GPs face rheumatology challenge

Primary care will face significant workload challenges from musculoskeletal (MSK) disorders as the population ages and NHS resources shrink, experts have warned.

Dr Alan Nye: GPs will have to begin to explain variation in their practice
Dr Alan Nye: GPs will have to begin to explain variation in their practice

Speakers at the Rheumatology 2013 conference in Birmingham last month said conditions such as rheumatoid arthritis and spinal problems already take up a huge amount of GPs' time. This will grow as the population ages, they said.

The NHS has a long way to go to improve care for the condition, speakers warned, with services plagued by unwarranted variation in quality, fragmentation and lack of integration. They called for more GP training in the management of MSK conditions.

A greater emphasis on preventive action is needed to avoid hospital admissions, particularly concerning falls, they said.

The event was one of the first major national clinical conferences since the NHS reorganisation came into effect on 1 April.

Speaker Dr Chris Deighton, consultant rheumatologist and president of the British Society for Rheumatology, said MSK conditions placed a 'massive burden' of work on the NHS.

Working days lost

About 20% of people consult their GP about an MSK disorder each year, and these illnesses cost the UK economy 7.6m working days a year. The UK also lags behind other developed nations in treating MSK disease.

Dr Deighton said the NHS faced a significant challenge from the ageing population. DH estimates show the number of people aged over 65 will rise 51% by 2030.

In addition, 'flatlining' NHS resources and the NHS reorganisation in England pose further problems, he warned.

Dr Deighton said that primary care must tackle the 'enormous' variation in practice to cope with these future pressures.

Professor David Oliver, consultant geriatrician at NHS Royal Berkshire Foundation Trust, said frailty had become 'core business' for the NHS.

'7% of the entire population over 65 will pass through emergency departments each year following a fall,' he said. 'It's critical that each fall or fracture is a red flag for case-finding, an opportunity to intervene, which we're missing at the moment.'

He said too little is being done to prevent fractures. 'Primary prevention of bone fragility across the life course from wider determinants such as exercise and diet doesn't feature very highly in most public health strategies locally at the moment.'

North Staffordshire GP Dr Mark Porcheret told the conference that GPs faced 'guidance overload' on how to treat and manage MSK conditions.

He said NICE has issued 777 MSK recommendations for primary care in 22 guidelines within the past two years alone. 'Not surprisingly, GPs feel there's too much of it, a huge amount to do.'

Swamped GPs are struggling to keep up with the latest advice. A recent survey of 768 GPs suggested just 446 (58%) had read the latest NICE osteoarthritis guideline from 2008.

In another study, only 15% of GPs said they did not require more help in managing osteoarthritis. 'It does strike me there is a skills gap out there in terms of GPs being able to implement this guidance,' said Dr Porcheret.

Dr Alan Nye, GPSI in rheumatology in Greater Manchester and director of the Pennine MSK Partnership, said tackling unwarranted variation will be a particular priority for CCGs looking to improve MSK care.

He told delegates: 'Even though the CCGs do not hold the GP contract, they have been charged with performance management and governance in primary care. They will begin to have to step up to the mark and GPs will have to begin to explain variation in their practice.'

However, Dr Nye believes the biggest MSK challenge facing the GP workforce is training in undergraduate medicine and GP education.

Speaking to GP after the event, he said: 'It's a challenge for everyone involved in education: the GMC, royal colleges and us, doing our own appraisals and setting our own educational needs.

'There is far too little emphasis on broad MSK. Twenty per cent of consultations are for MSK conditions, yet there's only a few weeks of it in undergraduate education, and in some cases it forms no part of GP education. Given this, I don't think you can be critical or surprised when you see variation.'

Case study - Sheffield back pain scheme

A local programme to improve the management of back pain in general practice has led to a 50% drop in referrals to orthopaedic surgeons.

South Yorkshire GP Dr Oliver Hart and colleagues were asked in 2008 to improve the 'inequitable' access to physiotherapy in Sheffield, where some patients had to wait eight weeks for an appointment.

In response, the team asked GPs in the city to refer non-urgent cases only to multidisciplinary spinal teams, instead of directly to orthopaedic surgeons. These teams determined the severity of cases and decided whether patients needed to see a surgeon or a physiotherapist.

Dr Hart told the Rheumatology 2013 conference: 'Just doing that halved the number of people going to surgeons, so we immediately had the commissioners interested.'

Next, they mandated GPs to use the STarT Back tool developed at Keele University in Staffordshire. This takes just 40 seconds to complete and measures biopyschosocial traits, scoring patients as facing low, medium or high risk of chronic back problems. Patients could then be matched to the correct level of treatment or physiotherapy.

Now, 100% of GP referrals have a biopsychosocial assessment, and referrals to physiotherapy and secondary care have fallen. Dr Hart said: 'The right patients are getting physio and patients who were going to get better are kept in primary care.'

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