by Dr. Alan Nye, President Primary Care Rheumatology Society, Executive Director, Pennine MSK Partnership Ltd.
This is my final month as President of the Primary Care Rheumatology Society and it’s been a very interesting 2 years for me. I apologise that this blog is England-centric, but England is the totality of my NHS experience and I cannot write about areas outside of my experience. I would like to cover, albeit briefly, three areas that over the past few years have become very dear to my heart:
• MSK training for primary care
• MSK networks and commissioning MSK services
• Shared decision-making
For a long time the lack of training for front line GPs has been a real issue for the NHS. Yet action to address this on a national level remains painfully slow. This creates issues for patients such as delayed referral, for example in inflammatory arthritis, causing pain and avoidable disability, and this generates many unnecessary referrals for conditions that are better managed within primary care. As 20% of the GP workload is for MSK conditions, there is an urgent need for MSK to be a part of every GP trainee’s curriculum. However I do not hold any expectation that this will happen in the near future.
One solution would be to bring more specialists into primary care, particularly extended scope physiotherapists, who could provide a very cost-effective solution to growing MSK referrals. However, the current contracting and funding arrangements make this seemingly simple solution difficult to deliver. The NHS that has developed over the past 10 years is one of silos, with separate contracting and funding for primary, community and specialist care. MSK, like other long-term conditions, needs an integrated team approach. The Kings Fund in their report on out-of-hospital care has also highlighted this issue, and our MSK service in Oldham has also served as a model for others.
There are some glimmers of light on the horizon, however, with moves away from payment by results to a “year of care” tariff and different funding and provider models such as prime contractors; but there remains a “Berlin Wall” across many patient care pathways, with Primary Care being centrally commissioned with a variety of contracts (GMS, PMS or APMS) and community, mental and specialist care being delivered under standard NHS contracts and commissioned largely by CCGs. Where commissioners have re-tendered MSK services based on the prime contractor model we have developed in Oldham, transfer of financial risk rather than driving continual improvement in patient care is often the main priority. In our model in Oldham the financial risk still sits with the CCG and all savings from the programme budget are reinvested in patient care and are not taken as profit. This, in my opinion, has been one of the main factors in our success, and it’s an element that many others have failed to replicate. Whatever the provider model is, there has to be advantage in commissioning an entire care pathway and coordinating care to maximize the clinical outcomes, patient experience and financial spend. Also I feel many CCGs are just too small and lacking in specialist clinical knowledge to effectively and efficiently commission care, and the financial challenge faced by them is so great that they cannot invest in new care models unless they deliver savings within year.
One way of sharing and developing new models is ARMA’s MSK clinical Networks Project, which has the support of the NHS Confederation and is attracting a lot of interest from CCGs. Even though it is sadly under-resourced, this has to be the way forward, with local clinical communities working together with patient groups to deliver effective patient-centred care. Speaking at ARMA’s annual lecture last week, Lord Hunt said as much himself. The MSK Networks will take some years to develop and grow, and I hope central government and NHS England realise the need for some financial and management support. The responsibility for making the network project work lies with all of us, patient groups, professional bodies and clinicians.
Finally I would like to touch upon shared decision-making. Everyone now agrees that this is a “good thing” and three Cochrane reviews have highlighted the many benefits for patients, clinicians and the wider health service. It is now even part of the standard NHS contract. However there is also an assumption that “we do it already”, and yet looking at the scale of unwarranted variation in some care pathways, or the evidence from the National Patient Survey, indicates that we do not do it. The default position of many clinicians is one of unintentional paternalism, and there is a lack of recognition that to deliver effective shared decision-making we need to train clinicians and measure the outcome. Frustratingly, training staff and measurement is fairly easy to do and yet there is no general agreement on whose role or responsibility this is. Shared decision-making is yet another casualty of the Health and Social Care Act moving from having a centrally-commissioned programme to relative obscurity; it is much spoken about and referred to but seldom delivered in a systematic way.
So, in summary: I feel that on one hand we face tremendous challenges with the financial squeeze and a commissioning, contracting and payments system that act as a barrier to integrated care, while on the other we do have the answers to these problems ourselves. The MSK network project is a way we as an MSK community can work together to achieve cost effective and patient-centred care. To quote Peter Kay, the MSK NCD, “the elements identified in the ARMA project sit absolutely at the centre of the Five Year Forward View that the NHS and politicians have now signed up to,” and “there is now an excellent opportunity to drive this forward,” so we must all take ownership of it and make it happen.
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