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Health Policy

by Greta McLachlan, Fellow at the Strategic planning and development cell, NHS England and Improvement, part of the Change Challenge Collaborative.

The change challenge collaborative is a group of professionals who have come together to work across the MSK, orthopaedic and rheumatology specialties to try and capture beneficial changes that have occurred within the NHS during COVID- 19. The aim being to try and capture these changes and ideas to ensure that these innovations are not lost when the NHS comes out of its pandemic measures.

Healthcare provision and delivery has changed greatly during COVID-19. Some changes have been detrimental to patients but not all. In fact there has been a whole host of innovations and different ways of delivering care across the NHS that have occurred in several weeks rather than the usual NHS pace of years.

We asked the communities of MSK, rheumatology and orthopaedics to tell us about the changes they had seen or instigated on a platform called Crowdicity.

Crowdicity is an online platform that allows collaboration of ideas and engagement through comments and discussion around each post. It was the ideal platform for us as it had been previously been used by NHS Horizons, but allowed our project to reach far further than a few emails for feedback might do.

In total over the four weeks that the platform was open for submissions, we had over 180 change ideas posted to the website, over 400 users registered, over 800 comments and some 10,000 plus page views. Our hashtag #nhschangechallenge got over 3 million impressions on twitter.

Once all submissions were closed, each change idea was discussed for its impact and feasibility and was assigned ‘themes’ so that we could see what commonalities there were between change ideas. The discussion that took place around each change idea took a co-productive, collaborative approach. For example, the group that discussed the rheumatology change ideas was made up of two consultant rheumatologists, one consultant physiotherapist, a patient with lived experience of MSK, a chair and secretary. The impact and feasibility were based on the premise that whilst some change ideas might be great during a pandemic and for a short period of time, they may not be feasible on a national scale or with the long term picture in mind. The same for impact. We wanted to be able to identify changes that would have greatest impact across the NHS, not just changes that have helped a small niche of patients or clinicians.

Now comes the hard part of this journey. Taking these change ideas forward and trying to work out how to champion them to the wider communities. ARMA has been a great supporter of this work, and helped us get to this point and I know will help us continue to make this project such a unique one as we look to next stage of this collaborative process. ​

A new COVID-19 rapid guideline: arranging planned care in hospitals and diagnostic services NICE guideline [NG179] has been released by NICE. The publication makes recommendations for how these services should be organised to balance the risks associated with covid-19 and the potential harms that could arise from delays in elective treatment and diagnostic procedures.

The guidance states that people having planned care involving any form of anaesthesia and sedation should follow social distancing and hand hygiene measures for 14 days prior to admission – a change from 14 days of self-isolation. For elective surgery, patients need to take a covid-19 test three days before surgery, and self-isolate for three days prior to surgery.

 

report coverThe report emergent from Baroness Cumberlege and the Independent Medicines and Medical Devices Safety review was published in early July and has been welcomed by the British Orthopaedic Association. This comprehensive review has demonstrated the impact on the physical and mental health of patients when implants fail. The review shows that there is a clear need for detailed surveillance of implants, and we welcome the recommendation for the establishment of more National Implant Registries.

Read the BOA’s full position on this issue.

The BOA also continues to update their website with information for both patients and health professionals regarding COVID and its impact on trauma and orthopaedics. This information specifically for patients can be found on the FAQs for Patients page, and wider information is available via the Information for BOA Members page.

The fourth meeting of the All Party Parliamentary Group for Axial SpA took place on 15 July 2020. The meeting focussed on axial SpA (AS) services during the COVID-19 pandemic and also how services may now change as a result.

A full report is available via the news page on the NASS website.

The guidance ‘Management of Patients with Musculoskeletal and Rheumatic Conditions on Corticosteroids’ has now been superseded by the following guidance, issued on 16 June 2020. It applies to:

Management of patients with musculoskeletal and rheumatic conditions who:

  • – are on corticosteroids
  • – require initiation of oral/IV corticosteroids
  • – require a corticosteroid injection

The new guidance can be read here [open PDF].

SOMM’s Injection Module Coordinator, Paul Hattam, has submitted his view on the guidance for corticosteroid injection that has been provided throughout the COVID-19 pandemic, as an open letter to the CSP’s ‘Frontline’ magazine. You can read his letter here [open PDF].

Guest blog by

Cormac Kelly, Consultant Upper Limb Surgeon at The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust

and

Peter Kay, National Orthopaedic Alliance (NOA) Lead Clinician and Consultant Orthopaedic Surgeon at Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust

The COVID-19 crisis has changed the delivery of planned orthopaedic surgery drastically. As the pandemic continues to subside, the NHS, with various guidance from Public Health England, Medical and Surgical Colleges, the British Orthopaedic Association, and others, is working on a plan to get surgery back on track.

The information on the risks to patients and staff when operating during this crisis continues to emerge. In light of research from around the world indicating an increase in complication rates and mortality if patients contract COVID-19 around the time of surgical intervention, we are taking every precaution possible to develop processes to reduce the risk to our patients. These have included the appropriate use of PPE (personal protective equipment), routine testing and using a “clean” area for surgery away from COVID-19 positive patients. Despite this, it is clear that the risk to patients is likely to be higher than normal. How much higher, we do not know. Thus, we are progressing slowly and carefully to restore the delivery of non-urgent orthopaedic surgery. Through organisations such as the National Orthopaedic Alliance (NOA), providers of orthopaedic care are working together to ensure the restoration of planned orthopaedic surgery is safe for both patients and staff.

We are aware that some patients are at home – possibly in self-isolation suffering joint and soft tissue pain. Some are in high risk categories because of lung diseases, diabetes and other medical conditions, and may wish to wait several months and see how the pandemic recovery unfolds before moving forward with planned orthopaedic surgery. Others are living with progressive pain and may be reluctant to let us know that they need help for fear of ‘disturbing’ an already stretched NHS. We ask these patients to please not suffer in silence.

Recovery planning and restarting planned orthopaedic surgery is complicated as we have to consider joint issues along with other conditions such as cancer treatments and progressive sight loss. The volume of work we can do as we restart will be reduced because of factors including the availability of staff, PPE and resources such as theatres as these facilities are still being used to treat sick COVID-19 patients.

We all now know how to socially distance but this also needs to be considered when bringing elective orthopaedic patients back into hospital. Many patients have admitted to us that they are frightened of this new world and thoughts of visiting hospital. We understand that and have been investigating ways to help. Many patients are now able to take advantage of virtual clinics and are receiving telephone and video calls which we hope helps.

We continue to work to make sure patients have all the information, tricks and tips they need to help with pain as our therapists and nurses are constantly looking at new ways to deliver care. The ARMA website has some useful information on managing pain during the crisis. Although we strive, for patient’s protection, to avoid unnecessary face to face contact, this can be made possible after we discuss the risks and possible benefits. We are redesigning outpatients so that if patients do have to attend in person, it is as safe as possible.

Remember that we are still here for patients and we encourage them to let their orthopaedic care provider know if they are in trouble and are dealing with uncontrolled pain. Providers can work with them on a short-term solution while we work to restore elective and planned orthopaedic surgery post COVID-19.

——-

About Cormac Kelly

Cormac is a Consultant Upper Limb surgeon at The Robert Jones and Agnes Hunt Orthopaedic Hospital in Oswestry, Shropshire. He assists with the facilitation of the National Orthopaedic Alliance (NOA) COVID-19 webinar series.

 

About Peter Kay

Peter is a Consultant Orthopaedic Surgeon at Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust and Honorary Clinical Professor of Orthopaedic Surgery at Manchester University. He is the current Clinical Lead for the National Orthopaedic Alliance.

 

About The National Orthopaedic Alliance

The National Orthopaedic Alliance (NOA) brings together orthopaedic centres around the UK to share best practice and address shared challenges. The alliance is based on a quality standards membership model founded on evidence-based descriptors of ‘what good looks like’ in orthopaedic care. For more information visit www.nationalorthopaedicalliance.co.uk or email info.noa@nhs.net

Suggestions are rolling in for which changes the NHS has made during the pandemic that people think we should keep.

You can see the other suggestions and add or vote by visiting the NHS Change Challenge website.

MSK First Contact Practitioner roles; are they fit for the future for Primary Care?

by
Amanda Hensman-Crook FCSP, HEE AHP National Clinical Fellow, Consultant MSK Physiotherapist
Neil Langridge FCSP, Consultant MSK Physiotherapist
Laura Finucane FCSP, MSK Consultant MSK Physiotherapist
Chris Mercer FCSP, MSK Consultant MSK Physiotherapist

MSK First Contact Practitioner roles and the advancing practice agenda is moving at pace and as a result, there has been some anxiety around the MSK First Contact workforce. This has been expressed about several aspects of the roles, including:

  • numbers needed to ensure sustainability without wider destabilisation of the MSK workforce
  • where the workforce will come from with the requisite capability
  • concern about governance of the roles
  • who provides the supervision and support
  • a general need to understand the offer of the role to primary care
  • concern from other MSK professions that they are not included in the GP contract reimbursement scheme (DES) and where they might fit in the bigger picture.

Work is being done collaboratively with Health Education England (HEE), NHS England (NHSE) and NHS England Improvement (NHSEI) to address all of the above to ensure that the education, governance, supervision, strategy and infrastructure is in place to ensure a sustainable model of MSK care at the front of the care pathway.

Standards

Quality and governance are key to first contact roles. To ensure this, the right capabilities at the right level need to be credentialed and accredited. The minimum requirement for a first contact role is to be working at an advanced level clinically i.e. at level 7 (masters level). It is desirable that the clinician who meets that criteria is also on the Advanced Clinical Practice pathway (ACP) to fulfil level 7 across all four pillars – clinical, education, research and leadership.

In physiotherapy, an important step has been taken with an agreement on a national UK standard across all MSK speciality groups. A piece of work was undertaken by Birmingham University that has led to this agreement, funded by HEE, which cross referenced the International Federation of Orthopaedic and Manipulative Physiotherapists (IFOMPT)* standards against the multi-professional advanced practice framework and the MSK core capabilities framework (Rushton, Hindle, Noblet and Heneghan 2020 in press).

The outcome of this exercise demonstrated that the two frameworks aligned with the IFOMPT standards. These findings are significant as the IFOMPT standards are already used in Higher Education Institutions (HEIs) leading to Musculoskeletal Association of Chartered Physiotherapists (MACP) membership, along with the HCPC standards to examine clinicians against a level 7 framework. This agreement is central to an educational roadmap from graduate to level 7 to credential a portfolio route in the workplace to Advanced Clinical Practice.

For physiotherapy this standard is now set, but the vision is to create a common MSK standard across all MSK professions that will assure the system of advanced practice in the UK.

This will be achieved by cross referencing other MSK professional standards against the updated IFOMPT standards and making any changes, if needed, to accommodate any gaps. The outcome will be that education in MSK to advanced practice in the UK will be standardised, and all professions will be able to sit on the MSK educational roadmap to develop their career pathway.

Education

Educational Roadmap

To create an MSK pathway from graduation to level 7 Advanced Clinical Practice, a roadmap is being developed. This will provide educational support that will aid clinicians in identifying learning opportunities in the workplace, gaining advanced skills and knowledge, and generating knowledge from reflective practice. It will give clear guidance of what competencies need to be achieved at each level, and ways on how to evidence this. Ultimately this will support different routes including an equivalence (portfolio) route to Advanced Clinical Practice from graduation over an expected minimum of 5 years.

Portfolio sign off to clinical level 7 in the workplace

FCP roles have a minimum requirement of advanced (level 7) sign off in the clinical pillar of ACP. Outside the HEIs, the development of a portfolio supported by HEE to advanced clinical practice incorporating mandatory primary care learning is underway which will be held by the APPN. This can be adopted by all MSK professions. Capability sign off will be carried out by both the clinical supervisor in the workplace and the clinician who will sign against a declaration to their professional registration.

Higher Education Institutions (HEIs) and professional special interest groups

There is a lot of work going on in the development of courses in universities (HEIs) across England and within MSK special interest groups linked to HEIs to develop level 7 FCP standalone modules and ACP Master’s degrees.

To make the ACP Masters easier to develop and to tailor to a specific profession or speciality, the overarching core generic capabilities are being mapped by HEE from the multi professional ACP framework. The capabilities specific to primary care for FCP modules on top of the already defined core, are also being identified. This will give a central minimum requirement for HEIs to build advanced practice Master’s degree courses from and enable them to pull stand-alone level 7 modules such as a First Contact Practice module or MSK module into an ACP course to tailor to the specific need of the clinician.

The taught level 7 First Contact stand-alone modules teach the nuances of working in primary care, largely modelled around the eight CPD modules in the Health Education England’s MSK primary care e-learning. The e-learning modules cover: What is primary care, identification of the ill and at risk, mental health in primary care, complex decision making, public heath, persistent pain, overview of medicines and prescribing and serious pathology of the spine.

These e-learning modules are a minimum requirement for a clinician who is already working at clinical level 7 outside primary care to prepare for an FCP role and are free CPD to all in the NHS and can be bought outside the NHS to complete.

To support upskilling MSK clinical capabilities for all MSK professions to clinical level 7 (advanced level) the Society of Orthopaedic Medicine has now opened all their courses out to all MSK clinicians, and the Musculoskeletal Association of Chartered Physiotherapists are developing their course curriculum further to be a vehicle for advanced practice educational sign off as well as signing off at level 7 via the equivalence (portfolio) route, and in-house FCP modules.

The diagram below provides a visual diagram of where FCP sits and the routes to ACP. CAP is the Centre of Advanced Practice that sits in HEE.

FCP ACP routes diagram

Supervision

To support clinicians, there is a need for supervision for both clinical work and CPD. In primary care day to day clinical supervision is to be provided by a named supervisor at the GP practice. CPD supervision is to be provided by the Trust or private provider with the exception of an individual directly employed by a Primary Care Network (PCN) who needs to be supervised by the PCN.

There is an Advanced Practice supervision framework coming out soon to support this.

Further information

For further information with links to a timeline and FCP papers and resources, please refer to this paper: ‘A retrospective review of the influences, milestones, policies and practice developments in the First Contact MSK model’, Langridge, Hensman-Crook 2020, http://arma.uk.net/wp-content/uploads/2020/05/FCP-MSK-review-with-authors_v3.pdf

*(IFOMPT is an international body of 22 national groups who are clinical experts in MSK)