Impact of a Dedicated Fracture Liaison Service (FLS) Pharmacist: A Quality Improvement and Innovative Learning

Introduction: Osteoporosis affects approximately 3.5 million individuals in the UK, resulting in over 500,000 fragility fractures annually. An initial fracture significantly increases the risk of subsequent fractures, particularly in very high-risk patients. Current clinical guidelines advocate a "treat-to-target" strategy using ‘anabolic first’ for individuals at very high risk of fracture. The aim of this study is to develop and evaluate an innovative approach to improve system efficiency, timeliness and prudent delivery of anabolic osteoporosis drugs.

Methods: Specialist anabolic osteoporosis agents require careful initiation and subsequent sequential therapy. Process mapping demonstrated that each anabolic drug assessment, including consultation, required approximately 45 minutes. Additional steps such as issuing blood request forms, dictating correspondence, reviewing results, prescribing, pharmacist approval, and updating home-care plans could introduce delays of several days before treatment initiation.

Using the Plan–Do–Study–Act (PDSA) quality improvement methodology, we implemented a series of interventions between 2024 and 2025 to streamline care delivery.

A £5,000 National Six Goals (Wales) grant supported a proof-of-concept pilot in January 2025, enabling the introduction of a dedicated Fracture Liaison Service (FLS) pharmacist (Band 8a, 0.2 WTE; one day per week; £3,000 per quarter). This resource streamlined prescribing workflows and enabled the consistent integration of NICE-recommended shared decision making into routine practice. The model of care was re-designed from a predominantly clinician-led (paternalistic) approach to a collaborative, patient-centred decision-making framework.

Key changes included weekly multidisciplinary team (MDT) meetings to weigh risks and benefits, reduction of duplicated steps, and the introduction of one-stop, face-to-face consultations that actively engaged patients in understanding treatment options and sequencing plans.

Results: Anabolic osteoporosis drugs were prescribed to 60 patients in 2024 and 89 patients in 2025. The mean time from first consultation to treatment initiation was 186 days (range 35–464) in 2024, which reduced to 136 days (range 29–307) in 2025.

Quarterly analysis in 2024 showed mean times to treatment of 223 days (n=10) in Q1, 147 days (n=12) in Q2, 188 days (n=18) in Q3, and 188 days (n=18) in Q4. In 2025, the first three quarters demonstrated a progressive reduction, with mean times of 182 days (n=21) in Q1, 128 days (n=21) in Q2, and 83 days (n=13) in Q3.

Enhanced multidisciplinary team working, faster decision-making, and more cost-effective prescribing resulted in savings of £18,000 per quarter, with a net cost avoidance of £15,000 per quarter. These efficiencies supported substantive annual funding for a 0.2 WTE FLS pharmacist (£17,314).

Conclusion: A dedicated FLS pharmacist improved patient engagement and facilitated multidisciplinary team discussions for patients at very high risk of osteoporosis. Wider adoption of the dedicated FLS pharmacist model is recommended, alongside further economic evaluation.