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

Health Policy

The incidence of MSK conditions, particularly neck and shoulder pain, has gone up during the pandemic. This represents a significant amount of pain that would not have happened without the pandemic changing the way we live and work. Which got me wondering how much of the pre-pandemic MSK conditions would have been preventable.

MSK ill-health represents many thousands of lives impacted and restricted by pain and poor mobility. However great the services we have, prevention is the better option where possible.

If we look at the data pre-pandemic, we can see that the incidence of MSK conditions and chronic pain is not equally distributed. Black people are more likely to experience chronic pain than white people. Areas of social deprivation see more back pain. Something is happening which is not just about “natural ageing” or the inevitable consequence of being human. If that was all it was, the distribution would be even across all geographies and communities.

I hear a lot of talk about prevention, but I see very little action where it matters for MSK health. The NHS has a role to play in ensuring secondary prevention programmes, such as Escape Pain or Good Boost, are available. They should be a core part of an MSK pathway, which means they need to be commissioned. Social prescribing services could have a big role to play in enabling people with MSK conditions to manage their conditions.

Primary prevention requires the concerted effort of a much wider system, including public health, local authorities and the third sector. The NHS cannot address issues such as parks that aren’t safe to exercise in, town centres that are hard to walk about or employers who take the MSK health of their employees for granted.

Last year we celebrated the publication by Public Health England of Musculoskeletal health: 5 year prevention strategic framework. Whatever happens to the functions of Public Health England next year it is essential that the priority for MSK prevention remains at a national strategic level.

Many of the changes needed to create MSK-healthy places lie outside the NHS. But that doesn’t mean that MSK professionals cannot take action. If local public health is not making MSK a priority, the NHS should be asking why not and what they are going to do to implement the framework. We must champion not just MSK services but MSK health.

2021 begins with the UK back in lockdown, with MSK needs and waiting lists rising. Vaccines offer the hope that this will change. We have shown in 2020 that the MSK community can come together and achieve extraordinary things. Let’s apply that creativity in different ways so that by the end of 2021 we are building new collaborations to focus on promoting MSK health.

On Monday 23 November 2020 the campaign to prioritise extra capacity in orthopaedics surgery ‘went’ to Parliament in the form of a roundtable event. The virtual roundtable brought together a wider range of stakeholders including representatives of charities, surgeons, clinicians and industry to make the case in Parliament as to why orthopaedics should be a priority for the NHS over the next few years.

The event was hosted by Dr James Davies MP – a GP, member of the Health and Social Care Select Committee – and a Conservative MP for the Vale of Clwyd in North Wales. Dr Davies has a long held interest in building capacity into the NHS to tackle waiting lists and the growing backlog, and has offered his continued support for the campaign, as we engage with more MPs from all parties to see progress on this issue.

During the event those who attended heard first hand from Caryl Wright from Norfolk, who is waiting for joint replacement surgery in one of her knees, following a previous surgery on one of her hips. Caryl – a campaigner with the charity Versus Arthritis – explained the impact of waiting so long for surgery and living with pain is having on her overall quality of life and the importance of mobility to maintain her independence.

One of the other speakers, Professor John Skinner – a Vice-President of the British Orthopaedic Association (BOA) and Orthopaedic surgeon at RNOH Stanmore with a special interest in hip and knee replacement surgery – explained that ‘green’ or non-Covid19 sites were the answer to ensuring more patients could access surgery in the NHS in safe environments. Professor Skinner also explained the causes behind the latest statistics showing that in September 2020, 31,000 people on waiting list over 1yr (was 436 in Jan); 271,000 people on waiting list over 18 weeks (was 105,000 in January); April-Sept: 212,000 fewer admitted operations than same time in 2019. Professor Skinner spoke about the detrimental impact waiting on waiting lists has on people’s health and well-being, and their ability to keep as mobile as possible, particularly for those in later life.

The final speaker for the event was Sue Brown – the Chief Executive of Arthritis and Musculoskeletal Alliance (ARMA) – an umbrella body representing the breadth of musculoskeletal (MSK) conditions and professions. Sue highlighted that addressing the issue of a large backlog had not been caused by the pandemic, but had exacerbated an existing challenge facing the NHS. Sue also emphasised that building capacity into the system also requires appropriate rehabilitation support in the community post-operations, and that keeping in regular contact with patients with advice and information through-out the process is vitally important.

The event was organised by the ABHI Orthopaedics Group, a special interest group made up of leading orthopaedic implant manufacturers. The vision of the group is to make a positive contribution to orthopaedic care and help shape future delivery for NHS patients.

The group will be building on this event to persuade more MPs about the importance of prioritising Orthopaedics surgery, particularly in light of the commitments made by Rishi Sunak MP in the Spending Review, about extra resources to tackle backlogs in the NHS.

by Andrew Bennett, National Clinical Director for Musculoskeletal Conditions NHS England and NHS Improvement

It’s been a year since I was fortunate to attend the annual ARMA lecture at the canal museum in London and enjoyed a fantastic talk by Brendan Stubbs about physical activity and mental health. New to the role of National Clinical Director for MSK, this was the first time I met Sue Brown the CEO of ARMA, as well as number of other colleagues from the MSK world. Little did we all know at that time about what lay ahead, and the close working relationships we would develop.

What followed has been a rollercoaster of a year. The coronavirus pandemic has impacted us all both professionally and personally, and as an MSK community we must all take pride in our collective response. Professionally we have rapidly adapted our provision, worked out of our comfort zones, and dealt with a wide range of significant challenges. We have had to balance increased workplace stresses with the personal impact of the pandemic. We have to juggle social distancing, home schooling and managing our own physical and mental health.

These professional and personal challenges continue to evolve, both in the context of the Covid second wave and the need to restore service provision. We are working hard to get primary community and secondary care back on track, in collaboration with our colleagues across mental health, social services and the third sector. We are balancing this challenge with need to cope with the second wave of the pandemic. A challenge further complicated by the impact of social isolation, delays in planned care and the potential impact of post-Covid symptoms on MSK health.  The impact of Covid-19 has been massive and whilst we need to continue to rapidly adapt to meet these daunting challenges ahead, we also need to continue to look after our own wellbeing, and it is timely to reflect on Brendan’s message regarding the importance of physical activity to maintain our own mental health as well as that of our patients.

I am ever an optimist, and out of this massive challenge comes opportunity. Adaptive innovations in care have been rapidly implemented, particularly with regard to virtual provision. We have looked to capture examples of such innovations and share the principles underpinning these new ways of working though our #NHSChangeChallenge project. The objective is to help support local leads to make best use of resources to be as productive as possible. This all needs to continue to be focused around a collective vision of enabling lifelong best MSK health across all communities, and delivering evidence-informed, personalised high quality care of value for all. Moreover, quoting Sue’s excellent recent blog, ‘if it doesn’t work for patients then it doesn’t work’, I believe key to achieving this vision and aim in this challenging time is collaborating with those with lived experience to co-produce our strategy moving forward.

So as our rollercoaster ride continues, I would like to thank the MSK community for your support and efforts both over the last year and moving forward, with confidence that together we can rise to the challenges ahead and build on our innovations to inform future service transformation to support best MSK health.

Twitter @andypbennett79

The information in this briefing is based on the collated experiences of many of those shielding and information from patient helplines about the enquiries they were receiving earlier this year. For more information about the experiences of people with MSK conditions during lockdown, please see the report ‘MSK Lived Experience Themes of What Matters.’

Earlier this year, over 2 million people including some with musculoskeletal conditions, received a letter advising them to “shield” by remaining in their homes for 12 weeks. These were people identified as extremely clinically vulnerable to COVID-19. At the end of July shielding was paused. People identified as clinically extremely vulnerable are being written to again, giving them advice on what they should do depending on the risk level in their area.

People who were asked to shield had very different experiences of shielding. The pause in the advice also effected people differently depending on their circumstances and living situation. The advice was difficult to follow, requiring people to remain at home and keep their distance from others in their household. Children, parents, particularly of young children, people in work who couldn’t work from home and people living alone had particular difficulties. Responses varied from those who did not follow the advice fully, to those who are still shielding despite the advice that it is no longer necessary. Some people felt pressure from friends and family to meet up once shielding was paused, even when they did not feel this was safe.

Generally, people who were shielding experienced poor communication and difficulties accessing the support they needed, particularly food at the start of the shielding. Support required people to have the formal shielding letter, but there were many delays and errors in the distribution of the letters. During shielding, some became very isolated and keeping active was a challenge. Knowing how to safely access health care services was also an issue. About one third of those shielding are of working age, but the media image was almost always about older people. Government announcements rarely mentioned shielding. This left many people feeling forgotten and ignored.

People who were shielding are now being given guidance which is more clearly advisory, and depends on the risk level of the area they live in. They continue to need to access healthcare and may need face to face appointments or treatment. When you are talking to people who were shielding about how they should keep themselves safe, these are some things to bear in mind.

Understanding risk

Making rational decisions about risk is extremely difficult. Being told you are clinically extremely vulnerable adds to the concern and fear experienced by the general population. Shielding was reported as difficult and stressful. The end of the shielding period was also confusing and stressful for many. People will need time and clear information to help them decide how they balance risks over the winter. Understanding how much risk they face personally is an important part of this decision making.

The advice in April was very clear – stay at home. For some people the ability to make their own judgements is preferable to fixed advice. However, many find the new advice confusing and contradictory.

Accessing healthcare

Some people are still extremely anxious about the idea of coming into a healthcare setting. Very few people know what hospitals are doing to reduce the risk of infection. Make sure that anyone you ask to attend an in-person appointment knows what steps will be taken to keep them safe. Reassurance will help people attend. Discussions may be needed with transport to aid their arrival.

Employment

People in employment have significant problems, especially if they cannot work from home. Current advice for those living or working in a tier 3 area is that they are strongly advised to work from home if at all possible, but that if there is no alternative they can go to work. Employers should be ensuring that everything possible is put in place to protect those who are vulnerable to the virus, including a change of role if needed. Not all employers are as flexible or have the financial capacity to be adaptable.

During the COVID-19 period, employers were able to furlough people who could not work because they had been advised to shield. This gave people some protection. However, now this is not possible and anyone unable to work from home may have to rely on SSP or Universal Credit, both of which have eligibility criteria that people may not meet and are paid at a very low level. This process is also very slow.

People may need to discuss what “COVID-secure” means in relation to their risk levels. They also may be facing impossible choices between income and safety. Depending on the person’s work it may be impossible to make the job safe enough. These pressures are especially relevant for those who are self-employed, working in the gig economy or less secure working arrangements such as zero hours contracts.

Travel to work is also an issue where people need to use public transport. Travel to work is not mentioned in the guidance, but the advice is to stay off public transport if at all possible especially in tier 3 areas. Some people may be able to use the Access to Work scheme to pay for additional travel costs (e.g. taxi fares) if they need it due to being vulnerable to COVID19.

The NHS Change Challenge site continues to publish the most impactful initiatives submitted. Wave two included a number of digital initiatives and wave three will be related to rheumatology services. Each idea has a short slide deck explaining the change and how it was done, the impact and issues to consider for embedding it.

The information is brief and practical, enabling you to easily use the initiatives that are helpful to you. If you want to comment you can also join the discussion.

The role of osteopaths as AHPs in the NHS

An independent panel of leading healthcare professionals, chaired by Professor Adrian Newland CBE, has authored a report including its findings on the role of osteopaths as Allied Health Professionals within the NHS, and their potential to provide much needed additional capacity to the delivery of NHS MSK services to improve patient care.

The report was launched at a virtual event with NHS commissioners, at which Sue Brown, CEO of ARMA, joined as part of the panel. Read more about the report here from the iO website.

NICE published its final guideline on behaviour change: digital and mobile health interventions on its website . You can also find the supporting evidence, tools and resources as well as all the stakeholder comments. NICE has produced an equality impact assessment to support the guideline.

NICE included the recommendations from this guideline in the NICE Pathway on behaviour change: digital and mobile health interventions, which brings together everything we have said on behaviour change: digital and mobile health interventions in an interactive flowchart.

Joint statement from professionals and patients on MSK services in the event of a second wave of Covid-19

With cases of Covid-19 rising and the prospect of increased pressure on hospitals this winter as a result, it will be unacceptable for the NHS to respond to this by treating only urgent and emergency cases in musculoskeletal (MSK) services.

As organisations representing patients and professionals, we recognise that this was a necessary response in spring of this year. However, it came at significant cost to patients’ physical and mental health, and the resulting suffering will continue for many months, perhaps years, to come. People needing surgery such as joint replacement, people needing to see rheumatology specialists and people needing access to community MSK services were all hit hard in the effort to ensure that the NHS could respond to Covid-19 patients.

With the benefit of all the learning of the last six months, the NHS needs to ensure that pathways for MSK patients are kept open as much as possible. There have been many beneficial innovations in MSK services in response to the virus which will help maintain services. Services also need to make the maximum possible use of available resources to support self-management including patient support groups, such as our patient member organisations, who can help ease the pressure on the NHS. The government must act to ensure that the NHS has the testing service it needs, and steps are taken to manage infection rates, so that the NHS does not see the suspension of much of its core services.

Before the pandemic, many MSK services, and especially joint replacement waiting times, were falling well short of targets. This situation is now significantly worse with much longer waiting times, backlogs of missed appointments and concerns that people with serious conditions may not have yet been able to access diagnosis, still less treatment. In England as at the end of July, there were over 36,000 people were waiting more than 18 weeks for rheumatology treatment.  There were also over 320,000 people who have been on the waiting list for over 18 weeks for trauma and orthopaedic care, including joint replacement surgery. They are likely to be in considerable pain, with reducing mobility and experiencing deterioration of their overall physical and mental health.

“If my RA continues to worsen this may impact my chances of remission. Just prior to lockdown we were discussing changing my meds; that is off the table for the foreseeable.”
(Person living with Rheumatoid Arthritis)

Delays in treatments lead to much poorer outcomes, with a long-term impact on people’s ability to remain active and in employment and to manage their general health. Delays in diagnosing inflammatory and autoimmune conditions can lead to irreversible damage with long term impact on the individual and cost to the NHS of subsequent treatment. Delays in accessing joint replacement surgery result in worse outcomes and deterioration in general health and fitness.

“I feel I’ve been forgotten about. I have so many questions as I was diagnosed in February 2020, and it was while I wasn’t able to have a face-to-face appointment at the doctors, so he told me on the phone and wasn’t helpful at all. I’ve been told the diagnosis but with no info regarding what to do next – I desperately need advice on what next with medication or physio but I’m just waiting and waiting.”
(Person living with Axial Spondyloarthritis)

“I’m generally an upbeat person so I’ve been able to deal with it, but it’s becoming hard to keep going physically and mentally.”
(Person living with rheumatoid arthritis, osteoarthritis and asthma.)

Inability to access community MSK services leads to reduction in function and muscle strength and increased pain. These services are already under additional pressure due to post-Covid rehabilitation and the impact of lockdown on people’s MSK health. In this context, redeployment of significant numbers of community MSK staff to respond to a second wave is untenable.

MSK health, and therefore MSK services, are vital to people’s ability to live healthy and active lives. It would be unacceptable for MSK services to be expected to shut down, and people with MSK conditions to face the same inability to receive the treatment they need, a second time.

ARMA Members:

  • Arthritis Action
  • BackCare
  • British Association of Sport Rehabilitators and Trainers
  • British Chiropractic Association
  • British Dietetic Association
  • British Orthopaedic Association
  • British Society of Rehabilitation Medicine
  • Chartered Society of Physiotherapy
  • College of Podiatry
  • Ehlers-Danlos Support UK
  • Faculty of Sport and Exercise Medicine
  • Fibromyalgia Action UK
  • Hypermobility Syndrome Association
  • The Institute of Osteopathy
  • Musculoskeletal Association of Chartered Physiotherapists
  • National Axial Spondyloarthritis Society
  • National Rheumatoid Arthritis Society & JIA
  • Podiatry Rheumatic Care Association
  • PolyMyalgia Rheumatica and Giant Cell Arteritis UK
  • Primary Care Rheumatology Musculoskeletal Medicine Society
  • Psoriasis Association
  • Rheumatology Pharmacists UK
  • Royal College of Chiropractors
  • RCN – Rheumatology Forum
  • Scleroderma & Raynaud’s UK
  • Society of Musculoskeletal Medicine
  • Society of Sports Therapists
  • UK Gout Society
  • Versus Arthritis

Download and share this document [PDF]