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
Persistent low back pain impact • 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
Individual impact MSK conditions • 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;
Impact on the UK workforce Changing landscape
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 only • 17.2% experience both Arthritis and Musculoskeletal Alliance, 2018
Evidence-informed Guidance
Return on Investment Interventions • 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
NICE Guidance LBP, 2016 • 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 opinion, they may not need imaging. • Consider imaging in specialist settings only if the result is likely to change management.
Physical Activity Interventions for MSK ARUK, 2017
Changing Landscape
NHS Long Term Plan (2019) • 5 year plan • Enhance primary medical services and community health • Improve maternity care • Personalised care for older people in community • Mainstream digital health
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)
Person-centred Approaches Framework • NHS constitution • 3 steps • Behavioral change approach - health coaching - making every contact count (MECC) - motivational interviewing (MI) 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
MSK Capabilities Framework for First Contact Practitioners (FCPs) 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 2018
GP Partnership Review (2019) 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. 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
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
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