Population Context
The West Suffolk Community FLS serves a population of approximately 257,000, including 102,800 people aged over 50 and 53,970 aged over 65. The area is predominantly rural and semi-rural, comprising 6 Integrated Neighbourhood Teams, 26 GP practices, and 49 care homes, within Suffolk and North East Essex ICB. The service is nurse-led.
Background
In 2012, fracture prevention services across Suffolk were inequitable. While East Suffolk had an established Fracture Liaison Service (FLS), West Suffolk had no provision despite repeated failed hospital-based business cases. The local Clinical Commissioning Group therefore secured time-limited innovation funding to establish a community-based FLS, deliberately positioned outside the acute trust.
Two Band 7 nurses designed and implemented the service, with a focus on system integration, digital working, and equity of access, rather than physical location within a hospital.
Service Model
From inception, the West Suffolk FLS adopted an IT-enabled, remote-first model. Monthly fracture data for patients aged over 50 years attending West Suffolk NHS Foundation Trust are received via a data-sharing agreement with the hospital information team. These fracture lists are digitally triaged using hospital and GP records to identify fragility fractures, without reliance on ward trawls.
Assessment is undertaken by telephone where appropriate, with home visits offered to older, frailer, housebound patients and care home residents. This ensures equitable access across a geographically dispersed population. Each patient receives a comprehensive fracture risk, bone health, and falls assessment, including lying and standing blood pressure. Follow-up continues until treatment is initiated, tolerated, and stable.
The service operates a long-term, open-access model, allowing patients (and where appropriate carers and families) to re-contact the FLS at any point in the future.
Case Finding and Referral
Eligibility criteria include age ≥50 years with a fragility fracture, with prioritisation of fractures most strongly associated with osteoporosis (hip, spine including vertebral and incidental findings, wrist, humerus, pelvis). Ankle fractures are considered on a case-by-case basis. Ribs, feet, skull, digits, and high-energy trauma are excluded.
In addition to hospital fracture data, referrals are received from:
General Practice
DXA services (all reports sent monthly to FLS)
Trauma practitioners
Orthogeriatric MDTs
Respiratory services, including the lung cancer screening programme (incidental vertebral fractures)
Self-referral
The team has worked closely with radiology colleagues to improve wording and coding of reports, significantly improving identification of incidental vertebral fractures.
Community Denosumab Service
In 2022, the FLS assumed responsibility for delivering the entire community denosumab pathway for West Suffolk, developed during the COVID-19 pandemic when hospital delivery became unviable.
The pathway includes prescribing, monitoring, administration, and six-monthly follow-up, delivered across multiple community health centres. Approximately 700 patients are currently managed, including those with renal impairment or intolerance to bisphosphonates. Some patients have now been maintained on denosumab for over ten years, demonstrating a high level of continuity and specialist expertise.
Workforce
The service operates with a lean, predominantly part-time workforce, led by an Advanced Clinical Practitioner prescriber, supported by nursing and administrative staff. Clinicians work remotely except for community clinics and home visits, enabled by full digital access to GP, hospital, and community records.
Patient-Centred Care
All patients, and where appropriate carers and families, receive verbal and written education covering:
Bone health
Lifestyle and nutrition
Medication
Falls prevention
Strength and balance exercise
Longer initial appointments support shared decision-making and long-term adherence. Care is tailored using a biopsychosocial model, combining pharmacological and non-pharmacological interventions. Referrals are made as appropriate to strength and balance services, exercise on referral, occupational therapy, vision and hearing services, social prescribing, medication review, frailty assessment, and falls services.
Follow-Up and Digital Integration
The service is fully digital, with shared records across General Practice, community services, and the acute trust. Long-term management plans are shared with both patients and GPs. Patients are followed up as often as required, with:
A 12-month follow-up questionnaire for most patients
Six-monthly FLS follow-up for denosumab patients
Proactive follow-up for anyone not on treatment
Patients are discharged only when treatment is established, declined with informed decision-making, or no longer clinically appropriate, with Patient-Initiated Follow-Up (PIFU) thereafter.
Outcomes, Strengths and Learning
Key strengths include:
A robust secondary fracture prevention safety net
Home visiting capacity reducing health inequalities
Long-term treatment continuity
Strong informal integration with orthopaedics, orthogeriatrics, rheumatology, radiology, DXA, and General Practice
High patient satisfaction, particularly regarding access, continuity, and avoidance of hospital attendance
Challenges include geographical boundaries, cross-border populations, hospital coding delays, and historic DXA capacity issues, all of which have impacted FLS-DB metrics. These reflect system and data definition issues rather than service quality. DXA services are now in recovery under consultant rheumatology leadership, with improving waiting times.
Conclusion
The West Suffolk Community FLS demonstrates that a fully digital, nurse-led, community-based model can deliver effective, equitable secondary fracture prevention across a rural population. With appropriate data alignment, digital access, and commissioning boundaries, this model is scalable, sustainable, and transferable, offering a credible alternative to traditional hospital-based FLS delivery.
