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

Guest Blog

By Dr Helen Branthwaite, MSK Project Lead, College of Podiatry.

The rapid changes in shoe design and the increasing number of choices that occur in the footwear market might make a consumer with painful feet quiver at the thought of buying any new shoes. Yet, humans have been wearing shoes on their feet for thousands of years as protection against the environment. Problems have only been recorded in the last 600 years when shoes have been used more as a fashion statement as well as a status symbol. In fact, it was only considered normal for a western culture to wear shoes as standard after the first world war. However, it is well established that incorrect shoe choice can cause pain or injury yet the advice available about which shoes to purchase can be inconsistent. Within ARMAs campaign to heighten the awareness of the amount of pain that people suffer with MSK complaints, it is vital that the choice of shoes selected for painful feet are considered.

Currently, most people own many different pairs of shoes and choose what to wear based on the activity that they are planning to do. The choices are dominated by fashion and image with colour being considered before correct fit. Trends are set by celebrity endorsements and can often end up as a staple in everyone’s wardrobe. Think of the Ugg Boot®, designed in the first instance to be a slipper for surfers in Australia using surplus sheep’s wool. This boot initially rose to fame when Hollywood celebrities paired it up with the latest catwalk fashion but now Ugg® is a worldwide brand and the “boot” has many less than desirable imitations, all which have been correlated to causing pain. Footwear trends do come and go and sometimes the styling can help the wearer have more comfortable feet and other times they create a problem. The main complaint though from people who have painful feet, is working out what is best for them and what is the right choice.

Podiatrists frequently engage with patients about footwear choices and advise them on their selections. This can be as part of a treatment to prevent development of further complaints or can also be to improve the function of the foot to reduce pain. It is commonly thought that high heel shoes are really bad for users, but in some cases the use of a heel between 2-4cm can actually alter ankle movement reducing strain on the plantar fascia and Achilles tendon, two of the most common structures that cause pain in the heel and ankle. This is not the case for everyone though and for some people wearing a heeled shoe can increase the pressure on the front of the foot and cause problems with the digits and metatarsals. That’s why when issues like the equality act on high heel shoes for females was debated in parliament, the College of Podiatry presented the argument that heeled shoes should be the wearers choice and not a stipulation of uniform, as wearing high heeled shoes does alter mechanical function and is different for everyone.

The influence of marketing and trends can also be seen in the running community where scientific research and development aims to create a running shoe that can break world records, reduce injury, maximise efficiency and improve function. The rapid evolution of the running shoe leads to most active runners being in a state of bewilderment as to what is right for them. It also leads to governing bodies banning certain styles, as performance enhancement is considered.

With a drive to become more active in society to improve MSK health, where does this confusion leave the average park runner who is wanting to complete their 5k run in a quicker time, injury free?

I guess some of the answers lie in getting a full footwear assessment tailored to your individual requirements and needs. This should be in conjunction with an assessment and diagnosis of any pain you are suffering from. Provision of footwear rules and advice from a podiatrist can certainly make the scenario of purchasing new shoes more bearable and could possibly improve pain and function too. Don’t forget, that just by simply wearing shoes there are many changes that occur to the way you move and how you use your feet.

by Clare Jacklin, Chief Executive, NRAS

I heard a good joke during the Christmas break –

Question: What do you think next year will bring?
Answer: How would I know…? I don’t have 2020 vision!

Albert Einstein is widely credited with saying, “The definition of insanity is doing the same thing over and over again but expecting different results.”

Now, I’m not for a moment saying we’re all going insane but I wonder how many of you reading this feel (as I do) a sense of déjà vu that we’ve heard the same thing over and over but little change has occurred. We hear so much rhetoric about ‘shared decision making’, ‘patient centricity’, ‘shared care’ etc. but still our NRAS helpline gets far too many calls from people who feel excluded from their own treatment and care! These are people without power to choose or influence or contribute to their own therapy.

NRAS has been leading the way since 2001 for the rights of those living with RA and JIA to have access to the right care, at the right time provided by the right people. This is a challenge that is still ongoing; despite so many promises and policies being made by various stakeholders over this last decade, there is still blatant evidence of the UK being victim to postcode lottery health care.

People living in the UK with inflammatory arthritis have access to the very best of medicines, the very best of multi-disciplinary team care but only if they happen to live in certain areas of the country. Too often we are hearing from people who not only struggle with the day to day issues of living with RA or their child with JIA, but are battling to get appointments, fighting to get onto particular treatments or being denied choice or input into their care. So, who or what is making these decisions? Not surprisingly in my opinion it is the loudest voice of all that calls the shots… money! That old adage ‘money talks’ has never been more evidently true than it is today. Short term gains are prioritised over long term improvements to individuals’ lives, the NHS as a whole and the UK economy.

Within the first half of 2020, NRAS will be launching our two new websites (one for NRAS and one for JIA at NRAS), as well as the first of our e-learning modules. All of which along with our informative resource booklets are aimed at giving people living NRAS logo with RA or JIA the knowledge, tools and confidence to keep on demanding what is rightfully theirs… the right to be part of their own care and treatment. The NRAS Right Start New2RA service (launched at BSR conference 2019) is also evidencing that giving individuals the right information at the very beginning of their journey with RA is making a significant difference to their prognosis and outcomes. Better outcomes for patients leads to less demand on NHS services, improved adherence to treatment which in turn reduces wastage of medicines, individuals who have the right care at the right time also are more likely to stay working hence contributing to the economy which in turn is reducing the strain on the welfare system but most importantly improving their quality of life and reducing the risk of developing depression and anxiety. So, if ‘money talks’ then surely all of this is currency for conversation!

This is why I was keen that NRAS re-joined ARMA so that collaboratively with all our fellow ARMA Members we can be bold and brave as we enter this new decade to bring about and support new initiatives that can contribute to efficiency savings and investment in projects such as the First Contact Practitioners initiative. I am hopeful that by engaging with and offering supportive training to practitioners in primary care that NRAS, along with other ARMA Members, can bring about earlier diagnosis for many with inflammatory arthritis which in turn can contribute to all of the above.

In summary, my 2020 vision is to banish those déjà vu moments of the last decade and see clear change for the better, living up to the NRAS strapline of Changing Minds, Changing Services and Changing Lives for all those living with RA and JIA.

Guest blog by William Pett – Senior Policy Advisor, NHS Confederation

As people grow older, health conditions often become both more complex and chronic. Evidence shows that rates of those living with multimorbidity rise significantly with age; a recent study revealed that 30% of adults aged 45 to 64 years report at least two chronic conditions, increasing to 65% of adults aged 65 to 84 years and more than 80% for those above 85 years old.

For older people living with multimorbidity, musculoskeletal conditions are common. Organisations such as Versus Arthritis have drawn attention to this in recent years, highlighting that among those over 45 who report living with a major long-term condition, more than 3 out of 10 also have a musculoskeletal condition.

Yet, as those who have lived with comorbidities may tell you, the NHS has not historically dealt well with patients with multiple conditions. The health system has traditionally been focused around episodic care – one provider contracted to treat for one condition, another contracted to treat for a second condition. This in turn has made care pathways somewhat arduous for patients, requiring them to go to different locations for different conditions – especially problematic, of course, if you are older and less mobile.

Fortunately, things are beginning to change. The NHS Long Term Plan, which builds on the principles of the Five Year Forward View, looks to break down silo working across the health system and sets out how integration of services will improve outcomes for patients. There are likely to be several beneficiaries of more integrated working – including not just patients but also clinicians and the tax-payer – but it may well be those with multiple conditions who benefit most.

For those with musculoskeletal conditions specifically, care pathways are being made easier and more direct for patients through direct access to First Contact Practitioners (FCPs). Recognising that musculoskeletal conditions account for 30% of GP consultations in England, FCPs will allow those with conditions such as arthritis to see a physiotherapist at a local surgery straight away, without the need to go through a GP.

More broadly, the old model of GPs referring patients out to different specialist and community services is being streamlined through Primary Care Networks (PCNs). These will bring together GP practices and community services in neighbourhoods across England, with the aim of achieving fully integrated community-based health care. A key feature of PCNs will be multidisciplinary teams, comprising a range of staff from pharmacists to district nurses to physiotherapists, as well as those from the social care and voluntary sectors. Someone living with multimorbidity will therefore be able to have a single comprehensive care plan that recognises the complexity of living with multiple conditions at community level.

We are, however, in the very early stages of the new integrated world. Clinical directors leading PCNs are still settling into roles that didn’t exist a year ago, within networks that didn’t exist a year ago. There are multiple expectations being placed on PCNs and many clinical directors are beginning to feel overwhelmed. This is where the NHS Confederation comes in. The Confederation has launched NHS Primary Care, which will act as the voice of PCNs as they develop and begin to deliver against new service specifications. Crucially, if the ambitions of the Long Term Plan are to be achieved – and if care is to improve for those living with comorbidities – then it is vital that new integrated care models are given the time and resources they need to succeed.

by Ellie Davies, Acting Project Manager, Falls and Fragility Fracture Audit Programme (FFFAP)

The challenge:

520,000 cases of fragility fracture occur every year amongst those (primarily over-50s) suffering with the bone-weakening disease known as osteoporosis. That is 520,000 broken bones caused by as little as slipping in the shower, stepping off a curb even. This is not only a huge economic burden on the NHS, approximately £5.25 billion, but an epidemic that has lasting physical and emotional repercussions for sufferers. It is upsetting to learn that 42% of older people say that osteoporosis has made them feel more socially isolated.

And it’s going to get worse. For as life expectancy steadily increases, it is estimated that there will be 25% more fragility fractures by 2030, and with that a 30% rise in healthcare costs that the NHS is simply not equipped to meet. A sobering prospect yes, but a crucial reminder nonetheless that now is the time to target improvement.

The solution:

Of course, eradicating the occurrence of fragility fractures altogether is the ultimate goal. However, given that any such fracture approximately doubles the risk of another, most likely within two years, focusing on secondary prevention is an effective starting point. Rapid assessment and timely treatment post index (first) fracture could avoid thousands of secondary cases.

Fracture Liaison Services (FLS): what are they and why are they so important?

A fracture liaison service (FLS) is an NHS service which aims to reduce the risk of subsequent fractures by systematically identifying, treating and referring all eligible patients aged 50 and over who have suffered a fragility fracture to appropriate services. A FLS is a proven approach, recommended by the Department of Health, for targeting these high-risk groups and improving secondary fracture prevention.

Fracture Liaison Service Database (FLS-DB): Our mission

According to the Fracture Liaison Service Database: Commissioner’s report 2019, there are significantly fewer fracture liaison services (FLSs) available for older patients in some parts of England and Wales than others. The Fracture Liaison Service Database (FLS-DB) is not only working towards improving the care provided by existing services but making these preventative services available more widely and avoid approximately 50,000 life-altering fractures in the process.

Dr Kassim Javaid, RCP clinical lead for the FLS-DB said “Those suffering broken bones are often the most vulnerable in society and it is unacceptable that such variation exists in service accessibility depending on where in the country they live. Fracture liaison services are proven to reduce the risk of experiencing further fractures, reducing the impact on older patients, and save the NHS millions of pounds. I implore all Clinical Commissioning Groups to ensure that FLSs are commissioned in their areas so that millions of older people receive the care they deserve.

What can you do?

  • Watch and share our short animation with information about fragility fractures and the care that should be provided
  • Read and share our guide to strong bones after 50 to help reduce the occurrence of fragility fractures
  • Find out about the data available for healthcare professionals and academic institutions for research and analysis
  • Follow us on twitter @RCP_FFFAP to find out more about the FLS-DB and other related audits.

 

Guest blog by Dr Alison Giles, Associate Director for Healthy Ageing, Centre for Ageing Better and Public Health England; and Elaine Rashbrook, Consultant Specialist, Life Course, Public Health England.

In October this year, Public Health England (PHE), together with the Centre for Ageing Better (CfAB) launched the Consensus Statement on Healthy Ageing.  Over 70 organisations, including ARMA, have signed up and pledged to take action on the five principles set out in the Statement.

The average age at which people report a health condition or disability that interferes with daily life is just 62.  With today’s 65-year olds set to live well into their 80s, many of us could face nearly two decades in poor health or living with a disability. This, in turn, could prevent us from working or volunteering for as long as we want or need to, make it more difficult for us to remain living in our own homes and connected to our communities, and make it harder to get out and about and spend time with the people we love.

The best way of ensuring a long life in good health is to have the best start in life, a decent education, a warm and loving home, and an income sufficient to meet our needs[i].

Across the public, private and voluntary sectors, action is needed beyond simply encouraging healthy behaviours. That’s because for the poorest among us, disability-free life expectancy shrinks to just 52 years, and studies consistently show that the quality of our jobs, our homes and the environment around us can make a huge difference to our health – and even our life expectancy.

In a new YouGov survey of people aged 40-60, commissioned by the Centre for Ageing Better and Independent Age, 62% said they worry their physical health will affect their ability to be financially secure, 55% worried it could impact how physically active they can be, and 43% were concerned it could affect the kind of home they could live in when they reach 65.

This is why the following principles, as set out in the Consensus Statement are so important:

  • Putting prevention first and ensuring timely access to health and social care when needed. There are small changes we can all make to increase our likelihood of staying healthy for longer, from stopping smoking and reducing alcohol consumption to eating more healthily and being more physically active.  But these individual actions need to be supplemented by fiscal and economic interventions, which will have a bigger impact on the places in which we live, work and age.[ii]
  • Removing barriers and creating more opportunities for older adults to contribute to society. We want employers to promote health at work, deliver flexible working, and introduce policies to recruit, develop, promote and retain staff of every age. And we want to see more opportunities for people to volunteer and engage with creative, learning and cultural activities.
  • Ensuring good homes and communities to help people remain healthy, active and independent. We want our housing stock to be improved, and new homes built to be accessible and adaptable. People on low incomes should have access to funds to repair and improve homes, and every community should have accessible transport links, good quality green spaces and good quality services and facilities.
  • Narrowing inequalities. This means giving everyone equal access to a great education, good work, a decent home and meaningful social connections, regardless of their wealth or where they live.
  • Challenging ageist and negative language, culture and practices. We must offer a realistic, representative picture of later life that values ageing as a positive and recognises the diversity of backgrounds, experience and ambition amongst older people.

Over the next 12 months, the Centre for Ageing Better and Public Health England will encourage other organisations to sign up, and will take forward a programme of work to build on the momentum of the statement and create action. Working together across partnerships, we can do more to make England a place in which we, our children and grandchildren can all enjoy a long, healthy and disability-free life.

References
[i] https://publichealthmatters.blog.gov.uk/2019/02/01/duncan-selbies-friday-message-01-february-2019/
[ii] Marteau, T.M. et al. Increasing healthy life expectancy equitably in England by 5 years by 2035: could it be achieved? The Lancet, 2019. Vol 393, issue 10191. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31510-7/fulltext

Guest blog by Amanda Woolley, Policy and Implementation Lead for the Elective Care Transformation Programme at NHS England and NHS Improvement

The NHS Long Term Plan set the ambition to reduce outpatient attendances by a third over the next five years. Rheumatology services are leading the way in developing alternatives to the traditional outpatient model so that patients can access the support and treatment they need, at the time they need it.

Most people seen by rheumatology services will have chronic, long term conditions, such as rheumatoid arthritis and will require continuing specialist input to support management of their condition. In fact, rheumatology sees more follow-up attendances for each new first attendance than any other high-volume specialty after oncology and haematology.

However, the traditional outpatient model of routinely scheduled appointments at three, six or twelve month intervals rarely provides an optimal level of care for these patients. With a routine appointment, patients have to attend hospital even if their symptoms are currently well managed. This can be inconvenient and costly for the patient and is an inefficient use of NHS resources. Conversely, patients are not always able to get the support and treatment they need at the time they need it when their condition worsens.

Unsurprisingly then, rheumatology services are paving the way for transforming how to deliver ongoing specialist care for those with long term conditions. New approaches to outpatient delivery established in rheumatology settings include patient-initiated follow-ups, telephone clinics, use of remote monitoring apps, and better education programmes to support self-management. In addition, rheumatology services have taken the opportunity of using specialist allied health professionals, nursing staff and pharmacists to ensure timely access to the right support for managing different aspects of these chronic conditions.

While there are numerous examples of innovative practice, these approaches are not universally implemented across England. The challenge over the next five years is to learn from what has already been achieved and spread this to all areas of the country, both in other rheumatology services and across other specialties.

The Elective Care Transformation Programme supports local health care providers and commissioners to make sure that patients requiring a specialist opinion or treatment see the right person, in the right place, first time and every time. We are delighted to partner with ARMA in hosting the Rheumatology follow-ups: Transforming Outpatients webinar to share the learning of what is already in place and discuss the barriers to further implementation across rheumatology and beyond.

Anyone involved in redesign of outpatient and elective care services is welcome to join our online community of practice where they will find information and guidance for outpatient transformation across 14 high volume specialties and numerous potential interventions and ideas for service redesign. The community of practice also hosts online discussion forums and regular webinars where members can ask questions and share ideas.

To join the elective care transformation community of practice, email ECDC-manager@future.nhs.uk.

by Simon Chapman, Deputy Director, Personalised Care Group, NHS England.

Twelve years ago I was working for a charity just north of Kings Cross. My office looked out on a derelict area of forgotten buildings and toxic land. Over the next 10 years, things gradually changed as the infrastructure was renewed: old buildings were renovated and new spaces and buildings were created for people and communities to visit, use and inhabit. Now, where there was wasteland, parents watch their children play in the Granary Square fountains. It’s a terrific example of well-designed development infrastructure providing a framework that enables life, community and wellbeing to flourish.

And NHS England is taking a similar approach to expanding social prescribing, as part of an expanded team of people working in general practices. We are definitely not approaching it from a standing start, and we are not taking the credit for what is a vibrant social movement that many have worked in for decades. Across the country people have been working in communities to support activities that are good for people’s wellbeing. But, like the landscape I saw from my old office, social prescribing in primary care needs some design principles and infrastructure to be resilient, robust and widespread.

Our commitment in the Long-Term Plan is to have at least 1000 trained social prescribing link workers in primary care networks (PCNs) by 2020/21, and more beyond that, so that at least 900,000 people can be referred to social prescribing by 2023/24. This is the largest investment in social prescribing made anywhere by a national health system. And it’s not happening in isolation: social prescribing is one of six components of the NHS’s comprehensive model of personalised care.

We intend to secure a sustainable future for social prescribing in primary care so that it’s available for all who need different forms of support. Community approaches and social prescribing are at the heart of the NHS’s vision for its next 70 years. No longer nice to do; central to the future. That’s why we have built funding for the new link workers into the new GP contract so that it has contractual protection.

Social prescribing may not be new, but our ambition to make it universally available is. Achieving this means we must keep to some clear principles. Building on existing know-how for what makes effective social prescribing, we have worked with current social prescribers, as well as the voluntary sector and people with lived experience, to co-produce a standard model for social prescribing. It’s captured in a summary guide.

Perhaps the most radical thing about link workers is that they are employed to give people time. They will have the time and the space to work alongside people often with complex needs and life circumstances. They can help people who may become isolated, whose innate gifts have become buried deep, providing time and relationships that are critical to building confidence and reconnecting. Or they might support people for whom movement is difficult and life is challenging, by helping them to connect with walking, dancing, gardening – or other forms of community activity that helps to keep them moving and connected.

Link workers in primary care will become part of the networks of support that exist in communities. Although the GP’s surgery is often a place people come to when they don’t know where else to go, health services are only part of the picture. It’s been estimated that at least 20% of people consult GPs for what is primarily a social rather than a health issue. Link workers will be able to connect people with debt, benefits and financial advice, housing support, as well as community-based activities and support. There are many possibilities, depending on the person’s priorities and what’s available locally, including: walking and other outdoor activities; arts, singing and cultural groups; sport and exercise; lunch clubs.

Successful social prescribing in primary care will work alongside what’s already happening in communities and the local system, enabling people to build on strengths that are already present.

by Catherine Holmes, National Service Improvement Manager, Anchor

I was thrilled to read Sue Brown’s (CEO, ARMA) September blog and the proposed plan for an event on physical activity. The importance and benefits of staying active is already widely accepted and understood in terms of maintaining joint movement, bone and muscle strength and this is especially important for residents living in care homes. The challenge for care is to create opportunities for people with a wide variety and often multiple and complex health needs such as musculoskeletal, limited or a lack of mobility and living with dementia to keep engaged and active. I believe the solution may require us to rethink what constitutes activity and movement within the context of the individual and use alternative methods including technology, where appropriate, to create a sense of achievement and wellbeing.

If we do this, we first need to accept that some residents may not feel inclined, able or confident to join in energetic physical exercise sessions to the beat of ‘Tiger Feet’ or that they may feel distressed and anxious being outside of the care home. This in turn should challenge us to look more closely and creatively at what could work, considering musculoskeletal and wider health needs such as individual ability and capacity, together with guidance from healthcare professionals. This may mean that participation in gentle, seated stretching exercises possibly on a one-to-one basis might provide an initial starting point, and the NHS website provides clear guidance. Technology is often perceived as an expensive option, but it certainly has a place in encouraging physical activity, especially where mobility is restricted. In Anchor care homes we are using Memoride  – technology based on google maps where sensors are placed to a fitness device such as foot pedals or rollers to enable residents to move through familiar streets or countryside at their own pace. We’ve also invested in OMI Vista interactive projectors which project onto communal tables, floors or bed trays encouraging residents to stretch and move as they engage with quizzes, games and therapeutic activities; all which link with visually stimulating reminiscence and music.

AgeUK states ‘our bodies were made to move and it’s a myth that getting older means an end to being active,’ which is something I genuinely believe to be true regardless of where or how you live. Whether it’s taking a walk in the garden, reminiscing about the plants and seasons, or creating stimulating environments in hallways which invite and intrigue our residents to keep moving onwards, we should recognise, encourage and celebrate all that is active in whatever context individuals can achieve.