Posted on: 8 May 2019
The demand for musculoskeletal (MSK) services for muscles, joints and bones continues to increase year on year. This has resulted in the budget for these services being one of the largest in the NHS. There’s no doubt that this ever-increasing rise in demand will continue, particularly as we have an ageing population, so we must transform MSK services to make sure they are the best they can be - now and for the years to come.
Transforming MSK services
The Partnership, through its planned care programme, is transforming local MSK services and making positive changes that focus on clinical evidence, and on the patient as an individual. We have developed a new MSK pathway that sets out the various steps in the care of people referred onto MSK services by their GP or other healthcare professional.
This diagram of the MSK pathway gives an overview of those steps and sets out the different types of treatment and support services available within the pathway. The development of the new pathway considered feedback from public engagement carried out on behalf of the Partnership between April 2014 and November 2017 and involved clinicians, commissioners and service providers. At its public meeting on 7 May 2019, the Partnership’s Joint Committee agreed to adopt the pathway in the nine Clinical Commissioning Groups (CCGs) across West Yorkshire and Harrogate.
The new MSK pathway
The new MSK pathway for West Yorkshire and Harrogate includes a full range of treatment and support services, many of which can be accessed from GP surgeries or in community settings. Patients have told us that they want to be able to access healthcare closer to home, whenever that is possible. This pathway reflects that feedback, and helps to reduce pressure on hospital services at the same time.
The pathway supports self-management with its inclusion of services that promote physical activity, pain management and psychological therapy. It also supports shared decision making which means it’s not about clinicians telling patients what will happen, it’s about clinicians discussing the best options with patients so they can make an informed decision about their own care.
It makes sense to try other treatments and therapies before considering a procedure such as a hip or knee replacement but for some people, surgery will be necessary and that’s a big decision to take. Major surgery involves long recovery times so patients need to have control over when they want to have their operation to be able to fit it in with everything else that’s going on in their lives. To support this, people will be able to leave the MSK pathway, and come back into it at the point at which they left, whenever this is clinically appropriate. Patients may feel they are being ‘bounced around’ the system if they leave a clinical pathway and then have to go back to the start if they re-join it, but this will no longer be the case. If someone requires surgery, they can choose to leave the pathway and re-join it later to have their operation when the time is right for them and their families.
Services provided on the MSK pathway
For patients on the MSK pathway, there are various points at which these joint decisions are made about their care. These points are known as ‘clinical thresholds’ and are used to decide which treatments will be provided and funded by the NHS to provide the best care for patients.
Different CCGs across West Yorkshire and Harrogate currently have different policies for some of the MSK services they plan and buy (commission). In transforming MSK services, we are standardising these policies to remove the so called ‘postcode lottery’ that currently exists. Having a consistent approach will help us to make sure that all patients receive the best and most appropriate course of treatment for them, no matter where they live.
The process of standardising our commissioning policies for MSK services involves local clinicians in primary and secondary care, healthcare providers, patient representatives and partner organisations. This collaboration means that all our MSK policies will reflect the most up-to-date clinical evidence, guidance and patient insight to offer the right type of treatment at the right time.
The right type of treatment
NHS England’s Evidence-Based Interventions policy which is being implemented in West Yorkshire and Harrogate is based on clinical evidence showing that some ‘traditional’ MSK treatments are simply not effective in most cases. One example of this is the use of spinal injections for non-specific low back pain. The National Institute for Health and Care Excellence (NICE) recommends that spinal injections should not be offered for non-specific low back pain because less invasive options, like pain management and physiotherapy, have been shown to work just as well, if not better. Similarly, MSK surgical procedures including shoulder decompression and knee arthroscopy (washout) are not the best solution for the majority of patients.
Personalised care is key to providing the right type of treatment. This approach means that people who would benefit most from a specific operation or treatment would get it. Patients who would be unlikely to benefit would be offered alternative healthcare interventions that they, and their clinicians, have decided is the right thing to do for them.
Interventions such as manual, physical or psychological therapies can offer patients better results and a more positive experience of healthcare. Manual therapy is usually carried out by a physiotherapist and involves the kneading and manipulation of muscles, and joint mobilisation. Physical therapy helps to strengthen and exercise muscles in a safe and effective way. This is also beneficial for joints and bones.
Some patients with MSK conditions such as chronic back pain or arthritis may never be totally free from pain but there is support that can help reduce its impact. Psychological therapy helps people deal with the emotional impact associated with such conditions and alongside good pain management, can make a big difference to a patient’s everyday life.
Another key feature of the new MSK pathway is the inclusion of exercise on prescription. Exercise can increase muscle strength and improve flexibility which can help reduce the symptoms of some MSK conditions. In addition to improving overall health and fitness, exercise helps people maintain a healthy body weight. Being overweight can increase the risk of developing MSK conditions and can hinder the recovery from MSK symptoms. For patients who do need to have surgery, being a healthy weight before their operation will reduce the risk of complications and increase the likelihood of a successful outcome.
A diverse range of MSK services
The public and patient engagement carried out on behalf of the Partnership mentioned earlier indicated that people want to see an increase in the range of MSK services available at GP practices and in community settings. The new MSK pathway reflects that ambition by including various non-clinical therapies and support services alongside clinical services such as podiatry and rheumatology.
Feedback from this engagement, included in our Review of engagement and consultation activity on elective care and standardisation report, also highlighted that people want to be seen by the right person, first time. A GP is not necessarily the best person to deal with a condition related to the muscles, joints or bones so for example, seeing a physiotherapist first would usually be far more beneficial for the majority of MSK patients – and for the busy GP!
This public feedback and insight has fed into the development of a new scheme that is currently being trialled in Leeds and Harrogate but will be rolled out across the region over the next few years. The ‘First Contact Practitioners (FCP)’ scheme has physiotherapists based in GP surgeries as a first point of contact for people with MSK conditions. This direct access to a physiotherapist means there are no unnecessary delays for MSK patients accessing the care they need. FCP physiotherapists are MSK specialists so they are able to quickly assess a patient’s condition and carry out any required treatment. They also have more time to spend with patients than a GP would, and can refer patients into MSK services if the need for further investigation or surgical assessment is identified.
Having a variety of services provided by a range of MSK specialists offers patients a more integrated approach to healthcare. Feedback from the engagement also told us that patients feel more empowered, and experience better outcomes, when they can make informed decisions about their own care. Patients need reassurance that their care will be escalated to hospital services when appropriate but are keen to have access to different treatments and practitioners to benefit from the course of action that is right for them.
Our MSK policies
A standardised policy for spinal services was the first of our West Yorkshire and Harrogate MSK policies to be agreed for implementation across all nine CCGs. We are currently developing policies for hip, knee and shoulder procedures and it is anticipated that these policies will go to the Partnership’s Joint Committee for approval in September 2019. More MSK policies will be reviewed and standardised in phases as the work progresses over time.