As part of the Connect Health Change webinar series, we present the Q&A summary from our panel who discussed Community MSK – how to alleviate elective care pressures
With a record 7.1m people in England waiting for NHS hospital treatment and winter pressures already hitting hard, tackling the NHS backlog is a huge challenge which requires a system wide approach.
2023/24 priorities and operational planning guidance, released on Christmas Eve, sets out the most critical, evidence-based actions that will support delivery of the three priorities over the coming year: recover core services and productivity; as we recover, make progress in delivering the key ambitions in the Long Term Plan (LTP), and; continue transforming the NHS for the future.
This timely webinar helped commissioners and NHS Leaders plan for elective recovery by taking into account a new improvement framework for MSK, released 10 January.
Delegate feedback included:
- Good variety of speakers with lots to go away and think about for our area
- Speakers were good and kept to time
- I liked the expertise of speakers
Watch the Webinar in Full
Chaired by:
Dr Ian Bernstein, Clinical Director for Musculoskeletal Health and Chair Musculoskeletal Health Improvement Network, NHS England – London Region; Musculoskeletal Physician, Connect Health
Q&A
Kate Jackson, Assistant Director Community Transformation Community Health Services, NHS England
Question 1: What do you think are the 3 most important areas to support successful implementation of the Community MSK Improvement framework?
Answer: In terms of success measures there are three huge challenges that we need to focus on in terms of being able to deliver this framework and for it to be successful and that’s Workforce, data, and commissioning. We know we’ve got a huge issue in terms of supply, retention and recruitment in our Workforce for MSK practitioners. Looking outside of the traditional box in terms of registered and non-registered members of Staff in the Workforce who have the skills and experience to deliver what our patients need, we’ve been doing work influencing the national Workforce strategy. There’s work going on in terms of the department for health inequalities and disparities at work on the MSK hubs and working with the leisure sector, increasing physical activity and getting people back to work. As an occupational therapist this is the absolute benefit that we can add value to a community MSK service.
Community data again was a huge challenge, three years ago we didn’t have the data which I showed in my presentation. It’s not perfect, it’s not granular enough at the moment, but it does demonstrate a picture of what is happening out there in the community, and we can use that to influence policy and produce a data improvement plan that looks at faster data flows, more real-time data.
Thirdly, commissioning work that we’ve done. Pre-pandemic has shown us the unwarranted variation in commissioning of our community MSK services. The next steps would be around developing some commissioning guidance that looks at contracting and standardising outcomes in terms of what should be commissioned in community MSK. I think that will come, like the government’s major condition strategy which was published recently. MSK is one of their six major conditions, so this is great news for us in terms of keeping MSK at the top of people’s minds.
Question 2: How do you intend to continue using coproduction as part of these national next steps and future plans?
Answer: I’m proud that our lived experience partners were valued members of the team and of the programme. People with lived experience are integral to being able to develop a national policy, I don’t know how we could develop the policy without listening to people who are living with these conditions and associated difficulties and issues every single day. It makes absolute sense to me that we should be co-producing at a local level, not just a national level. It’s difficult and I know we can get it wrong but we learn from it.
Next steps for us in terms of co-producing and working with people is to have the crowdsourcing platform #solvingtogether platform. We’re starting to use that for the next month to hear people’s ideas and views about how we can enhance self-referral to Community Services MSK. We know absolutely that self-referral and open access for services is not new, we were doing it 10 years ago when I was working in community services. We need to hear from people about what would make it easier for you to be able to access a service, where it’s working well, where have you made a bit of a mess, so we can share this learning. We should be doing that not only at a national level but at system and local level too.
Question 3: What is the status of the Best MSK Health programme?
Answer: The programme has shifted and reduced in size to working alongside GIRFT. NHS England is going through a consultation and we’re having some organisational changes. I can’t tell you what it’s going to look like but it’s in the mix. The government strategy includes MSK as one of its six major conditions is a really positive step as well.
Question 4: Within the definition of ‘priority’ the third bullet point can be tricky to operationalise. Pain that impacts of function +/- sleep +/- work +/- care duties i.e. impactful pain, reflects the majority of patients that seek MSK care. How would Kate suggest this is best interpreted and implemented?
Answer: We went to extreme lengths in terms of developing these three definitions. It’s a little bit like developing acceptable wait thresholds rather than standards, it’s meant to support conversations for local systems. It’s a framework to support you to stratify your list of people waiting so that you can locally manage that more effectively.
Matthew: Firstly, we need to acknowledge that the third bullet point is open to some level of interpretation, so we need to treat it in that way and secondly, we need to trust our clinicians to be able to make those subjective decisions around patient criteria. The third thing that adds a lot of value here is data. I can think of examples where we’ve used data to track individual variation in terms of triaging of referrals, how many are placed on an urgent list versus how many are placed on a routine list. So as long as you’ve got a safe space for sharing learning, you could use that data to help anyone who’s an outlier, either not highlighting enough urgent patients or highlighting too many to make sure that there’s a level of consistency.
Andrew: The key dependency for me on this is the quality of the referral, particularly a triaging clinician may not necessarily always get enough information to be able to understand the impact of symptoms upon the kind of criteria outlined here. There’s an element around referral quality, referral optimisation, that allows you to get a bit of a feel as to whether or not somebody does meet this priority definition. However, if we’re utilising more digital innovations how do we ensure that any kind of digital triage platform that may be in place also reflects this priority. I think that’s something that has probably been considered across a number of providers at the moment, particularly as we’ve seen the increase in digital uptake both during and since the pandemic to aid recovery.
Sharon: You might see some local interpretation around this framework. It needs to be personalised to the individual patient using good quality information.
Matthew Carr, Clinical Director, NHS Sussex & Sussex MSK Partnership East
Question 1: Which of the opportunities you have presented do you think will have the greatest impact in alleviating elective care pressures?
Answer: Focussing on our community setting is the right place to prioritise our care. Community clinicians are the influencers that can help to inform and educate. They can really affect improved interfacing between community and secondary care services. Making sure that we give the community team the space, the autonomy and the resource and to recognise that they are likely to be the team that can have the most amount of impact in improving things both upstream and downstream in the MSK programme would have the greatest impact.
Question 2: What staffing level were you commissioned for in order to split FCPs between PCN and community MSK?
Answer: Our Sussex journey has been varied. What has worked best is where community teams have proactively created the business cases to inform commissioners and the PCN’s on the workforce level needed to achieve a split FCP/community MSK workforce.
Primary care often want more than community services can deliver. There is a lot of benefit to be gained by identifying who is a key decision maker around influencing policy at Primary Care level. I would encourage Community Services to reach out to your ICB colleagues to ask where this work is happening and who within the ICB can we engage with to challenge that thinking and to strengthen the value of FCPs working in Primary Care. We need to form a real alliance.
Andrew: A slightly controversial stance on this might be that they won’t necessarily always need to see the benefit of an FCP physiotherapist. ARRS funding is up to the Primary Care Network currently to decide how they best spend that resource. It may be that if you have a functioning community in MSK pathway with ready access to self-referral but don’t have some of the newer roles such as health coaches, the funding may be better spent to support personalised care in those newer roles for that Primary Care Network.
It’s looking at a system-wide view and working with partners across primary care to understand what’s going to add benefit to the population.
Andrew Cuff, Consultant Physiotherapist and Head of MSK, Connect Health
Question 1: Given what you proposed around cross cutting interventions in a number of long-term conditions, what would be your proposed first step to progress this from idea to reality?
Answer: Answering in one word, it would be influence. If I reflect on the number of ICBs and ICSs that are currently redesigning MSK Pathways, and some of them I’m involved with, how that’s being approached then largely what’s currently being provided in an area; I’d say look at what’s currently working well and try to piece that together to take the things that are working well and do more of them. However, we must be aware that some work that’s happening in MSK is happening in other long-term conditions as well so there is a possibility that we would be duplicating mistakes. Instead, could we embrace value, could we look for opportunities of synergy and to reduce duplication and just be brave in terms of doing things a little bit differently.
Question 2: If staffing and retention are important to deliver quality care, what is being done to improve these?
Answer: We may have assistants to help with the workload but there should still be qualified staff ensure quality.
Sharon Barrington, Head of Planned Care and Long Term Conditions at Buckinghamshire, Oxfordshire and Berkshire West (BOB) ICB
Question 1: What do you think the impact of the development of ICBs and Integrated care systems will have on MSK services?
Answer: We can’t have FCPs working in isolation, they’ve got to be supported and part of the system approach. There needs to be some work done by ICBs with ICSs to provide the support and education and to look at outcomes across the system to ensure we’ve got some outcomes in place in the first place. It is about reducing variation for the population, making sure shared decision-making is in place and recognising the important part of prevention.
Watch the webinar again, which includes further insight from the speakers including a full Q&A session, and read more about the speakers here:
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