The idea of systematically monitoring the care of hip fracture patients on an individual basis originated in Sweden with the Rikshöft, which started as long ago as 1988 and is still going strong today [73].

From there it was transported to Scotland and the Scottish Hip Fracture Audit (SHFA) ran continuously from 1993 to 2010, when its government funding was withdrawn in the belief that the problem of hip fracture management was now solved! In parallel with the SHFA, the Scottish Intercollegiate Guidelines Network (SIGN) produced guidelines on the Management of Hip Fracture in Older People, which were regularly updated (SIGN-15 in 1997, SIGN-56 in 2002, SIGN-111 in 2009). The SIGN guidelines benefitted from the data that the SHFA generated and the practice of hip fracture management benefitted from the publication of the guidelines, in a way that the SHFA was able to measure and document. This experience in Scotland was of the utmost importance, because it demonstrated the powerful synergy between guidelines/standards and audit in changing clinical behaviour for the better. However, it is to be noted that this only works if the audit is continuous, with individual patient-level data fed back to the participants as a benchmark of their performance against national peers. Clarity on this point was crucial in the design of the UK NHFD.

Another lesson that was applied in setting up the NHFD was that a minimal dataset, including only those variables that are necessary for benchmarking, is much more useful than an elaborate dataset because – in a busy fracture unit – the minimal dataset is the only one that will be captured with any degree of completeness. However, there are times when more detailed data are needed, so the NHFD was designed so that the basic dataset, common to all, could be supplemented by more detail for a limited time in a limited group of hospitals.

The NHFD dataset contains the patient variables that are needed to casemix-control the outcomes (including ASA score and pre-fracture domicile). The process measures include perioperative orthogeriatric care, pressure sore prevention, time to theatre and secondary prevention (falls as well as bone health). The outcome measures include return to home within 30 days and mortality at 30, 120 and 365 days – the latter is obtained reliably from the Office for National Statistics. From the outset, it was agreed that, since the care was a team effort, data would never be reported at the level of the individual surgeon, only at the level of the fracture unit as a whole. However, individual hospitals are named in the annual reports, which are in the public domain [74].

The NHFD went live in 2007 [75], using money raised from industry. Most of the funding was needed to employ coordinators, who were experienced orthopaedic nurses seconded from the NHS. These, together with lead clinicans from orthopaedics and geriatrics, were a crucial resource, in spreading the idea of continuous audit and how the data could be used to obtain better facilities, as well as helping the data-inputters understand the details of the web-based data entry forms. The number of hospitals making use of it steadily rose and, by 2009, the government had realised that the NHFD was improving care for patients and they took over its funding.

As well as producing annual reports covering all hospitals, the NHFD provides near-real-time web-based feedback to individual hospitals, with run-charts showing trends over time. They can show, for example, the 30-day mortality, or average time to surgery, for that hospital’s hip fracture patients, displayed as a time series against the national or the regional average. These provide ideal discussion material for Fracture Unit audit or strategy meetings, which are very useful in keeping a high level of interest and awareness in spite of the inevitable turnover of staff.

In 2010, the UK Department of Health went a step further, by instituting a Best Practice Tariff (BPT) for hip fractures. This meant that – on an individual patient basis – a case that was treated to a high standard was reimbursed at a higher level than one that was not. The criteria for quality were orthogeriatric co-management, time to theatre less than 36 h and secondary prevention (both falls and osteoporosis). This brought the remaining hospitals into the NHFD and now at least 95 % of cases are captured in the NHFD. The annual reports of the NHFD show that the proportion of patients receiving high quality care (according to the BPT criteria) rose from 24 % in 2010 to 67 % in 2015.

A study by Neuberger and colleagues [76], using data independent of the NHFD (NHS Hospital Episode Statistics), showed that year-on-year improvements in process and outcome accelerated after hospitals began participating in the NHFD. However, the study also showed that this was at least equally true before the BPT was introduced. The implication is that the financial incentive is not essential; participation in continuous audit of hip fracture care is in itself a powerful driver of positive change.

One of the factors that allowed standards in the UK to rise so quickly was the role played by specially trained nurses. Although the UK is relatively well-endowed with geriatricians, it is not possible for them to spend time on a daily basis in the fracture wards, except in the largest fracture units treating many hundreds of cases per year. Experienced nurses, from a geriatric or orthopaedic (or both) background, when employed permanently as Elderly Trauma Nurse Coordinators – or some such title – on a fracture ward, quickly become expert at recognising complications or comorbidities and assisting the junior surgeons in managing them per protocol or by contacting the orthogeriatrician.

This is hard for doctors in many countries to accept, because they are culturally conditioned to view nurses as caring but inexpert doers of the doctors’ bidding. Yet it is obvious that a previously already-experienced nurse, who has then specialised in hip fracture care for 5 years and seen well over a thousand cases, has something to offer a young surgical trainee with less than 6 months’ experience on the fracture ward. The experience in the UK has been that this relationship is usually a comfortable one, with benefits all round. It needs to be reinforced by several ward-rounds per week where the consultant geriatrician teaches them both at the bedside. For young doctors, particularly those whose destiny is to be other than surgeons, this training is invaluable because, with an average age of 83 years, hip fracture patients provide rich medical experience.

It is to be hoped that international attitudes to nurses’ roles can change rapidly because there are many parts of the world where there is neither the time nor the money to train large numbers of geriatricians in time to meet the tsunami of hip fractures that is on the way.

The UK experience described above has been echoed in many other countries, mainly in Europe, North America and ANZ. It is now pretty clear that a multidisciplinary approach to the acute management of elderly fragility fracture patients, incorporating the philosophy and principles of geriatric medicine, not only gives a better quality of care, but also does so in a cost-effective way [44]. Although the details of how such a service can best be supplied will vary in the different healthcare systems around the world, the principle probably applies everywhere. The question arises – how, in practice, can that perspective be shared around the world, particularly in the emerging economies, where the trajectory of population ageing is such that extremely rapid increases in incidence will occur? Two international organisations are prominent in grappling with this challenge.