The Challenge
Osteoporosis is often described as a silent disease. Many patients remain undiagnosed until they experience a fragility fracture, by which time significant harm has already occurred. In primary care, inconsistent coding, fragmented recall processes and limited capacity can make it difficult to identify those at greatest risk before preventable fractures occur.
Working within a Primary Care Network, our Advanced Practice Physiotherapist, Claire Southey, recognised an opportunity to intervene earlier. Through her work supporting women during menopause and perimenopause, she observed that patients receiving timely intervention, including strength-based exercise advice and appropriate management, often maintained their independence for longer. At the same time, many post-menopausal patients were presenting later in the pathway following avoidable fragility fractures.
Rather than accepting this as inevitable, Claire asked a simple but important question:
“How many patients at risk of osteoporosis are we currently missing?“
Our Approach
To answer this question, Claire led a comprehensive audit of the practice population.
The findings revealed that more than 700 patients (approximately 8% of the registered population) were potentially at increased risk of osteoporosis and frailty, with many having no documented DEXA scan, structured recall process or appropriate follow-up.
Working collaboratively with the wider practice team, Claire designed and implemented a sustainable improvement programme that focused on prevention rather than reaction. This included:
- Comprehensive identification and review of high-risk patients.
- A phased DEXA referral programme aligned with GP capacity to ensure safe implementation.
- Improved clinical coding to accurately identify patients requiring ongoing monitoring.
- Robust recall systems to ensure appropriate follow-up.
- Structured referral pathways for assessment and ongoing management.
- Clear action plans for GPs and the wider multidisciplinary team.
Recognising that opportunities for earlier intervention were also being missed elsewhere in the healthcare system, Claire worked with local emergency and orthopaedic services to strengthen communication following fragility fractures. This collaborative approach helped establish a more integrated pathway, ensuring patients presenting with fractures could be identified, appropriately coded and referred for timely osteoporosis assessment.
The Impact
The programme has transformed osteoporosis management from a reactive service into a proactive population health approach.
Key outcomes include:
- Identification of more than 700 patients at increased risk of osteoporosis and frailty.
- Earlier assessment and intervention for patients who may previously have remained undiagnosed.
- Standardised coding and recall systems to support long-term population health management.
- A sustainable referral process that improves patient access without overwhelming existing services.
- Stronger collaboration across primary, secondary and community care.
- A scalable model that is already generating interest from other practices across the Primary Care Network.
Most importantly, patients who may previously have remained invisible to the healthcare system are now being identified earlier, supported proactively and offered interventions that can reduce fracture risk, maintain independence and improve quality of life.
Why It Matters
As the population ages, preventing fragility fractures has become an increasingly important priority for health systems. Earlier identification of osteoporosis not only improves individual patient outcomes but also reduces demand across urgent care, orthopaedics and general practice.
This project demonstrates how clinical leadership, population health management and practical pathway redesign can deliver meaningful improvements without requiring significant additional resource. By embedding prevention into everyday primary care, Promni Health is helping healthcare systems move from responding to fractures towards preventing them altogether.
Looking Ahead
The approach developed through this project provides a scalable model for proactive osteoporosis and frailty management that can be adopted by practices and Primary Care Networks across the NHS.
By combining data-driven population health management with clinical expertise and integrated working, Promni Health continues to support healthcare organisations in delivering earlier intervention, reducing health inequalities and improving outcomes for patients living with long-term musculoskeletal conditions.
