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Clinical Networks Project

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 part of our Clinical Networks Project, ARMA wants to find out what is happening to improve MSK services across England in order to see how we can best target our support for improvements. Please let us know what is happening in your area by completing this short questionnaire, which should take only five minutes to complete. The information is anonymous and we won’t name individual CCGs or STPs.

The report on the findings will give a national picture of what is happening and help all those working to improve services better target their work. Thank you for taking the time to respond to this survey. The information you provide will be used to help to improve services for people with musculoskeletal conditions.

Bringing knowledge together, bringing people together: those are the aims of ARMA’s clinical networks project. Bringing them together to improve the lives of people with MSK conditions, of course. That really sums up what ARMA is all about. We are about breaking down silos and professional boundaries, creating services which work in pathways, where multidisciplinary teams ensure people get the right support at the right time. We are about sharing knowledge and good practice so that professionals know what works and can replicate excellence in their local area.

The project is about to move into a new and exciting phase, with the launch of local networks and the on line MSK Knowledge Hub. The knowledge hub will include an on-line forum where people can share experience and learn from each other. Both this and the networks are a bit of a leap into the unknown. There isn’t a set programme or a set of measurable outputs. The point is to let local people take the lead and respond to their own priorities. We can provide some tools to help, but we can’t control what happens.

As someone who likes project plans, measurable outputs and KPIs, that makes me a bit nervous. But I think it is the right approach. This blog from the Kings Fund talks about change as “a messy, non-linear process. It is unpredictable and difficult to chart in absolutes or step-by-step project plans with a neat beginning, middle and end.” I hope the ARMA project will help those of you involved in the messy, unpredictable process of working to improve services to share ideas and enthusiasm, to find out what has worked elsewhere and why, and to connect with others who know things can be better.

Let’s celebrate the unpredictable, the creative and the messy in the interests of driving positive change. Look out for more details on the network on our website shortly and in the next newsletter.

Get involved: sign up to the network, join the hub and make a difference.

NHS England and the Arthritis and Musculoskeletal Alliance (ARMA) are delighted to be hosting a South East Regional Musculoskeletal (MSK) one-day conference on Tuesday 28 November 2017 at the Arora Hotel, Crawley. The event is sponsored by NHS England and ARMA and is part of their joint MSK programme and will be organised by the Kent Surrey Sussex Academic Health Science Network.

Register now! using this link:

The South East System MSK event will promote a coherent approach to transforming MSK services across the region by working directly with South East Sustainability Transformation Plans (STPs) footprints to support improvement in the quality of MSK care. Throughout the day we’ll be:

  • promoting best practice by sharing local case studies
  • looking at what’s working well and what’s not
  • understanding trend data relating to MSK pathway
  • explore data sources and national tools to help us gain insight into making much needed improvements
  • exploring what this means for service delivery at a local level

Chaired by Mr Nigel Acheson, Regional Medical Director (South), NHS England and Professor Anthony Woolf, ARMA chair confirmed topics and speakers include:

  • Musculoskeletal conditions: a national perspective, Professor Peter Kay, National Clinical Director, NHS England
  • A public health approach to musculoskeletal care, Dr Benjamin Ellis, Consultant Rheumatologist/Senior Clinical Policy Advisor, Arthritis Research UK
  • Getting It Right First Time – Regional Variation, Mr Mike Hutton, Spinal Surgery Clinical Lead, Royal Devon and Exeter NHS Foundation Trust
  • Local case studies: a series of presentations on good practice examples

By conference close, we hope to have identified and agreed local priorities and actions which will have the greatest impact for this patient group.

This free event is for all professionals from the rheumatic and MSK community including commissioners, patient representatives, relevant clinicians, primary, secondary and community care. The event will be hosted at The Arora Hotel, Crawley on Tuesday 28 November, 9.30 – 4.00pm. Please share this invitation with any colleagues you feel would also benefit from attending.

For full conference details and to book your place, please use the link below:

We look forward to seeing you there and transforming our local MSK care services together.

Best wishes,

Jill_Firth-pennine-mskby Dr Jill Firth, BHPR President, Consultant Nurse in Rheumatology and Director for Service Improvement at the Pennine Musculoskeletal Partnership Ltd in Oldham.

Over the past 20 years of working as a special  ist nurse, I have witnessed first-hand the changing face of care for people with Musculoskeletal conditions (MSK) – particularly Rheumatoid Arthritis – leading to better outcomes for patients.

This can, in part, be attributed to advances in treatment strategies, including biologic therapies, but is also a consequence of better access to care provided by a multi-disciplinary team (MDT) comprising consultant rheumatologists, specialist nurses, physiotherapists, occupational therapists and podiatrists as a core nucleus.

Data emerging from the second year of the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis provides further evidence of the importance of this team approach in achieving NICE Quality Standards for the management of RA and other MSK conditions.

pennine-msk-quoteIn year one of the audit we found that higher numbers of consultants were associated with shorter waiting times to first appointment, facilitating early diagnosis and rapid access to care. Only 37% of patients were seen within three weeks of referral (NICE Quality Standard 2) and 25% of patients waited seven weeks or more for a specialist assessment.

The Royal College of Physicians recommend that one rheumatology consultant for every 86,000 people is needed to provide an adequate service, but this year’s audit found only one rheumatologist for every 116,000. Less is known about recommended workforce models for other members of the multi-disciplinary team.

This year we have undertaken additional analyses which demonstrate that higher numbers of specialist nurses are significantly associated with patients starting combination disease modifying drugs within six weeks (NICE Quality standard 3). Early access to combination treatment is crucial to improve pain, maintain function, aid work retention, and protect joints from irreversible damage in early disease.

Higher specialist nursing numbers are also associated with the prescription of short-term glucocorticoids which are used to bridge the gap whilst slow acting disease modifying drugs have chance to work, helping to control inflammation in the joints in the interim. Nurse led clinics facilitate treating to target and this data builds on existing evidence from RCTs demonstrating that specialist nurses provide high quality, cost-effective care for patients with inflammpennine-mskatory arthritis.

It is encouraging that we are starting to see successful business cases for additional consultant and specialist nurse staffing as a result of the year one audit findings.

Investment in additional specialist staff delivers improved outcomes for patients and has the potential to reduce the long term costs to the NHS and wider health economy. The reconfiguration of existing referral pathways, services and staffing through changes in referral pathways and organisational structure, such as the provision of early arthritis clinics, can also make improvements at no-cost.

Overall though, as in year one, there were many gaps in in access to the MDT: 72% of providers reported that their patients have access to specialist physiotherapy; 76% to specialist occupational therapy and 51% to specialist podiatry with marked regional variation. Despite the fact that 90% of people with RA experience foot problems, the provision of specialist podiatry remains markedly low indicating room for improvement.

Timely access to the specialist MDT is crucial not only in early RA but to support people living with a long term condition that is characterized by a fluctuating course. The added value of specialist nurses and allied health professionals working in rheumatology has long been recognised by our medical colleagues, primary care teams, patients and carers but we need to ensure that service managers and commissioners fully appreciate our worth to drive improvements in care. Only then can we work together to configure services that meet the needs of our patients with clear pathways and high quality cost effective care provided by appropriately trained and skilled workforce.

British Society Rheumatology is promoting a webinar, as part of the MSK Network Series of webinars, on 30 September 2016, 12.00-13.00: “Coordinating a person-centred pathway to high quality care for people with rare autoimmune disorders”.

The webinar is presented by Ben Fisher from the University Hospitals Birmingham NHS Foundation Trust, who was British Society Rheumatology Best Practice Awards 2016 awards winner in the Outstanding Best Practice category.

In this webinar we describe how we have set up a multidisciplinary clinic run by rheumatologists and attended by oral medicine and ophthalmology to streamline the diagnostic pathway and reduce frequency of visits. Key components are access to a slit lamp for eye examination, provision of a lip biopsy clinic, and standardised histopathological reporting following guidelines we have developed.

  • The webinar is aimed at commissioners, clinicians and providers.
    Once you have registered you will be sent a calendar invite containing details on how to join.

by Professor Peter Kay, National Clinical Director for Musculoskeletal Services for NHS England.

Peter-Kay_nlI was asked to write a blog to raise the profile of my MSK work supported by the Long-Term Conditions Team and, through the cryptic labyrinth of various schemes and initiatives, share with you my thoughts on how we can support sustainable, cost-effective transformation whilst still championing the more person-centred approach.

Easy task right?

Increasingly we are faced with the challenge of implementing population-level interventions in a bid to tackle unwarranted variation within our local areas. At the same time, many of us are striving to strike a balance that enables us to deliver care more holistically – that is in a way that empowers patients, supports families and carers and promotes decisions led by the needs and wants of those who are specialists in their own care: the patients.

It’s not always possible to be all things at once. Nor is it possible to come up with all the ideas yourself. Enter our solution! The MSK Knowledge Network is a forum which was set up through a process of co-production with all the main patient-led and professional organisations active in the field of MSK. Its overarching aim is to improve outcomes, increase value and reduce unwarranted variation in MSK care. This is achieved by enabling better communication between sectors, facilitating the sharing of good practice and promoting a multidisciplinary and collaborative approach to problem-solving, both cross-professionally and cross-organisationally.

One way we are seeking to do this is to draw together the strands of work beating through the hearts of our partner organisations through a programme of national webinars. From government-funded bodies to voluntary sector charities, the wealth of experience and knowledge within our MSK community is breath-taking. The investment in improving the outcomes and experience for patients with MSK disorders alongside the initiatives aiming to increase prevention and strengthen resilience is inspiring. The chance to share ideas, challenge preconceptions and support new ways of thinking is something we are really proud of.

But we still face our own challenges. The question for us is how to develop a sustainable network, one that continues to build momentum and holds the interest of its members. To do this, the MSK Programme Team and I will continue to work with the MSK community – through the Arthritis and Musculoskeletal Alliance – to support the development of MSK networks from a regional level, with a string of events due to take place this coming autumn. The events will follow from, and build on, the excellent national seminar which many of you attended in January this year. Various MSK professional groups already have a national network of regional reps, who you are invited to get in touch with if you haven’t already. If you already have an MSK network, or are keen to develop one, and you want to be involved in hosting or helping to organise one of these events, please get in touch for more information about how you can get involved.

Reflecting on how my experience has shaped my view of the puzzle that is the ever-developing landscape of transformation in the NHS, I notice success means different things to different people. For me it is creating a programme of work with such merit that it can become self-sustaining. And to others? Well I defer to this analogy… 3 orthopaedic surgeons took 5 days to do a jigsaw and were proud of their achievement. When asked why they were so proud they said because it said 3-5 years on the box.

For now I’ll just keep hoping the bookings for the other (less funny) Peter Kay keep rolling in so I can continue to raise the profile of the excellent work underway across the MSK community.

#MSKcommunity – Find out more at the Knowledge Network’s Yammer site.

#A4PCC – Sign up and make your Declaration for person-centred care.


Sarah-Marsh-Guest-Blogger2by Sarah Marsh, National Policy Lead, Long Term Conditions, NHS England

As we begin the new financial year and our plans for the upcoming months become more structured, I thought it would be a good opportunity to share my thoughts on the challenges heading our way; as well as a chance to share our ideas and reinforce our bid for your support as we further the momentum of all the work streams, including the MSK Knowledge Network Programme.

My aim for this coming year is to continue to support our programme strategies whilst reinforcing the links established with other MSK work ongoing within NHS England and our partner organisations: Department of Health, Public Health England and Health Education England. Our commitment to a National Clinical Director for MSK will provide the clinical leadership necessary to raise the programme profile further. We hope to hear the formal announcement in April.

Our ambition is that this will be the year that finally joins the disparate initiatives to form one, cohesive whole. One where our successes are shared and our lessons are learnt uniformly across the healthcare sector. Looking for an analogy, we are aiming for less Shakespeare’s Romeo and Juliet (miscommunication and tragic ending) more Kylie and Jason Especially for you (circa 1988 happy ending – not the subsequent drug-addled, chaotic reunion version).

We are constantly challenged to demonstrate how the outcomes achieved can be causally linked to the efforts we put in. As such, additional to our wider desire to create more unity within the community of MSK projects and programmes, we have highlighted specific objectives to take our programme of work forward and are looking at ways in which we can measure their impact.

These include:NHS-England-header-logo

  • To further develop and strengthen the networks programme including a more specific focus on regional support and delivering the national agenda in the scope of local change.
  • Increasing our work on prevention, both primary and secondary including initiatives aimed at strengthening resilience.

Of course it is our hope that through the broadening scope of our communications and engagement agenda we will reach further audiences, support the greater dissemination of good practice and effect maximum change. With your help we are confident we will succeed.