title: Making the case for a fracture liaison service: a qualitative study of the experiences of clinicians and service managers.
abstract: BACKGROUND
  To develop services, healthcare professionals must make business cases to managerial bodies within Hospital Trusts and if approved, to commissioning bodies. Patients with hip fracture are at high risk of subsequent fracture. To prevent this, guidance recommends structuring fracture prevention services around coordinator based models. These are known as Fracture Liaison Services (FLS).
  
  
  METHODS
  33 semi-structured qualitative interviews were conducted with healthcare professionals with experience of making business cases for FLS. Data was analysed thematically.
  
  
  RESULTS
  Challenges in the development of business cases included collecting all the relevant data and negotiating compartmentalised budgets that impeded service development. Participants described communication and cooperation between providers and commissioners as variable. They felt financial considerations were the most important factor in funding decisions, while improved quality of care was less influential. Other factors included national guidelines and political priorities. The personalities of clinicians championing services, and the clinical interests of commissioners were seen to influence the decision-making process, suggesting that participants felt that decisions were not always made on the basis of evidence-based care. Effective strategies included ways of providing support, demonstrating potential cost effectiveness and improved quality of care. Using a range of sources including audit data collected on the successful Glasgow FLS, and improving cooperation between stakeholders was advocated. Participants felt that the work of commissioners and providers should be better integrated and suggested strategies for doing this.
  
  
  CONCLUSIONS
  This study provides information to healthcare professionals about how best to develop business cases for FLS. We conclude with recommendations on how to develop effective cases. These include using guidance such as toolkits, aligning the aims of FLS with national priorities and benchmarking services against comparators. Introducing a 'Local Champion' to work alongside the service manager and establishing a multi-disciplinary working team would facilitate communication between stakeholders. Involving commissioners in service design would help integrate the roles of purchasers and providers.
authors.affiliation: Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK. sarah.drew@ndorms.ox.ac.uk.
authors.forename: Sarah
authors.initials: S
authors.lastname: Drew
authors.affiliation: School of Clinical Sciences, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK. R.Gooberman-Hill@bristol.ac.uk.
authors.forename: Rachael
authors.initials: R
authors.lastname: Gooberman-Hill
authors.affiliation: Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK. andrew.farmer@phc.ox.ac.uk.
authors.forename: Andrew
authors.initials: A
authors.lastname: Farmer
authors.affiliation: Neurosciences, Trauma and Specialist Surgery, Oxford University Hospital Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK. Laura.Graham@ouh.nhs.uk.
authors.forename: Laura
authors.initials: L
authors.lastname: Graham
authors.affiliation: Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK. kassim.javaid@ndorms.ox.ac.uk.|MRC Lifecourse Epidemiology Unit, University of Southampton,, Southampton General Hospital, Southampton, SO16 6YD, UK. kassim.javaid@ndorms.ox.ac.uk.
authors.forename: M Kassim
authors.initials: MK
authors.lastname: Javaid
authors.affiliation: Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK. cc@mrc.soton.ac.uk.|MRC Lifecourse Epidemiology Unit, University of Southampton,, Southampton General Hospital, Southampton, SO16 6YD, UK. cc@mrc.soton.ac.uk.
authors.forename: Cyrus
authors.initials: C
authors.lastname: Cooper
authors.affiliation: Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK. andrew.judge@ndorms.ox.ac.uk.|MRC Lifecourse Epidemiology Unit, University of Southampton,, Southampton General Hospital, Southampton, SO16 6YD, UK. andrew.judge@ndorms.ox.ac.uk.
authors.forename: Andrew
authors.initials: A
authors.lastname: Judge
mesh_terms: D004739:England / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006282:Health Personnel / Q000592:standards*; D006302:Health Services Research / Q000379:methods / Q000592:standards*; D006620:Hip Fractures / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D006801:Humans; D008297:Male; D010865:Pilot Projects; D036301:Qualitative Research