Viewpoint: What global burden of disease tells us about real challenges facing the NHS

Earlier this month, The Lancet published UK-specific data drawn from December's landmark Global Burden of Disease study. It paints a striking picture, in more ways than one, say Federico Moscogiuri and GP Dr Tom Margham, lead for primary care, Arthritis Research UK.

Dr Tom Margham and Federico Moscogiuri: 'Biggest long-term gains for the NHS and patients alike lie in early intervention.'
Dr Tom Margham and Federico Moscogiuri: 'Biggest long-term gains for the NHS and patients alike lie in early intervention.'

Most of the mainstream coverage of this data focused on life-threatening diseases and the fact that the UK is lagging behind many other European countries in terms of reducing premature mortality.

The response, not surprisingly, focused on prevention and lifestyle choices. In particular, it was cigarette packaging and alcohol pricing which, not for the first time, got the lion’s share of attention as potential policy solutions.

Leaving aside the practical and philosophical merits of deterrence, particularly as applied to healthcare (you can’t deter people from getting ill), a deterrence-based approach to improving health misses the point. And in doing so, it fails to get to grips with the real challenge facing the NHS.

Real challenge

A key finding of the Global Burden of Disease study is that in Western countries like the UK, the burden of life-threatening disease (calculated in years of life lost; YLL) is decreasing as a proportion of overall burden of disease (calculated in disability-adjusted life years; DALY). What is increasingly a greater impact on population health, however, is the other half of the DALY: ie the burden of disability (calculated in years lived with disability; YLD). It is perhaps ironic that as we are getting better at treating and averting the big killers that are heart disease, stroke, cancer, lung and liver disease, more and more people are living longer with more long-term conditions and their associated co-morbidities - many of which arise, or become heightened, in later life.

Of all health conditions, musculoskeletal disorders are the single biggest cause of disability in the UK, at 31.3% - nearly one third of the entire burden of disability. Of these, low back pain is the single biggest cause of disability, followed closely by osteoarthritis. When combined with mental health disorders, which is often the case with chronic painful musculoskeletal conditions and depression, they make up over half the total burden of disability.

Living longer is clearly a good thing. But living longer with debilitating arthritis is another matter, and this has a big impact on a person’s quality of life. From the NHS perspective, providing care for someone with more than one complex condition over many years can be very costly and resource-intensive.

Long-term conditions

From that of wider society, people who are unable to work and look after themselves because of a long-term condition do not contribute to the economy and risk becoming increasingly reliant on welfare support. 7.6 million working days are lost each year due to musculoskeletal problems alone. A recent report by the CSP also found that 40% of NHS staff sickness absence is due to disorders such as back, neck and joint pain. Clearly, this is a very large-scale problem with many ramifications.

This is the big, unsung story of the latest Lancet data – and this is where the big challenges lie, as health services are required to deliver more for less to provide cost-effective care for an ageing population. But this is also where the biggest wins are. As previously demonstrated, most musculoskeletal disorders can be effectively managed in primary care. Integrated care pathways, supported self-management and shared decision-making are cost-effective ways of delivering high-quality, patient-centred care that will not only improve patients’ lives, but deliver better outcomes and cost-effective care.

Prevention

To achieve this, we need a sophisticated understanding of prevention which does not stop lifestyle advice but which addresses the real burden of disability on society and the NHS. Even the healthiest people will need care eventually, and, erecting new barriers to influence or indeed coerce people into making healthier lifestyle choices will only ever go so far. For the 10 million people living with a musculoskeletal disorder in the UK, the solution has little to do with the price of a unit of alcohol and much more to do with coordinated, person-centred care.

In this respect, The King’s Fund’s 10 Priorities for Commissioners clearly highlights the role of both primary and secondary prevention, among other things, noting also how ‘cost savings are likely to accrue over the medium term, as patients are prevented from going on to suffer a wide range of adverse events as their life expectancy lengthens’.

Indeed, the biggest long-term gains for the NHS and patients alike lie in early intervention; preventing manageable long-term conditions from deteriorating; avoiding unnecessary admissions or readmissions; reducing the risk of avoidable harm; and empowering patients to take control of their conditions and thus retain a good quality of life. In other words, we need a public health agenda centred around self-management and patient empowerment.

Musculoskeletal disorders

The Global Burden of Disease report states that ‘musculoskeletal disorders will only increase inimportance in view of present trends and require more urgent policy attention’. The director forlong-term conditions at the NHS Commissioning Board, Dr Martin McShane, tweeted in response to the report: ‘Can do better on prem[ature] mortality, MUST do better on mental health and MSK (musculoskeletal)'. Never a truer word was said.

Musculoskeletal disorders are very broad and do not always fit neatly into our current, biomedically-dominated approach to delivering, and measuring outcomes in, healthcare. They are often complex, are associated with many co-morbidities and many of them tend to fluctuate.

But it is precisely because they are so cross-cutting that they are highly relevant to a very broad range of issues. As this latest report demonstrates, however we choose to measure health improvement and clinical outcomes, musculoskeletal disorders are a top concern, and we mustn’t let the limitations of our current approaches stifle our rightful ambition to help people with musculoskeletal disorders lead a good quality of life, free from pain and with improved functional levels. Doing so is not just an important goal in its own right, but will also help people improve their overall health.

  • Federico Moscogiuri is director of the Arthritis and Musculoskeletal Alliance (ARMA), the umbrella body providing a collective voice for the arthritis and musculoskeletal community in the UK, and Dr Tom Margham is a GP in Tower Hamlets, east London, and lead for primary care, Arthritis Research UK.

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