Delivering high‑quality fracture prevention at scale while reducing avoidable patient travel and achieving a net carbon‑negative service.
The issue
- Rising demand and national expectations: Fracture liaison services (FLS) systematically identify, investigate and initiate treatment for adults aged ≥50 years following a fragility fracture. In Wales, a 2023 ministerial commitment mandated national FLS implementation, achieved by September 2024.
- An ageing, geographically dispersed population: In Gwent, 20.3% of residents are aged ≥65 years and 41.1% are aged ≥50 years, spread across an extensive and diverse geography. Traditional hospital‑centred pathways risked inequitable access, growing waiting lists and thousands of miles of avoidable travel.
- Environmental impact: Increasing activity through conventional face‑to‑face models would have amplified transport‑related emissions, contrary to national sustainability goals and the Royal College of Physicians’ recommendations on climate‑smart care.
The solution
The last Welsh government set out an expectation for all health boards to achieve 100% coverage for FLS by September 2024. To deliver that commitment, maintain clinical excellence and protect the environment, the Aneurin Bevan FLS (AB-FLS) redesigned its pathway through a multi-phase quality improvement programme with a virtual-first, community-integrated model:
- Single, centralised FLS serving the entire health board to improve consistency and efficiency.
- Virtual first review: All new fragility fracture cases were triaged remotely by a FLS nurse specialist and handed to an FLS administrator who allocate patients to inpatient, outpatient or community‑managed pathways, reducing unnecessary attendances.
- Telephone assessment by bone health nurses: Comprehensive remote consultations covered assessment, risk communication, treatment planning and DXA referral, removing the need for clinic visits for many patients.
- Partnership with community teams and GPs: Routine tests and prescribing were completed locally wherever possible, eliminating whole journeys to hospital.
- One‑stop clinics for specialist therapies: Patients requiring injections or infusions attended streamlined appointments combining assessment, education and treatment, avoiding repeat visits.
- 6-week and 52-week follow-up clinics: Delivered by FLS remotely as far as possible, including giving blood test results and DXA results.
This stepwise redesign delivered evidence‑based, equitable care while systematically minimising avoidable travel.
The impact
A 3‑year retrospective analysis (2022–24) assessed travel distances for the first consultation only using mapping data and standard vehicle emission factors:
- 6,477 patients were assessed (mean age 78 ± 10 years, 77.2% female).
- 24,916 net miles avoided through virtual and community‑based management.
- 9,966 kg of CO₂ emissions avoided, resulting in a net carbon‑negative service despite substantial growth in activity.
Benefits were multifaceted:
- For patients – safer, more convenient access to care; fewer hospital visits; maintained evidence‑based treatment.
- For staff – more efficient workflows; focused use of specialist clinics; improved ability to manage rising demand.
- For healthcare systems – delivery of national FLS commitments at scale; reduced transport emissions; alignment with sustainability and climate‑health priorities.
Conculsion
Over 4 years, AB‑FLS demonstrated that major expansion in fracture identification and secondary prevention can be achieved without increasing environmental burden. By embedding virtual‑first assessments, strengthening community partnerships and streamlining specialist clinics, the service delivered high‑quality osteoporosis care while achieving a net carbon‑negative impact.
This case study shows that environmentally sustainable practice can be integrated into high‑demand clinical services, supporting both patient outcomes and wider health system responsibilities to mitigate climate change.
Contributors: Dr Inderpal Singh (national clinical lead, Bone Health, Wales); Dr Avtar Singh; Dr Rashpinder Kaur; Amara Williams; Sophie Shah; Reetika Singh.
Institutions: Aneurin Bevan University Health Board, Wales | St John’s College, Cardiff