REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales; the REDUCE study 

Breaking a hip is a devastating injury to sustain. 80,000 older adults break (or fracture) a hip each year in the UK. Despite national guidelines, how health services organise hip fracture care varies greatly across UK hospitals. Finding out which parts of the hip fracture care pathway explain variation in patient outcomes will tell us what service changes are needed and help us to develop a new step-by-step guide to ensure consistent, high quality care is equally available to all.

Using large anonymised clinical datasets which have been collected systematically across England and Wales, we will be able to assess hip fracture services, including how care is delivered in emergency departments, on wards, in operating theatres, and during rehabilitation. Statistical analyses will identify which organisational factors explain variation in patient outcomes after hip fractures (e.g. death, length of hospital stay, hospital readmissions, osteoporosis treatment) and identify hospital care pathways that are associated with high-quality consistent patient outcomes. Cost analyses will calculate the costs from hip fractures which are attributable to different organisational factors. Interviews with staff from hospitals providing different levels of fracture care will identify barriers and facilitators to optimal care delivery. With our system-wide understanding of hip fracture care we will develop an Implementation Toolkit in partnership with key national stakeholders, particularly the Royal Osteoporosis Society, to overcome organisational barriers when implementing sustainable high-quality fracture services for patients. We will make this Toolkit freely available to hospital managers, clinical leads and those who organise healthcare services.

Researchers: Prof Celia Gregson, Prof Andrew Judge, Prof Yoav Ben-Shlomo, Dr Elsa Marques, Professor Rachael Gooberman-Hill, Dr Sarah DrewDr Rita Patel, Dr Katie Whale, Dr Petra Baji

External Collaborators: Mr Tim Chesser, Mr Xavier Griffin, Dr M. Kassim Javaid, Mrs Jill Griffin, Dr Antony Johansen

Funder: Versus Arthritis (£396,264)

Project timeline: 2019-2023

Implementation Toolkit:

Hip fracture toolkit | ROS (

REDUCE in the news:

July 2023: Hip fracture health costs and care | News and features | University of Bristol

August 2022: hip-fracture | News and features | University of Bristol

August 2022: Hip fracture care too slow in some hospitals, study says - BBC News

Publications to date:

Patients’ recovery of mobility and return to original residence after hip fracture are associated with multiple modifiable components of hospital service organisation: the REDUCE record-linkage cohort study in England and Wales BMC Geriatrics, July 2023

Organisational factors associated with hospital costs and patient mortality in the 365 days following hip fracture in England and Wales (REDUCE): a record-linkage cohort study. The Lancet Healthy Longevity, July 2023

Complex organisational factors influence multidisciplinary care for patients with hip fractures: a qualitative study of barriers and facilitators to service delivery. BMC Musculoskeletal Disorders, February 2023

Multiple hospital organisational factors are associated with adverse patient outcomes post-hip fracture in England and Wales: the REDUCE record-linkage cohort study. Age and Ageing, August 2022

REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE): protocol for a mixed-methods study. BMJ Open, May 2021

Project Data:

To answer our research questions we are analysing a large national dataset from the Royal College of Physician’s Falls and Fragility Fracture Audit programme (RCP FFFAP), specifically the National Hip Fracture Database (NHFD) alongside data from NHS Digital. NHS Digital links the data from NHFD to information it collects and extracts details of all hospital admissions (Hospital Episodes Statistics; HES) and data from the Office of National Statistics (ONS) for the study.

NHS Digital securely transfers the linked data to the University of Bristol as pseudonymised data (i.e. all patient identifiers are removed and replaced with a unique patient ID), so patients cannot be identified. The data are then held securely at the University of Bristol (the Data Controller).  The ONS data provides us with information as to whether people have died at specific time points throughout the year following hip fracture.

NHS Research Ethics Committee approval: January 2020

NHS Digital Data Sharing Agreement: September 2020

FFFAP approval: December 2019

Further details regarding the NHFD data are available here, including the process to follow if you do not want your data to be included in this clinical audit and associated research activity. 

REDUCE newsletters:

REDUCE newsletter December 2019 (PDF, 666kB)

REDUCE newsletter April 2020 (PDF, 326kB)

REDUCE newsletter August 2020 (PDF, 314kB)

REDUCE newsletter November 2020 (PDF, 648kB)

REDUCE newsletter January 2021 (PDF, 631kB)

REDUCE newsletter May 2021 (PDF, 212kB)

REDUCE newsletter August 2021 (PDF, 253kB)

REDUCE newsletter October 2021 (PDF, 238kB)

REDUCE newsletter February 2022 (PDF, 246kB)

REDUCE newsletter Nov 2022 (PDF, 343kB)

REDUCE newsletter Mar 2023 (PDF, 303kB)

REDUCE newsletter Oct 2023 (PDF, 406kB)


Privacy notice

The REDUCE study uses health care data from the National Hip Fracture Database, NHS Digital and NHS Wales Informatics Service.

The University of Bristol is committed to using health care data in a safe and responsible manner. We use this information to study the NHS hip fracture service, how it functions and how it might be improved. This information is about the public and how they use NHS services, you therefore have a right to know what information we have and how we intend to use it. Below you will find information to help you understand the data we hold.

The data controller is the University of Bristol. For more information please contact Dr Rita Patel ( who is the researcher responsible for management of these data.

The purpose

The data held by the University of Bristol will be used for a programme of work based around improving the NHS hospital hip fracture care pathways, by examining organisational factors responsible for variations that may affect patient recovery after a broken hip. This will involve identifying the magnitude and causes of variations in hip fracture patient care. In addition, it will involve calculating the costs to the NHS for hip fracture care of inpatient, outpatient and unplanned admissions. The study will conduct applied health research and implement research evidence, to improve health and healthcare across the UK. The REDUCE study is funded by the research charity Versus Arthritis (

The REDUCE study brings together a collaboration of clinicians, charities, universities (including the University of Bristol, Bristol Medical School), patients and members of the public.

The data

We will hold linked data from the National Hip Fracture Database (NHFD), Hospital Episode Statistics (HES), Patient Episode Database for Wales (PEDW) and Civil Registration Database (CRD) data. NHFD records all hip fractures in the NHS in England and Wales. HES and PEDW are a record of all people who attend hospital in England and Wales, respectively.

Individual NHS hospitals send patient-identifiable information to the Falls and Fragility Fracture Audit Programme (FFFAP, which is run by the Royal College of Physicians [RCP] on behalf of the Healthcare Quality Improvement Programme [HQIP]) to populate the NHFD. The NHFD data is processed by Crown Informatics Ltd on behalf of the FFFAP.  Crown Informatics will send limited patient-identifiable data (including NHS number, date of birth, postcode, gender, injury date, and a unique FFFAP ID) to NHS Digital. NHS Digital in turn will match the NHFD records to patients’ HES and CRD data before returning these (together with the FFFAP ID but without the other sensitive fields, e.g. NHS number) to Crown Informatics. Similarly, NHS Wales Informatics Service will use limited patient-identifiable data (including NHS number and a unique FFFAP ID) to match the NHFD records to patients’ PEDW before returning these (together with the FFFAP ID but without the other sensitive fields, e.g. NHS number) to Crown Informatics.

From data we receive from Crown Informatics we will know the age and gender of these patients, what hospital they went to and what they went to hospital for. We will not know who the patient is, nor their name or address, or any other information which could be used to accurately identify them. The data we receive are ’pseudonymised’ which means we may have applied a ‘key’ or unique reference to a participant, the originators of the data are still able to match that reference back to an individual. This study does not involve any automated decision-making or profiling.

Legal basis for processing

For NHFD, HES and PEDW data are under Section 251 NHS Act 2006; Article 6(1) (e) - processing necessary for the performance of a task carried out in the public interest; and Article 9(2) (j)- processing necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and interests of the data subject.


These data will be stored in a safe and secure way and only accessed by specific members of the research team. The data will only be used to study the NHS and not used commercially. The data are not shared.


At the completion of the research the data will be archived and retained in line with the funding body policies. The retention period is until: 01/10/2023

Your rights

Legislation gives you the right to see what information an organisation stores about you and request copies of it as well as other rights in respect of the processing of your personal data.

You can find out more about these rights, when they might apply and how to exercise them in your data protection rights here:

Opt out

If you would like to opt out and not have your data used for this type of research, please contact:

Falls and Fragility Fracture Audit Programme, FFFAP (NHFD data): 

NHS Digital (HES data):

NHS Wales Informatics Service (PEDW data):


More information on opting out can be found on the NHFD website:

NHS Digital website:

NHS Wales Informatics Service website:"


In addition the University of Bristol provide fair processing information via websites at 

Fair processing information is given to patients participating in NHFD by their enrolling hospitals and


Data Protection Officer

The University is required to have a data protection officer who can be contacted if you have any queries, concerns or complaints about the way your personal data is processed. The University of Bristol’s Data Protection Officer (DPO) is Henry Stuart:

Henry Stuart

Information Governance Manager & Data Protection Officer

University Secretary's Office

University of Bristol

Beacon House

Queens Road

Bristol, BS8 1QU

Tel: 0117 39 41824

The Information Commissioner’s office is responsible for regulating data protection in the UK. We hope to resolve any of your questions, queries or concerns but if you remain dissatisfied you can contact the Information Commissioner's Office

Image of a hip fracture - source National Hip Fracture Database
Image credit: National Hip Fracture Database
Royal Osteoporosis Society logo
REDUCE Study logo - reducing unwarranted variation in the delivery of high quality hip fracture services in England and Wales; the REDUCE Study
Some of the REDUCE team at Jan 2020 Core Investigator Meeting
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