Hip fracture care survival is shaped by where you live, more than by age, sex, ethnicity or socioeconomic background

The latest National Hip Fracture Database (NHFD) report has identified that a patient's chances of surviving a hip fracture can depend more on the hospital where they are treated than their age, sex, ethnicity or socioeconomic background. The report also highlights a need for more universal provision of care to be provided by fracture liaison services, calling on hospitals and other parts of the healthcare system to work more closely together to prevent secondary hip fractures.

The NHFD, delivered by the Royal College of Physicians (RCP) as part of the Falls and Fragility Fracture Audit Programme (FFFAP) in association with the BOA and commissioned by the Healthcare Quality Improvement Partnership (HQIP), has published its latest report, focusing on inequalities in hip fracture care.  

Each year, more than 72,000 people are treated in hospital for a hip fracture in England, Wales, Jersey and Northern Ireland. These patients occupy around one in 30 hospital beds, costing the NHS an estimated £1.1 billion annually, and social care a further £1.25 billion in the first 120 days after injury.  

The new NHFD report sets out several key findings:  

• A patient's chances of surviving a hip fracture depend more on the hospital they attend than their socioeconomic background: Variation in 30-day mortality between hospitals was five times greater than the difference seen between the most and least deprived communities. 

• Delirium remains a major and preventable threat to recovery after hip fracture: Patients experiencing delirium are three times more likely to die in hospital and three times more likely to move into a care home after their injury. Hospital screening rates vary dramatically.  

• Thousands of hip fractures could potentially be prevented: Around a quarter of patients admitted with a hip fracture each year have previously suffered a fragility fracture, yet many were not receiving treatment to strengthen their bones and reduce the risk of further fractures. Nearly half of NHS trusts in England do not have a Fracture Liaison Service.   

• Patients with other fragility fractures are missing out on specialist care: Nearly all hospitals provide specialist geriatric assessment for hip fracture patients, but people with pelvic and other fragility fractures are significantly less likely to receive equivalent care.  

• People living in more deprived areas face a higher risk of hip fracture: Men in the least deprived communities are around half as likely to experience a hip fracture as those in the most deprived communities. The report states that more than 8,500 hip fractures among men could be avoided each year if this inequality in risk were reduced. 

• Waiting times for surgery have worsened since COVID-19: Average time to theatre increased from 33.6 hours in 2020 to 39.3 hours in 2025, reflecting ongoing pressures on NHS services. 

Previous work using NHFD data showed that ethnicity was not associated with significant differences in adjusted outcomes, although patients from ethnic minority backgrounds were less likely to be mobilised on the day after surgery, highlighting the importance of accessible patient information and family involvement in rehabilitation.  

The NHFD report makes four key recommendations for national commissioning bodies and other organisations planning healthcare: 

• Mandatory monitoring of routine delirium screening using the 4AT - a brief bedside assessment tool used for the rapid initial detection of delirium and cognitive impairment in clinical settings, for all hip fracture patients. 

• Address variation in care for people with pelvic and other fragility fractures. 

• Monthly clinical governance meetings in every hip fracture service to review outcomes, safety events and patient feedback. 

• Universal provision of effective fracture liaison services to improve secondary fracture prevention. 

Antony Johansen, previous NHFD orthogeriatrician clinical lead and member of the BOA Trauma Committee said,

“It is reassuring that this NHFD report shows that care after a hip fracture is unaffected by who someone is; by their age, sex, ethnicity or socioeconomic status. Instead it emphasises how dramatically the quality of care can vary, depending on which hospital they attend after a hip fracture. This postcode variation remains the main challenge that the NHFD seeks to address; so that people attending any hospitals, and people admitted with fractures of any bone, can all receive the high-quality care provided by the best hip fracture units.”

Fergal Monsell, President, BOA said,

“The BOA has supported calls by the Royal Osteoporosis Society and others for universal access to Fracture Liaison Services. Fracture Liaison Services play a vital role in identifying people aged 50 and over who have suffered a fracture and may be at risk of osteoporosis. By assessing bone health, arranging treatment where needed and supporting ongoing care, FLS help prevent life-changing fractures before they happen. The government has committed to a nationwide service in England by 2030, but this report shows that with nearly half of NHS trusts in England without a Fracture Liaison Service in place there is much to be done.”