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Research

State of Health reportState of health and care: The NHS Long Term Plan after COVID-19

A new report from IPPR shows the extent to which the coronavirus pandemic has disrupted progress on the NHS Long Term Plan. The report looks at cancer, mental illness, cardiovascular disease and multiple long term conditions, but the findings are equally relevant to MSK services.

The report argues that COVID-19 should not become an excuse for low ambition, and that world-class healthcare must remain the overall goal. To achieve this, the report recommends a package of six ambitious changes designed to do three things:

  • Ensure the pandemic does not cause lasting damage to healthcare services for future generations.
  • Bring in areas – like social care and public health – that are not covered in The NHS Long Term Plan, but which are integral to healthcare.
  • To capture the innovations that occurred during the pandemic.

The six recommendations are:

  1. Ensure a sustainable workforce: a new deal to catalyse recruitment and retention – including a pay rise, a new wellbeing offer, and improved training and progression.
  2. Fund the NHS to deliver and sustain transformation: funding to meet the elective care backlog and rise in mental illness to avoid a trade-off between transformation and the pandemic care backlog.
  3. Empower integration from the bottom up: through system focussed regulation, reformed financial incentives and permissive legislation.
  4. Upgrade the digital NHS: providing internet access as a basic public service, understanding patient preferences and investing in the NHS’s digital infrastructure.
  5. Fund and reform social care: including free personal care for everyone aged 65 and over, improving the quality of social care, better pay for care workers, and immigration rules that do not lead to catastrophic shortages.
  6. Level up the nation’s health: a public health cabinet committee to co-ordinate policy functions across Whitehall, and greater devolution of funding and powers to local government to tackle the primary determinants of health.

Read the full report on www.ippr.org.

Summary of article published in Rheumatology Advances in Practice on 5 January, 2021

“Disease impact of rheumatoid arthritis in patients not treated with advanced therapies; survey findings from the National Rheumatoid Arthritis Society”

Authors: Elena Nikiphorou, Hannah Jacklin, Ailsa Bosworth, Clare Jacklin, Patrick Kiely

Background

In 2020, NRAS conducted a survey amongst its members and non-members who had RA with a disease duration more than 2 years, who were not on advanced therapies (i.e. biologic/biosimilar or targeted synthetic DMARDs (JAK inhibitors)), with the aim of revealing the everyday impact of living with RA in people not treated with advanced therapies. It aimed to assess in detail a wide range of aspects of quality of life and everyday living using the RA Impact of Disease (RAID) patient reported outcome questionnaire and other measures of the impact RA (on work).

Introduction

It is widely established that prompt and effective treatment in RA using tight control (treat-to-target) strategies improves disease outcomes. (For more information on tight control, please see our booklet ‘Living Better with RA’ and our website). The aim of tight control is to get disease into remission, or if that is not possible, as low a disease activity state as possible. The 28-joint count Disease Activity Score (DAS28) is used in the UK to determine how well disease is being controlled by current medication, and assess eligibility to move on to advanced therapies, if standard disease modifying drugs are not working well enough (current NICE guideline requires a DAS 28 of greater than 5.1 for a patient to be considered for moving onto advanced therapies).

Results

There were 612 responses from patients having an average age of 59 years. 88% were female and 37.7% had a disease duration of 2–5 years and 27.9% a disease duration of 5–10 years. In the last year, 90% had reported a flare of their RA, with more than 23% reporting six flares. As part of the survey, participants completed the RAID questionnaire which measures 7 domains: pain, functional disability assessment, fatigue, sleep, physical wellbeing, emotional wellbeing and coping. Only 12.4% of participants recorded an ‘acceptable state’ as measured by the scoring system for the RAID questionnaire.  On an individual patient level, a score below 2 is deemed ‘a patient acceptable state’ on a scale of 0-10. More than 50% of participants scored each of the seven domains in the high range (indicating a worse state); 74.3% scored sleep problems and 72% fatigue in the high range.

Difficulties at work were measured using a selection of questions taken from the Work Productivity and Activity Impairment (WPAI) questionnaire. A need to change working hours was reported by 70%. The survey results showed increasing difficulties with daily physical activities. Reduced emotional and physical well-being in the past week were all strongly linked to levels of pain reported as well as number of flares and ability to cope. The total RAID score strongly predicted the number of flares people reported.

Key outcomes from this study

  • In established RA, patients who are not on advanced therapies, indicate high levels of suffering as reported by the RAID.
  • The RAID ‘acceptable state’ is very uncommon.
  • High levels of pain, physical disability, sleep difficulties and fatigue are key symptoms experienced.

To read the full paper, go to the news section of the NRAS website.

The challenge of the next decade: are hip fracture services ready?

The National hip Fracture Database (NHFD) has recently released its latest annual report focussing on the six NHFD key performance indicators used to monitor and drive up standards across the country. 2020 will no doubt prove to be one of the most challenging years in the history of the NHS. This report also presents the first data about the effect of COVID-19 on trauma units around the country and on outcome for patients with hip fracture who have COVID-19 when admitted to hospital or develop it after their operation.

We would like to thank Captain Sir Tom Moore for his support for the NHFD and its aims to drive up the standards of care for hip fracture sufferers like himself.

He is a shining example of what can be achieved after breaking a hip and is in many ways a symbol of the inspirational resilience of multidisciplinary teams across the country at this challenging time. As he says himself: ‘We have to keep on going.’ At the time of writing, Captain Sir Tom Moore is being treated for COVID-19 and our thoughts are with him and his family.

How can the NHFD data be used?

  • NHS leaders should use the NHFD data on COVID-19 to understand the course of the pandemic and the impacts on frail older people
  • Local hip fracture teams should review the NHFD KPIs for their unit and target below average KPI’s with local QI projects
  • Ward teams should reflect on the additional challenge of social distancing for frail older people and ensure they are offering patient information leaflets and carer support information
  • Hospital managers should use the NHFD run charts for their hospital to understand the impact of the pandemic
  • NHFD clinical leads should use the new NHFD casemix adjusted mortality run charts to check the quality of their data

Should you have any queries about the latest report findings, please contact NHFD@rcplondon.ac.uk or NHFD Senior lead clinician: antony.johansen@wales.nhs.uk.

The report is available to read here alongside a recording of a webinar in which NHFD clinical leads Dominic Inman and Antony Johansen discussed the report findings, the first data on Covid-19 and answered attendees’ questions. The webinar also includes a presentation from the Programme’s Patient and Carer Panel, Julia Ellis, introducing a new and much-needed resource for family carers whose loved one is in hospital after a hip fracture.

RA disease impact in patients not treated with advanced therapies; survey findings from the National Rheumatoid Arthritis Society

by NRAS

Recently NICE published a Final Appraisal Document in respect of a new JAK inhibitor (filgotinib –  Jyseleca) giving access to people with RA who have so called ‘moderate’ disease in addition to those with ‘severe’ disease. This is the first time NICE have broadened their eligibility criteria for access to advanced therapies and is warmly welcomed by NRAS. This comes at the same time as a paper published by the National Rheumatoid Arthritis Society (P. Kiely et al – Rheumatology Advances in Practice – 5/1/21) entitled RA disease impact in patients not treated with advanced therapies; survey findings from the National Rheumatoid Arthritis Society.”

The paper describes the results of a survey of over 600 people with RA who are not currently receiving an advanced therapy, and demonstrates very clearly that many of these individuals experience profound difficulties in everyday living with RA, across a broad range of measures. The survey included the RA Impact of Disease (RAID) questionnaire and only 12.4% of respondents were currently in a patient acceptable state, as defined by a total RAID score <2. The high impact of so-called “moderately active” RA on everyday life is further emphasised by the finding that in all seven domains >50% respondents recorded scores in the high range, indicating a significant burden in the last week. This is supported by impact on work data from the survey, with 70% of respondents reporting a change in working hours due to their RA. Difficulties with daily physical activities, and worsened physical and emotional well-being were significantly associated with higher pain, greater number of flares and worsened ability to cope. RA flares were extremely common with 90% experiencing at least one flare and nearly a quarter reporting 6 or more flares in the last year. Thus, across all assessed patient reported outcome measures, many RA patients not currently taking advanced therapies experience a related burden of adverse outcomes from their disease.

NRAS has always advocated that access to the most appropriate treatment at the right time to bring RA disease activity under optimal control will greatly reduce the impact and burden of disease on individual lives. This change will also enable many more people living with RA to continue to work and live full, productive lives. Earlier treatment in the disease pathway of those with uncontrolled disease will benefit not only the individual but their families, the economy and the health service leading to potentially less surgical and clinical intervention and ultimately less disability. Most European countries do not have the very high eligibility criteria imposed by NICE in the UK for the last two decades which, by comparison, has disadvantaged people with RA in the UK. This very welcome news regarding filgotinib (Jyseleca) brings us a step closer to alignment with most of the rest of Europe.

Recently, Pain Alliance Europe conducted a 6-week short survey on Covid-19 and chronic pain in twelve languages to see the current situation of chronic pain patients in Europe.

The survey showed initial results that during the pandemic 15% of people worried and feared taking prescribed medication. There was also impact on self-management plans – of those people who had a plan, 29% indicate they are not able to continue with their care plan. From all countries, the respondents in the UK reported the highest impact of pain interfering with their normal functionality.

You can now find the summary report here and the findings by country here. PAE are undertaking detailed analysis of the survey results and a full report is expected in March 2021.

The British Assistive Technology Association (BATA) has launched a survey, supported by the WHO’s GATE Programme (Global Cooperation on Assistive Technology), called the UK Priority Assistive Products List National Survey.

It is a survey about the most essential assistive products for people, aiming to create a list similar to the essential medicines list from WHO, of essential assistive devices. This is to help identify priorities of need and improve access for those who require an assistive device.

There are a number of categories, one is mobility. This includes devices like walking frames, footwear, orthoses and bracing.

More information: bataonline.org.uk
Survey: surveymonkey.co.uk/r/LD7MYJ6

A new report from Public Health England examines data on chronic pain in England and analyses inequalities in the experience of chronic pain. The report will be useful for those commissioning and delivering services for those experiencing chronic pain and policy makers in central and local government. The findings on inequalities include that chronic pain is more prevalent in women than men; in people from the Black ethnic group than other ethnicities; and in those in more deprived areas.

The Global Burden of Disease Study 2016 has highlighted pain as one of the most prominent causes of disability worldwide. Low back and neck pain have consistently been the leading causes of disability internationally, with other chronic pain conditions featuring prominently in the top 10 causes of disability. Chronic pain has a significant impact on peoples’ lives, it is associated with negative outcomes including depression, job loss, reduced quality of life, impairment of function and limiting daily activities.

The report sets out the overall prevalence of chronic pain amongst the general population as well as identifying differences between sub-groups. It examines the site and severity of the chronic pain for those who are experiencing pain, as well as the impact on their mental health. It finishes with an analysis of the use of specialist pain services.

The findings include:

  • 34% of respondents reported some level of chronic pain.
  • Women (38%) reported a higher prevalence of chronic pain than men (30%).
  • All ethnic groups showed similar reporting of chronic pain, except for people in the Black ethnic group who reported a significantly higher prevalence at 44%.
  • Those living in more deprived areas were more likely to report having chronic pain (41%) than those in the least deprived areas (30%).
  • Among those who reported chronic pain, 36% also reported a long-lasting musculoskeletal condition

For those reporting chronic pain the most common long-lasting illnesses were musculoskeletal conditions. The report says the need to address inequalities in chronic pain suggests more can be done within the health system to understand why certain groups are affected more than others. This observation will allow a focus to be placed on these groups to reduce the overall burden of chronic pain.

The report also mentions that a multidisciplinary approach to chronic pain management, one which addresses all the areas related to chronic pain, would be beneficial during treatment.

Read the full report: on the gov.uk website.

Key reports exploring the role of osteopaths in supporting NHS services for the benefit of patient care, including the results of research into osteopaths as primary care First Contact Practitioners, have been published and are available from here.