Arthritis and Musculoskeletal Alliance
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Commissioning

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.

Arthritis Care’s innovative commissioned service with West Berkshire Commissioning Support Unit (CSU), covering four Clinical Commissioning Groups, has moved from a two-year pilot to a contracted service. The service enables individuals to make better informed decisions around if and when to undergo knee or hip replacement surgery.

Joe Smart, Transformation Lead from the CSU confirmed “a new contract has been agreed with Arthritis Care which offers excellent value for money and enables the charity to bring in additional resources to provide the service on a larger scale”.

The NHS has confirmed that the service saw 642 patients over two years, of which only 98 have gone on to have a surgical intervention within 24 months of receiving our service. The resulting 544 fewer surgical interventions over a two year period was credited with generating savings to the NHS of £2.6 million.

ACare-895000

NV-Six-principles-diagramThe People and Communities Board, one of the Five Year Forward View programme boards, has published Six principles for engaging people and communities: putting them into practice.

The principles offer a practical steer on developing the ‘new relationship with people and communities’ set out in the Five Year Forward View. The six principles aim to help build knowledge, confidence and motivation to develop person centred, community-focussed approaches to health and care.

The principles will be useful for anyone engaged in transforming health and care – including Sustainability and Transformation Plan leads, local authorities, CCGs, NHS Trusts, GP surgeries, frontline staff, and the voluntary and community sector. www.bit.ly/thesixprinciples

bjd document cover

The first internationally-informed Framework for Developing and Evaluating Musculoskeletal Models of Care has been developed by a team of Australian researchers in partnership with The Global Alliance for Musculoskeletal Health.

What are Models of Care?

Models of Care are guides or policies that outline the principles of care for particular conditions and how to implement that care in a local setting.

Who is the Framework for?

The Framework is intended to help those tasked with planning, implementing or evaluating health services to achieve an optimal Model of Care and its sustainable implementation. While the World Health Organisation has developed a guide to assist nations in assessing capacity for responding to the burden of cancer, diabetes, cardiovascular disease and lung diseases, this Framework assists nations specifically address musculoskeletal health challenges through Models of Care.

How was the framework developed? BJD-2015-square

Led by Associate Professor Andrew Briggs (Curtin University, Australia), the Framework was informed by experts from 30 nations, representing high, middle and low-income economies, using a phased research approach.

Why is it important?

As Governments and other agencies worldwide recognise the immense burden of disease associated with musculoskeletal conditions, Models of Care will become increasingly important as a system-wide response. The Framework will help to support development efforts in Models of Care and offer an approach to standardising evaluation.

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.

 

Zoe-Cole-FLS-lecture#FLSChampions

Dr Zoe Cole giving a presentation on how the National Osteoporosis Society was instrumental in developing a successful business case for a Fracture Liaison Service.


Risk of breaking a bone depends on where you live

Funded by the National Osteoporosis Society, a study showed that the risk of having a fracture varied by geography and socio-economic status.

Professor Nick Harvey and the team at Southampton University’s Medical Research Council Lifecourse Epidemiology Unit, undertook an analysis of the UK Clinical Practice Research Datalink database and calculated the risk of an individual experiencing a fracture.

They found that there were marked differences in fracture rates according to where individuals lived, with the highest fracture rates in Scotland and Northern Ireland where rates were 50% greater than those in London.

 

NOS-banner-460Service Improvement Manager vacancy

The National Osteoporosis Society is recruiting a Service Improvement Manager to support our ambitious work in developing and improving Fracture Liaison Services across the UK. Closing date for the application is 10th May 2016.

https://www.nos.org.uk/about-us/vacancies

By Lawrence Dunhill, Health Service Journal, 7 January 2016

Simon Stevens has said a court decision supporting a major reconfiguration in Greater Manchester presents a “wider lesson” for the NHS.

The NHS England chief executive also criticised Wythenshawe Hospital, saying spurious claims were made to advance a “mistakenly conceived institutional self-interest”.

As revealed earlier on Thursday 7th January, a High Court judgement has backed commissioners’ decision to remove emergency and high risk general surgery from Wythenshawe, which is run by University Hospital of South Manchester Foundation Trust.

Mr Stevens said on Thursday afternoon: “Lives will be saved by this welcome ruling, which is a decisive vindication of the leadership being shown by NHS commissioners across Greater Manchester, working in close partnership with hospitals and local councils.

“Today’s result rejects the spurious claim that better emergency care for patients in Greater Manchester, Derbyshire and Cheshire should have been sacrificed to advance one hospital’s mistakenly conceived institutional self-interest.

“That’s a wider lesson that the whole of the NHS will need to learn from, as we kick off the process for developing shared sustainability and transformation plans locally to implement the Five Year Forward View.”

A judicial review was brought by a group of doctors at the hospital, while UHSM also submitted evidence that questioned the Healthier Together consultation process and the expected impact on other specialised services. It was revealed earlier this week that the FT’s chief executive, Attila Vegh, had resigned.

Keep Wythenshawe Special, the company formed to pursue the case, said: “We want to reiterate that patient safety and benefit for the people who need our hospital was our only reason for mounting this campaign.”

In his ruling, Mr Justice Ian Dove said the proceedings were “brought and defended out of a passionate concern, on all sides, for the health and wellbeing of all those who depend on healthcare provisions in Greater Manchester”.

UHSM chair Barry Clare said: “Due to the extensive range of services that Wythenshawe Hospital provides, there is a need for strong, onsite emergency general surgery.

“Our work will continue with the already established clinical leadership group which is made up of representatives of senior clinicians from UHSM, Central Manchester University Hospitals and our commissioners, to address the remaining clinical concerns and develop solutions designed to accommodate them during the implementation stage of the project.”

phe-logoFrom the Public Health Matters blog, Public Health England
, 11 January 2016 — Health and Wellbeing

Life expectancy in England has risen by more than five years in the past two decades, yet for many people, a longer life will involve more years spent in ill-health.

Earlier this year, The Global Burden of Disease project – an international study ranking the diseases and risk factors that cause death and disability – highlighted the toll that musculoskeletal conditions are taking on people’s health.

2000px-Lumbar_region_in_human_skeleton.svgMusculoskeletal conditions are disorders of the bones, joints, muscles and spine. They can cause pain, stiffness or a loss of mobility and dexterity that can make it difficult to carry out everyday activities.

Low back and neck pain is now the leading cause of disability in England for both men and women combined. Falls, which are often a result of poor musculoskeletal health, also remain in the top ten causes of disability adjusted life years – a combination of the number of years of life lost to disease and the number of years lived with disability as a result of disease.

 

The wider effects

Each year 20% of people in the UK see a doctor about a musculoskeletal problem, and the NHS in England spends £5bn each year treating these conditions.

As well as causing pain and disability, musculoskeletal conditions can affect people’s physical health more generally. For example, people with osteoarthritis have an increased risk of cardiovascular disease, and falls among older adults increase the likelihood of early mortality.

Although many musculoskeletal conditions become more common as we age, they are not limited to older adults. A report published by Arthritis Research UK in 2014 highlighted that, in the past year, one in six adults aged over 25 had reported back pain lasting more than three months. Obesity, physical inactivity and injury are all major risk factors for back pain.

Mental health conditions can also increase the likelihood of developing some musculoskeletal disorders. For example, people with depression are at greater risk of developing back pain. Here lies a vicious cycle, as musculoskeletal conditions can also have a significant impact on mental health. Living with a painful condition can lead to anxiety and depression, and depression is four times more common among people in persistent pain compared with those without pain.

People with musculoskeletal conditions are also less likely to be employed than people in good health, and are more likely to retire early.

DALY

Musculoskeletal health: making a difference

Steps can be taken to improve musculoskeletal health at every stage of life, and tackling a number of risk factors could result in the dramatic improvement in the musculoskeletal health of the public.

Bones, joints and muscles begin to develop before birth, and continue to develop throughout childhood. Women who have a good diet and are physically active have babies that go on to have stronger bones throughout life. Conversely, childhood obesity can put pressure on vulnerable joints, increasing the risk of MSK conditions.

Regular physical activity and exercise at every stage of life can reduce the risk of many musculoskeletal conditions, including arthritis, back pain, neck pain, falls and fractures. Indeed, many of the NICE guidelines on physical activity to prevent disease or improve health are directly relevant to musculoskeletal health. A healthy balanced diet is also important for good bone health, to prevent osteoporosis and falls in later life.

There is also a lot that can be done in the workplace to reduce any threats to musculoskeletal health, including adapting physical environments and work practices, as well as early interventions to identify and address problems.

It’s important to note that, for the three leading musculoskeletal conditions that cause the most DALYs in England, there are evidence-based interventions that work (see table).

msk-interventions

Evidence-based interventions for the musculoskeletal conditions that cause the most DALYs in England, including low back and neck pain, falls and osteoarthritis.

 

At Public Health England, we’re working to reduce the impact of musculoskeletal conditions in a number of different ways:

Data and surveillance resources

The Arthritis Research UK report puts a clear emphasis on the need to urgently improve the extent and quality of clinical data on musculoskeletal health. More work is needed fill these gaps, but two useful weapons in our data arsenal are currently available:

The PHE Global Burden of Disease Compare tool helps local authorities to see the burden of musculoskeletal conditions on their local populations, while the Public Health Outcomes Framework enables us to see which risk indicators for musculoskeletal disorders are high in each local authority area.

 

Programmes for patients and professionals

Moving from evidence into action, PHE is working with partners on a number of prevention programmes and resources for people across all stages of life, as well as initiatives to help commissioners procure services to help prevent musculoskeletal ill-health.

For example, the Every Body Active Every Day framework sets out our vision of everybody being physically active, every day. It details clear steps for local authorities and partner organisations to promote change and encourage active lifestyles.

Our Falls prevention booklet explains how older people at risk of falls can reduce their risk and stay active. We have also developed a Falls and Fragility Fraction Population Healthcare Programme to help local authority public health teams gather and disseminate information about their local FFF system. The programme also supports local FFF initiatives, assesses and tracks performance and enables local partners to learn from best practice.

 

Partnerships and public engagement

Improving musculoskeletal health requires commitment from many different stakeholders, and will benefit patients, the health care system and other groups such as employers. We’re working with several partners to find joined-up ways of improving musculoskeletal health across the life course, such as our Workplace Wellbeing Charter to help employers provide workplace environments that support and encourage a healthy workforce.

We’re also working with Arthritis Research UK to make sure that improving the musculoskeletal health of the population is on the agenda of both the public health community and local and national government. Bedfordshire Clinical Commissioning Group is a great example of how some parts of the NHS are already using an integrated approach to improving MSK services. Last year it commissioned one single provider for its entire MSK programme with responsibility for delivering a service that joins up with other elements of the care pathway and focuses on outcomes for patients.

 

Reducing the burden of disease

As health care professionals, we must work together to promote good musculoskeletal health as a way to address multi-morbidity and protect mental health and wellbeing. At PHE, we are committed to working with partners and academics to identify health interventions that really work, supported by world-class knowledge and data, and to improve the capability and capacity of the NHS and the wider public health workforce to identify and treat MSK conditions, and implement effective and efficient prevention programmes.

The Global Burden of Disease study highlighted the fact that, as a nation, we must do better to reduce the burden of chronic diseases. Tackling musculoskeletal conditions and their wider impacts on health and wellbeing is a crucial step.