Dr Andrew Cuff, Director of Clinical Strategy at Connect Health responds to the latest report by Versus Arthritis.
“Each year, Versus Arthritis produce a report titled “State of Musculoskeletal Health”. This report provides an overview of a variety of factors affecting, or affected by, MSK Health such as estimates of how many people experience MSK pain, have osteoarthritis, or have another associated long-term condition (LTC). Ensuring a holistic view, the report clearly outlines the wide-reaching factors that should be understood or considered by all those involved in the provision of MSK care.
“The term ‘MSK’ means different things to different people. For some, a traditional viewpoint of MSK relates to conditions or presentations that are predominantly seen as self-limiting, related to bones, joints and muscles with a focus on treatment. More recently, the broader view of what is meant by ‘MSK’ has become popular again, encompassing those that are experiencing chronic pain or inflammatory conditions. This is a conversation that we have visited regularly within Connect, were we an ‘MSK provider’, were we an ‘MSK and Pain provider’, ultimately deciding we were a ‘community service’ provider. However, even the term ‘community’ means different things to different people! With the political landscape (once again) committing to “providing care closer to home” and a greater focus on “primary and community care” – what is meant by ‘community’?”
‘Community’
“From an MSK perspective (taking the broad view of what is meant by ‘MSK’), Community can be used to refer to either the space in which services operate between primary and secondary care or the social unit made up of a group of people living in the same space or area. Whilst describing two different forms, their function is intrinsically interdependent. This is made clear within the State of MSK report when considering the bi-directional social impacts within MSK health – arthritis and chronic pain are more common in areas of greater poverty; MSK conditions are the third most common reason for working days lost. Integrated Neighbourhood Teams offer an opportunity to harness the potential that exists between both forms of Community. Developing collaboration and clear links between the commissioned MSK pathway and organisations from the voluntary sector, local authority provision, or additional roles – promoting personalised care and supporting someone to thrive within their community.
“These are important aspects to consider within the current political and financial climate. 90% of NHS activity occurs in primary or community care (the space between primary and secondary), whilst receiving 10% of the funding. Day-by-day we are seeing ICSs reporting increasing hospital waiting lists, stretched ED provision and growing financial deficits (whilst receiving increasing funding). Increasingly, we are seeing the ‘community’ being hailed as the solution to all these problems. However, at the same time, community funding is reducing as ICSs look for low-hanging fruit to optimise in-year spend. These two things can’t both be true – if the community is going to play a significant role in a more prevention-focused system, then the funding has to flow out of hospitals to support this. This involves change. This involves challenging traditional models, pathways, and ways of working. This involves people working differently. Is the current system as a whole up for this? I’m not sure. I’m coining a new term “NIMCA” – not in my clinical area!
“I recognise that I’m in a privileged position. To work for Connect Health means embodying our values and behaviours. These values (people-centred, dynamic, pioneering, quality) and behaviours (clear, proactive, positive, authentic, accountable) lead to innovation, embracing change, doing things differently. Now more than ever our health and care system need to champion such values and behaviours. If Wes Streeting delivers on his vision to enhance funding into primary and community care this can’t be about doing more of what’s not worked before. Secondary care has not delivered within budget for years alongside the development of significant waiting lists, often for interventions with a limited evidence base (e.g. subacromial decompression). Pouring more and more money into that sector does not meet with scaling those things that we know currently work. What is needed is innovation and challenging traditional models that are inefficient and feed vested interests, whilst at the same time not meeting the needs of the public, or specifically our current and future patients.”
LTCs
“I outlined above how what was meant by ‘MSK’ is now more broadly accepted to include chronic pain and inflammatory conditions. But does that go far enough? Increasingly MSK conditions are being recognised as ‘long-term conditions’ – a physical condition that requires ongoing management. This is reflected through the inclusion of ‘MSK’ as one of the six conditions contained within the ‘Major Conditions Strategy’ – time will tell whether this strategy comes to fruition. Reconceptualising MSK conditions as something to be managed rather than to be cured is a core component of our HSJ award winning Flippin Pain campaign, seeking to engage, educate, and empower those living with MSK conditions.
“The State of MSK report hammers home the impact of MSK conditions:
- 35m people in England have either Hip or Knee OA – likely underestimated when considering those that may not access care, or the limitations of data-coding.
- Prevalence of Hip/Knee OA is higher in most deprived tenth of society than the least deprived.
- Risk of developing OA increases by 1% for each 1kg/m2 increase in BMI.
- 28m (42%) people in UK have chronic pain – of this 28m, 42% have LBP and 10% have Fibromyalgia
- Top 3 causes of years lived with disability (a measure which combines the prevalence of a disease with a rating of how disabling that disease is) are LBP, diabetes, depression.
- 11m people in the UK experience LBP each year
- 53% of fit notes issues for MSK conditions sited episodes lasing 5+ weeks.
“It stands to reason that some of these relationships are bi-directional, both cause and effect, impact and impacted. Someone from a more deprived background is more likely to be obese, with obesity more like to develop MSK pain, with MSK pain more likely to be out of work etc.
“Those with an MSK condition are 1.2x more likely to have another LTC; have 61% higher risk of developing diabetes; and are 3x more likely to have ischaemic heart disease or heart failure – likely to be because of shared underlying risk factors. Given this overlap and the clear interdependencies, is it not time to stop designing pathways around conditions and instead around people?”
Prevention
“Redesigning pathways or reconceptualising how we treat or manage MSK conditions in the context of being a LTC is one thing, but how can we seek to stop people developing impactful MSK conditions in the first place? Prevention in MSK is not new, nor is it easy, nor is it a silver bullet. The State of MSK report focused on the role of Physical Activity (PA) within a preventative context. Regular PA reduces risk of:
- Hip/Knee OA by 6%
- Back pain by 25%
- Falls by 76%
- Depression by 25%
- Hip fractures by 25%
“It’s been said before, but if physical activity was a drug…
“Despite this, 25% of people in the UK are physically inactive (defined as doing less than 30 minutes of moderate PA in a week) which can increase the risk of developing an MSK condition. This rises to 38% in those with an LTC:
- 70% of those with MSK conditions would like to be more active
- 77% said they’d like practical support to be more physically active.
“When surveyed as part of the recent “Bridging the Gap” report from ‘We are Undefeatable’, those with a LTC identified that pain was the biggest barrier to becoming physically active. This revealed an empathy gap with health professionals perceiving ‘motivation’ as the biggest barrier. The importance of our Flippin’ Pain campaign has never been so clear. As for further practical support to becoming more physically active, the ‘community’ – in both senses of the word – is fundamental to achieving this.”
Closing Thoughts
“The State of MSK report inspired me to put some thoughts down into words. I’m hoping this blog has initiated some thoughts and maybe starts a conversation. However, we need to move beyond thinking and conversation. As the ARMA report outlines for Health Inequalities – we need to ‘Act Now’! To realise the potential of the community space requires bold leadership and redirection of current or new funding for implementation. Such leadership is something that unfortunately is lacking currently from both NHSE and GIRFT with regard to community MSK. I recognise the role of NHSE/GIRFT is not to implement however, increasingly it appears that more and more resources are being produced, but are they being utilised to great effect? Are we truly shifting the dial on the key aspects of the State of MSK report?
“The role of healthcare isn’t to solve societal problems – we need to think upstream and think about how we can aide a prevention agenda, how we can contribute to a better society – one that inspires wellness rather than illness and that means change. Change is always desirable, until it involves you…”
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