2019 Presidents Lecture Musculoskeletal practice: Current state of - - PowerPoint PPT Presentation

2019 President’s Lecture Musculoskeletal practice: Current state of play, opportunities and challenges

Professor Lesley Haig, Principal, AECC University College

Setting the scene

Musculoskeletal conditions: scale, burden and impact

Scale of the problem - UK

Arthritis Research UK, 2017

Burden of arthritis and other MSK conditions

Economic impact of MSK

• MSK conditions cost ~ £10bn healthcare

spending each year

• Hip fractures - £1.96bn
• Ankylosing spondylitis - £3.8bn
• 336m prescriptions MSK - £223.6m

Impact on health and social services Primary care

• 1 in 5 consult GP for LBP
• 30% GP consultations MSK
• 4.6m GP appointments per annum = 793 WTE

GPs Secondary Care

• Over 25% all surgical interventions in NHS

Social Care

• Personal Independence Payments £8.61bn

• Leading cause of global disability (YLD) of 291

conditions Hoy et al, 2014

• 11% of disability burden in UK
• £20bn each year economic cost
• £5bn NHS cost
• Over 45% EU workforce suffer backache over 12

months Eurofound, 2012

• 50% seek care – 35% private sector

Persistent low back pain impact

• Pain
• Distress
• Functional limitation
• Loss of sense of self
• Need for validation
• Social impact – roles, work, income, isolation
• Need to navigate care system
• Coping strategies

Duffield et al, 2017; MacNeela et al, 2015; Snelgrove et al,2013;

Individual impact MSK conditions

Changing landscape

Impact on the UK workforce

Risk factors and associated multimorbidities

Risk Factors

• Non-modifiable – age, gender (F)
• Modifiable
• Physical inactivity e.g. OA
• Obesity e.g. regional pain

syndromes

• Smoking e.g. inflammatory arthritis
• Poor nutrition
• Direct causal relationships e.g. RA

vs CVD and osteoporosis

Duffield et al, 2017

Associated Co-morbidities

MSK and Mental Health

• In England 4.6m have MH and physical health

conditions

• Those with long term physical health problems

2-3 x more likely to develop MH problem – mood disorders, anxiety, substance abuse, depression

• Working aged disabled people:
• 35.2% experience MSK conditions only
• 20.2% experience mental health conditions
• nly
• 17.2% experience both

Arthritis and Musculoskeletal Alliance, 2018

Evidence-informed Guidance

• Literature review
• STarT Back √
• Physiodirect √
• Physio self-referral √
• ESCAPE-pain (knee) √
• CBT with exercise x
• Vocational advice in primary care x
• Yoga for healthy lower backs x

PHE, 2017

Return on Investment Interventions

• Self-management – information and advice √
• Group exercise √
• Manual therapy √
• Belts / corsets x
• Traction x
• Acupuncture x
• Ultrasound x
• PENs / TENs x
• IFT x

Imaging

• Do not routinely offer imaging in a non-specialist setting
• Explain to people that if they are being referred for specialist
• pinion, they may not need imaging.
• Consider imaging in specialist settings only if the result is likely

to change management.

NICE Guidance LBP, 2016

Physical Activity Interventions for MSK

ARUK, 2017

Changing Landscape

• 5 year plan
• Enhance primary medical

services and community health

• Improve maternity care
• Personalised care for older

people in community

• Mainstream digital health

NHS Long Term Plan (2019)

Public Health Role

Healthy Ageing and MSK

Focus:

• Inflammatory

conditions

• MSK pain – OA/LBP
• Osteoporosis and

fragility fractures PHE, 2017

Focus on Patient-centred Care (PCC)

• NHS

constitution

• 3 steps
• Behavioral

change approach

• health coaching
• making every

contact count (MECC)

• motivational

interviewing (MI)

Person-centred Approaches Framework

HEE, 2017

Characteristics of PCC:

• Biopsychosocial perspective
• Patient-as-person (not disease)
• Sharing power and responsibility
• Therapeutic alliance
• Individual preferences, needs and values guide clinical decisions
• Respectful and responsive care

HEE, 2017

Communication Skills

• Enhance therapeutic alliance

Ferreira et al, 2013

• Influence patient outcomes

Darlow et al, 2012

• Influence patient satisfaction

Hush et al, 2011

• Identify patient readiness to change
• Identify and work with patients resistant to change (discordant)

Miller and Rollnick, 2013

• Enhance treatment planning and goal setting Parry, 2004

2018

Range of settings Not prescriptive

• 14 capabilities in four

domains:

• A. Person-Centred

Approaches

• B. Assessment, Investigation

and Diagnosis

• C. Condition Management,

Interventions and Prevention

• D. Service and Professional

Development

MSK Capabilities Framework for First Contact Practitioners (FCPs)

GP Partnership Review (2019)

Recommendation 3: The capacity and range of healthcare professionals available to support patients in the community should be increased, through services embedded in partnership with general practice. …….enabling the creation of population-based multi-professional teams across primary and community care The current model of care in the NHS is too dependent on hospital-based care. This model is not sustainable, and we cannot move forward without change that includes general practice and partnerships at its heart.

Innovation and Collaboration

• Academic Health Sciences

Networks

• NHS Innovation Accelerator
• NHS RightCare

Digital Health Agenda

• Develop digital infrastructure
• Better use of resources
• Promote prevention / self

management

• Protect and manage data to

support patient journey

• Can be anxiety-provoking –

‘Heart age’, self-diagnosis

• Telehealth and telecare
• Remote consultations
• Telephone triage

Public vs Private Sector

• 11% population PMI
• 18% individual subscribers
• 53% NHS consultants in

private practice

• NHS Trusts can earn up to

49% income from private care

• Currently £600m
• Around 30% income in

independent hospitals – NHS funded

• NHS going global

HSJ, 2017; King’s Fund, 2014

Challenges

Visibility and recognition

• Numbers:
• Chiropractic – 3.3k
• Osteopathy – 5.3k
• Physio – 58k (MSK network 14k, Physiofirst members 4.5k,

Pain 11k, SEM 14k, MACP 1.1k)

• We are all aware of excellent case studies
• Awareness – multiprofessional education / working /

exposure

• Demystification / education of others about the

profession

• Autonomy as prescribers – nurses, some AHPs
• NHS recognition as AHP?
• NHS is huge, internally facing, medicine and nursing-focused

Missing out?

• GPs and nurses were deterred from referring patients to services such

as pain management (incorporating CBT), acupuncture, chiropractic and osteopathy, by a perceived lack of NHS services, and/or a lack of familiarity with local providers of non-physio services.

• For many, the only NHS-funded option after physiotherapy was to refer

to a pain management clinic, which could be associated with high NHS costs, long waiting lists, and resource implications for patients.

Opportunities

NHS Saviours?

• NHS austerity
• Innovative ideas are welcome especially

where they fill a gap / reduce burden on primary care

• FCP
• GP review – models / case studies / evidence
• Triage
• Advanced practitioners
• Don’t wait to be asked!

Opinion Leaders

• Exemplary MSK skill set – especially in areas which nurses,

physios, fitness professionals do not have

• Teach them some of your techniques – they will see how

great you are

• Extend skill set? Rehab, public health
• Employ other professionals and lead by example
• Continue to demonstrate evidence-base – increase doctorally-

qualified researcher base

• Optimise chiropractic pre-qualifying curricula so graduates

are abreast of wider health and social care agenda and have skills to work with a wide range of professionals

Conclusions Make the vital visible!

Thank you for your attention