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  • 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.

Tag: mental health

Designing care for people living with both mental health problems and persistent back and neck pain

by Jenna Collins, Marketing and Communications Manager, Q Labs, The Health Foundation

In September 2018, the Q Improvement Lab (part of the Health Foundation) and Mind embarked on a year-long collaboration to understand how care can be improved across mental health and persistent back and neck pain.

The Q Lab and Mind have recently shared the first insights from this work, drawing on the experiences of over 100 collaborators to give an overview of why this challenge warrants attention and promising opportunities to improve care. A small number of organisations are now developing and testing ideas and the findings will be shared later this year.

Read essays, learning and insights from the Mental health and persistent back and neck pain project.

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

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.

by Sue Brown, CEO ARMA

I write this reflecting on my day yesterday, which was unexpectedly dominated by discussions on pain. Pain is, of course, something we all talk about a fair bit in the MSK health world, as it’s one of the shared factors that cuts across all MSK conditions. I’m increasingly realising it is something we don’t always deal with particularly well.

My day yesterday began with reading New Scientist on the train, including an article about UK doctors’ concerns that we will follow the US into an opioid crisis. The question raised in the article was: is there a risk we will take things the other way, so that when someone does need opioids, they won’t be able to get them? The day ended at a wide-ranging lecture by Simon Stevens, Chief Executive of the NHS, including a slide showing opioid prescription rates by region: a wide variation, with London the lowest, and the North East the highest.

My discussions throughout the day all touched on pain in some way, but with a much broader agenda. Pain is rarely a simple matter which can be solved by pills alone. Yet that’s the only option offered to so many people. ARMA promotes a person-centred, integrated, biopsychosocial approach for anyone who experiences chronic pain. The prevalence of chronic pain is highest in the North East of England, and lowest in London (43.1% vs 29.0%). There is something going on here which is not just physical. We know that there are strong links between physical and mental health, which is why ARMA recently organised a roundtable on mental health. It is clear from my discussions yesterday that this is crucial in the context of chronic pain.

My issue with the debates about opioids is that they are about opioids. It seems to me that this is starting in the wrong place. The question is not what can we do about the increase in opioid prescription but what can we do about the increase in chronic pain? We need a much more sophisticated discussion. If pain is complex and individual, then the solutions must be personalised and multidisciplinary. We need to be able to refer people for psychological support. That might be IAPT psychological services for people with MSK pain. It might be health psychology in the context of a specialist pain service. We need to have appropriate peer support and social prescribing offers. We need to look at the underlying causes of pain and treat those where possible. The best pain services in the world are not useful if what the patient really needs is joint replacement surgery or rapid access to physiotherapy. And we need appropriate prescribing, and clinicians confident to discuss the different options and engage in good shared decision making with their patients.

This is not an issue which can be addressed by one profession. Patients in chronic pain may need GPs, rheumatologists, surgeons, pharmacists, psychologists, physiotherapists and others, working together. As with so much else in MSK healthcare at the moment, this support doesn’t join up and in the case of psychological support, too often isn’t available at all. This is why ARMA has made mental health a priority for this year. Together with our members, we will be pushing for improved access to joined-up, multidisciplinary personalised biopsychosocial support for people in chronic pain. We’ve already had some webinars on the subject, including how to deliver an integrated pain service and how to integrate mental health into physical health services. We’ve held a roundtable and produced our report. Look out for more activity including webinars and our annual lecture in November that push this agenda forward.

Join with us in calling for action to provide comprehensive services which address chronic pain from all angles. Patients with chronic pain deserve nothing less.

In April 2019, ARMA, supported by UK charity Arthritis Action, released a new report looking at the impact of mental health on people with arthritis and other musculoskeletal (MSK) conditions. The report followed a roundtable event, organised by ARMA in March, which, for the first time, brought together leaders from Mind, NHS England, Arthritis Action, and other health charities to look at ways to improve access to effective psychological support for MSK patients. ARMA published the report during Mental Health Awareness Week.

roundtable-document

Sue Brown, CEO of ARMA, says:

“It’s not surprising that mental health is so common amongst people with conditions which cause long term pain. What is surprising is how little support with their psychological well-being is offered to people who live with daily pain. This roundtable report should be an important first step in changing this. There are interventions that have been shown to work, but they aren’t available in most areas. ARMA believes that everyone who could benefit from them should be offered them.”

MSK conditions comprise over 100 different diseases and syndromes that interfere with a person’s ability to carry out their normal daily activities. MSK conditions are thebiggest cause of disability in the country, with around 17.8 million people in the UK affected by them.[i]

Around one in five people with osteoarthritis, the most common form of arthritis, report depression and anxiety.[ii] In terms of receiving mental health support, one in five patients with rheumatoid arthritis report being asked about emotional issues by a rheumatology professional, even though almost half of the population would like the opportunity.[iii]

Key themes highlighted in the report are:

  • Treating emotional and mental health conditions should be a fundamental part of managing arthritis from point of diagnosis. A recent survey found that two in five people with arthritis had never been asked by a healthcare professional about their emotional wellbeing [iv].
  • Mental health support is needed at every diagnosis/transition point in a person’s journey.
  • People with MSK conditions often feel that they are the only ones experiencing them. Contact with patient support organisations, either through helplines or support groups, can help people understand their experiences are common.
  • Keeping people in work is as important as getting them into work.
  • Training/supporting employers in managing staff with long-term conditions is key.

Recommendations:

  • Integrated physical and mental health support should be available from basic educational materials to integration in pain clinics and rheumatology.
  • Every healthcare professional with an MSK patient should ask about their emotional/psychological wellbeing at every appointment.
  • Healthcare professionals should ensure that patients are aware of patient support groups and organisations available, both nationally and locally.
  • MSK professionals should receive training and CPD to help them better understand and assess mental health. Training should include risk assessment and knowledge of referral pathways.

Leigh Walmsley, arthritis patient and London 2012 Paralympic Archer, says:

“I developed osteoarthritis after a serious cycling accident aged 11, but noticed the first signs of inflammatory arthritis in my 20s. The impact arthritis had on my life was very significant. I couldn’t run in PE with my classmates, walk too far, stand for too long and as my inflammatory arthritis began to rear its head; there were times I almost couldn’t walk home after work. The fatigue of chronic pain is debilitating and causes depression.

“Arthritis Action appeared in my life when I was at a low point. It was a huge comfort to know there were other people like me, that have the same ideals as me and most importantly, they allow me to help other people with arthritis. I was so inspired, I decided to start a support group for the Charity in the North West. Groups are a great way of bringing people together, helping them feel less isolated or alone, which is really beneficial for our mental health.”

Read the Mental Health Roundtable Report.

[i] Versus Arthritis: State of Musculoskeletal Health Report 2018
[ii] Versus Arthritis: State of Musculoskeletal Health Report 2018
[iii] National Rheumatoid Arthritis Society (NRAS): Emotional Health & Well-being Matters Survey 2018
[iv] National Rheumatoid Arthritis Society (NRAS): Emotional Health & Well-being Matters Survey 2018