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Health Policy

23 July 2019

The Arthritis and Musculoskeletal Alliance, an alliance of prominent health charities, professional and research bodies, welcomed the publication of the Advancing our health: prevention in the 2020s consultation document from the UK Government.

The Green Paper recognises that for the last 30 years, problems with joints, bones and muscles have been the most common cause of years lived with disability in England and the Green Paper’s proposition includes increasing the join-up across mental and physical health services. It includes ensuring businesses are equipped with the knowledge and tools they need for musculoskeletal health, convening a reference group on this. The document also recognises the scale and cost of MSK conditions – to individuals and the economy – and the need to take further action.

We are pleased to see the importance placed on musculoskeletal health in the prevention green paper as there are effective ways to prevent many musculoskeletal conditions, which is why Public Health England recently published a strategic framework for musculoskeletal prevention. However, there also needs to be sustained financial and political commitment if we are going to improve health outcomes in the long term.

Guest blog by Andy Bell, Deputy Chief Executive, Centre for Mental Health

Having a musculoskeletal condition increases your risk of having a mental health problem, and people with a mental health condition are more likely to have a range of MSK problems. Yet the way services for both are organised and the ways professionals in each are trained offers little recognition of the overlaps between them.

Mental health and MSK conditions share some common traits and challenges. Both are complex and diverse. Many are poorly understood. And neither has traditionally been afforded priority status within the NHS.

Nonetheless, both are finally gaining recognition by policymakers as causes of long-lasting distress, pain, poverty and disability. The NHS Long Term Plan, for example, includes a welcome focus on improving mental health support, including an extension of psychological therapy provision for people with long-term physical conditions. And a new five-year MSK strategy sets out a range of actions that statutory bodies such as Public Health England and charities including Versus Arthritis and ARMA will take to prevent MSK conditions and improve support for those living with them.

The MSK strategy specifically notes the links with mental health, citing a fourfold higher risk of depression among people living with chronic pain and a 50% higher risk of back pain among people with depression [1]. It goes on to note that integrated working may therefore help to support people with co-occurring needs more effectively, though gives little detail about what that might mean in practice.

Centre for Mental Health is now working with partners in both mental and physical health to highlight the often neglected physical health needs of people living with long-term mental health conditions such as schizophrenia, bipolar disorder or personality disorders through a collaborative called Equally Well [2]. Having a severe mental illness is known to cut short life expectancy by 15-20 years. But for many it also comes with chronic pain and disability. And too often people’s physical symptoms are ignored or overshadowed by their mental illness.

We want to change that by ensuring that people working in and using mental health services have a bigger focus on physical health, and that those working in physical health can work equally well with someone who has a mental health diagnosis as they can with someone who does not. For MSK professionals, this may mean being more aware of the nature and impact of mental health conditions, and being able to work in trauma-informed ways [3]. Building links with mental health professionals and service users can help to ensure people get timely help where possible to prevent MSK problems and whenever necessary to offer the right help and support to people who need it.

Some services, for example Sussex MSK Partnership [4], understand the importance of ‘no health without mental health’ (one of its three core values) and the value of people who use services being recognised as equal partners in designing and delivering this sort of support [5].

It is vital that people living with long-term mental health conditions get the same recognition for their physical health needs, with MSK professionals available to meet their needs in ways that they find helpful and convenient (including for those who may be in hospital for their mental health).

Achieving equal health for people with mental health conditions requires the whole health and care system to work differently. But ultimately, it is about the interactions professionals have with people day to day. And through Equally Well we hope to work with ARMA and colleagues across the MSK sector to enable people to bring about change at every level of the system and to ensure no one is left without the support they need for their physical and mental health.

References:

[1] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/810348/Musculoskeletal_Health_5_year_strategy.pdf
[2] https://www.equallywell.co.uk
[3] https://www.centreformentalhealth.org.uk/engaging-complexity
[4] https://sussexmskpartnershipcentral.co.uk/
[5] https://www.hsj.co.uk/patient-and-public-involvement/patient-leadership-for-real-the-sussex-model-for-patient-partnership/7022549.article

NICE are inviting organisations to register as a stakeholder for the guideline: ‘Safe prescribing and withdrawal management of prescribed drugs associated with dependence and withdrawal’.

Registered stakeholders will have the opportunity to comment on the draft scope and guideline during consultation and all comments received from registered stakeholders will be considered and responded to individually. You will also be privy to an embargoed release of the guideline prior to publication in the public domain.

To register as a stakeholder, please complete the online form from the NICE website, and you can find more information about NICE’s guideline work here.

Rheumatoid Arthritis (RA) is very much on my mind as I write this during RA Awareness Week. Yesterday I attended a roundtable discussing the NHS Long Term Plan (LTP) and RA. Rheumatology doesn’t get a specific mention in the plan, but there is plenty of content on related issues. There is mention of chronic pain, for instance, which is very relevant to ARMA and to RA. Access to integrated pain services is something ARMA members have identified as a priority following the publication of our mental health report last month, and by the time this is published I will have presented at a meeting of the Chronic Pain Policy Coalition.

MSK gets a number of mentions in the Long Term Plan but it’s easy to get the impression that this is all about osteoarthritis. ARMA is very clear that rheumatology is part of MSK, and just as important a part of our work as orthopaedics. I am part of an advisory group for the NHSE review of elective care access standards (waiting times in plain English) and I know that this is a vital issue for rheumatology. There are delays in patients recognising that their symptoms might be serious, and often further delays in GPs making a referral to rheumatology so, once referred, it’s vital that there isn’t a long wait to see a rheumatologist. But the roundtable heard that only 32% of RA patients are seen in a time recommended by NICE and almost 10% wait longer than the general waiting time target of 18 weeks.

The roundtable heard that three things impact on remission rates for RA and one of them is rapid access to specialist assessment.  Another is starting therapies quickly. The Long Term Plan talks about reducing delays in access to evidence based treatment. The example it gives is joint replacement surgery, but access to biologics in RA is another excellent example.

The final factor increasing chances of remission is a person centred holistic approach to care. The roundtable heard about unmet needs of RA patients, including pain, anxiety and depression. ARMA’s roundtable report on mental health and MSK has been well received in both MSK and mental health sectors. It’s very relevant to RA patients, and we will be pursuing the recommendations over the coming months.

After the meeting I was asked what would help rheumatology get the best out of the Long Term Plan. Part of my answer was that it needs to be clearly part of MSK, which is included in the plan. Which is why ARMA’s core offer for local NHS Plans includes rheumatology. Let’s be clear, no CCG, STP or ICS can say it is delivering good MSK services if it hasn’t included rheumatology, pain and mental health in their plans.

In the run up to the publication of the Government’s Green Paper on prevention, the IPPR has published a report Ending the blame game: The case for a new approach to public health and prevention. The UK has made significant progress on prevention in the past, IPPR says, but we appear to have ‘hit a wall’ with limited progress since 2010. They call for the government’s prevention green paper to deliver a paradigm shift in policy from interventions that ‘blame and punish’ to those that ‘empathise and assist’.

Meanwhile Public Health England’s Health matters: Prevention – a life course approach guidance published last month focuses on taking a life course approach to the prevention of ill health and signposts to evidence-based interventions and tools, as well as to evaluation and monitoring techniques.

It looks at addressing the wider determinants of health that will help improve overall health by helping to improve the conditions into which people are born, live and work. Unlike a disease-oriented approach, which focuses on interventions for a single condition often at a single life stage, a life course approach considers the critical stages, transitions, and settings where large differences can be made in promoting or restoring health and wellbeing.

One major criticism of the NHS Long Term Plan was the lack of any detail on workforce. This detail has begun to emerge with the publication of the Interim People Plan for the NHS. It looks at the need to transform the way the entire workforce, including doctors, nurses, allied health professionals (AHPs), pharmacists, healthcare scientists, dentists, non-clinical professions, social workers in the NHS, commissioners, non-executives and volunteers, work together. It works on the basis that multi-professional clinical teams will be the foundation of the future workforce, rather than treating the workforce as a group of separate professions.

This new multi-professional way of working will be essential for MSK services, where there are high levels of multimorbidity and good person-centred care is rarely the responsibility of one professional.

The plan has 5 themes:

  • Making the NHS the best place to work
  • Improving the leadership culture
  • Tackling the nursing challenge
  • Delivering 21st century care
  • A new operating model for workforce

A full, costed five-year People Plan will be developed later this which will build on the vision and actions in this interim Plan. This will set out in more detail the changes to multi-professional education and training, career paths, skill mix and ways of working needed and quantify in more detail the full range of additional staff needed for each of the NHS Long Term Plan service priorities.

There are accompanying documents setting out the vision for the future workforce for allied health professionals and psychological professions; dental; healthcare science; medical; and pharmacy.

Public Health England has published two documents related to MSK prevention. The first is a whole-system strategic framework for prevention of musculoskeletal conditions across the life-course. The purpose is to provide stakeholders and system collaborators with a clear statement of PHE, NHS England and Versus Arthritis’ commitments to promote MSK health and to prevent MSK conditions. Each collaborating organisation, including ARMA, has identified what they will be contributing, and in some cases, leading on.

The document contains information about a range of MSK prevention activities and links to resources and tools to help prevention activity.

Alongside this is an MSK prevention logic model which provides an overview of the programme vision: help maintain and improve the musculoskeletal health of the population in England (across the life-course), supporting people to live with good lifelong MSK health and freedom from pain and disability which will be delivered by system partners and collaborators within 5 years.

The ARMA Alliance with Versus Arthritis and the British Orthopaedic Association voiced its concerns previously about rationing of joint replacement surgery for people with MSK conditions. ARMA published a position paper on this in 2017.

So what does the latest data tell us about hip surgery? In June, Deborah Ward and Lillie Wenzel from the policy team at The King’s Fund published a blog post: ‘A new trend in elective hip surgery’. They examine the trend in hip replacements, health gain and health gain reported by patients and interpret these trends. Are the trends symptoms of a service under pressure?

Read their article in full via the King’s Fund website.