Arthritis and Musculoskeletal Alliance
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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.

Commissioning

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.

Since the NHS Long Term Plan (LTP) was published on 7 January 2019, the Universal Personalised Care: Implementing the Comprehensive Model has been published.

The document defines personalised care: people have choice and control over the way their care is planned and delivered based on ‘what matters’ to them and their individual strengths, needs and preferences.

There are six components to the model:

  1. Shared decision making
  2. Personalised care and support planning
  3. Enabling choice, including legal rights to choice
  4. Social prescribing and community-based support
  5. Supported self-management
  6. Personal health budgets and integrated personal budgets.

The document sets out the key principles of each component and what evidence would show that it is implemented.

Social prescribing – includes a reference to the need for this to be appropriately funded. There should be a one stop shop connector service with link workers (up to 5 per Primary Care Network) about to connect people to community groups and voluntary organisations that are supported to receive referrals. There should be community-based approaches to providing peer support. ARMA would argue that there is a role for patient groups in providing this peer support.

Supported self-management – This can include:

  • Health coaching or structured group coaching course
  • Self-management education approaches (face-to-face and virtual), which include disease-specific, generic and online self-management courses
  • Peer support through a link worker

Personal health budgets – People will have an indication of how much money they have available for healthcare and support, enough to meet the health and wellbeing needs and outcomes agreed in the personalised care and support plan. They will be able to use the money to meet their outcomes in ways and at times that make sense to them, as agreed in their personalised care and support plan.

 

Implementation

The document lists 21 actions needed to deliver personalised care at scale. These include:

  • Workforce training, including to all GPs.
  • An intensive face to face training programme for 75,000 health care professionals by 2023/4
  • Recruit and train over 1,000 social prescribing link workers by 2020/21
  • Work with partners in the voluntary and community sector, and others, to explore the best models for commissioning the local voluntary and community sector to support innovative provision.
  • Support for programmes to enable self-management
  • Train up to 500 people with lived experience to become system leaders by 2023/24.

For more details, see the full universal personalised care document.

 

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.

The draft scope for this NICE guideline is now out for consultation; it is a valuable opportunity to ensure that the guideline considers issues important to your members. The consultation page contains the documents, background papers and instructions on how to comment.

The consultation on this draft scope will close at 5pm on 15 February 2019.

NICE will also be recruiting people with a practitioner, care provider or commissioner background and lay members (people using services, family members and carers, and members of the public and community or voluntary sector) to join the Committee for this guideline.

You will be able to find more information on these positions at the Committee recruitment page.

How to implement the National Back and Radicular Pain Pathway (NBRPP)

12.30 – 1.30pm Friday 8 March 2019

The webinar aims to support the implementation of the National Back and Radicular Pain Pathway. It will initially explain the pathway and present data from early implementers to help make the case for change in your local area. The physiotherapist who led the implementation of the NBRPP across Cheshire and Merseyside as part of the Walton Centre Vanguard Project will talk about her experiences, common barriers to implementation and strategies to overcome them.

Back pain is the largest single cause of disability in the UK, with lower back pain alone accounting for 11% of the total disability of the UK population as well as the largest cause of sickness absence.

The NBRPP is the product of a unanimous consensus of 29 stakeholders based on best evidence. Its objectives are to provide a streamlined care pathway for radicular pain and an effective, managed pathway for patients with low back pain. Value impact analysis has indicated substantial cost savings in early implementation in the North East. The Pathway is demonstrating improved clinical results in patient clinical outcomes and patient satisfaction.

Who should attend: All professionals involved in the commissioning and delivery of spinal care.

Register in advance for this webinar:
https://zoom.us/webinar/register/WN_pmMKfZ-LSE-Bi0KvA65EPQ

Presenters:
Stephen Hodges, NHS RightCare
Samantha Davies, The Walton Centre