With NHS England waiting lists hitting a record 7.2m, it could be time to ‘be brave’ and ‘take a blank sheet of paper’ to design new patient care pathways. This was among several key points raised by health professionals as they discussed how elective care pressures can be alleviated through community MSK services, at Connect Health’s latest Change event.
The event followed the launch of a new NHS improvement framework for MSK and 23/24 planning guidance, aiming to use a system-wide approach to tackle patient backlog.
Event chair Dr Ian Bernstein, Clinical Director for Musculoskeletal Health and Chair of MSK Health Improvement Network, NHS England – London Region, set the scene of the current, post-Covid landscape. Of the 7.2 million people in England waiting for NHS hospital treatment, there are “785,000 people waiting for hospital orthopaedic appointments or admission, and many people waiting for community musculoskeletal treatment. Tackling the backlog is a huge challenge, compounded by winter pressures and staffing issues,” said Dr Bernstein.
Flagging the activity and cost implications of where people with MSK conditions are treated in the NHS, he said:
Costs increase as people move through specialist care settings. Pre-pandemic data shows that 75% of people with musculoskeletal conditions are managed in primary care, costing 13% of the programme budget for MSK conditions including prescribing costs. 22% of people are seen in community, outpatient and A&E settings, costing 44% of the budget, and 3% are admitted for elective, emergency surgery or inpatient treatment for MSK conditions, costing 43% of the programme budget.
We need to bear these figures in mind as we discuss the context for transforming pathways of care.
Kate Jackson, Assistant Director Community Transformation Community Health Services, NHS England, talked through the new NHS improvement framework for MSK, “developed to support the reduction in waiting lists, while also improving patient outcomes and experiences and ultimately alleviating elective waits. This is the first publication of its kind to define what community MSK services should look like”.
Kate said:
We have been clear around community triage…and also what we would expect providers of MSK services to be defining as their priority patients – patients who’ve had recent surgery and require rehabilitation, patients who’ve had a recent injury fracture or dislocation requiring rehabilitation, and patients with acute or complex needs, who are experiencing high levels of pain or a significant loss of function affecting their daily life.
She emphasised the importance of co-production for the framework:
We’ve taken a strong stance in terms of how this work nationally was co-produced, in partnership with patient groups – ARMA, Versus Arthritis and so on. This is very much a collaborative piece of work.
It’s something I’m really proud of, that our lived experience partners were valued members of the team. This was paid work, not voluntary – people with lived experience are integral to developing national policy. I don’t know how we could inform policy without listening to people who are living with these conditions – and associated difficulties and issues – every single day.
Matthew Carr, Clinical Director, NHS Sussex & Sussex MSK Partnership East, discussed taking a ‘whole systems view, optimising opportunities downstream to alleviate pressures upstream’.
Presenting recent data from community services in Sussex, Matthew said:
It’s not great at the moment – data shows that 12 weeks after starting a community episode of care, only around 55% of patients say they’re in a better place than when they started. The numbers speak volumes and will allow us to really drill into which patients aren’t achieving meaningful improvement. What can we do differently? Data is key, but rehab needs to come back up the priority list and be an absolute linchpin of what we deliver in community care.
He argued:
What also stands out is that we’re not always making sure we address the environmental and social factors that contribute to someone living well, or recovering well from MSK conditions.
If I reflect on my own journey as an MSK physiotherapist, when you’re new and novice, you want to be the expert in things like anatomy and physiology and rehab principles – there is less focus on thinking about how the patient’s environment and social factors impact on their recovery.
We need to support our community clinical workforce so they become personalised care champions for patients, really understanding their values, preferences and contributing factors. Our MSK clinicians in primary care need to be given space to develop relationships with health coaches and social prescribers. They need to be knocking on clinical directors’ doors, saying, ‘look, I’ve got these patients with these needs, and I can’t do anything with them, because we don’t have the right workforce’. That’s the greatest opportunity in primary care – to help improve the flow of patients and optimise their care at that point.
Andrew Cuff, Consultant Physiotherapist and Head of MSK, Connect Health looked back at a framework for MSK services from 2006, asking, “So MSK community, have we progressed our thinking across the last few decades?”
He asserted that the framework from 17 years ago “all sounds a bit too familiar…a predominantly community-based pathway that facilitates self-management, draws on a wide-ranging number of professions across primary, community and secondary care, interfacing with a number of different health, social, local authority and sector agencies”.
Highlighting similar plans for managing frailty and diabetes, he said:
It appears that we design pathways in the same way we’ve been doing for a number of years, across specialties. Which kind of makes sense – we apply a frame of reference we’re familiar with, that we’re anchored to, with all our underlying biases and outlook. And of course, there is evidence of both impact and effectiveness in these methods – but the key question is, could we do better next time?
Andrew outlined the prevalence of duplication across care pathways, highlighting the potential patient benefit of reducing it.
If I see a patient in clinic with back pain, arthritis or tendinopathy, I’ll discuss physical activity, positive lifestyle behaviours, maintaining a healthy weight, [their ability to] work [and continuing] their valued activities in a way that matters and is accessible to them. Yet that person is also likely to receive similar advice from their diabetes team, their cardiovascular team, their mental health support workers.
If we designed a pathway that removes this duplication, particularly for those with long term conditions, it could enable people to be supported and to benefit from high value interventions and ensure that specialist care is in turn provided within the relevant specialities.
Could we embrace value, look for opportunities of synergy, look for opportunities to reduce duplication and be brave in terms of doing things differently? Is it time to adjust our frame of reference and finally reach for that blank sheet of paper?
Sharon Barrington, Head of Planned Care and Long Term Conditions at Buckinghamshire, Oxfordshire and Berkshire West (BOB) ICB, presented the ‘ICB view: how MSK has impacted secondary care’. Highlighting patient data from the last four years, she identified that ‘activity hasn’t really recovered back to pre-Covid levels for admitted patients’, with ‘infection prevention and control measures still in place, which have limited the number of people who can be operated on and seen in outpatients’.
Sharon discussed the issue of secondary care services ‘getting more referrals than they felt they ought to’, and the potential to manage some referrals ‘differently’ with the right skills and good information in community services and secondary care support/governance.
Better information at triage [is needed], more face-to-face assessments where appropriate to understand fully and avoid onward referral if possible. With a lack of good information in the first place, it’s very difficult to make a decision about where the right place is and who the right healthcare professional/service is for the patient.
There are opportunities for joint working which is essential for a good integrated service. Good triage is essential with a conversation with the patient, whether virtual or face-to-face adds value to that, particularly for complex patients. We need to manage risk across the system. We need a joined-up approach between acute and MSK primary care to ensure that those patients get into the right place, first time. That’s what creating integrated care systems is all about.
Shared decision-making is essential in creating personalised care plans, and including opportunistic conversations about health and wellbeing and prevention, in the discussion using the principles of making every contact count (MECC). Sometimes the more opportunities there are to have conversations, the more patients might think about changing what they’re doing and what they might do in the future; it is about planting that seed. It’s about giving them opportunities to make real change.
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