This is a category taken from the full feed of Musculoskeletal and Arthritis news provided by ARMA's members.
  • The Arthritis and Musculoskeletal Alliance (ARMA) is the umbrella body for the arthritis and musculoskeletal community in the UK, and our mission is to transform the quality of life of people with musculoskeletal conditions. We have 33 member organisations ranging from specialised support groups for rare diseases to major research charities and national professional bodies.

Health Policy

governemnt logoFor the first time since Public Health England (PHE) came into being, musculoskeletal conditions have been mentioned in the Government’s remit letter to PHE. PHE is the national body with responsibility for the nation’s health and wellbeing and tackling health inequalities. Each year the Government sends them a set of instructions about their priorities. In 2019/20 this specifically includes ‘work-focused musculoskeletal prevention activity’.

In 2018, PHE made musculoskeletal conditions one of its priority programmes, and so it’s great that these conditions are now taking their place on the national agenda. This summer, PHE will publish their 5-year prevention plan for musculoskeletal conditions, which Versus Arthritis has been working in partnership on.

The Institute for Voluntary Action Research (IVAR) has developed free support resources for health, care and voluntary sector leaders who want to drive action through partnership working around the NHS Long Term Plan. The resources include online learning, webinars, workshops, coaching and individual support and are aimed at ICS/STP leads, commissioners, clinicians, and professionals from the voluntary sector.

The NHS Long Term Plan commits local healthcare systems to working in a new way, including a focus on prevention and reducing health inequalities. Building relationships – with other health agencies, local government, providers and communities – will be essential for the leaders charged with bringing this ambitious vision to life.

The NHS Long Term Plan recognised the role Voluntary, Community and Social Enterprise (VCSE) organisations could play, in partnership with the NHS, to help deliver its vision. At a strategic level, NHS England is committed to working with VCSEs and establishing models for more equitable partnerships and better integration, and to increase the influence of the voice of patients. More locally, STP’s/ICS’s, as with any relatively new player in a system, are taking time to build consistently high and constructive levels of engagement with VCSE organisations and communities more widely. 

The Building Health Partnerships programme and this wider support offer – Transforming Healthcare Together – have been designed in response to all these challenges, to work intensively with statutory services to test and pilot new approaches to partnership working, and to support the leaders working to bring the NHS Long Term Plan to life.

The free support offer is for health, care and VCSE leaders who want to drive action through partnership working. There is a range of support for different levels, whether you are just getting started or have been working in this way for some time.

The Oxford University Hospitals Foundation Trust Pilot

By Dr Christopher Speers, Sport and Exercise Medicine Consultant Oxford University Hospitals Foundation Trust

Physical inactivity is the fourth leading cause of death worldwide1 and it contributes significantly to the worldwide burden of non-communicable disease2, 3. Hospitals, historically, have been dominated by a culture of rest4. Promoting rest contradicts the evidence which clearly demonstrates that disease outcomes are better for moving more and that post hospital syndrome, or hospital deconditioning, leads to increased risk and adverse outcomes5, 6. Furthermore, there is a significant evidence-base demonstrating the potential for physical activity to improve management and treatment outcomes for a wide range of long-term health conditions, including arthritis7.

Healthcare provides a unique point of access to a section of the population who are likely to gain the most from only small improvements in increasing their physical activity. Therefore hospital admission is a key opportunity to influence patients to change behaviour for the better. This preventative approach to healthcare is a key objective of the NHS 10 year plan8.

‘Moving Healthcare Professionals’ forms part of Public Health England’s (PHE) ‘Everybody Active Every Day’ strategy9, and aims to engage professional networks to support understanding and awareness of, and greater engagement in, physical activity among the wider public.

In 2017, PHE and Sport England invited expressions of interest from applicable NHS Trusts (i.e. the Trust employs a Sports and Exercise Medicine (SEM) consultant to deliver a SEM pilot in secondary care. We were successful and were commissioned to deliver an SEM pilot that focused on the integration of physical activity into care pathways within secondary care.

The primary aim of the SEM pilot was to explore the potential for multi-disciplinary SEM teams in secondary care to contribute to patient outcomes through targeted and tailored support to integrate physical activity into the care plans of in-patients prior to discharge. We developed physical activity interventions across five different clinical pathways involving multi-morbidity and frailty (figure 1). Each intervention was designed using the COM-B model and Behaviour Change Wheel10. A clinical champion was employed within each pathway to develop and deliver the interventions, provide leadership and training to other staff within that clinical setting.

clinical pathways diagram

A range of different interventions were used to improve the levels of physical activity in patients, but underpinning our approach was an ambition to target healthcare professionals and change their behaviour to improving the frequency and quality of conversations between staff and patients about physical activity. Tools to do this included integrating the Exercise Vital Sign11, 12 into electronic patient records, staff training in motivational interviewing, exercise classes, as well as bed-, chair-based, and standing-exercise programs matched to functional ability of patients. A community navigator was available to help patients and staff members find community-based exercise teams and classes during the discharge process to ensure integrated care.

External independent evaluation was undertaken by the National Centre for Sport and Exercise Medicine in Sheffield; early reports have shown that this approach is highly valued and acceptable to patients and staff within the NHS. We have learnt a huge amount about integrating physical activity into secondary care systems throughout the pilot, and are going to publish our findings, learning and experience in the form of an ‘Active Hospital Toolkit’ later in 2019. This will be accessible through the Moving Medicine website.

References:

  1. Kohl HW, Craig CL, Lambert EV, Inoue S, Alkandari JR, Leetongin G, Kahlmeier S; Lancet Physical Activity Series Working Group. The pandemic of physical inactivity: global action for public health. Lancet. 2012 Jul 21;380(9838):294-305.
  2. Lee IM, Shiroma EJ, Lobelop F, Puska P, Blair SN, Katzmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012 Jul 21;380(9838):219-29.
  3. Blair SN. (2009) Physical inactivity: the biggest public health problem of the 21st century. British Journal of Sports Medicine; 43:1-2
  4. Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc . 2009;57:1660–1665.
  5. HM Krumholz Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med 2013; 368:100-102.
  6. Wen CP, Wai JPM, Tsai MK, Yang YC, Cheng TYD, Lee M, et al. (2011) Minimum effort of physical activity for reduced mortality and extended life expectancy. The Lancet; 378:(9798): 1244-1253.
  7. Gleeson, M., Bishop, N. C., Stensel, D. J., Lindley, M. R., Mastana, S. S. & Nimmo, M. A. 2011. The anti-inflammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease. Nature Reviews Immunology, 11,
  8. NHS England NHS Long Term Plan. https://www.longtermplan.nhs.uk/ (accessed on 27.03.2019.
  9. Public Health England 2014. Everybody Active Everyday: National Physical Activity Framework. In: ENGLAND, P. H. (ed.). London: Public Health England.
  10. Michie, S., Atkins, L. & West, R. 2014. The behaviour change wheel: A guide to designing interventions, Great Britain, Silverback Publishing
  11. Sallis R, Franklin B, Joy L, et al. Strategies for promoting physical activity in clinical practice. Prog Cardiovasc Dis 2015;57:375–86.
  12. Coleman KJ, Ngor E, Reynolds K, et al. Initial Validation of an Exercise ‘Vital Sign’ in Electronic Medical Records. Med Sci Sport Exerc 2012;44:2071–6

Return to top

ARMA has been working with the Medical Technology Group (MTG) to raise concerns about increasing rationing of joint replacement surgery.

The MTG is a coalition of patient groups, research charities and medical device manufacturers working to improve access to cost effective medical technologies for everyone who needs them. MTG has concerns about treatment rationing in general and have launched the Ration Watch campaign to highlight care inequality and the impact it has on patients’ lives.

Ration Watch aims to expose the scale of rationing and the issues around local commissioning across the UK.

Ration Watch looks at individual commissioning polices, NHS activity and waiting times to describe the challenges some patients face. The campaign will work with local politicians, councillors, MPs, and national decision makers to help improve patient access to treatment regardless of where you’re based in the UK. Their website asks patients who have been denied life-enhancing treatments, such as hip surgery, to share their rationing stories.

Ration Watch believes that what you need, not where you are, should dictate the care you receive.

The Health Foundation, Kings Fund and Nuffield Trust recently published a report Closing the Gap: key areas for action on the health and care workforce. The report looked at two areas – nursing and general practice, both very relevant to MSK health care. At the moment the future looks bleak, with 41,000 nursing vacancies in the NHS and another 5,000 in social care. There are 2,500 fewer GPs than are needed. The report, however, is optimistic that these shortfalls can be addressed, provided policy changes are made.

On nursing, the recommendations include increased training, international recruitment and a range of measure on pay and career opportunities. There are particular issues for recruitment of specialist nurses, something which ARMA member the Rheumatology Nursing Network is very aware of.

Proposals for general practice chime exactly with the work ARMA members have been doing around First Contact Practitioner. The report recognises the potential for nurses and AHPs to work across traditional boundaries and deliver more patient-focused care, moving from a traditional GP model to multidisciplinary team working. It is important to remember that these changes don’t just help make up the shortfall in GP numbers, they also have the potential to improve patient care.

Last week saw a momentous event for people living with axial SpA (AS) in the UK, when NASS held the inaugural meeting of the first ever all-party parliamentary group (APPG) specifically for Axial Spondyloarthritis. Parliamentarians, policy makers, clinicians, healthcare commissioners and NASS members and staff came together to identify and address concerns about AS care.

You can read NASS CEO Dr Dale Webb’s reflections on the meeting and more of what’s to come from NASS’ Every Patient, Every Time campaign.

Musculoskeletal support professionals in the community

by Dr Rob Hampton, GP and Occupational Physician

Across the world, chronic musculoskeletal conditions such as osteoarthritis, inflammatory disorders and common regional conditions such as back, neck, shoulder, hip and knee pain now represent the single greatest cause of years lived with disability 1. When measuring their negative impact on employment, self-reported wellbeing and day-to-day function, chronic musculoskeletal pain conditions are every bit as invasive as other chronic conditions such as heart failure, diabetes and COPD. People with chronic conditions increasingly have access to dedicated, usually nurse-led services that provide support with exacerbations and link the patient to GP and secondary care when required. Even the traditional ‘Cinderella’ conditions of dementia and mental health now benefit from improved recognition and coordinated care. I would argue that chronic musculoskeletal conditions are now the true Cinderella in the UK, a fact recognised by NHS England through their partnership with the Arthritis and Musculoskeletal Alliance (ARMA) called the MSK Knowledge Network. Its focus is on bringing knowledge and people together to improve outcomes for people with MSK conditions in England.

There are several projects that show the value of community-based support for people with musculoskeletal problems. The Joint Pain Advisor pilot in South London 2 is an example of the power of professional support to help people adapt to chronic pain problems and reduce demands on healthcare resources, particularly GPs. The power to encourage self-care and de-medicalise chronic musculoskeletal pain have been cornerstones of pioneering services such as the Back Pain Programme in South Tees 3 and the Pain to Prospects Programme in Leicester 4. These services win awards, are reproducible beyond the pilot phases and could provide a level of support to the people with chronic musculoskeletal conditions similar to that for conditions such as heart failure, diabetes and COPD. My impression is that the biopsychosocial approach required is just ‘not medical enough’ to receive CCG funding but ‘too medical’ to attract financing from the social or welfare sector.

Will the evolution of Primary Care Networks announced in January 2019 through the NHS long-term plan provide the right environment for ongoing community based musculoskeletal support? Let’s hope so. If ARMA take up this cause with NHS England, progress can be made.

References:

  1. Global Burden of Disease Study 2013 Collaborators. (2015) Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386:743–800. 
  2. A Walker, R Williams, F Sibley, D Stamp, A Carter, M Hurley. (2017) Improving access to better care for people with knee and/or hip pain: service evaluation of allied health professional‐led primary care. Musculoskeletal Care. https://doi.org/10.1002/msc.1189
  3. NHS England (2017) National Low Back and Radicular Pain Pathway 2017, Together with Implementation Guide http://www.ukssb.com/pages/Improving-Spinal-Care-Project/National-Backpain-Pathway.html. (accessed January 2019).
  4. Hampton R. (2013) From Pain to Prospects? – helping people on welfare benefits with chronic pain. Pain News. 2013;11(4):227 –230.

Since the NHS Long Term Plan (LTP) was published on 7 January 2019, the NHS Operational Planning and Contracting Guidance 2019/20 has been released. It gives guidance on how the additional funding settlement for the NHS should be used.

Key points of interest are:

 It is the start of the process of producing the local plans that will be the implementation of the NHS LTP. For 2019/20, every NHS trust, NHS foundation trust and clinical commissioning group (CCG), will need to agree organisation-level operational plans which combine to form a coherent system-level operating plan. This will provide the start point for every Sustainability and Transformation Partnership (STP) and Integrated Care System (ICS) to develop five-year Long-Term Plan implementation plans, covering the period to 2023/24.

The document covers:

  • System planning
  • Financial settlement
  • Operational plan
  • Process and Timescale

System planning

Every STP/ICS must produce a system operating plan for 2019/20. This must include an overview of how the system will use its resources to meet population health need, including specialised commissioning and direct commissioning as well as CCG plans. It must also include a system aggregation showing how individual plans align to form a system plan.

All NHS providers and CCGs must be part of a plan. The focus should be on how to work together to provide efficiency savings, not cost shunting from one organisation to another.

Financial settlement

The focus of this section is on CCG funding settlements and tariff payments. It then addresses efficiency savings and steps that systems need to focus on to become more efficient. This includes working to make outpatients and community services more efficient through use of digital technology.

There is a list of ongoing opportunities which includes medicines value – e-prescribing; removal of low value prescribing; and greater use of biosimilars.

There is a list of specialist commissioning which includes reference to long term conditions, but specifically mentions hepatitis C and neurosciences. Also reference to rapid diagnosis of rare diseases, but in relation to genomics. Integrating specialist commissioning into locally commissioned services is also seen as an opportunity, including the move to a pathway approach to planning care for populations.

Operational plan requirements

This section lists the priorities seen as fundamental to transforming urgent and emergency and elective care. The nine deliverables are:

  • Emergency care – reducing the time for which patients are hospitalised.
  • Referral to treatment times – The expectation is that over 5 years the volume of elective care will go up, and waiting lists will come down, starting in 2019/20. However, waiting times commitments relate to 6 month and 52 week waits. The clinical standards review will look at waiting time standards (this is where we have a concern that the 18-week target may be changed/scrapped). There is also reference here to First Contact Practitioners for MSK patients.
  • Cancer treatment
  • Mental health – a series of deliverables for mental health includes a target that 50% of those on IAPT should recover. Depending how you define recover, this might be a barrier for MSK patients with long term conditions for whom managing their mental health is more realistic than recovery.
  • Learning disability and autism
  • Primary and community care – The focus of this is on primary care networks. STPs/ICSs must set out how they will achieve sustainability and transformation of primary care. Additional funding to primary care must deliver investment in transformation. A local workforce plan including multi-disciplinary teams and a primary care network development plan.
  • Workforce
  • Data and Technology
  • Personal health budgets – by March 2021 50,000 – 100,000 people must have a personal health budget.

The longer-term deliverables are those in the LTP.

Timeline

Draft organisation/operational plans submitted by 19 Feb with 5-year plans by Autumn 2019.

For more detail see the full document.