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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.



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.

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.


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).


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.

HSJ-2015_squareWide variations in elective surgery rates among the most affluent and deprived areas in England raise serious questions about the use of NHS resources, a leading public health expert has warned.

1 October, 2015 | By Lawrence Dunhill, Health Service Journal.

  • HSJ investigation finds huge disparities in rates for elective surgery in affluent and deprived populations
  • Experts warn the variance raises serious questions about use of NHS resources
  • Disparity in elective surgery commissioning

HSJ’s investigation, which examined the rates for elective surgery funded by the clinical commissioning groups covering the 10 most affluent and 10 most deprived populations in the country, has revealed huge disparities. The 2014-15 data was obtained from the CCGs by Freedom of Information requests. All the average rates were calculated using NHS England’s weighted populations.


Charts: Disparity in elective surgery commissioning

These charts (click link above) are designed to take account of factors such as age and deprivation, and factor in the higher life expectancy in affluent CCG areas, as well as “unmet need” in deprived populations.

Findings highlighting the variance in rates for four of the most common elective procedures include:

  • Hip replacement: The average rate in affluent areas was 181 treatments per 100,000, compared to just 58 in the deprived areas. The highest rate in Guildford and Waverley was 408 per 100,000, compared to 15 in Knowsley.
  • Knee replacement: In the affluent areas the average rate was 200 per 100,000, compared to 88 in the deprived areas. Bracknell and Ascot had the highest rate, of 344 per 100,000, compared to 42 in Tower Hamlets.
  • Inguinal hernia repair: The average rate in the affluent areas was 155, compared to 84 per 100,000 in the deprived areas. Guildford and Waverley again had the highest rate, of 257, nearly five times that in Tower Hamlets.
  • Cataract operations: The average rate in the affluent areas was 705, compared to 510 in the deprived areas. Despite being one of the most deprived areas, Blackpool’s rate of 1,098 per 100,000 was the highest, and more than four times the rate in North Manchester.


10 most affluent and 10 most deprived CCG populations

Most affluent areas:

  • Wokingham
  • Rushcliffe
  • Surrey Downs
  • Surrey Heath
  • Horsham and Mid Sussex
  • Guildford and Waverley
  • North East Hampshire and Farnham
  • Bracknell and Ascot
  • Windsor, Ascot and Maidenhead
  • North West Surrey

Most deprived areas:

  • Bradford City
  • North Manchester
  • Liverpool
  • Newham
  • City and Hackney
  • Knowsley
  • Sandwell and West Birmingham
  • Birmingham South Central
  • Blackpool
  • Tower Hamlets

The 20 CCGs were selected using the deprivation scores in the Indices of Multiple Deprivation.

disparity-john-applebyJohn Appleby, chief economist of the King’s Fund, who highlighted similar trends in a 2011 report, said: “This once again highlights persistent and widespread variation in the use of surgical procedures. Some of this variation is justified but much of it is unwarranted, inefficient and unfair on patients. Tackling unwarranted variations in treatment is key to delivering better value in the NHS and meeting the productivity challenge.”

The CCGs were also asked for their total spending on elective surgery, although these figures will be less robust as some have used different definitions. According to the figures provided, the CCGs in affluent areas spent £136 per head of population, compared to £102 in the deprived areas. “Much of the variation is inefficient and unfair on patients”, John Appleby said.

Sir Muir Gray, an adviser to Public Health England and director of Better Value Healthcare, highlighted HSJ’s findings when he launched the NHS Atlas of Variation last month. They were shared with hime earlier. He told HSJ: “This raises important issues about under-provision in the most deprived areas, and the possibility of overuse and oversupply in the most affluent areas. People from wealthier populations are perhaps getting these procedures done before the optimum point. We’re seeing an application of resources based on demand, but the NHS might be able to get more value by using the resources in other ways.”

He said the weighted populations may not fully account for the age related factors, but thought other factors could cause an opposite effect, such as the likelihood that more patients in affluent areas would receive non-NHS care.

CCG leaders outside the 20 also told HSJ they had serious concerns that their main provider was “driving demand” for elective surgery in order to maximise income via the payment by results system.

The findings for primary hip replacements in the atlas, which is based on data from 2012-13, are broadly in line with HSJ’s findings. There appears to be less correlation with deprivation on cataract surgery, however, while knee replacements and hernia repairs are not featured.

Some of the affluent population CCGs questioned the reliability of HSJ’s findings, suggesting the weighted populations may not fully take account of age-related factors. Some of the CCGs in deprived areas said cultural factors in areas with large ethnic populations meant patients were less likely to opt for surgery, and this would not be reflected in the figures. CCGs may also have used different procedure codes when responding.

However, James Blythe, director of commissioning and strategy for Surrey Downs CCG, said: “Taking into account the health needs of our ageing population, elective activity in some areas, such as hip, knee and cataract operations, is still higher than we might expect. In order to fully understand the reasons for this, we are currently undertaking a comprehensive review of planned care pathways.”

A spokesman for Guildford and Waverley CCG said an external review suggested its elective spending was “slightly above average, but not excessive”. He added that a Surrey priorities committee was “currently in discussion with orthopaedic colleagues about evidence based thresholds for hips and knee replacements which may reduce numbers in future”.

Bradford City CCG said it was currently investigating its low rates for hernia surgery. Its GP lead for partnerships and health inequalities, Ishtiaq Gilkar, added: “Bradford City CCG is fully committed to reducing the health inequalities associated with deprivation.”

A spokeswoman for Tower Hamlets and Newham CCGs said: “Some patients may present as emergencies rather than elective planned. There is significant evidence that late presentation of symptoms is more of an issue in areas of high deprivation and high population growth and turnover, such as east London, resulting in more emergency care. We also know that the same pattern is apparent within boroughs, whereby less deprived members of the population, tend to use more elective services than those who are less deprived.”

Sandwell and West Birmingham CCG said it did not commission any cataract operations in the last two years, but did not respond to requests for comment, and was discounted when calculating the average. Knowsley CCG said the atlas suggested it was not an outlier for hip replacement surgery. Blackpool CCG did not respond.

guidelines-in-practice-logoDr Ian Bernstein and Stephanie Griffiths answer questions on the nationally acclaimed musculoskeletal service in Ealing and how it was implemented.

The redesign started about 20 years ago, when all musculoskeletal services were provided in secondary care. There was no GP access to physiotherapy; patients would be referred to a consultant and could be waiting for up to a year before seeing a physiotherapist. In the 1990s, under GP fundholding, a small number of GP practices in Ealing bought physiotherapy services. Following the demise of fundholding, a community musculoskeletal service was set up using the same pot of money, but it then had to cover the whole of Ealing, and not just the few leading fundholding practices…

Read more from the Guidelines in practice website.


by Matthew Bennett, President, British Chiropractic Association

As we all know back pain is the single biggest cause of disability in the UK according to the Global Burden of Disease Report. Despite this huge cost both in human and financial terms, care can often appear to be disjointed. In 2009 NICE published guidelines on the Management of persistent non-specific low back pain but many regions in the UK still struggle to implement the guidance and with many different providers being involved in the management of back pain an integrated approach is elusive. Due to the episodic nature of much low back pain, multiple GP appointments are often needed for essentially the same condition. Onward referral for secondary care can be inconsistent and prone to delays resulting in increased chronicity and comorbidity.

Some areas in the UK have good provision for manual therapy including manipulation eg. North-East Essex PCT and other areas have very limited access with complicated care pathways and many different providers responsible for different elements of care. Part of the problem is identifying which professional group should be seeing a patient at a particular time. If manual therapy is required, the norm is to refer for physiotherapy which at one time was synonymous with hands-on treatment like massage and exercises.
As the range of skills that physiotherapists provide has grown so too has the range of services they offer. Physiotherapy is no longer a treatment in itself it is now a profession whose members provide a package of care which may include elements of counselling, advice, electrotherapy and acupuncture based on extensive diagnostic skills. So too chiropractors and osteopaths once thought of as only providing spinal manipulation now provide a broad range of treatment services based on strong diagnostic skills.

If the health care system in the UK is to cope with the massive burden of MSK problems then integrating all the resources available is important. With three different professions providing manual therapy how are commissioners to choose who is best for treating these patients? The recent National Pathway of Care for Low Back and Radicular Pain proposed that we move from commissioning based on specialties or professions to commissioning based on competences. NICE have recognised this and recommend particular interventions rather than professional groups in their guidelines.

When talking about spinal related disorders such competences should include clinical screening for serious pathologies as well as diagnosing particular spinal conditions; bio-psychosocial assessment and advice; advice on self-management and pain relief; appropriate referral for imaging and secondary care; conservative management of spinal pain and finally the role MSK problems play in broader public health issues such as mental health, obesity and diabetes. Such a spine care expert would be would be responsible front-line triage, diagnosis and management, improving patient care and potentially saving costs throughout the care pathway.

It is time to move beyond MSK care divided along professional boundaries and move to commissioning based on competences. With its many different stakeholders ARMA is well placed to facilitate such a process.