Development of services for older patients with falls and fractures in England: successes, failures, lessons and controversies.

Falls and fragility fractures are becoming a major epidemic of aging, with each year around one third of people aged 65 and over, and half of people over 80 years, experiencing at least one fall. This has major implications, both for older people themselves, and for health- and social-care services. There is evidence for benefits to be gained from interventions to manage fracture patients better, responding to and preventing falls, identifying and treating those with bone fragility, and to maximizing population health by preventing or delaying frailty. In addition, the most consistently proven way of ensuring that patients with fracture receive evidence-based secondary prevention in practice is through the use of specialist services linking hospital-based fracture services with follow-up on patient discharge. Here we describe the evolution of the approach taken by the English National Health Service (NHS) over the past decade to address this issue, along with the successes, failures and lessons potentially relevant to other health systems. Approaches used have included national guidelines, national audits and involvement of Department of Health Resources to drive up quality. The key themes are "responding to the first fall to prevent the second", "better recognition and treatment for osteoporosis", "responding to first fragility fracture to prevent the second" and "better interdisciplinary management of patients admitted with hip fracture", and the audit systems which now exist to describe changes in practice and the outcomes which follow.