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FLS Implementation Toolkit

The FLS Toolkit aims to take some of the hard work out of establishing a new fracture liaison service (FLS) or improving an existing one. It has been specifically designed to help develop a business case, saving you the time and trouble of researching and drafting the required documents.

We recommend you follow the six steps laid out below, in order to develop your business case to implement or improve an FLS in your locality.

The templates are fully editable and formatting has been kept to a minimum to allow maximum flexibility and ease of use. The templates include guidance, as well as some sections where local information/data may need to be entered. These are highlighted [using bold text in square brackets].

We can support you

The charity offers a team of experienced commissioners and clinicians who have been supporting the development of services from business case right through to outcomes and performance measurement.

This support has already proved to be effective in achieving service improvement in a number of areas and is provided free of charge.

A summary of evidence for providers and commissioners.

Service Improvement Guide

A descriptive guide setting out step-by-step actions for providers to achieve a service improvement.

A list of tasks and activities for a development project.

The benefits calculator is currently offline.

Outputs from the calculator can be obtained by contacting our team at

A part populated service specification suitable for use with NHS standard contracts.

Business Case

Part populated case for investment in an FLS.

How to effectively communicate your business case to commissioners and get to "yes" by avoiding the pitfalls.

Practical, evidence-based indicators to demonstrate service improvement.

This toolkit is endorsed by the following organisations:

Additional information

The FLS Implementation Toolkit aims to help commissioners and healthcare professionals to...

  • Understand the local impact of fragility fractures, both in terms of numbers and socioeconomic costs.
  • Predict the local increase in fragility fractures over the next 5-10 years because of the ageing population.
  • Provide a local model of the clinical and cost effectiveness of developing an FLS through an evidence-based
  • business case.
  • Commission high-quality, effective FLS, integrated within a system-wide approach to falls and fracture prevention.
  • Provide sustainable high-quality services based on available evidence, demonstrating positive clinical outcomes.
  • Make implementation easier, cheaper and more effective for commissioners and providers.

This template is provided free as part of the FLS Implementation Toolkit by the Royal Osteoporosis Society. This template does not represent the views of the Royal Osteoporosis Society. Every effort has been made to make sure that the information contained within this document is accurate and in full compliance with UK law and with best practice at the time of writing. There is no guarantee as to the accuracy or reliability of any of the information contained in this template and use of this template is entirely at the user's risk and no liability whatsoever is accepted by the Royal Osteoporosis Society.

This resource has been developed by the Royal Osteoporosis Society and has been produced with financial support from Lilly.

5IQ Model

To be effective a FLS also needs a strong culture of quality. The Royal Osteoporosis Society has taken this concept of the five 'Is' (identify, investigate, intervene, inform, integrate) plus quality to develop the '5IQ' model for service improvement.

Bone Densitometry

A bone densitometry scan is a special type of X-ray test used to measure the calcium content of the bone.

Business Case

A document that describes all of the costs and benefits of the project. It is usually needed to help the Trust, Board or other organisations take a decision on whether to go ahead with the project.

Call to Action

A concise summary of evidence for providers and commissioners on FLS.

Cost Calculator

A financial model to calculate the service requirements.

Clinical Champion

The role of the Clinical Champion is to engage and inspire clinicians, managers, patient groups and others to give their time and energy to the project.

Clinical Commissioning Groups (CCGs)

NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England.

Clinical Governance

A system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

Clinical Lead

These are individuals who are directly or indirectly involved in providing care to people with fractures, people at risk of falls or people with osteoporosis (often referred to as Clinical Champions).

Clinical Pathway

Clinical pathways, also known as care pathways, are one of the main tools used to manage the quality in healthcare concerning the standardisation of care processes. It has been shown that their implementation reduces the variability in clinical practice and improves outcomes.

Clinical Process Measure

Use of process measures to monitor the quality of clinical practice.


The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare providers' income to the achievement of local quality-improvement goals.


Dual energy X-ray absorptiometry (DXA) scans are the established standard for measuring bone mineral density (BMD). DXA scans are used to measure and therefore diagnose low bone density and also to monitor patients where a diagnosis of low bone density has been made.

Evidence Library

A compendium of published materials on relevant topics.

Fracture Liaison Service

A process of systematically assessing patients for osteoporosis and then offering appropriate interventions to reduce future fracture risk. A FLS is a service that systematically identifies, treats or/and refers to appropriate services all eligible patients over 50 years old within a local population who have suffered fragility fractures, with the aim of reducing their risk of subsequent fractures.

Fracture Liaison Service Implementation Toolkit

A set of tools that support healthcare providers and aids the commissioning of services to improve the care of people with osteoporosis and fragility fractures in the NHS.

Fragility Fractures

A type of pathologic fracture that occurs as a result of normal activities, such as a fall from standing height or less.

Gateway Criteria

A mechanism to ensure that all of the essential tasks have been completed successfully before the formal sign off by the project sponsor, and to bring an end to the control stage and move on to the testing stage.

Implementation Plan

A tool used to capture timelines and activities to prepare for service delivery.

Medical Assessment Unit

Acts as a gateway between a patient's GP, the emergency department, and the wards of the hospital. The MAU helps the emergency department produce a quicker turnaround for patients.

Royal Osteoporosis Society

The only UK-wide charity dedicated to improving the diagnosis, prevention and treatment of osteoporosis and fragility fractures.

NICE Quality Standards

Concise sets of prioritised statements designed to drive measurable quality improvements within a particular area of health or care.

NICE CG146/GC161

These clinical guideline offer evidence-based advice on risk and assessment/prevention of fall risk in adults.

NICE Technology Appraisal TA160

NICE guidance on the use of alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the prevention and treatment of osteoporotic fragility fractures in postmenopausal women.

Patient Reported Experience Measure (PREM)

The Patient Reported Experience Measure (PREM) for urgent and emergency care measures the experience of paediatric patients 0-16 years in all urgent and emergency care (U&EC) settings including GP surgeries, walk-in centres, emergency departments and the ambulance service.

Patient Reported Outcome Measure (PROM)

PROMs measure health gain in patients undergoing hip replacement, knee replacement, varicose vein and groin hernia surgery in England, based on responses to questionnaires before and after surgery.

Percentage of Population in Hospital Catchment

The percentage of people in the catchment areas for the 17 Acute Trusts in England.

Performance Indicators

A set of practical, evidence-based indicators that could be used to demonstrate improvement in a service.

Process Mapping

A technique used to identify all of the interconnected pathway steps and decisions in a process.


The acquisition of goods, services or works from an outside external source.

Project Database

Excel spreadsheet containing names, contact details, emails, etc. of all for the people you identify in your stakeholder analysis.

Project Initiation Document (PID)

A written document that describes the project including objectives, timelines and responsibilities. The purpose of the PID is to communicate the essential details of the project to anyone who is interested and will be used throughout the duration of the project for this purpose.

Project Planning Tool

A comprehensive list of tasks and activities for an improvement project formatted for use by local project teams.

Project Sponsor

Ownership of projects on behalf of the client organization. Project sponsorship includes the identification and definition of the project and is responsible for the project's business case.

Project Steering Group

A group of people who are interested in getting the project up and running.

Project Team

A group of colleagues that comprise those individuals who are committed to the success of the project and able to give the time needed to see it through, including regular meetings of the team itself.

Public Health Outcome Measure

The new Public Health Outcomes Framework sets out desired outcomes for public health - and how outcomes will be measured.

Quality and Outcomes Framework 2014-15

A government initiative that rewards contractors for the provision of quality care and helps to standardise improvements in the delivery of primary medical services.

Service Improvement Guide

A descriptive guide setting out step by step actions for the commissioners to achieve a service improvement.

Service Model

A detailed outline of the key service to be delivered, who will be involved and the processes for engagement.

Service Specification

A part-populated service specification suitable for use with NHS Standard Contract.

SIGN Clinical Guidance 71

NICE guidelines on the identification and management of familial hypercholesterolemia.


A group of key individuals, businesses and organisations that have a ventured interest in the service model and who affect or can be affected by the organisations actions.

The British Orthopaedic Association's Blue Book 2

Outlines best practice in care of fragility fractures. It identifies aspects of good care that should be aimed for in every patient.

The NHS Scotland Quality Improvement Hub

A national collaboration between special Health Boards and Scottish Government Health Directorates which aims to support NHS boards with implementation of the Healthcare Quality Strategy through effective partnership working between the collaborating organisations.

The FLS Implementation Toolkit is open to all healthcare professionals and commissioners with an interest in setting up a FLS in both Primary and Secondary Care settings.

This may include individuals from the following groups:

  • Services on fractures pathway (e.g. Emergency department, orthopaedics, endocrinology, rheumatology, older people's care, radiology etc.)
  • Relevant local charities (e.g. Age UK)
  • Medicines management and pharmacy
  • Carers and carer organisations
  • Community exercise services
  • Trust/Health Board director
  • Patients/patient advocates
  • GPs and practice managers
  • Commissioners/payors
  • Social services
  • Public health
  • Care homes
  • Falls service

If you would more information on the FLS Implementation Toolkit and the resources within it, please contact:

Will Carr

Head of Service Delivery
Royal Osteoporosis Society
Tel: 01761 473231