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.

Tag: public health

Guest blog by Dr Jeanelle de Gruchy, President of the Association of Directors of Public Health

To its great credit, New Zealand has become the first country in the world to produce a “wellbeing budget” – a commitment to prioritise population wellbeing as the main mission of the government. A similar philosophy was adopted in Wales in 2015, with the Well-being of Future Generations Act requiring public bodies to think about the long-term impact of their policies on both people and places.

This is a bold and exciting approach for anyone living with a musculoskeletal condition or campaigning for change on their behalf – and for the wider public health community. It puts the highest value on quality of life when it comes to national policy and investment decisions. The Association of Directors of Public Health has long championed taking a whole system and long-term view of how we create and support the health and wellbeing of everyone in society.

What does that mean in practice?

The ADPH recently published updated versions of our life course policy position statements capturing the collective views of Directors of Public Health in local government. There are four documents covering: Best Start in Life, Living and Working Well, Healthy Ageing and Health Inequalities.

Our statement on Living and Working Well focuses on the ‘working age’ population – the approximately 63% of people between the ages of 16-64 – and how to promote healthy, happy and productive lives. We know that the biggest causes of poor health (‘morbidity’) in England are low back and neck pain.

Delivering change means putting a greater emphasis on improving the social determinants of health – such as housing, air quality, education, income and food – factors which overwhelming shape our health and driving down inequalities in how long we live in good health (‘healthy life expectancy’).

It means promoting good mental health by intervening early to prevent the adverse childhood experiences that can have a lifelong impact. We know that along with mental health, poor musculoskeletal health (like back and neck pain) accounts for the majority of sickness absence in the UK, making this an issue of concern beyond the health sector. As ARMA highlights in its policy paper Musculoskeletal and Mental Health, we need to understand the inter-relationship between MSK conditions and mental health rather than treating them in isolation.

It means enabling people into good work and creating healthy workplaces which prevent many musculoskeletal conditions arising, as well as supporting those with musculoskeletal conditions to thrive in work.

These are all areas that need to be addressed in the upcoming green paper on prevention.

Finally, more funding for public health is now critical. A spending review is expected at some point this year and there is a growing consensus that public health investment – in its widest sense – must be a priority. In February, ARMA – and many of its members – signed up to a public letter in the Times, coordinated by ADPH and supported by 54 organisations, setting out the case.

The government has the welcome ambition to improve healthy life expectancy so that, by 2035, we are enjoying at least five extra years of healthy, independent life, whilst closing the gap between the richest and poorest. If the public health funding gap continues to grow, this ambition will not be met, with the costs being borne by the NHS, the economy and individuals.

We look forward to working with ARMA in the months ahead to raise the voice of public health and echo the call recently made by the APPG on Wellbeing Economics for a spending review which walks the walk on wellbeing.

Harnessing the power of social media to promote public health

The Institute of Osteopathy (iO) has launched a new community Facebook page ‘Osteopathy for Health’ with the aim to provide the public with useful health advice and tips to support positive lifestyle behaviours.

The iO first launched ‘Osteopathy for Health’ as web-based information, supported by a series of advice leaflets that could be distributed by osteopaths and other healthcare practitioners. The project has now evolved to utilise the power of social media to spread health and lifestyle messages on exercise, diet, getting older, sleep, and mental health on a dedicated Facebook page ‘Osteopathy for Health’.

The iO team will be working on developing more advice and promoting these on social media in the coming weeks and months and encouraging osteopaths to promote these public health messages through their own online networks.

Osteopathy for Health advice for the public:

  • Online. General health advice to the public is available from the iO website. Topics range from healthy eating to information to persistent pain. In the next year we will be transforming these pages: www.iOsteopathy.org/osteopathy-for-health
  • Social Media. Scroll Facebook, Instagram and Twitter for posts using #OsteopathyforHealth. You can search using the hashtag. Don’t forget: if you like it, share it!
  • Advice leaflets. The leaflets are available from the iO. To purchase copies please email enquiries@iOsteopathy.org

For more information about the Institute of Osteopathy’s ‘Osteopathy for Health’ public health advice programme, please contact comms@iOsteopathy.org

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.

Prevention seems to have been the theme of my February. The possibility that a lot of the pain and disability of MSK conditions might be prevented, and that this is being taken seriously is an exciting prospect. Even where the conditions can’t be prevented, good self-management support can make a big difference to the impact of the condition. The Government is clear that the future sustainability of the NHS depends on prevention, and that it wants to improve healthy life expectancy by at least five extra years, by 2035. With MSK conditions the largest cause of years lived with disability, this puts MSK centre stage.

There are two different debates and approaches to prevention. The first is what preventative services we can provide? There are lots of MSK examples – ESCAPE pain, Fracture Liaison Services, Strength and Balance programmes, yoga for healthy backs, weight loss support. Then there is a much broader, whole system approach to prevention. Our health is determined not just by our genetics and personal lifestyle decisions. It’s also about the environment we live in; the food we see advertised; our housing; social networks; how easy it is to walk to the shops if you need to sit down half way to rest; the support you might get from your employer to remain in work; your doctor making it easy for you to find peer support for your condition from a patient group. Public health is everyone’s business.

A physiotherapist speaking at one of the Public Health England regional meetings spoke of his experience of first encountering public health. He had been working in an “NHS Bubble”, unaware that the local authority had staff looking at prevention through a different lens, but with the same objectives. This disconnect is replicated up and down the country. I think the NHS long term plan and the prevention green paper give us an opportunity to join them up. If local government, not just public health, but also planning, housing, transport and environment, aren’t included, we will still be fighting against the wider determinants of health. I think there is a real opportunity with the new Primary Care Networks (PCN), to bring this together. At the moment, the remit of the PCNs is joining up primary, secondary and community healthcare. I think they are also in a great position to also bring in local government and address population health more widely. Smaller than an STP/ICS, they should be more able to look at local relationships and bring together all those who influence the systems that determine our health.

ARMA will be engaging with the implementation of the NHS Long term plan and the development of the Green Paper. We need both approaches for good population MSK health – services and a whole system approach. But the gains could be enormous, both for the NHS and individuals. This is everyone’s business. Let’s work together and see just how big a difference we can make.

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

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.

Since the NHS Long Term Plan (LTP) was published on 7 January 2019, the Universal Personalised Care: Implementing the Comprehensive Model has been published.

The document defines personalised care: people have choice and control over the way their care is planned and delivered based on ‘what matters’ to them and their individual strengths, needs and preferences.

There are six components to the model:

  1. Shared decision making
  2. Personalised care and support planning
  3. Enabling choice, including legal rights to choice
  4. Social prescribing and community-based support
  5. Supported self-management
  6. Personal health budgets and integrated personal budgets.

The document sets out the key principles of each component and what evidence would show that it is implemented.

Social prescribing – includes a reference to the need for this to be appropriately funded. There should be a one stop shop connector service with link workers (up to 5 per Primary Care Network) about to connect people to community groups and voluntary organisations that are supported to receive referrals. There should be community-based approaches to providing peer support. ARMA would argue that there is a role for patient groups in providing this peer support.

Supported self-management – This can include:

  • Health coaching or structured group coaching course
  • Self-management education approaches (face-to-face and virtual), which include disease-specific, generic and online self-management courses
  • Peer support through a link worker

Personal health budgets – People will have an indication of how much money they have available for healthcare and support, enough to meet the health and wellbeing needs and outcomes agreed in the personalised care and support plan. They will be able to use the money to meet their outcomes in ways and at times that make sense to them, as agreed in their personalised care and support plan.

 

Implementation

The document lists 21 actions needed to deliver personalised care at scale. These include:

  • Workforce training, including to all GPs.
  • An intensive face to face training programme for 75,000 health care professionals by 2023/4
  • Recruit and train over 1,000 social prescribing link workers by 2020/21
  • Work with partners in the voluntary and community sector, and others, to explore the best models for commissioning the local voluntary and community sector to support innovative provision.
  • Support for programmes to enable self-management
  • Train up to 500 people with lived experience to become system leaders by 2023/24.

For more details, see the full universal personalised care document.

 

Musculoskeletal conditions are common – we all know that. But it hadn’t struck me until recently just how common compared to other long term conditions. 17 million people in the UK have an MSK condition. Compare that with the 850,000 with dementia and think about how much we talk about dementia. It’s a similar picture for other conditions: diabetes, 3.5 million people, cardiovascular, 7 million. Only mental health exceeds the prevalence of MSK conditions.

Of course, we are rightly worried about dementia. But perhaps we should all worry a little more about our MSK health. It’s not “just pain” or something that is to be expected as we get older. It affects people of all ages and impacts of every aspect of life: work, friends, family, hobbies, the basics of independent living. We should all be working to maintain our MSK health throughout our lives. We should all be able to expect the right physical and psychological support and treatment if we do have MSK conditions.

Anything which has such major impacts on daily life takes its toll psychologically. ARMA members have been pooling their understanding of the links between MSK conditions and mental health. One recommendation we will be making to NHS England about their ten year plan is that everyone diagnosed with a long term MSK condition should have rapid access to psychological support. A pilot with other long term conditions has shown significant savings to the NHS. Providing access to people with respiratory illness, diabetes or a cardiovascular condition led to a saving of £200,000 for just 500 patients through reduced GP appointments, A&E attendance and hospital admissions. Including people with MSK conditions could double those figures.

As well as engaging with the ten year plan we’ve been making plans for the autumn. ARMA members have been supporting the parkrun ambassadors and we’re looking at what more we can do together. Our annual lecture will be on the 21 November and will have the CEO of parkrun as one of the speakers – look out for details in the next newsletter. Our webinar series begins again – see below for details of how to sign up for the first ones. And look out for more on mental health and MSK.

As you can see, there has been lots happening for ARMA over the summer. It feels very positive – MSK is rightly rising up the agenda. 17 million people need it to rise still further. ARMA will be working with you to make sure it does.

Guest blog by Ms. Nuzhat Ali, National MSK Lead, Public Health England

Health inequalities are avoidable, unjust differences in people’s health that are persistent and difficult to shift, until and unless we actively focus on them as a society and a whole system.

People living in the most deprived areas in England can expect to spend nearly 20 fewer years in good health compared with those in the least deprived areas. The trajectory and the scale of the inequity worry me for at least three reasons – it is:

  • A societal injustice, one that has serious consequences for us all in many ways
  • A factor in slowing down life expectancy and healthy life expectancy
  • Increasing demand for health care which equates to increasing costs

Health is dependent on so much more than healthcare.  Research from the Canadian Institute of Advanced Research, Health Canada, Population and Public Health Branch found that healthcare contributed no more than 25% to our health, and others like McGiniss et al found from their research that it is a 15% contribution. Our genes, lifestyle behaviours, environment, housing, socioeconomic and working conditions, and much more are all key determinants of our health. Surely this points to the need for us all to focus greater attention to these factors in meaningful ways.

The Determinants of Health (Dahlgren and Whitehead, 1991)

The figure above shows the main determinants of health as layers of influence. At the centre of the model, individuals are endowed with non-modifiable factors that influence health potential, including age, sex and constitutional factors.  

Surrounding the individuals are layers of influence that can be modified. The innermost layer represents the personal behaviour and way of life adopted, such as smoking habits and physical activity, with the potential to promote or damage health. Individuals interact with friends, relatives and the community, and are therefore affected by the social and community influences represented in the next layer. Mutual support within a community can sustain the health of its members in otherwise unfavourable conditions.

The wider influences on a person’s ability to maintain health include their living and working conditions, food supplies, and access to essential goods and services. Overall, there are the economic, cultural and environmental conditions prevalent in society as a whole, represented in the outermost layer.

What do we know about the relationship between musculoskeletal (MSK) health and inequality?

Gender differences:

An estimated 17.8 million people live with a MSK condition in the UK, which is around 28.9% of the total population. Of these, 7.7 million are men and 10 .1 million are women.

Socioeconomic differences:

People who live in the most deprived areas are much more likely to report arthritis or back pain than people in equivalent age groups who live in less deprived areas. 40% of men and 44% of women in the poorest households report chronic pain, compared to 24% of men and 30% of women in the richest households.

Among people aged 45–64, the prevalence of arthritis is more than double in the most deprived areas (21.5%) compared to the least deprived areas (10.6%). Further, people of working age (45–64 years) are almost twice as likely to report back pain (17.7%) as those from least deprived areas (9.1%).

Physical inactivity, obesity and comorbidity are all strongly associated with deprivation. People in the most deprived areas develop multi-morbidity 10–15 years earlier compared to those in the least deprived.

My top three humble suggestions on how we might tackle this wicked system problem:

  • Balance the medical model of health with the social model of upstream efforts on wider determinants of health. This means working in partnership and collaboratively across sectors and with our community’s
  • Focussed secondary prevention in primary care is the best way to get quick wins in narrowing health inequalities (King’s Fund)
  • Provide targeted support to help people find and remain in good work

Public Health England (PHE)’s mission is to protect and improve the nation’s health and wellbeing, and reduce health inequalities. PHE have published a range of tools and resources to support professionals to tackle inequalities. PHE’s guidance – Reducing health inequalities: system, scale and sustainability – set out a revision of the DHSC’s Health Inequalities National Support.

For further information, you can visit PHE’s return on investment tool for MSK conditions, Health Matters and the recently published review on muscle and bone strength and balance.