Andrew Conkie, CEO, Red Star
One of the most common concerns I hear from FLS leads considering digital infrastructure is some version of: “We’re already stretched thin. We can’t take on a new system on top of everything else.”
I understand the instinct. FLS teams are under-resourced, under-staffed, and under pressure. But there’s an assumption in that sentence worth examining: that a digital FLS sits on top of existing work. It doesn’t. It replaces the manual processes that are consuming most of your team’s time. It is the workflow, not an addition to it.
And once you see it that way, the capacity problem and the infrastructure problem start to look like the same problem.
Let’s explore this.
What an FLS nurse actually does all day
An FLS nurse spends a significant part of their day on tasks that have nothing to do with patient care. Pulling fracture lists from discharge summaries, radiology reports, or coding systems. Cross-referencing those lists against previous referrals. Manually entering patient data into local spreadsheets or databases. Chasing DXA scan results. Following up with GPs about treatment initiation. Compiling data for the FLS-DB audit. Sending letters. Logging activity.
Every trust uses different source documents to identify patients, which means every FLS has its own workaround for extracting and reconciling fracture information from whichever systems happen to be available locally. Some services pull from A&E discharge summaries. Others work from radiology reports. Some rely on clinical coding that arrives days or weeks after the fracture event. The variety makes the job harder, not easier, because there is no standardised, automated route from “fracture identified” to “patient in pathway.”
Ask any FLS nurse what proportion of their day is clinical versus administrative and the answer will be uncomfortable. But here is the telling part: nobody can give you a precise number, because these services do not have the data infrastructure to measure their own workflows. The very problem we are describing prevents us from quantifying it. What we do know, from every FLS team we have worked with, is that the administrative burden is the dominant complaint and the primary reason nurses feel they cannot see enough patients.
The paradox
Here’s where the logic breaks down. When a service says “we don’t have the capacity to adopt a digital platform,” what they’re really saying is: “we don’t have enough staff time.” But the reason they don’t have enough staff time is that their staff are spending most of it on administrative tasks that a digital platform would handle.
Digital FLS infrastructure automates fracture identification from hospital data feeds. It creates structured patient pathways with built-in prompts and timelines. It generates audit data as a by-product of clinical workflow rather than as a separate manual exercise. It tracks follow-up systematically instead of relying on spreadsheets and memory.
None of that requires more staff. It requires the same staff spending their time differently.
The question is not “can we afford to take this on?” It is “can we afford to keep doing this manually?”
What changes in practice
In Scotland, where our digital FLS infrastructure is on track to cover around half the country’s population by mid-2026, the difference is measurable.
Vertebral fracture identification is one of the clearest examples. In manual services, vertebral fractures are notoriously under-identified because they often appear as incidental findings on radiology reports that nobody systematically reviews for bone health implications. Paskins et al. (2026) note in their JBMR Plus position statement that only 30 percent of vertebral fractures are clinically diagnosed. In our digitally managed services, automated radiology integration surfaces these fractures as part of the standard workflow. Identification rates for vertebral fractures are multiples of the English national average because the system surfaces them automatically, regardless of which clinician is on shift.
Follow-up tells a similar story. National FLS-DB data shows that most English services discharge patients after 12 months with no systematic follow-up thereafter. In a digital system, follow-up is structured into the pathway. Patients do not fall out of the system because nobody remembered to check a spreadsheet.
The capacity gain is tangible. It is an FLS nurse who now has time to have a proper conversation with a patient about their treatment options, because they did not spend the morning pulling fracture lists from three different hospital systems.
The service review question
Some trusts tell us they need to complete an internal service review before considering new infrastructure. This is understandable, but there is a circularity to it: a service review asks “what can we deliver with current capacity?” The honest answer, for most manual FLS services, is: not enough. FLS-DB data for England tells a stark story: non-spine fracture identification sits below 40%, spine fracture identification below 29%, and the numbers only get worse from there. Sixteen-week follow-up is under 32%. One-year drug adherence is under 25%. Almost every KPI is in the red.
That pattern points to systems design, not staffing. And the service review itself becomes clearer with data visibility. You cannot optimise what you cannot see.
An honest note on implementation
I will not pretend that adopting any new system is effortless. There is an onboarding period. Clinical teams need to learn new workflows, though in practice these replace existing manual processes rather than adding to them. Integration with local hospital systems takes time, and every trust’s IT landscape is different.
But that is a one-time investment measured in weeks. The alternative is an ongoing daily cost measured in years of clinical time spent on administration that a system should be handling. At some point, the maths stops being debatable.
The real capacity problem
A recent position statement from Paskins et al. (2026) called for “scalable, sustainable, and digitally optimised solutions” to close the osteoporosis care gap. The authors, who include some of the most influential voices in UK bone health, identified that the current model of care is consumed by administrative burden at the expense of person-centred, multidisciplinary support.
The capacity challenge facing FLS teams is real and well understood. But it is worth considering whether the answer lies in more resources for the current model, or better infrastructure to support the people already in it.