Executive summary
NHS Greater Glasgow and Clyde (NHSGGC) South Sector implemented a digitally enabled Fracture Liaison Service (FLS) using the Red Star FLS platform to address long delays, workforce pressure, and inequitable case finding within osteoporosis care.
The intervention transformed fracture identification from a largely manual process taking 15–24 months into a near-real-time digital pathway, identifying eligible patients within an average of three days.
Without increasing staffing, the service doubled annual FLS enrolment (from 3,000 to 6,000 patients), freed up around 50% of specialist nurse time, and enabled more consistent prioritisation of high-risk patients, particularly those with vertebral fractures.
Following full implementation, the South Sector observed a 10% reduction in hip fractures compared with baseline, during a period when rates elsewhere were rising. While causation cannot be definitively proven, no other major service changes occurred during this period.
The challenge
Like many FLSs across the NHS, NHSGGC faced multiple, compounding pressures:
Manual case finding reliant on ward visits, trauma lists, virtual fracture clinics, and duplicated reviews
Significant workforce constraints, particularly specialist nursing capacity
Delayed identification of fragility fractures, especially vertebral fractures often found incidentally on CT
Lack of electronic patient management, limiting audit, accountability, and service improvement
Missed opportunity for early treatment within the high-risk 12–24 month post-fracture window
Before digitalisation, it could take 15–24 months for some patients—particularly those with vertebral fractures—to be identified by the FLS, undermining the clinical effectiveness of secondary fracture prevention.
The intervention
NHSGGC South Sector partnered with Red Star through an Innovate UK (SBRI) process to design a locally tailored digital FLS, embedded within existing NHS data infrastructure.
Key features
Automated radiology case finding using text-based analysis of imaging reports
Near-real-time surfacing of eligible patients onto a clinician dashboard
Single-screen clinical decision support, integrating:
Radiology findings
Biochemistry (eGFR, calcium, vitamin D, etc.)
Historic DXA results
Prescribing history (including glucocorticoids and bone-active drugs)
Workflow and task management, ensuring patients are visible, tracked, and actioned
Audit-ready data, enabling performance monitoring and reporting
The system was introduced in phases between November 2022 and March 2023 across four acute sites feeding into the South Sector.
Implementation approach
Phased rollout by hospital site to manage risk and workload
Clear clinical ownership led by consultant leadership and osteoporosis nurse specialists
No increase in staffing during or after implementation
Defined prioritisation rules, particularly for vertebral fractures
Daily digital worklists, replacing large manual backlogs
This approach ensured staff confidence, operational stability, and rapid adoption.
Impact
1. Productivity and workforce
FLS enrolment doubled:
3,000 patients/year (pre-digital)
6,000 patients/year (post-digital)
Achieved with no increase in nurse staffing
50% reduction in nurse time spent on case finding
Clinical time redirected to:
Patient assessment
Treatment decisions
Follow-up and prioritisation
2. Timeliness of care
Average time from fracture imaging to FLS identification reduced from months to 3 days
Patients identified within the high-risk fracture window, enabling earlier intervention
Vertebral fractures systematically prioritised rather than incidentally managed
3. Quality and consistency
Reduced duplication and missed patients
Standardised decision-making using integrated clinical data
Clear accountability: patients are visible until actioned
4. Patient outcomes so far
Following full implementation, the South Sector has recorded a 10% reduction in hip fractures
No other major changes to FLS structure or treatment pathways occurred during this period
While multifactorial and not definitively attributable, the timing and contrast with other sectors are notable
Financial and system value
Although precise cost-effectiveness modelling is challenging in real-world services:
The intervention did not require additional clinical staff
It increased throughput without increasing fixed workforce costs
Earlier identification and treatment are expected to:
Reduce future fracture admissions
Avoid high-cost hip fracture care
Improve patient quality of life and independence
The system also creates the data foundation required for audit, assurance, and continuous improvement, which manual services do not reliably provide.
Key learning from the Glasgow team
1. Digital case finding is not about creating demand
It reveals unmet need that already exists and shifts care upstream.
2. Workforce efficiency gains are substantial
Digital tools can release large amounts of specialist clinical time without reducing care quality.
3. Equity depends on infrastructure
Without digital systems, patients’ access to secondary fracture prevention varies by geography.
4. Perfect evidence should not block necessary change
Randomised trials are impractical for service infrastructure; decision makers should consider plausibility, scale of benefit, and opportunity cost.
5. Case finding is only the first step
Digital FLS enables—but must be matched by—DEXA capacity, alternative risk stratification, and flexible prescribing models.
Next steps and opportunities
Scale digital FLS across remaining NHSGGC sectors to address internal inequity
Integrate DXA and explore CT-based bone assessment to relieve diagnostic bottlenecks
Expand pharmacist- and nurse-led treatment pathways
Enhance digital patient communication and adherence support
Align digital FLS data with national audit and commissioning frameworks
Conclusion
The NHSGGC South Sector experience demonstrates that digital enablement of FLS is feasible, scalable, and impactful, even in a constrained workforce environment.
For decision makers seeking to improve secondary fracture prevention, reduce unwarranted variation, and maximise existing clinical capacity, digital FLS represents a high-value system intervention rather than an optional add-on.
