Musculoskeletal Conditions

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1. Background

Musculoskeletal (MSK) conditions affect bones, joints, muscles and spine. MSK are a common cause of severe long-term pain, loss of dexterity and physical disability. There are 3 groups of MSK conditions: 

  • Inflammatory conditions, for example, rheumatoid arthritis 
  • Conditions of MSK pain, for example, osteoarthritis, back pain and gout 
  • Osteoporosis and fragility fractures, for example, fracture after a fall at standing height. 

    Multiple risk factors increase susceptibility to MSK conditions; physical inactivity, being overweight or obese, vitamin D or calcium deficiency, smoking, older age, and genetic predisposition. 

    MSK conditions are the third-largest cause of Disability Adjusted Life Years (DALYs) (Source: Global Burden of Disease 2019) and account for 30% of GP consultations in England (Source: NHS England). Whilst life expectancy has risen, lives are lived longer but in poorer health, and poor health is particularly true for older adults, and those living in more deprived areas. Long term pain, particularly lower back pain, affects MSK sufferers, significantly impacting individuals, employers, the health service, and the wider economy. Impacts can be reduced with rapid access to treatment. 

    2. Policy Context
    • NICE provide detailed information and guidance of Musculoskeletal conditions supporting care pathways and clinical interventions 
    • The Musculoskeletal Disorders and the Global Burden of Disease study by the World Health Organisation (WHO) highlights the global impact of MSK and calls for action. 
    • NHS England provides specification for High Impact MSK interventions  
    • The NHS England Long Term Plan (2019) states that most MSK needs should be met by primary care using First Contact Physiotherapists (FCP), without referral to secondary care services.  
    • The MSK Networks of Care project is a partnership between NHS England and the Arthritis Musculoskeletal Alliance, to foster relationships between care sectors, and share innovative and best practice (NHS England, 2018). 
    • An online MSK Knowledge Network hosts webinars, blogs and presentations for commissioners, providers, clinicians and patient groups to support local MSK improvement plans. 
    • The online State Of Musculoskeletal Health report (2021) clearly shows statistics regarding prevalence, risk and impact of MSK conditions. 
    • The Lincolnshire Joint Health and Wellbeing Strategy has Obesity and Physical Activity as priorities – key risk factors for MSK conditions. 
    3. Local Picture

    MSK complaints, particularly lower back pain, comprise a sizeable contribution to Lincolnshire’s burden of disease. Several contributory factors include; high smoking rates, obesity levels, sedentary lifestyles, an ageing population, and a large proportion of manual labour. 

    MSK services, outpatient appointments, and procedures cost services over £75.5m a year. Hospital admission rates, length of stay, and the number of procedures vary greatly across the county, due to differing age profiles, labour types, and lifestyle factors. Overall, Lincolnshire displays a greater spend on elective admissions but a lesser spend on emergency admissions compared to England averages (Source: NHS England). 

    Impaired MSK health is consistent with increased frailty, functional decline, loss of well-being, independence, and increased mortality (Cooper et al., 2010). These effects are interrelated and often lead to greater social isolation and loneliness. The (higher than national average) number of people with MSK conditions in Lincolnshire is contributing to an increasing number with co-existing anxiety, or depression. The burden is noticeable amongst young people. 

    More Individuals from the poorest households report MSK chronic pain, compared to the richest households (NHS Health Survey for England 2012). This suggests a barrier to preventative measures in deprived communities. In addition, those with pain living in the most deprived areas do so at a relatively young age: people of working age (45–64 years) are almost twice as likely to report back pain as those from least deprived areas (Source: State of Musculoskeletal Health 2017). 

    Life with MSK conditions causes many to claim Disability Living Allowance (DLA), resulting in wider socioeconomic impacts. The proportion claiming DLA for MSK conditions is higher for those aged 65 years and over compared to other age groups, and is higher for women compared to men. DLA claims show that Arthritis adversely affects older age groups, whereas disease of muscles, bones or joints is more commonly reported amongst those under 50 years. Patterns of DLA claimants are reflected nationally, however, the gradual replacement of DLA with Personal Independence Payments (PIP) means it is difficult to review trends over time. 

    Higher prevalence of MSK morbidity, impairment and sickness is found for women, for a number of MSK conditions (Gjesdal et al., 2011). Reasons for this are complex and not completely understood. Evidence does show that women are more likely to admit they are in pain, and, consequently, accept treatment. Women are more likely than men to sustain a hip fracture – and incidence rises with age; associated with a decrease in oestrogen production after menopause, which accelerates bone loss. 

    MSK conditions affect some ethnic groups; Gypsy, Irish Traveller, White Irish, White British and Black Caribbean ethnicities, more than others (The State of Musculoskeletal Health, 2021). 

    4. Local Response

    Lincolnshire’s Integrated Care System (ICS) has identified a case for change for Lincolnshire’s MSK pathway as part of the System Improvement Plan. The MSK task & finish group highlighted the following:  

    • Too much activity and spend compared with peers. 
    • Outpatient appointments are higher than national average.  
    • Service provision fragmented across sectors and settings with many providers 
    • Different referral systems across Lincolnshire (a legacy of 4 CCGs).          
    • Patient experience is poor with a high number of appointments across the county. 
    • Lincolnshire residents have greater risks than peers for obesity, smoking and physical inactivity. 
    • Lincolnshire reports the highest % of MSK problems in the Midlands. 
    • A spend of 13,459 Orthopaedic WAU compared to 10,756 amongst peer organisations. 
    • Health gain is slightly lower than peers for hip and knee procedures. 
    • In Lincolnshire, fracture neck of femur (thigh bone) emergency admissions accounted for about 12% of emergency admissions following a fall. 
    • Hip and Knee procedures account for 54% of MSK elective procedures. 

        In February 2022, the MSK programme was refocussed on developing an improved clinical pathway for hip and knee replacement, and the design and development of a supporting, standardised, MSK digital platform. Working together, clinicians are redesigning the hip and knee joint replacement elective pathway to support a single MSK service – working as a multi-disciplinary team across primary care, community acute, and social care.  

        Improved and personalised care for people is central to this approach, promoting shared decision-making and self-management through early health promotion and prevention.  

        Shared decision-making will be integral for the pathway; with measures to ensure patients have the required information and accessible resources, and frequent opportunities to ask questions and lead in decisions about their care. 

        New Pathway for Hip and/or knee conditions 

        80% of patients presenting with MSK conditions will be assessed by a First Contact Practitioner (or GP with special interest in MSK). Outcomes of this assessment may be: 

        1. Reassurance and support to self-manage in Primary Care: Pain medication, exercise regime, advice, signposting to appropriate resources (including One You Lincolnshire), or tertiary sector support. Strength and Balance training may be an option.  
        2. Direct Orthopaedic referral: For clear cut cases. 
        3. Request for a First Contact Physiotherapist or a GP with Special Interest review 

            Pre-operative assessments, pre-habilitation and post-operative care will include an appropriate offer of physiotherapeutic advice, and exercises (with possible referral to external providers). This will embed the benefits of movement and physical activity throughout the pathway. 

            The new pathway will comply with Clinical Guideline Osteoarthritis: care and management [CG177] and NICE Guidance Joint replacement (primary): hip, knee and shoulder [NG157] 

            The new Standard Operating Procedures document was agreed by the Early Adopter Group in September 2022, and is now being trialed at Early Adopter sites. 

            5. Community & Stakeholder Views

            Health Watch Lincolnshire have gathered patient views about Community Pain Management services. The Community Pain pathway contract specification was influenced by findings from the Healthwatch Lincolnshire survey, 2017. Bespoke patient questionnaires were completed with a patient led sense-checking workshop. 

            HealthWatch Lincs led the capture of patient experience for the proof of concept of the new MSK pathway, linking with Imp Healthcare, Lincoln Health Partnership, Lincs South Rural, and Spalding PCNs. 

            6. Gaps and Unmet Needs

            Current community pain management provision for chronic/persistent pain across Lincolnshire is a pharmacological/injection led service via the acute trusts and private providers. However, there is no alternative biopsychosocial provision. The South of the county has limited access to provision of pain management with an offer via the Northwest Anglia Foundation Trust. 

            7. Next Steps
            • Evaluation and assessment of the efficacy & effectiveness of the MSK pathway, and further rollout as appropriate. 
            • NHS England is working with the Arthritis and Musculoskeletal Alliance to realise meaningful activities that promote quality of life. Their partnership should develop national MSK improvement plans, and develop cohesive care networks to bring local improvements in care and patient outcomes (NHS England, 2018). 
            • Build local resilience and opportunities for prevention. Support independent living, participation in social activities, return to work, and engagement in meaningful activities. 
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