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  • The Arthritis and Musculoskeletal Alliance (ARMA) is the umbrella body for the arthritis and musculoskeletal community in the UK, and our mission is to transform the quality of life of people with musculoskeletal conditions. We have 33 member organisations ranging from specialised support groups for rare diseases to major research charities and national professional bodies.

CEO Update

Two things happened in July which will be significant for MSK services: the publication of the Prevention Green Paper Advancing Our Health, and the creation of over 1,200 Primary Care Networks (PCNs) across England. ARMA will be supporting members to engage with the Green Paper and to ensure PCNs deliver what is needed for MSK. We hope all our newsletter readers will get involved too.

I was pleased to see that Advancing Our Health gives plenty of profile to MSK. We’d like to see more focus on action and we’ll all be pushing for this in our responses. See the analysis of the content from an MSK perspective by our members in this month’s newsletter. It is a consultation document and anyone can respond online. I would encourage everyone to respond and encourage others to do the same. Government needs to hear that there is support for bold action to prioritise prevention and that the MSK sector is ready to collaborate to make a real difference.

Primary Care Networks were the subject of a presentation at our AGM this year. The Medical Director for Primary Care and Digital Transformation for London explained that GP practices will work collaboratively with each other and health, social care and voluntary partners to deliver services that can’t be delivered on a smaller scale. This animation explains how they are intended to work. PCNs will be important in providing MSK services, First Contact Practitioners and social prescribing. As with any collaboration, they will take time to establish and will take different forms in different areas. We heard worrying reports from members that PCNs weren’t giving it as much focus as is needed. Worrying given the profile for MSK in the Prevention Green Paper and in most CCGs priorities. We all need to work together to change that as the PCNs get established.

The AGM was also a chance to hear ARMA members views of what we should be doing. This year we have been working on some key priorities such as mental health, physical activity and what the NHS Long Term Plan means for MSK services. Members felt these are broadly the right priorities but that we should consider what we might be able to do about pain and about children and young people with MSK conditions.

Our webinar programme has taken a bit of break across the summer, but I’m pleased to say that we have two new webinars planned in September and available to book now. We also have plans for some exciting topics in October and November, so look out for those in future newsletters. Our webinars are a great way to learn from good practice and all the recordings are available to watch if you missed the live delivery.

We always like to hear from the commissioners, health care professionals, policy makers and others who make use of our information and materials. So if you love the newsletter, value our webinars or have thoughts on what we could do next to make a difference, do let us know by email or on twitter. The Green Paper and the PCNs give us opportunities which we must all engage with, because none of us can make the changes we need by ourselves.

Rheumatoid Arthritis (RA) is very much on my mind as I write this during RA Awareness Week. Yesterday I attended a roundtable discussing the NHS Long Term Plan (LTP) and RA. Rheumatology doesn’t get a specific mention in the plan, but there is plenty of content on related issues. There is mention of chronic pain, for instance, which is very relevant to ARMA and to RA. Access to integrated pain services is something ARMA members have identified as a priority following the publication of our mental health report last month, and by the time this is published I will have presented at a meeting of the Chronic Pain Policy Coalition.

MSK gets a number of mentions in the Long Term Plan but it’s easy to get the impression that this is all about osteoarthritis. ARMA is very clear that rheumatology is part of MSK, and just as important a part of our work as orthopaedics. I am part of an advisory group for the NHSE review of elective care access standards (waiting times in plain English) and I know that this is a vital issue for rheumatology. There are delays in patients recognising that their symptoms might be serious, and often further delays in GPs making a referral to rheumatology so, once referred, it’s vital that there isn’t a long wait to see a rheumatologist. But the roundtable heard that only 32% of RA patients are seen in a time recommended by NICE and almost 10% wait longer than the general waiting time target of 18 weeks.

The roundtable heard that three things impact on remission rates for RA and one of them is rapid access to specialist assessment.  Another is starting therapies quickly. The Long Term Plan talks about reducing delays in access to evidence based treatment. The example it gives is joint replacement surgery, but access to biologics in RA is another excellent example.

The final factor increasing chances of remission is a person centred holistic approach to care. The roundtable heard about unmet needs of RA patients, including pain, anxiety and depression. ARMA’s roundtable report on mental health and MSK has been well received in both MSK and mental health sectors. It’s very relevant to RA patients, and we will be pursuing the recommendations over the coming months.

After the meeting I was asked what would help rheumatology get the best out of the Long Term Plan. Part of my answer was that it needs to be clearly part of MSK, which is included in the plan. Which is why ARMA’s core offer for local NHS Plans includes rheumatology. Let’s be clear, no CCG, STP or ICS can say it is delivering good MSK services if it hasn’t included rheumatology, pain and mental health in their plans.

by Sue Brown, CEO ARMA

I write this reflecting on my day yesterday, which was unexpectedly dominated by discussions on pain. Pain is, of course, something we all talk about a fair bit in the MSK health world, as it’s one of the shared factors that cuts across all MSK conditions. I’m increasingly realising it is something we don’t always deal with particularly well.

My day yesterday began with reading New Scientist on the train, including an article about UK doctors’ concerns that we will follow the US into an opioid crisis. The question raised in the article was: is there a risk we will take things the other way, so that when someone does need opioids, they won’t be able to get them? The day ended at a wide-ranging lecture by Simon Stevens, Chief Executive of the NHS, including a slide showing opioid prescription rates by region: a wide variation, with London the lowest, and the North East the highest.

My discussions throughout the day all touched on pain in some way, but with a much broader agenda. Pain is rarely a simple matter which can be solved by pills alone. Yet that’s the only option offered to so many people. ARMA promotes a person-centred, integrated, biopsychosocial approach for anyone who experiences chronic pain. The prevalence of chronic pain is highest in the North East of England, and lowest in London (43.1% vs 29.0%). There is something going on here which is not just physical. We know that there are strong links between physical and mental health, which is why ARMA recently organised a roundtable on mental health. It is clear from my discussions yesterday that this is crucial in the context of chronic pain.

My issue with the debates about opioids is that they are about opioids. It seems to me that this is starting in the wrong place. The question is not what can we do about the increase in opioid prescription but what can we do about the increase in chronic pain? We need a much more sophisticated discussion. If pain is complex and individual, then the solutions must be personalised and multidisciplinary. We need to be able to refer people for psychological support. That might be IAPT psychological services for people with MSK pain. It might be health psychology in the context of a specialist pain service. We need to have appropriate peer support and social prescribing offers. We need to look at the underlying causes of pain and treat those where possible. The best pain services in the world are not useful if what the patient really needs is joint replacement surgery or rapid access to physiotherapy. And we need appropriate prescribing, and clinicians confident to discuss the different options and engage in good shared decision making with their patients.

This is not an issue which can be addressed by one profession. Patients in chronic pain may need GPs, rheumatologists, surgeons, pharmacists, psychologists, physiotherapists and others, working together. As with so much else in MSK healthcare at the moment, this support doesn’t join up and in the case of psychological support, too often isn’t available at all. This is why ARMA has made mental health a priority for this year. Together with our members, we will be pushing for improved access to joined-up, multidisciplinary personalised biopsychosocial support for people in chronic pain. We’ve already had some webinars on the subject, including how to deliver an integrated pain service and how to integrate mental health into physical health services. We’ve held a roundtable and produced our report. Look out for more activity including webinars and our annual lecture in November that push this agenda forward.

Join with us in calling for action to provide comprehensive services which address chronic pain from all angles. Patients with chronic pain deserve nothing less.

by Sue Brown, ARMA CEO

MSK services seem to me to operate very like an ecosystem.  If any part of the system isn’t in balance, the pressures will be felt elsewhere. No ESCAPE-pain means surgeons spending time with people who don’t need surgery; poor understanding of inflammatory conditions in primary care means more pressure on GPs as people don’t reach the rheumatologist; no Fracture Liaison Service means more fractures and more pressure on hospitals. Always the result of the system being out of balance is a person, in pain, not getting what they need.

As this newsletter goes out, ARMA will be at the BSR conference in Birmingham. It’s a great opportunity to engage with a wide range of our stakeholders. Many of our patient member organisations exhibit there too and we have many supporters working with rheumatoid arthritis and other inflammatory conditions. Our stand always gets lots of interest. If you are at the conference, do drop by.

Last month we welcomed our latest member, BASRaT, who represent sports rehabilitators. How do they fit with an organisation that covers inflammatory conditions you might ask? My answer is that, even though individual MSK conditions may be very different, they all rely on an effective MSK health service. That service must work together as a seamless pathway, an ecosystem that supports people’s need holistically. Almost everyone sees a physiotherapist at some point in their journey. Everyone comes into the system through primary care. If your inflammatory condition damages your joints, then you may need a surgeon. We depend on radiologists to correctly interpret scans, specialist nurses to help people manage their conditions, pharmacists to assist with multiple medications. Many are supported to recover from or manage their conditions through exercise programmes, which is where BASRaT, and other ARMA members, come in.

nice iconThis ecosystem is wider still. Responding to a submission from ARMA, NICE included a recommendation to ensure seating is provided at regular intervals along footways that are key walking routes in their guidance on physical activity and the environment. It doesn’t matter if you need to rest because of osteoarthritis, rheumatoid arthritis, fibromyalgia or any other MSK condition. Those seats could be the difference between a short, slow walk, that will keep you moving and improve your health, and staying at home while someone else goes to the post office for you. The forthcoming prevention green paper is not just about older people and OA, it is a vital part of the MSK health ecosystem.

Our MSK core offer for local NHS plans expresses the breadth of that system. Our webinars show the range of topics that we cover, from physical activity and MSK to pregnancy and inflammatory conditions.

As I write this, Extinction Rebellion have been blocking roads in London for a week, demanding action on climate change to prevent imbalance in the ecosystem. Like climate change, the importance of MSK health has been ignored for too long. But this is changing and there is a growing understanding of how central MSK is to the nation’s health and economy. An effective MSK health offer must be at the centre of solving the problem of NHS sustainability; I hope we won’t need to bring London to a standstill with an MSK rebellion to put it there.

CEO update by Sue Brown

March has been a very impactful month for ARMA. My highlight was probably the ARMA roundtable on mental health. The statistics about incidence of mental health amongst people with musculoskeletal conditions don’t surprise me. It’s obvious why long-term pain and difficulty moving would go along with high levels of depression and anxiety. What surprises me is how little support people get with their mental well-being and that’s something ARMA is determined to change.

ARMA members will be discussing what they want to do next on mental health at this week’s members meeting. Personally, I’d like to see an IAPT service for MSK/pain commissioned in every area. I know that whatever we decide to focus on, we now have colleagues in the mental health sector who understand how vital this is and are ready to work with us.

The round table is an example of where ARMA works at its best, bringing people together to find common ground and collaborate. Another is our engagement with the Department for Health and Social Care on prevention. We have come together to identify our priority proposals for MSK prevention so that we can give a clear message to government. The clarity and cross sector support means we can make a much bigger impact than each of us working individually.

Our webinars continue to go from strength to strength. In March we delivered our most popular webinar ever on the National Back Pain Pathway. We’ve got a really interesting one at the start of April on supporting women with inflammatory conditions around pregnancy. See the ARMA webinar page to join or watch the recording. As you can see, we cover a range of topics, so if there’s a webinar you’d like to see us run, please let us know.

I always enjoy talking to members, large and small, about their work and how ARMA can support them. So, it was good to find out more about the priorities for the RCN Rheumatology Nursing Network. One of our smaller members, they have some ambitious plans for the next year. I’ve also been talking to a few new organisations who want to find out more about joining us.

ARMA is nothing without our members, and we value the contribution of everyone, large and small. We’ll be exhibiting at the BSR conference at the end of April, so if you are there do come and say hello. And if you know of an organisation that would benefit from collaborating on MSK heath, please suggest that they join us. There are so many opportunities to push things in the right direction for patients, and far more that unites us than divides us. The more of us we are, the stronger our voice can be.

Prevention seems to have been the theme of my February. The possibility that a lot of the pain and disability of MSK conditions might be prevented, and that this is being taken seriously is an exciting prospect. Even where the conditions can’t be prevented, good self-management support can make a big difference to the impact of the condition. The Government is clear that the future sustainability of the NHS depends on prevention, and that it wants to improve healthy life expectancy by at least five extra years, by 2035. With MSK conditions the largest cause of years lived with disability, this puts MSK centre stage.

There are two different debates and approaches to prevention. The first is what preventative services we can provide? There are lots of MSK examples – ESCAPE pain, Fracture Liaison Services, Strength and Balance programmes, yoga for healthy backs, weight loss support. Then there is a much broader, whole system approach to prevention. Our health is determined not just by our genetics and personal lifestyle decisions. It’s also about the environment we live in; the food we see advertised; our housing; social networks; how easy it is to walk to the shops if you need to sit down half way to rest; the support you might get from your employer to remain in work; your doctor making it easy for you to find peer support for your condition from a patient group. Public health is everyone’s business.

A physiotherapist speaking at one of the Public Health England regional meetings spoke of his experience of first encountering public health. He had been working in an “NHS Bubble”, unaware that the local authority had staff looking at prevention through a different lens, but with the same objectives. This disconnect is replicated up and down the country. I think the NHS long term plan and the prevention green paper give us an opportunity to join them up. If local government, not just public health, but also planning, housing, transport and environment, aren’t included, we will still be fighting against the wider determinants of health. I think there is a real opportunity with the new Primary Care Networks (PCN), to bring this together. At the moment, the remit of the PCNs is joining up primary, secondary and community healthcare. I think they are also in a great position to also bring in local government and address population health more widely. Smaller than an STP/ICS, they should be more able to look at local relationships and bring together all those who influence the systems that determine our health.

ARMA will be engaging with the implementation of the NHS Long term plan and the development of the Green Paper. We need both approaches for good population MSK health – services and a whole system approach. But the gains could be enormous, both for the NHS and individuals. This is everyone’s business. Let’s work together and see just how big a difference we can make.

As I sat down to write this, NHS Chief Executive Simon Stevens was on the radio talking about plans to increase the ability of patients to see pharmacists and physios rather than a GP as their first point of contact in the NHS. Ensuring we have the right workforce to meet the growing health needs of an ageing population is a real challenge. ARMA’s different professional members have a lot to contribute, as I discovered when I spent a day at the Royal College of Chiropractors conference.

Not all speakers at the conference were chiropractors. A rheumatologist spoke about the way chiropractors are often important partners in patient’s pathways for both diagnosis and management. A bold statement from another speaker, a physiotherapist: “chiropractors can help to save the NHS”. The chiropractors speaking all focused on how to improve practice, to increase skills in psychological and social aspects of health, taking a public health approach and making every contact count. It was the non-chiropractor speakers who challenged the delegates to step up to a leadership role. Based on my conversations in the breaks, I think there were plenty of delegates ready to rise to that challenge.

As CEO of an alliance, this is the sort of thing I love. Not professional rivalry (which I see too often) but professional collaboration. Yes, take a pride in your own skills and training, but do so with an understanding of what you have to offer to a multidisciplinary team. As the musculoskeletal patient population gets older, more complex and more likely to have other co-existing long-term conditions, no profession can act alone. The best surgeon can’t get good patient outcomes if rehabilitation is poor. The best rheumatologist can do nothing for the patient who wasn’t referred because no-one recognised the severity of their condition. Health is a system, not isolated episodes of care.

ARMA members include a whole range of professions who could contribute to the musculoskeletal health of the nation. The NHS Long-term plan presents us all with an opportunity. Benjamin Ellis of Versus Arthritis, another rheumatologist speaker at the conference said: “If the MSK community doesn’t get on the bandwagon, it will go without us.” We need to get on that bandwagon, with pride in what we can all offer, together as a community. That’s exactly what ARMA is here to facilitate.

NHS logo

by Sue Brown, CEO ARMA

The NHS Long-Term plan was published earlier this week. I was pleased to see quite a bit about musculoskeletal health throughout the document. There has been lots of immediate reaction, positive and negative. I think now is the time to focus on the positive, so here are my highlights.

The first reference to musculoskeletal health comes early on, (para 1.17) but seems to be mostly about frailty and older people. Great, I thought as I read this, but MSK isn’t just about older people. Read on.

The chapter on care quality focuses strongly on the major killers such as cancer and heart disease, and this is what got all the media coverage. But it also talks about the biggest disablers of our population. This is important because the fact that we are all living longer in poor health is just as important as tackling killer diseases. The plan “affirms the importance of therapies and planned surgical services for conditions that limit independence and affect quality of life.” In case you thought that MSK wasn’t included in this, the section includes increasing the use of First Contact MSK Practitioners and expanding access to the on-line version of ESCAPE-pain. There is also recognition in the appendix that MSK conditions are a big cause of sickness absence and that rapid access to treatment is important in reducing this.

NHS sickness chartCrucially the plan recognises that capacity for surgery such as joint replacement hasn’t grown fast enough, and that short waits are important. “Joint replacements and other planned surgery all help people stay independent and yield important quality of life gains.” This is great, although waiting times are a blunt measure and we also need to see a reduction in the hidden waiting list of people who need surgery but are being denied it on grounds with no clinical basis, such as BMI thresholds. But this recognition that joint replacement is important in helping people stay independent will help us make this case.

There is a tendency for the NHS to focus on the common MSK conditions such as osteoarthritis or back pain. Less common conditions such as Ankylosing Spondylitis also limit independence and affect quality of life. The first hurdle for these conditions is often the length of time it takes to get a diagnosis. If the plan is to tackle rapid access to treatment for these conditions it must address this delay in diagnosis.

Increased funding for community and primary care, greater emphasis on more person-centred care, expanding the number of AHPs, these are all things which will benefit people with MSK conditions. The plan also includes a commitment to expanding the IAPT (Increasing Access to Psychological Therapies) programme to people with long term conditions (para 3.91), and also includes a case study on a living well with back pain course which integrates physical and psychological support. This is encouraging as ARMA works to see the recommendations in our mental health position paper implemented.

Inevitably there are omissions in the plan, but for now I’d prefer to focus on the opportunities it delivers and make the most of them. For now, the plan is just words on a page. It’s what happens next that’s important.  Every area is now expected to set out a local plan to deliver the commitments (para 7.3). We need to work to make sure that people with MSK conditions are included in every local plan. The MSK community is ready to engage and make things happen – in the end, that’s what will make the difference.