This is a category taken from the full feed of Musculoskeletal and Arthritis news provided by ARMA's members.
  • 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.

Commissioning

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.

The Royal College of GPs (RCGP) has published a vision for general practice for 2030. It sees a very different place for general practice from the current model, with increased multidisciplinary working and a greater focus on prevention and well-being. This was developed with the involvement of patients, GPs and other stakeholders.

This is a response to the changing nature of health needs with more people presenting with complex and multiple conditions. The current primary care workforce is stretched and the numbers of GPs per 1,000 of population have declined by 5% in the last ten years.

The document sees general practice in 2030 remaining the first point of contact for most patients, but not focused on GPs, more on multidisciplinary teams, freeing up GPs to do what needs a GP. Practices should become well-being hubs addressing psychosocial needs of patients. They should host prevention, well-being and social action projects, and play a role in building strong resilient communities. They will provide links with secondary care. One example given is the potential for practices to run MSK clinics currently delivered from hospitals.

The document lists six enablers needed to deliver this:

  • Funding
  • Training
  • Workforce
  • Digital
  • Modern premises
  • Research and Innovation

The summary document contains many examples of practices already putting some of this into practice and more detail on each of the areas and enablers. Read it here.

The Institute for Voluntary Action Research (IVAR) has developed free support resources for health, care and voluntary sector leaders who want to drive action through partnership working around the NHS Long Term Plan. The resources include online learning, webinars, workshops, coaching and individual support and are aimed at ICS/STP leads, commissioners, clinicians, and professionals from the voluntary sector.

The NHS Long Term Plan commits local healthcare systems to working in a new way, including a focus on prevention and reducing health inequalities. Building relationships – with other health agencies, local government, providers and communities – will be essential for the leaders charged with bringing this ambitious vision to life.

The NHS Long Term Plan recognised the role Voluntary, Community and Social Enterprise (VCSE) organisations could play, in partnership with the NHS, to help deliver its vision. At a strategic level, NHS England is committed to working with VCSEs and establishing models for more equitable partnerships and better integration, and to increase the influence of the voice of patients. More locally, STP’s/ICS’s, as with any relatively new player in a system, are taking time to build consistently high and constructive levels of engagement with VCSE organisations and communities more widely. 

The Building Health Partnerships programme and this wider support offer – Transforming Healthcare Together – have been designed in response to all these challenges, to work intensively with statutory services to test and pilot new approaches to partnership working, and to support the leaders working to bring the NHS Long Term Plan to life.

The free support offer is for health, care and VCSE leaders who want to drive action through partnership working. There is a range of support for different levels, whether you are just getting started or have been working in this way for some time.

ARMA has been working with the Medical Technology Group (MTG) to raise concerns about increasing rationing of joint replacement surgery.

The MTG is a coalition of patient groups, research charities and medical device manufacturers working to improve access to cost effective medical technologies for everyone who needs them. MTG has concerns about treatment rationing in general and have launched the Ration Watch campaign to highlight care inequality and the impact it has on patients’ lives.

Ration Watch aims to expose the scale of rationing and the issues around local commissioning across the UK.

Ration Watch looks at individual commissioning polices, NHS activity and waiting times to describe the challenges some patients face. The campaign will work with local politicians, councillors, MPs, and national decision makers to help improve patient access to treatment regardless of where you’re based in the UK. Their website asks patients who have been denied life-enhancing treatments, such as hip surgery, to share their rationing stories.

Ration Watch believes that what you need, not where you are, should dictate the care you receive.

Musculoskeletal support professionals in the community

by Dr Rob Hampton, GP and Occupational Physician

Across the world, chronic musculoskeletal conditions such as osteoarthritis, inflammatory disorders and common regional conditions such as back, neck, shoulder, hip and knee pain now represent the single greatest cause of years lived with disability 1. When measuring their negative impact on employment, self-reported wellbeing and day-to-day function, chronic musculoskeletal pain conditions are every bit as invasive as other chronic conditions such as heart failure, diabetes and COPD. People with chronic conditions increasingly have access to dedicated, usually nurse-led services that provide support with exacerbations and link the patient to GP and secondary care when required. Even the traditional ‘Cinderella’ conditions of dementia and mental health now benefit from improved recognition and coordinated care. I would argue that chronic musculoskeletal conditions are now the true Cinderella in the UK, a fact recognised by NHS England through their partnership with the Arthritis and Musculoskeletal Alliance (ARMA) called the MSK Knowledge Network. Its focus is on bringing knowledge and people together to improve outcomes for people with MSK conditions in England.

There are several projects that show the value of community-based support for people with musculoskeletal problems. The Joint Pain Advisor pilot in South London 2 is an example of the power of professional support to help people adapt to chronic pain problems and reduce demands on healthcare resources, particularly GPs. The power to encourage self-care and de-medicalise chronic musculoskeletal pain have been cornerstones of pioneering services such as the Back Pain Programme in South Tees 3 and the Pain to Prospects Programme in Leicester 4. These services win awards, are reproducible beyond the pilot phases and could provide a level of support to the people with chronic musculoskeletal conditions similar to that for conditions such as heart failure, diabetes and COPD. My impression is that the biopsychosocial approach required is just ‘not medical enough’ to receive CCG funding but ‘too medical’ to attract financing from the social or welfare sector.

Will the evolution of Primary Care Networks announced in January 2019 through the NHS long-term plan provide the right environment for ongoing community based musculoskeletal support? Let’s hope so. If ARMA take up this cause with NHS England, progress can be made.

References:

  1. Global Burden of Disease Study 2013 Collaborators. (2015) Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386:743–800. 
  2. A Walker, R Williams, F Sibley, D Stamp, A Carter, M Hurley. (2017) Improving access to better care for people with knee and/or hip pain: service evaluation of allied health professional‐led primary care. Musculoskeletal Care. https://doi.org/10.1002/msc.1189
  3. NHS England (2017) National Low Back and Radicular Pain Pathway 2017, Together with Implementation Guide http://www.ukssb.com/pages/Improving-Spinal-Care-Project/National-Backpain-Pathway.html. (accessed January 2019).
  4. Hampton R. (2013) From Pain to Prospects? – helping people on welfare benefits with chronic pain. Pain News. 2013;11(4):227 –230.

Since the NHS Long Term Plan (LTP) was published on 7 January 2019, the NHS Operational Planning and Contracting Guidance 2019/20 has been released. It gives guidance on how the additional funding settlement for the NHS should be used.

Key points of interest are:

 It is the start of the process of producing the local plans that will be the implementation of the NHS LTP. For 2019/20, every NHS trust, NHS foundation trust and clinical commissioning group (CCG), will need to agree organisation-level operational plans which combine to form a coherent system-level operating plan. This will provide the start point for every Sustainability and Transformation Partnership (STP) and Integrated Care System (ICS) to develop five-year Long-Term Plan implementation plans, covering the period to 2023/24.

The document covers:

  • System planning
  • Financial settlement
  • Operational plan
  • Process and Timescale

System planning

Every STP/ICS must produce a system operating plan for 2019/20. This must include an overview of how the system will use its resources to meet population health need, including specialised commissioning and direct commissioning as well as CCG plans. It must also include a system aggregation showing how individual plans align to form a system plan.

All NHS providers and CCGs must be part of a plan. The focus should be on how to work together to provide efficiency savings, not cost shunting from one organisation to another.

Financial settlement

The focus of this section is on CCG funding settlements and tariff payments. It then addresses efficiency savings and steps that systems need to focus on to become more efficient. This includes working to make outpatients and community services more efficient through use of digital technology.

There is a list of ongoing opportunities which includes medicines value – e-prescribing; removal of low value prescribing; and greater use of biosimilars.

There is a list of specialist commissioning which includes reference to long term conditions, but specifically mentions hepatitis C and neurosciences. Also reference to rapid diagnosis of rare diseases, but in relation to genomics. Integrating specialist commissioning into locally commissioned services is also seen as an opportunity, including the move to a pathway approach to planning care for populations.

Operational plan requirements

This section lists the priorities seen as fundamental to transforming urgent and emergency and elective care. The nine deliverables are:

  • Emergency care – reducing the time for which patients are hospitalised.
  • Referral to treatment times – The expectation is that over 5 years the volume of elective care will go up, and waiting lists will come down, starting in 2019/20. However, waiting times commitments relate to 6 month and 52 week waits. The clinical standards review will look at waiting time standards (this is where we have a concern that the 18-week target may be changed/scrapped). There is also reference here to First Contact Practitioners for MSK patients.
  • Cancer treatment
  • Mental health – a series of deliverables for mental health includes a target that 50% of those on IAPT should recover. Depending how you define recover, this might be a barrier for MSK patients with long term conditions for whom managing their mental health is more realistic than recovery.
  • Learning disability and autism
  • Primary and community care – The focus of this is on primary care networks. STPs/ICSs must set out how they will achieve sustainability and transformation of primary care. Additional funding to primary care must deliver investment in transformation. A local workforce plan including multi-disciplinary teams and a primary care network development plan.
  • Workforce
  • Data and Technology
  • Personal health budgets – by March 2021 50,000 – 100,000 people must have a personal health budget.

The longer-term deliverables are those in the LTP.

Timeline

Draft organisation/operational plans submitted by 19 Feb with 5-year plans by Autumn 2019.

For more detail see the full document.

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.

Since the NHS Long Term Plan (LTP) was published on 7 January 2019 a new document, Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan, has been released which includes the roll out of the Primary Care Networks model. Here’s a summary of the relevant MSK elements.

The publication covers the following areas:

  • Addressing the workforce shortfall
  • Solving Indemnity Costs
  • Improving the Quality and Outcomes Framework (QOF)
  • Introducing the Network Contract DES
  • Going ‘digital-first’ and improving access
  • Delivering new network services
  • Guaranteeing investment
  • Supporting research and testing future contract changes
  • Schedule of future contract changes and development work

Workforce

Workforce is identified as the priority for primary care. Various steps are set out to enable recruitment of an additional 5,000 doctors and 1,000 nurses.

There is a reimbursement scheme for additional roles to enable increased multi-disciplinary teams. Five roles are listed as being eligible for reimbursement:

  • clinical pharmacists,
  • social prescribing link workers,
  • physician associates,
  • first contact physiotherapists
  • first contact community paramedic.

ARMA has raised with NHSE the fact that the role is First Contact Practitioner, not physiotherapist. If reimbursement is only available for physiotherapists in the role, we are concerned this will mean other professional training does not see FCP as something worth investing in, so reducing a potential source of suitable FCPs. This would be counterproductive in the context of a measure designed to address a workforce shortfall.

Primary Care Networks

Primary Care Networks (PCNs) are intended to bridge the divide between primary and community services. They focus on provision of services, not on commissioning. They will become the foundation of integration to deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care.

They are about primary care practices contracting to work together. A PCN should cover a population of around 50,000 patients (minimum 30,000) so that it is large enough to support a multidisciplinary team.

Networks will have a network agreement. Delivery will require collaborative working by members. Members of a network will be GP practices plus specialist, physical and mental health services and secondary care in the area.

Each PCN must have a clinical director and one lead practice which receives the funding for the network. NHS England will provide a range of support to PCNs.

Delivering new network services

There will be seven service specifications to be delivered in 2019/20:

  1. Structured Medications Review and Optimisation;
  2. Enhanced Health in Care Homes, to implement the vanguard model;
  3. Anticipatory Care requirements for high need patients typically experiencing several long term conditions, joint with community services;
  4. Personalised Care to implement the NHS Comprehensive Model;
  5. Supporting Early Cancer Diagnosis;
  6. CVD Prevention and Diagnosis; and
  7. Tackling Neighbourhood Inequalities.

Anticipatory care – Based on individual needs and choices, under the Anticipatory Care Service, people identified as having the greatest risks and needs will be offered targeted support for both their physical and mental health needs, which include musculoskeletal conditions, cardiovascular disease, dementia and frailty. Typically, this involves a structured programme of proactive care and support in which patients with multi-morbidities will have greater support– including longer GP consultations where appropriate – from the wider multidisciplinary team.

For more detail see the full document.