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Tag: musculoskeletal health

Since the NHS Long Term Plan (LTP) was published on 7 January 2019 a new document, Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan, has been released which includes the roll out of the Primary Care Networks model. Here’s a summary of the relevant MSK elements.

The publication covers the following areas:

  • Addressing the workforce shortfall
  • Solving Indemnity Costs
  • Improving the Quality and Outcomes Framework (QOF)
  • Introducing the Network Contract DES
  • Going ‘digital-first’ and improving access
  • Delivering new network services
  • Guaranteeing investment
  • Supporting research and testing future contract changes
  • Schedule of future contract changes and development work


Workforce is identified as the priority for primary care. Various steps are set out to enable recruitment of an additional 5,000 doctors and 1,000 nurses.

There is a reimbursement scheme for additional roles to enable increased multi-disciplinary teams. Five roles are listed as being eligible for reimbursement:

  • clinical pharmacists,
  • social prescribing link workers,
  • physician associates,
  • first contact physiotherapists
  • first contact community paramedic.

ARMA has raised with NHSE the fact that the role is First Contact Practitioner, not physiotherapist. If reimbursement is only available for physiotherapists in the role, we are concerned this will mean other professional training does not see FCP as something worth investing in, so reducing a potential source of suitable FCPs. This would be counterproductive in the context of a measure designed to address a workforce shortfall.

Primary Care Networks

Primary Care Networks (PCNs) are intended to bridge the divide between primary and community services. They focus on provision of services, not on commissioning. They will become the foundation of integration to deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care.

They are about primary care practices contracting to work together. A PCN should cover a population of around 50,000 patients (minimum 30,000) so that it is large enough to support a multidisciplinary team.

Networks will have a network agreement. Delivery will require collaborative working by members. Members of a network will be GP practices plus specialist, physical and mental health services and secondary care in the area.

Each PCN must have a clinical director and one lead practice which receives the funding for the network. NHS England will provide a range of support to PCNs.

Delivering new network services

There will be seven service specifications to be delivered in 2019/20:

  1. Structured Medications Review and Optimisation;
  2. Enhanced Health in Care Homes, to implement the vanguard model;
  3. Anticipatory Care requirements for high need patients typically experiencing several long term conditions, joint with community services;
  4. Personalised Care to implement the NHS Comprehensive Model;
  5. Supporting Early Cancer Diagnosis;
  6. CVD Prevention and Diagnosis; and
  7. Tackling Neighbourhood Inequalities.

Anticipatory care – Based on individual needs and choices, under the Anticipatory Care Service, people identified as having the greatest risks and needs will be offered targeted support for both their physical and mental health needs, which include musculoskeletal conditions, cardiovascular disease, dementia and frailty. Typically, this involves a structured programme of proactive care and support in which patients with multi-morbidities will have greater support– including longer GP consultations where appropriate – from the wider multidisciplinary team.

For more detail see the full document.

We all know that MSK is one of the two biggest causes of sickness absence in the UK. It’s perhaps no surprise that this is even more true in the construction sector. Every year, occupational ill‐health costs construction employers £848million in reduced productivity, sick pay, cover for absence and replacing staff who leave because of ill health. 76% of this relates to MSK conditions. In February, ARMA brought together some key players in the construction sector with stakeholders such as Department for Work and Pensions and Health and Safety Executive, to look at what might be done to improve this situation.

The group discussed a range of issues. Due to the nature of the work people fear speaking out about an MSK problem. This can lead to presenteeism, with loss of productivity, ending when there is a more serious injury, which might have been prevented if treatment had been provided earlier. There is a challenge of getting a message across to a workforce who are mostly on site, and how to make sure the key messages are communicated clearly without bombarding people with information that they can’t take in. It is a complex sector, with major contracting companies, who may not directly employ staff, and large numbers of very small companies who may have little or no occupational health infrastructure.

There will be a report following the meeting – look out for it on the ARMA website soon. Participants will also be taking forward some of the recommendations from the day. We would like to thank Volker Wessels UK, BAM Nuttall, Mace Group and Multiplex Europe for supporting the event.

by Sarah Duncan, Head of Clinical Policy, NHS England

An interview on the news recently about stem cell research into cartilage replacement for osteoarthritis, made me reflect on the phenomenal pace of change and progress in the relatively short time of my career. As a new physiotherapist in the mid-1980s we used short wave diathermy; long flexible heated tubes wrapped around a patient’s knees, to help with the pain of arthritis. Although patients really enjoyed the heat, it made little difference to their ongoing pain and mobility.

At that time, every orthopaedic ward housed patients on traction for spinal pain. Attached to heavy weights via tape stuck to their legs, patients were on bedrest for 6 weeks. It would be the physio’s job to get them standing up for the first time. Many people would nearly faint as their cardiovascular system tried to cope with being vertical again. I often thought the subsequent manoeuvres to get them flat again must have reversed the alleged benefits of the bedrest. This was a time when there were treatment regimes for everything and the main individualising factor was the surgeon’s preference.

I was working in Somerset when I came across a different approach to chronic pain management, led by Dr Alf Collins, now Personalised Care Group Clinical Director at NHS England. His approach for people living with persistent pain was to help them understand and come to terms with their pain, and adopt strategies which enabled them to lead as fulfilling and independent lives as possible. Physiotherapists ran education and exercise groups, which also enabled people to share their experiences with others who understood and could empathise. This approach really worked for many people, supporting both their mental and physical health, and they were empowered to take control of their condition. I learned that managing pain was less about giving a treatment to a passive recipient and more about collaborating and working with them.

Fast forward 30 years and I’m in a national clinical policy role, which includes the Musculoskeletal (MSK) Conditions programme. Digital technology, genomics, stem cell research, and advances in surgery are all enabling progress to be made, beyond anything imaginable in the ‘80s. This progress also includes the evidence-based personalised care approach that the membership organisations of ARMA have long supported and developed. In partnership with ARMA, NHS England has developed the MSK Knowledge Hub enabling the MSK community to debate innovative ideas, share learning and celebrate success. The NHS Long Term Plan published yesterday, has a whole chapter on personalised care building on the  Five Year Forward View, which recognised the need for better integration of services, and connection with the voluntary sector, to enable a more personalised approach.  The NHS Long Term Plan aspires to a fundamental shift in approach to deliver more person-centred care, including for musculoskeletal conditions.

We must continue to develop the focus on people as individuals amongst the high-tech treatment options, and ensure people are properly listened to. People with MSK conditions should have choice and control over the way their care is planned and delivered, based on what matters to them and not only on what’s the matter with them. I’m encouraged to see that the Long Term Plan for the NHS will build on the evidence and examples to show how personalised care could, and should be, business as usual across the health and care system.

“No health without MSK health”. Those were the words of our guest speaker at the ARMA AGM and they clearly struck a chord with members. They were on my mind last week when I attended a consultation meeting held by NHS England about the new ten-year plan for the NHS. At the moment MSK health doesn’t get as much profile as conditions such as mental health, cancer or cardiovascular. Not to downplay the importance of these conditions, but MSK health underpins all aspects of our ability to be independent and lead the active lives we want. We all know the cost to the NHS, to individuals and families, and to the economy is enormous.

The pain and limited mobility of MSK conditions also has a knock-on impact on other aspects of health – difficulty opening medication or food packaging; difficulty getting on the bus to shop for healthy food or attend appointments; difficulty carrying out all the self-care and self-management activities that enable us to manage other health conditions. Arthritis Research UK reports that by age 65 years, almost 5 out of 10 people with heart, lung or mental health problem also have a musculoskeletal condition. If you are struggling at home with your arthritis and you need to go into hospital for any reason, you are likely to need more support to return home as a result.

So why does MSK not get a higher profile? The answer is: at a local level it does. The majority of CCGs have MSK as a priority for service improvement locally. And at a national level NHS England has a plethora of relevant programmes and activity, it’s just they don’t all sit under the banner of a single MSK programme. By contrast, Public Health England has a new MSK programme which will be working on MSK initiatives and ensuring that MSK is embedded in other PHE work.

Wouldn’t it be great to see this all recognised with a profile in the ten-year plan? So as the NHS consults on the plan they will hear one message from ARMA members loud and clear: No health without MSK health.

By Chris Graham, Chief Executive, Picker Institute Europe

Arguments about the pressures on the NHS at a system level are well rehearsed; rising demand, financial restraint, and challenges around staffing numbers are well reported. But what of the impact of caring on healthcare professionals as people?

The NHS Staff Survey is an annual survey that aims to help providers to understand how it feels to work in the health service. In 2016, it recorded the experiences of more than 423,000 members of NHS staff – and provides fascinating insight into the health and wellbeing of NHS staff.

Some of the findings are troubling. Over the autumn of 2016, 60% of staff came into work despite feeling physically unable to perform their duties. Musculoskeletal (MSK) problems were a particular issue, with one in four (25%) reporting MSK problems resulting from work activities. MSK problems were even more prevalent in ambulance trusts: here, 41% of respondents and three in five (60%) ambulance technicians reported experiencing work-related MSK problems in the last three months.

Encouragingly, the staff survey does provide evidence that organisations can help to reduce MSK problems for staff. Organisations where higher percentages of staff respondents said that their employer “definitely” took positive action on health and wellbeing perhaps unsurprisingly reported lower percentages of staff respondents reporting MSK problems. The strong association between these measures shows the beneficial impact of pro-active approaches to health and wellbeing.

picker logoHealthcare professionals provide an indispensable role, often under difficult circumstances. Their employers rightly have a duty to look after them – and this should include a holistic approach to health that emphasises wellbeing and harm avoidance rather than simply remedial action.

Getting this right is important for staff, but is also vital to reducing pressure on services; organisations that take steps to prevent their staff from becoming patients will prevent sickness absences from stretching their workforce further.

I’d encourage you to take a look at how your organisation faired in the 2016 NHS staff survey – you can see the results here: What do you think of them? Soon, the 2017 survey will be circulated and it will be your opportunity to help us all understand what it’s actually like to work in the NHS in 2017; we need your opinions.

See ARMA’s page of resources related to Working with MSK.

Guest Blog by Dr Jo Larkin, Sport and Exercise Medicine Consultant FFSEM

The knowledge and principles used to treat elite professional athletes in Sport and Exercise Medicine can be used to treat injuries occurring in the rest of the population.

The musculoskeletal (MSK) rehabilitation plan must consider the fact that the objective of the patient is to return to the same activity and environment in which the injury occurred. Functional capacity after rehabilitation should at the minimum be to at the same level, if not better, than before injury. The goal of the rehabilitation process is to limit the extent of the injury, reduce or reverse the impairment and functional loss, and prevent, correct or eliminate the disability.

So why should we do this? Whether you are an elite athlete, weekend warrior or just someone that wants to remain active, the care pathway and rehabilitation in MSK Medicine is the same. Stakeholders such as coaches and corporate bosses should invest in allowing the time for this to take place because there is evidence to show physical activity has multiple health benefits.



Open full size infographic ‘Physical activity benefits for adults and older adults’:


Focusing on the workplace, Business Harvard Review published a document on work effectiveness and performance. It demonstrated that both effectiveness and performance was higher in people that regularly exercise. Exercise has also been show to elevate mood, which has serious implications for workplace performance.

A further study from the Leeds Metropolitan University, demonstrated that on the days that employees visited the gym, their experience at work changed. They reported managing their time more effectively, being more productive, and having smoother interactions with their colleagues. Interestingly this then lead to the individual feeling more satisfied at the end of the day, thus in theory could have a beneficial effect on the individuals’ home life.

Keeping the workforce working is key no matter if you are an international athlete, office worker or manual worker. Therefore, carefully mapping out the MSK care pathway for the individual is no different. The aim of rehabilitation is to restore function. This is done in very simple steps and starts with a correct and early diagnosis. Once this is established the basic parameters of any rehabilitation programme is to restore the range of movement, strength and then functional progression. The latter phase is generally sport, exercise and position specific. The goal of the rehabilitation process is to limit the extent of the injury, reduce or reverse the impairment and functional loss, and prevent, correct or eliminate the disability. Within the elite sport setting this is carried out by a multidisciplinary team in order to address all facets of the individual’s rehabilitation programme and optimise health outcomes, as this is an opportunistic time with the patient.

There are many ways to approach designing a rehabilitation programme and it should occur as soon as the injury takes place. I have provided an example below:

The Acute Phase – there will be some restriction in loading and range to allow for reduction in swelling and pain. However, the practitioner needs to continue to find ways of maintaining cardiovascular fitness.

The Restoration Stage – the programme will focus on range of movement and strength.

The Reacquisition Stage – where the focus will be progression of strength and initiation of the functional sport and exercise specific tasks.

The Refinement Phase – is to focus on building confidence, developing the complicated skills, progress the cardiovascular drills i.e. graduated return to running or activity. Increase capacity, both endurance and strength of the tissues.

The stages are designed to ensure functions of rehabilitation are systematically undertaken to ensure the patient has best potential return to normal activity.

The government has recently acknowledged the importance of managing MSK issues effectively in the joint green paper “Improving Lives. The Work, Health and Disability Green Paper” with the Department for Work and Pensions and the Department of Health. Therefore, it is imperative we draw on our knowledge from how we rehabilitate the sporting population and utilise our skills for the general population; but instead of using a return to sport as our objective end marker, we use the individual’s goals and link these with occupational return-to-work goals.

Instead of viewing exercise as something we do for ourselves, a personal indulgence that takes us away from our work, it’s time we started considering physical activity as part of the work itself and have this supported within the workplace. In summary, there are many similarities between the care pathway for returning sportspeople to activity and returning working people to their occupation.

Last Friday, March 31st, NHS England published a significant document about the future of the NHS: Next Steps on the NHS Five Year Forward View. The original NHS five year forward view set out why and how the NHS should change to address three issues: the health gap, the quality gap and the financial sustainability gap. The next steps updates on progress and sets out future plans.

Musculoskeletal conditions account for a major part of the workload of the NHS, 40% of which is due to potentially preventable risk factors. The NHS spends £5 billion a year treating them. Yet they get surprisingly little focus in Next Steps, at least directly. Musculoskeletal includes everything related to bones, joints and muscles, from back pain to rheumatoid arthritis. The associated pain and mobility problems have a significant impact on people’s ability to work (and pay tax), and to contribute to family and community life. This impact is set to rise as we all live longer and healthcare demands will increase with us needing to remain mobile and independent.

The most significant reference to MSK is to hip and knee replacements, including recognising that waiting times for these operations may go up. Whilst Next Steps talks about the huge increase in hip replacements in the last 15 years, a recent report from the Kings Fund found that in the last year there are signs that the number of hip replacements is going down. Given the high level of evidence of the effectiveness of this operation and the needs of the population, this is travel in the wrong direction.

Whilst there are few other explicit mentions of MSK in the rest of the document, it is clear to me that MSK services have a big role to play in these plans for the future of the NHS. Priorities include integration of services, better access to primary care and prevention. There are many links between these and good musculoskeletal services.

ARMA, working in partnership with NHS England, recently organised a series of regional events, bringing together professionals from primary and secondary care with patients, to talk about local plans to improve musculoskeletal services. The discussions would have felt very familiar to the authors of Next Steps. Integration, partnerships, moving care into the community, how physiotherapists in GP surgeries can reduce pressure on GPs and so save money. One frustrated physiotherapist said “we’ve shown it works for patients and saves money. Why is this not being rolled out everywhere?” Yet the chapter on primary care talks about a wider range of staff without mentioning physiotherapy.

Ultimately what this document is about is financial sustainability – saving money. All the evidence is that there is wide scope for more effective use of resources in musculoskeletal services to deliver what patients want and need. As our events showed, the will is there in the MSK community – both patient groups and professionals. What is needed is for the NHS, both locally and the national improvement programmes, to embrace this and make sure it happens everywhere.

nos-and-usbji2-animationThe National Osteoporosis Society, in conjunction with the United States Bone and Joint Initiative, has worked on an animation about osteoporosis which they have remastered for a UK audience. The animation has been voiced by the charity’s ambassador, Miriam Margolyes, famous the world over for her hundreds of film, theatre and television credits including Harry Potter, Blackadder and the Real Marigold Hotel.

The animation, titled “Learn more about osteoporosis with Miriam Margolyes,” is finished and ready to be launched. ARMA members who would like to see it pre-release can contact Sarah Wolf at the NOS to attain a preview password. 

The video will be publicly launched and promoted with the help of Miriam (who has the condition) within the next few weeks.