An innovative new approach to reduce the risk of older people breaking bones could save the NHS over £35 million, across the North of England, if it is fully scaled-out across the region.

The project will identify patients at high risk of breaking bones, evaluate medications and treat those patients, where appropriate, with a bone-sparing agent to improve bone density.

Scaled up to the population level of the North’s 16 million, this would equal £35,163,642 in direct costs and £8,454,046 in residential costs – a total of £43,617,688 potential savings in health and social care.

The project has been developed and tested by the AHSN NENC and the Innovation Agency (AHSN for the North West Coast). Now all four AHSNs across the North including Greater Manchester and Yorkshire and Humber are implementing the project.

The Northern AHSNs will be working in partnership with AMGEN, The Northern Health Science Alliance and Interface to deliver the approach to targeting fracture risk assessment and bone-sparing medication review at a Primary Care level.

The project is scheduled to run for one year and designed as a ‘proof of concept’ to provide the evidence for a future-proof sustainable model of fracture reduction.

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Northern Bone Health Project FAQs

What is the NHSA and what are the individual roles and responsibilities of each organisation within the partnership?
The overall aim of the Northern Health Science Alliance (NHSA) is to provide support to the four Northern AHSNs (The North East and North Cumbria, The Innovation Agency (North West Coast), Yorkshire & Humber and Health Innovation Manchester) in their collaboration with Interface Clinical Services (ICS) and AMGEN in the successful delivery of this project across the Northern Region. You can read the NHSA’s 2018 Annual Review here.

What framework of governance is in place and are there any issues relating to patient and data confidentiality?
A Joint Working Agreement has been drawn up between AMGEN and the NHSA which sets out the principles and values underpinning the project working arrangement. Each of the project member organisations has nominated a representative to sit on the Joint Project Group, which meets monthly and is chaired by the Deputy Chief Executive of the NHSA. The Joint Working Agreement follows NHS principles; namely that the joint working must be for the benefit of patients, be conducted in an open and transparent manner and take place at a corporate not individual level.
Any patient identifiers will be removed from data to preserve and respect patient confidentiality in line with relevant data processing legislation i.e. the Data Protection Act 2018 and European General Data Protection Regulation. For further information relating to regulatory compliance can be found here.

Can you provide some further evidence about the efficacy of this approach on the long-term bone health and health/care outcomes of the target population? Are there any longitudinal studies that can tell us more about the medium to long term impact of this approach?
A trial project by the Academic Health Science Network North East and North Cumbria (AHSN NENC), working with pharmaceutical company AMGEN, across a population of 579,508 found £1,274,045 could be saved in direct costs due to prevented fractures, and £328,143 could be saved in residential/nursing home costs. Scaled up to the population level of the North’s 16 million, this would equal £35,163,642 in direct costs and £8,454,046 in residential costs – a total of £43,617,688 potential savings in health and social care. The ​project has been developed and tested by the AHSN NENC and the Innovation Agency (AHSN for the North West Coast). Now all four AHSNs across the North including Greater Manchester and Yorkshire and Humber are implementing the project.

Is there a cost to the CCG for the project?
There is no cost in terms of financial outlay to the CCG for participating in the project.

How long will the project last?
The project will last for one year.

How is the project funded?
The project is funded by AMGEN through a joint working agreement with the NHSA.

Can delivery of this project contribute towards QOF?
The project will assist in supporting the GP in achieving the QOF osteoporosis indicators. The project can help identify areas within the practice that may need improvement in terms of coding of diagnosis or fractures but will not actively add patients to your QOF register, this would need to be completed by the practice. The osteoporosis domain has now changed in terms of treatment requirements for points attainment within QOF but still remains good clinical care.

What level of work and input would you require from the CCG and/or GP practices to support this initiative?
To review delivery of the project the lead GP and the Practice Manager would need 5 minutes at the start and end of every day. In addition, 30 minutes of GP time would be required at the end of morning surgery to gain signatures on the protocol; agree clinical rationale and intervention options in line with local pathway. These will then require subsequent referrals etc. The Practice Manager will need to arrange for the Pharmacist to access their clinical system.

Our clinicians have fed back mixed views on the efficacy and appropriateness of longer-term bisphosphonate use: what does the evidence say about efficacy and best practice use (including ‘drug holidays’)?
National Osteoporosis Guidance Group (NOGG) have issued guidance on the management for Osteoporosis in August 2017. It addresses most of the issues around bisphosphonate prescribing especially that which pertains to treatment holidays and duration of treatment. These guidelines have also been incorporated in the prescQIPP document (please see resources section). However, we would advise the participating practices to follow the locally agreed guidance and prescribing formulary. More information can be found here and here. Please also refer to https://www.nice.org.uk/guidance/qs149/chapter/Quality-statement-4-Long-term-follow-up

How much time will be taken up at Practice-level to participate in the project?
The number of days required to complete the review in the Practice will depend on practice population and demographics. At least one day on site and a remote dial in session in advance of this day to complete the data extraction process, but subsequent days may be required if large patient numbers are identified. Any subsequent days will be arranged on day 1 with the Practice Manager.

Will this project be looking to engage with CCG pharmacists and meds management teams, or pharmacists attached to practices and/or clinical networks?
If a practice, Primary Care Network or CCG Clinical Pharmacist is assisting the practice, they are encouraged to observe Interface during the patient review. The Clinical Pharmacist can assist the practice by facilitating some of the interventions, by way of example initiation of bisphosphonates, repatriation of patients from secondary to primary care.

Could you tell us more about which datasets are used to identify patients at risk of fracture and what variables are included?
A FRAX assessment is completed as part of the assessment process for all patients who meet the review criteria. This is limited to the data points within the patient’s clinical record.

Can delivery of this project contribute towards QIPP?
This project addresses the 4 components of Quality, Innovation, Productivity and Prevention. It aims at improving clinical effectiveness, patient safety and reduce care costs. Examples of how this has been achieved in East Lancashire can be read here and here, and in the North East here.