as Health Minister. She has always been immensely supportive on this issue, and I know how seriously she takes it. Her leadership will be crucial in advancing the cause of fracture prevention in the days ahead, and I look forward to hearing what she has to say.
Fractures caused by osteoporosis are one of the greatest threats to people living well in later life, affecting half of women and a fifth of men over 50. They are the fourth most-harmful health condition, measured by disability and premature death. They have a profound impact on those who suffer from this debilitating condition —as I saw in the case of my own mother, whose later years were blighted by it—and on those who care for them. Yet—this is perhaps the most upsetting aspect of this debate—they are entirely preventable with safe and affordable therapies.
Fractures impose devastating costs on people and the health service. The hospital episode statistics show that hip and other fractures are second and fourth on the list for total bed days lost to unplanned admissions to hospitals. Most of these patients are, on further investigation, found to have osteoporosis. Hip fractures alone cost the NHS £2 billion annually and are “heart attack-level” events that burden hospitals and our desperately overstretched social care system.
However, it need not be that way. Half of these patients had a previous fracture that could and should have flagged them as being at risk. That is where fracture liaison services—FLS—come in and why the Government’s commitment, made during the election, to making them universal was so welcome. The Secretary of State for Health and Social Care told the Daily Mail, which, alongside the Sunday Express, has been a steadfast campaigner for universal FLS—I pay tribute to them—that one of his first acts in government would be to task NHS England with developing a rollout plan so that every part of the country could access these vital services. I commend his leadership and vision.
As I said, the Minister has also been a determined campaigner. I recall her urging my noble friend Lord Kamall—whom I am delighted to see taking part this evening and who has also been extremely supportive —to acknowledge back in 2021 that two-thirds of people were not receiving the treatment they needed for osteoporosis. Three years on, that figure remains tragically unchanged. The postcode lottery for FLS means that 90,000 people are still missing out on urgently needed bone medications.
I am grateful to the noble Lord, Lord Black of Brentwood, for moving this debate so clearly and comprehensively. I hope that this is not an example of winning the argument, winning the campaign and then losing the starting gun. We need three things to happen immediately. We need that transformation fund to pump-prime fracture liaison services for the first 18 to 24 months when, as the noble Lord, Lord Black, has said, it is estimated that they will start paying for themselves. We need to allow the six integrated care boards that are ready now to begin commissioning services to go ahead, if necessary with some of that transformation fund to support them and, if necessary, before the national rollout plan.
We need clear leadership from the Government and the NHS so that there is a deliverable timetable to ensure that the half of the population not covered by fracture liaison services will be covered by 2030. Just one year’s delay will halve the total hospital bed days saved by 2029, compounding the burden on the NHS. Leadership is vital, because patients find it challenging to keep taking common osteoporosis medications, because they must be taken in a particular way and can cause side-effects. Patients do not feel better from taking them; they reduce long-term fracture risk rather than addressing any current symptoms. One GP who is extremely knowledgeable and committed in this area described how difficult it was to keep patients motivated to take their medication because of ignorance of the subject, no visible changes and the pressures in the system which mean failures to follow up. In England, only 36% of potential patients are reached.
Also, access to diagnostic services varies by region. There is a shortage of DEXA bone density scans and a shortage of radiographers. NHS England indicated that, in September 2024, 56,366 patients were waiting for a DEXA scan and 18.5% had been waiting for more than the target of six weeks. Believe it or not, that is an improvement on the 33.6% waiting more than six weeks in September last year.
My Lords, I thank the noble Lord, Lord Black of Brentwood, for securing this debate and for his tireless work in championing fracture prevention. I also ask the House to note that I am an ambassador for the Royal Osteoporosis Society.
Over the past 30 years, osteoporosis and bone health have been a blind spot in the women’s health policies of successive Governments. Some 50% of women over 50 will suffer fractures due to the condition, and the vast majority of the 90,000 people missing out on anti-osteoporosis medication are women. For this reason, the Fawcett Society, the British Menopause Society, Mumsnet and Gransnet are among the many charities and organisations supporting the Better Bones campaign.
The noble Lord, Lord Black, raised the idea of pump-priming new fracture liaison services with a time-limited transformation fund. I want to highlight the compelling example of exactly this approach in Wales, where the noble Baroness, Lady Morgan of Ely, has shown courageous leadership on the issue. In February 2023, as the then Welsh Health Secretary, the noble Baroness, Lady Morgan, made a bold commitment to mandating fracture liaison services in all health boards within 18 months. By September 2024, that target had been met, with every acute health board in Wales now providing fracture liaison services—an extraordinary achievement, but it did not happen by mandate alone.
As we heard, fracture liaison services quickly prove their value, breaking even within just 18 to 24 months. Beyond this point, they become cost-saving, preventing fractures and reducing hospital admissions to more than cover their ongoing costs. This is why pump-prime funding is so crucial, as it bridges that short window before the benefits become fully realised. The noble Baroness, Lady Morgan, recognised this when she pump-primed new fracture liaison services. As a result, Wales achieved universal coverage in under two years, showing what can be accomplished when ambition is backed with resource.
My Lords, earlier on today, I googled the meaning of the phrase, “It’s a no brainer”. Apparently, it applies to a question that is very easy to answer and, although it did not give an example, I suspect we could all think of one. As my noble friend Lord Black of Brentwood said, there is unanimity across your Lordships’ House on this.
As someone who lives with a bone condition, I am something of a reluctant expert on fractures, or at least on the excruciating pain they cause. The crunch as the bone fractures is immediately followed by the weird sensation of there being a void, because suddenly the broken bone cannot bear any weight. There is literally nothing there, and into that vacuum comes this all-consuming shockwave of pain. I make this point because some may assume that rollout is not urgent because, as my noble friend Lord Black of Brentwood mentioned with regard to hip fractures, it is not normally life-threatening. But this ignores the unnecessary human, as well as financial, cost.
I think of Stephen Robinson, a forklift truck operator, who suffered chronic, agonising back pain, dismissed for years as muscular by his GP. The doctor insisted that he should leave his manual job if he wanted his pain to improve. Eventually, the choice was taken away because the pain was so severe that Mr Robinson had to leave work altogether at 61. He remembers “living in the chair, drugged up to the eyeballs, counting the minutes until I could take the next painkiller”. My Lords, I have been there. It is not nice. A private DEXA scan is not easy to afford when you are unemployed, but it showed that Mr Robinson had 10 undiagnosed spinal fractures. An early assessment through a fracture liaison service would have given him back years of his life and saved him so much unnecessary pain.
In contrast, Alison Smith retired at 60, feeling fit, healthy and ready to embrace her new-found freedom. But nine months later a fall left her with fractured ribs and an alarming sense that something was wrong. Seen quickly by medics, she was referred to a fracture liaison service, which identified severe osteoporosis and started her on treatment. With the support of the fracture liaison service team, Alison received lifestyle advice and ongoing care, which prevented any further fractures happening and saved the NHS and the taxpayer money.
My Lords, it is very good to participate in this important debate on the fracture liaison service, especially since the issue of prevention in healthcare seems to be gathering pace. I thank the noble Lord, Lord Black, for having moved this debate.
We have heard that the fracture liaison service identifies people at risk of osteoporosis and reduces the risk of long-term fractures. Treatment provided by the fracture liaison service is often excellent, and often nurse-led. But, as we have heard, there are just not enough of them. Like many aspects of healthcare that we discuss in your Lordships’ House, provision varies by region, and there are also other inequalities of access to these services. We know that bone density decline can be accelerated by other factors, including smoking, diet and other illness.
We often discuss the fact that those living in the most deprived areas have consistently worse health outcomes and are therefore likely to be most impacted by the lack of coverage of this service. We have already heard in the debate that another element of inequity is that osteoporosis impacts women more than men: 50% of all women over 50 are affected. Last month, a study showed that menopausal women of Chinese and black African backgrounds are almost 80% less likely to be prescribed hormone replacement therapy, and less likely to receive appropriate care during menopause. While this debate is not about hormone replacement therapy, it has a lot to do with equitable access and is therefore significant to this debate.
Fracture liaison services demonstrate genuine value for money, as we have heard, and the Government should be keen to recognise and promote this. It is through services such as these that the shift from sickness to prevention and from hospital to community will happen. Evidence shows that for every pound spent on a fracture liaison service, £3.26 is saved. Given that hip replacements take up 1 million acute bed days a year and are often preventable, rolling this out is an important decision in forwarding the Government’s agenda on the NHS.
My Lords, I begin by thanking the noble Lord, Lord Black of Brentwood, for securing this vital debate. I welcome my noble friend the Minister to the Front Bench and declare an interest as a breast cancer survivor who is osteopaenic and therefore required to avail of bone density examinations in Northern Ireland, where there is excellent provision of fracture liaison services and where research has shown that there is 100% coverage. I hope that my experience and those of many people in Northern Ireland will be helpful to my noble friend in seeing the benefit of such service provision to many people, particularly those in the older cohort of the population.
We have seen encouraging signs in recent weeks that the Government are ready to act decisively on bold, proven ideas. There is a growing appetite for initiatives that will tackle ill health, reduce pressures on the NHS and keep people in work. Fracture liaison services, as we all know, are a perfect example across all three: a gold-standard, internationally recognised intervention that was invented here in Britain and has been adopted across the world. Yet, unfortunately, around half the trusts in England still lack access to this life-changing service.
We now have six integrated care boards across England that are ready to take action. These ICBs have done the groundwork, mapping pathways, securing local support and developing clear plans to establish high-quality fracture liaison services, so I ask my noble friend when they will be able to do that. Crucially, there is a clear road map to take us from these early adopters to full national coverage by 2030. With a phased rollout approach, we can learn from these trailblazers and build momentum over the coming years. What is needed now is targeted pump-priming funding to bridge the short 18 to 24-month period before fracture liaison services become cost-saving—an approach that has already proven successful in Wales, as pointed out by the noble Baroness, Lady Bull.
My Lords, it is a pleasure to follow the noble Baroness, and I thank my noble friend Lord Black for securing this debate. I refer noble Lords to my interests, as listed in the register, as a member of the osteoporosis APPG and a supporter of the Royal Osteoporosis Society.
My father and mother taught me that, “If you have nothing useful to say, don’t say anything”. I am afraid that, being seventh on the list this evening, I will not trouble noble Lords with the carefully timed and crafted four-minute speech I have prepared, because I follow six excellent and comprehensive speeches. But I will make two quick points.
First, I thank and congratulate Her Majesty, Queen Camilla, who has been associated with the Royal Osteoporosis Society for 30 years and its president for 23 years. I know politics is not business, but I hope the Government recognise that there is a business case here, on behalf of the patient and the taxpayer. I urge the Government to follow the recommendations they made when in opposition. The Government of the day promised, if they had been returned, to make speedy progress on the rollout of FLS across this country.
My Lords, I join in the congratulations to the noble Lord, Lord Black of Brentwood, on initiating this debate. I know, as another long-standing member of the all-party group, how active he has been in promoting the goal of a proper system of fracture liaison services.
I remember initiating a similar debate on NHS provision for tackling osteoporosis not long after I joined your Lordships’ House, way back in October 2007. At that time, I was focusing on the patchy provision and availability of DEXA scans across the country, and highlighting the postcode lottery whereby, while you might be identified as needing access to services aimed at preventing osteoporosis, whether those services were available depended very much on where you happened to live. It is therefore very frustrating that, even now, so many years later, we are still complaining about postcode lotteries and that, in England, we still do not have the nationwide system of fracture liaison services which everyone who has spoken in this debate has favoured.
As a long-standing supporter of devolution, I also find it frustrating that England, the most populous country, has once again been lagging behind the rest of the UK. I firmly believe that if devolution is to count as a UK success, it should be a process that fosters high standards of service to all our citizens in whatever part of the UK they live. I also hope that, perhaps with the emergence of regional mayors in England, there will be a renewed effort, supported by the Government, to tackle inequalities in healthcare provisions in different regions of our country.
I accept of course that my noble friend the Minister who will reply to the debate and the Government of which she is part have been in office for only a very short period of time. I am very pleased that the current Secretary of State for Health, in already committing himself to rolling out a system of fracture liaison services across the country, fully recognises not only the benefits this will bring to NHS patients but the financial savings to the NHS in the long term through the establishment of these much-needed preventive services.
8:12 pm
20 of 25 shown
In 2021, we also learned through a freedom of information request that only half of NHS trusts in England had a fracture liaison service in place. Yet again, almost nothing has changed since. Progress should be so easy, but the truth is that we are stagnating and, in the case of broken hips, that inaction costs lives. Earlier this year, the noble Baroness who is now the Minister from the other side of the Chamber asked my noble friend Lord Markham when would the Government’s
“promise to establish more fracture liaison services actually be delivered?”.—[Official Report, 5/2/24; col. 1443.]
We need to ask that again today, because time is running out. Fracture liaison services are the proven solution to the public health crisis of preventable fractures, offering a perfect fit with the Government’s laudable focus on moving from sickness to prevention and on getting people back into work.
FLS are the world standard in this area. They ensure that, after a person suffers their first fracture, they are assessed for osteoporosis, put on treatment and helped to stay on it. That prevents this horrible disease progressing and reduces significantly the chance of further broken bones. In areas without an FLS, the story is different. Many patients who suffer their first fracture are fixed up in A&E and then forgotten about. No assessment for osteoporosis is carried out and no anti-osteoporosis medication is prescribed. Far too many therefore end up back in hospital with multiple, more severe fractures. Over a quarter of hip fracture patients die within 12 months. That is a human tragedy.
FLS are perhaps the most powerful example that we have of preventive healthcare, which is why the Government’s commitment to rolling it out to every trust by 2030 is so critical. There is strong consensus in this House that this is the right thing to do. The Government support it, the Opposition support it and the Liberal Democrats support it. I can recall few other subjects where all parties are so united. So, in the interests of patients, the NHS, the taxpayer and the wider economy, let us get on with it, and fast. While 2030 may seem far away, the scale of work required to deliver universal FLS is substantial. We cannot afford to let this critical deadline creep up on us.
The Royal Osteoporosis Society’s data, scrutinised by Department of Health and Social Care officials, shows that universal coverage would save 750,000 hospital bed days in just five years, prevent 74,000 fractures and save almost 9,000 lives—that is 9,000 people who are someone’s mother or grandma, husband or dad. The ROS, whose campaigning work on this issue has been exemplary, has identified six integrated care boards ready to go. They are like horses at the starting gate: eager, ready and waiting for the Minister and her colleagues to fire that starting gun. If we do that now, we can just about bring those ICBs online by April. The ROS has proposed following this with 12 more ICBs in 2026, 2027, and 2028 respectively.
This proposal is a practical and cost-effective road map to real change. If those ICBs come online as planned, by 2029, FLS will save over 300,000 hospital bed days—that is 60,000 extra elective surgeries that the NHS can deliver by the next election. Further delay is not acceptable; if those first six ICBs do not start until 2026, by 2029 FLS in England will save only half the bed days—that means 30,000 fewer surgeries. Push it back two years and the benefits get pushed back even further into the future, with more preventable fractures, more lives lost, and more pressure on the overstretched NHS.
Many health initiatives take a decade to pay off, but the department has seen the comprehensive analysis which shows that these services break even within 18 to 24 months. All that is needed is a modest pump- priming fund to cover the first two years. Then, after break-even point, the cost savings can keep them sustainable within local budgets. I understand that the former Secretary of State, Victoria Atkins, identified funds within her budget for this very purpose as part of the major conditions review before the general election. Releasing this funding now would kick-start the rollout of FLS.
While the human cost of fractures will always be the most compelling reason to act, we cannot ignore the need to help older workers stay in the labour market, an important aspect of public policy. Independent analysis shatters the stereotype that people with osteoporosis are all retired, and lays bare the cost of inaction to our economy. Each year, osteoporotic fractures in working-age adults lead to over 1.5 million work days lost due to sick leave and carer absences, costing employers £130 million annually. The OBR has identified musculoskeletal conditions, a definition that includes osteoporosis, as the second greatest driver of long-term sickness. This has to change.
When we last debated this subject in September 2023, I ended with these words:
“This is a big strategic challenge for the whole of our society. Bold, visionary leadership from the Government could change the terms of the game, improving the lives of tens of thousands, relieving pressure on our beloved NHS and saving money for the taxpayer. We have such a huge opportunity here to save and change lives. I implore the Government to take that opportunity”.—[Official Report, 14/9/23; col. GC 232.]
I make no apology for repeating those exact same words, with a new Government and a new chapter opening in the history of the NHS. Let us give people with osteoporosis back their lives and the future they deserve, and let us start now. Again, I implore the Government to act, and I beg to move.
I am a member of the Royal Osteoporosis Society and I believed, when I joined it 12 years ago, that we had no osteoporosis in our family. I then discovered, 18 months ago, that my only brother had been diagnosed with it. This can hit in the most unexpected circumstances. I therefore urge the Government to give some indication of when the rollout may happen and when that transformation fund might become available.
During the last QSD on this matter, the noble Lord, Lord Evans of Rainow, responded for the Government and warmly endorsed the idea of what he called a “fracture tsar” within NHS England. Unfortunately, the previous Government did not follow through to establish such a role. The APPG on osteoporosis also noted the need for strong, visible leadership across local systems to get these services up and running. Osteoporosis falls between the cracks of clinical specialties, which is one reason it has been neglected historically. The APPG’s 2022 report recommended the appointment of a “national specialty adviser”—a tsar by another name—to address the lack of ownership and cut across historic boundaries between medical specialisms. I hope that this Government might take action on this where the previous one did not.
The Welsh example shows that a universal fracture liaison service is achievable, but it requires strong leadership and pump-priming to succeed. The Minister has been a steadfast advocate for universal fracture liaison services over many years. I hope that, in responding, she will confirm that the Government are willing to put both leadership and funding in place, so that the ambition for universal coverage is no longer just a commitment but becomes a reality.
In conclusion, any further delay in the rollout of these vital services would represent an inexplicable, unjustifiable false economy, because it is actually costing money not to proceed with universal provision. I look forward to the noble Baroness the Minister giving us reason to hope.
We have heard already in this debate that many ICBs may well be ready to go with such services. However, the Royal Osteoporosis Society reported earlier this year the closing of the South Nottinghamshire Fracture Liaison Service, with the ICB citing serious financial pressures and the lack of a government mandate as reasons for stopping commissioning the service. Commissioning pressures on the part of ICBs is an issue that often comes up when we talk about prevention, particularly shifting from acute to preventive services. I know that ICBs face serious financial pressure and challenges from acute services that often override prevention; however, if the Government are going to prioritise prevention and reduce health inequalities, there must be a way for ICBs’ commissioning decisions to stand against that pressure.
I welcome the promise of 100% coverage by 2030, so I look forward to hearing from the Minister what actions the Government will take to make that happen. Will this be considered in the formation of the NHS 10-year plan, so that health inequalities can be prioritised?
It is not just the ICBs that are ready to act. Across the country, there is a coalition of support poised to make universal FLS a reality. A shadow national implementation steering group has convened to support the Government in making FLS one of its early successes in prevention—a true example of a Darzi reform in action. Its members include the Royal College of Physicians and the Royal College of GPs, as well as Age UK and several other expert societies: pooled expertise to help the Government make quick progress.
What we need now is a clear plan setting out how these services will be delivered by 2030 or even sooner. The groundwork has been done, the support is in place and the opportunity is here; let us not waste it. By acting now, the Government can turn their ambition into reality, saving lives, easing NHS pressures and strengthening the economy. Acting together, along with the Government, we should take this opportunity and make it happen. I look forward to the Minister’s response outlining how that will happen.
I pay warm tribute to the Royal Osteoporosis Society for the work it has done over the years in raising awareness of osteoporosis and the various ways it can be prevented and tackled. It has been particularly successful in promoting national media coverage of the issue, which in turn has increased public awareness and public consciousness of its importance.
In correspondence with me, the Royal Osteoporosis Society has made the point that fracture liaison services fit very well into the recent update on the National Health Service from the noble Lord, Lord Darzi, particularly in the three key shifts that he highlighted and deemed necessary: a move from sickness to prevention, from analogue to digital, and from emergency-based care to community-focused models. Surely it is the case that fracture liaison services offer a practical example of how we can deliver on all three of these worthwhile aims, and do so in the short term as well as the long term.
Many speeches this evening have made very telling points, and I am sure the Minister will have listened carefully to them. Like others, I look forward very much to her reply to this debate.