Hip fracture and the rehab postcode lottery

The CSP’s Hip Sprint audit reveals wide variations in amount and timeliness of rehabilitation for people with hip fracture, writes Gill Hitchcock.

Alice Price, aged 88, didn’t expect to wait four months to be assessed and start physiotherapy with the local community team. Her daughter Iona describes how her mother, hospitalised with a fractured hip, was keen to leave the busy acute ward and be rehabilitated in a community hospital. 
‘Unfortunately, the rehabilitation hospitals were all full,’ she says. ‘I agreed it would be best if mum moved to a nursing home and when she was settled, start her rehabilitation with the community team. This proved to be a naïve decision. I had expected joined-up care for someone post-hip fracture, but in the community this does not always happen.’
Experiences such as this are all too common. The Hip Sprint survey of nearly 6,000 patients with hip fractures across England and Wales – from initial hospital treatment, to the rehabilitation ward, through to community therapy – shows a wide variation in the wait for treatment. While there were some pockets of excellent care, where there was no wait at all, these were few and far between.

Speedy response vital

The audit, commissioned by the CSP and published by the Royal College of Physicians in a report last month, found that many people waited several weeks for treatment. In one trust, it was reported that it was not unusual to wait several weeks for treatment. In another, some octogenarians waited up to 80 days for rehabilitation after leaving hospital.
Meanwhile, the average wait before starting therapy at home was 15 days and some patients were getting less than one hour of therapy each week. There was huge regional variation in the amount of rehabilitation people received in hospital, and 43 per cent missed a day’s therapy because no physiotherapist was available.
The findings reveal a postcode lottery which flies in the face of National Institute for Health and Care Excellence guidance. Its gold standard is that patients are offered physiotherapy and mobilisation the day after surgery. It calls for coordinated care through a multidisciplinary hip fracture programme to help people recover faster and regain their mobility.
43% missed therapy because no physio was available

Better rehab planning

NHS England’s commissioning guidance for rehabilitation, published in March 2016, also says this must be delivered early, with ongoing assessments and reviews. Rehabilitation, it emphasises, must be person-centred, so that it is an active and enabling process for each individual. 
Antony Johansen, clinical lead for the national hip fracture database at the Royal College of Physicians, says that if frail and older patients are to return to their normal lives, they must be helped to get up as quickly as possible after surgery. 
‘Patients need regular physiotherapy so they can start rehabilitation as soon as possible and maintain this throughout their recovery – from hospital to home,’ says Dr Johansen. 
In the report, the CSP calls for better planning for rehabilitation, to enable people to return to their pre-fracture condition and reduce the risk of serious injury from further falls. 
It says rehabilitation planning must include a good understanding of the individual’s pre-fracture status, because this will inform the long-term aims of rehabilitation. The plan must be drawn up in partnership with the patient or their carer, include short and long-term goals and identify who will deliver it. 
Very importantly, the CSP says the plan must be evaluated regularly so it remains effective and relevant to the patient’s changing circumstances. 
Ruth ten Hove, head of research and development at the CSP, believes it is crucial that the Hip Sprint data are used to improve services. ‘These data provide a national picture of rehabilitation,’ she says, adding that members who contributed to the survey were honest and objective, enabling a true picture of services to emerge.

There is a huge amount of national data which you can access easily online, which will enable you to measure your improvement’

‘A “heat map” of England and Wales includes details of every single service that took part in the audit,’ she says. 
Ms ten Hove is aware of examples of really good practice, citing services that offer continuity of rehab across the care pathway. They include services in Salisbury, Guildford, Havering and Redbridge, Bristol, Barnstaple in north Devon and London.
‘To make improvements to your services, you need to understand and accept the data, she says. ‘Then share with your local team how you might implement  improvements. There is a huge amount of national data which you can access easily online, which will enable you to measure your improvement.’

Rising demand

Iona Price recounts a story in her local newspaper about a lady unfortunate enough to be run over by a vehicle which reversed on to the pavement. When she was released from hospital, the victim was stunned to be told that she faced a 14-week wait for rehabilitation.
‘The paper interviewed the local MP and the local provider and the impression given was that things are a bit busy at the moment and we’re trying to cope,’ she says.
‘So I challenged our MP, saying the situation had been like this since 2012 and so it was not a temporary spike in demand.
‘Meanwhile, the response from the service provider included the following statement: “Our services have not been commissioned any differently since the beginning of our contract five years ago. But during this time we have seen the demand for services … considerably increase”.’

Potential of prevention 

Fragility fractures are very common in those over the age of 50. And Kassim Javaid, lecturer in metabolic bone disease at the University of Oxford, points out: ‘Being able to reduce the number of preventable fractures by over 50,000 would represent a substantial reduction in emergency admissions to our already over stretched hospitals. It would help to lessen the demand on social care, at a time when these services have never been so pressured. 
Dr Javaid adds: ‘It would also provide a huge benefit for patients, their families and carers in reducing the stress and suffering that fractures so often cause. We have an opportunity to close this gap in bone health care and we should work together to achieve it.’
Of course, rehabilitating older people can be a lengthy process. But as Iona Price says: ‘We must make sure that all patients have the opportunity to make the best recovery they can, however long their rehabilitation may take.’ fl

Further reading

The 'Recovering after a hip fracture' report and ‘heat maps’ of rehabilitation services are available here.
Gill Hitchcock

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