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MusculoskeletalFeb 17, 2023

'Do things differently' in MSK services to help alleviate elective care pressures, says expert panel

Community-based musculoskeletal (MSK) services have failed to make significant progress in recent decades and it’s time to bring in a fresh approach.

That was the message delivered by Andrew Cuff, a consultant physiotherapist and head of MSK at Connect Health, who was among a panel of speakers appearing in a webinar that was aired on 8 February. More than 100 people signed up for the event.

Referring to the approach set out in a 2006 framework for MSK services, Mr Cuff said the main themes all sounded a ‘bit too familiar’ today. They included a 'predominantly community-based pathway that facilitates self-management, draw[Ing] on a wide-ranging number of professions across primary, community and secondary care, interfacing with a number of different health, social, local authority and sector agencies’.

Photo Credit: Shutterstock
Physio Andrew Cuff asked if it's finally time to reach for a 'blank piece of paper' in MSK


'Underlying biases' spotted

Mr Cuff drew parallels with other plans that emerged for managing frail people and those with diabetes. ‘It appears that we design pathways in the same way we’ve been doing for a number of years, across specialties.’

Typically, he said planners adopt a familiar frame of reference that reflects their ‘underlying biases and outlook’. ‘And, of course, there is evidence of both impact and effectiveness in these methods – but the key question is, could we do better next time?’ he asked.

The event – the latest in a series with the theme of ‘change’ hosted by Connect Health – was prompted by the publication of an NHS improvement framework for MSK services. This also contains planning guidance for 2023-24, which promotes the use system-wide approaches to tackle backlogs. There are said be a record number of seven million patients languishing on NHS England waiting lists. 

Mr Cuff said: ‘If I see a patient in clinic with back pain, arthritis or tendinopathy, I'll discuss physical activity, positive lifestyle behaviours, maintaining a healthy weight, [their ability to] work [and continuing] their valued activities in a way that matters and is accessible to them. Yet that person is also likely to receive similar advice from their diabetes team, their cardiovascular team, their mental health support workers.'

Could we embrace value, look for opportunities of synergy, look for opportunities to reduce duplication and be brave in terms of doing things differently? Is it time to adjust our frame of reference and finally reach for that blank sheet of paper? [Andrew Cuff]

Time for change?

Mr Cuff threw out a challenge to viewers: ‘If we designed a pathway that removes this duplication, particularly for those with long term conditions, it could enable people to be supported and to benefit from high value interventions and ensure that specialist care is in turn provided within the relevant specialities.

‘Could we embrace value, look for opportunities of synergy, look for opportunities to reduce duplication and be brave in terms of doing things differently? Is it time to adjust our frame of reference and finally reach for that blank sheet of paper?’

Costs increase with specialist care

Ian Bernstein, Connect Health's clinical director for MSK health and chair of the MSK Health Improvement Network at NHS England’s London region, chaired the event. He said 785,000 people were waiting for a hospital orthopaedic appointment or admission, while many were also waiting for MSK treatments in community settings. ‘Costs increase as people move through specialist care settings,’ Dr Bernstein pointed out.

‘We need to bear these figures in mind as we discuss the context for transforming pathways of care’ Referring to data gathered prior to the Covid-19 pandemic data, he said the 75 per cent of people with MSK conditions who are managed in primary care cost 13 per cent of the programme budget for MSK conditions (including prescribing costs).

The 22 per cent of people seen in community, outpatient and A&E settings cost 44 per cent of the budget, while the 3 per cent admitted for elective, emergency surgery or inpatient treatment for MSK conditions cost 43 per cent of the programme budget, Dr Bernstein added.

Rehab should become a priority

Physiotherapist Matthew Carr, clinical director at NHS Sussex & Sussex MSK Partnership East, said data gathered from local community services were ‘not great at the moment’. Twelve weeks after starting a community episode of care, only 55 per cent of patients said they were in ‘a better place’ than when they started.

‘The numbers speak volumes and will allow us to really drill into which patients aren't achieving meaningful improvement. What can we do differently? Data is key, but rehab needs to come back up the priority list and be an absolute linchpin of what we deliver in community care.’

Mr Carr noted: ‘What also stands out is that we’re not always making sure we address the environmental and social factors that contribute to someone living well, or recovering well from MSK conditions.'

My 'journey' as an MSK physio

[MSK clinicians] need to be knocking on clinical directors’ doors, saying, “look, I've got these patients with these needs, and I can't do anything with them, because we don't have the right workforce [Matthew Carr]

Mr Carr continued: ‘If I reflect on my own journey as an MSK physiotherapist, when you're new and novice, you want to be the expert in things like anatomy and physiology and rehab principles – there is less focus on thinking about how the patient’s environment and social factors impact on their recovery.'

He added: ‘We need to support our community clinical workforce so they become personalised care champions for patients, really understanding their values, preferences and contributing factors. Our MSK clinicians in primary care need to be given space to develop relationships with health coaches and social prescribers.

'They need to be knocking on clinical directors’ doors, saying, “look, I've got these patients with these needs, and I can't do anything with them, because we don't have the right workforce". That’s the greatest opportunity in primary care – to help improve the flow of patients and optimise their care at that point.’

Joint working is 'essential'

Physiotherapist Sharon Barrington, head of planned care and long term conditions at Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board, discussed the issue of secondary care services ‘getting more referrals than they felt they ought to’.

Ms Barrington said there some referrals could be managed ‘differently’ with the right skills and good information in community services and secondary care support/governance. ‘Better information at triage [is needed], [with] more face-to-face assessments where appropriate to understand fully and avoid onward referral if possible. With a lack of good information in the first place, it’s very difficult to make a decision about where the right place is and who the right healthcare professional/service is for the patient.

She added: ‘There are opportunities for joint working which is essential for a good integrated service. Good triage is essential with a conversation with the patient, whether virtual or face-to-face adds value to that, particularly for complex patients.

‘We need to manage risk across the system. We need a joined-up approach between acute and MSK primary care to ensure that those patients get into the right place, first time. That’s what creating integrated care systems is all about.’

Collaboration is key

Kate Jackson, assistant director of Community Health Services at NHS England, said the improvement framework for MSK was the first publication of its kind to ‘define what community MSK services should look like’.

She emphasised the importance of co-production: ‘We've taken a strong stance in terms of how this work nationally was co-produced, in partnership with patient groups: ARMA [Arthritis and Musculoskeletal Alliance], Versus Arthritis and so on. ‘This is very much a collaborative piece of work,’ she added.

PhysioUpdate readers can watch the webinar here and read the session Q&A here

The event was organised by Connect Health, which is the largest, independent provider of integrated community musculoskeletal and pain services in the UK serving over 375,000 NHS patients each year.

To find out about forthcoming Connect Health events in the series, visit: https://www.connecthealth.co.uk/connect-health-change/

Author: Ian A McMillan
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