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Get tough on hip fracture care, commissioners urged

Patients wait too long for surgery once admitted; around 10% don’t get required physiotherapy

Caroline White

Thursday, 10 December 2015

Clinical Commissioning Groups should be more demanding when it comes to hip fracture care, because many patients are still not receiving an acceptable level of care, finds the latest report* published by the National Hip Fracture Database (NHFD).

In its commissioners’ report published today, the NHFD urges CCGs to investigate the quality of care patients receive at hospitals in their area and to question the length of stay for rehabilitation beds they commission for hip fracture and other conditions in community hospitals and care homes, because NHS information systems are failing to capture this information reliably.

The report found variations in the quality of care provided to patients across England, Wales and Northern Ireland.

Among its raft of recommendations, the NHFD says that clinical commissioning groups (CCGs) should challenge any local hospitals where fewer than 70% of patients receive the prompt surgery recommended by the National Institute of Health and Care Excellence (NICE) in its clinical guidance 124.

This states that patients with hip fractures should have surgery on their first or second day in hospital. The report found that while 72% of patients now receive surgery within this timeframe, the proportion of units reporting this ranges from 14.7% to 95.3%.

Total hip replacement was still only performed in around a quarter (26%) of the 11,722 patients who met the clinical criteria for this procedure, the figures showed.

And almost one in 20 (4.3%) of all hip fractures occurred in hospital, a figure that represents 1,859 inpatient hip fractures, equivalent to five such events each day across England, Wales, and Northern Ireland.

And some CCGs (1.4%) will need to question why more than 80% of their local population do not receive treatment in a hip fracture programme, a model of care that was central to NICE guidance, says the report.

Furthermore, 1 in 9 CCGs should consider why fewer than half of their patients were able to be mobilised out of bed the day after surgery, and question whether this reflects poor control of hydration, or a failure to provide the early physiotherapy assessment recommended in NICE QS16, it recommends.

The report recommends that CCGs examine their local hospitals’ performance, as detailed in the colour coded performance tables of the recently published NHFD annual report and in individual hospital dashboards available on the NHFD website.

Dr Antony Johansen, NHFD clinical lead for geriatric medicine said that an effective hip fracture programme will consider a patient’s treatment throughout their rehabilitation and recovery.

“This pathway of care is complex, and relies on working between secondary and community care providers. Commissioners of hip fracture services will want to ensure the quality of care is maintained throughout, and that the implications of post-acute rehabilitation in terms of both cost and quality are fully understood.”

Hip fracture is an ideal marker of the quality of care given to frail and older patients in the NHS, because it involves a wide range of specialists, clinical teams, healthcare departments and agencies, says the report.

Hip fracture is common, with 60,000 injuries each year across England. Patients face a significant risk of dying or of losing their independence, and their recovery depends on how well hospital and community services work together.

Katherine Murphy, Chief Executive of the Patients Association, said that the organisation repeatedly heard from patients on its helpline who had either waited too long for treatment or who had received poor care. 

“Cuts to social care budgets have left many hip fracture patients particularly vulnerable. A lack of available intermediate care is leaving these elderly patients at risk. We are on the brink of a winter crisis. Services are stretched and this is putting patients’ safety in danger. Elderly patients must have a network of social care around them to help restart their lives after such major surgery,” she insisted.

The variations in care quality needed to be ironed out, she added. “Hospitals must ensure that all patients are given the necessary hydration, drug and physiotherapist plans to allow them to recover from surgery. CCGs across the country must now implement these recommendations and work towards providing a consistent level of care for all hip fracture patients.”


* National Hip Fracture Database (NHFD) Annual Report 2015. Falls and Fragility Fracture Audit Programme (FFFAP), The Royal College of Physicians, December 2015.

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