Northern Bone Health Programme Northern Bone Health Programme NHSA Amgen


A mixed methods evaluation of the impact of the project was undertaken by Dr Jon Rees and Dr Stephen Dunne of Sunderland University using numerical data as supplied by the project and interview and questionnaire responses collected from health care professionals involved in delivering the intervention in primary care.

Data analysis is still ongoing and the full impact of the project on patient care together with the gathering of feedback has been somewhat delayed due to the COVID pandemic.

59 GP practices participated in the Northern Bone Health project. 551,550 electronic patient records in the participating GP practices were analysed using bespoke computerised software algorithms to identify cohorts of patients with and at risk of fragility fractures and osteoporosis.

Fracture risk assessment was done using the FRAX© fracture probability tool without bone mineral density values. Cohorts of patients with a high risk of osteoporosis and fragility fractures who met the NOGG criteria for treatment (primary prevention) and patients with fragility fractures and osteoporosis for secondary prevention were identified. Medication optimization, patient education measures, non-pharmacological interventions were initiated.

  • 153,206 (27.8%) patients identified for targeted risk assessment as per CG 146 (CG146 group).
  • 27,212 (17.8% of the CG146 group) were identified as having fracture risk above intervention threshold (high fracture risk group).
  • 14,499 (9.4% of the CG146 group) were identified as high risk for fractures but had no prior review/intervention.
  • 7,096 (4.6% of the CG 146 group OR 26% of high fracture risk group) were identified for primary prevention (no fractures have occurred in this group).
  • 5,944 (3.8% of the CG146 group OR 22% of high fracture risk group) were identified for further investigations (eg bone mineral density assessment).

This study provides the template for operationalising bone health management in primary care. A population health approach to primary and secondary prevention of fragility fractures and osteoporosis using FRAX-based clinical risk assessment software is an efficient method that can be adopted.

Early analysis of the qualitative data suggests the project has been well received in general practice with preliminary themes identified and illustrated with indicative quotes.

Primary Prevention

Identifying high risk patients and starting treatment before fracture occurs reduces the risk of further fractures including that of hip fractures.


new assessments were done


49% patients were recommended for primary prevention without any further investigations

Primary care is ideally suited for the systematic identification of those at highest risk of developing a fragility fracture. Preventing fractures, including hip and vertebral fractures, helps people lead a pain and disability-free life

Secondary Prevention

Treating patients who have had a fragility fracture and reducing the risk of further fractures including hip fractures.

14,076 patients with fragility fractures were identified

53% of patients in the over 75 age group
59% of patients in the 50-74 year age group were not on optimum treatment (pharmacotherapy and lifestyle measures). This increases their risk of further fractures

Osteoporosis Management

Optimising treatment for these patients reduces further fractures, disability and pain.

12,719 patients with osteoporosis were identified

47% of patients

were on bone-sparing agents

53% of patients

were not on current treatment

Medication Optimization

Putting patients on the right bone sparing treatment and ensuring compliance of taking the medications reduces their risk of future fractures.

6,866 new medication reviews were undertaken

3,478 new prescriptions

of bone-sparing medications were recommended

Patient safety issues in 97 cases were identified and 524 treatment holidays (treatment pause) were recommended**

Legacy and Sustainability

Participating practices have reported increased awareness of the condition and intend to put in place systems to improve bone health management in primary care.

Quality improvement projects to follow up the outcomes have been initiated.

Value to patient and GPs but with the patient at the heart of the process

The staff involved can perceive the benefits of the programme and appreciate the professionalism of the team and clarity of the processes.

Patient feedback has been overwhelmingly positive with some commenting on how pleased they are about the proactive nature of the project.

“And when I call patients, they seem to be very happy that we are being proactive about their care and preventing future fractures.”
“…there was the odd person that didn’t want to go ahead, and some people needed treatment changes and again choose not to go ahead but that was after discussion with the pros and cons, so it was pretty person-centred.”

The need to work smarter with hospitals and other health care providers

This and similar health care improvement innovations do produce an additional workload and this needs to be planned for and managed for things to be sustainable. This requires buy-in from the practices involved.

Bone health optimisation needs to be more closely coordinated between primary and secondary care and clearer regional pathways need to be developed for best outcomes to be achieved.

“It’s a complicated area….and the guidelines can be difficult, so it helps to know where to go next.”
“…when a project like this happens across sectors, we need to maybe have kind of better communications between the sector. So, for example ….we know what they want us to refer and the level of detail that they need.”

The ultimate goal is about making a difference to quality of life and keeping people well for longer

Osteoporosis (like hypertension) is an invisible illness with long term consequences, and it is all about having a conversation with patients about a treatment that will keep them well and active for longer.





“The benefit had been worthwhile because of course you look at these 90 year old ladies and you’ve got to think if they actually fell over and broke a hip that would be a disaster… and you have that conversation with them and …. it is the right thing for them to be on treatment.”
“It was really interesting to see and also satisfying to know that our work has made a difference.”