Musculoskeletal disorders (MSDs) affect 10 million people in the UK; are the fourth single largest area of spending in the NHS; are a major cause of disability and time off work; can be extremely debilitating; and account for up to one in three GP visits.
Early diagnosis, prompt referral and specialist intervention is essential for some inflammatory forms of arthritis, for example rheumatoid arthritis. But many people with MSDs, the vast majority of whom have osteoarthritis, can be managed effectively in primary care, if the care they receive includes a strong element of self-management and support to remain independent. For many, this also means avoiding potentially unnecessary (and expensive) interventions. Linked to public health targets, self-management is central to the prevention agenda.
In Oldham, Greater Manchester, the Pennine MSK Partnership covers all non-admitted services in rheumatology and orthopaedics, and has been very successful at diverting patients away from hospital through consultant-led pathways which have sought to transfer as much care as possible into the community and closer to the patient. All of the non-admitted rheumatology pathway is now delivered from the community-based service. What began as a triage service for rheumatology referrals in 2002 is now very successful, fully accountable, regulates quality and identifies variation across the entire musculoskeletal pathway and ensures that patient choice is offered at all appropriate points in the pathway.
However, self-management is not simply about keeping people out of hospital. Self-management is just as important following a surgical intervention, and helps avoid repeat or unnecessary visits. Nor is self-management simply about sending people in pain back home with an analgesic. Proper screening and referral processes are crucial to ensure that those who do need specialist intervention get it promptly. At the same time, organisations like Arthritis Care, the National Rheumatoid Arthritis Society and the National Ankylosing Spondylitis Society are well-equipped to provide additional information and support to self-manage. Care plans, developed together with the patient, also help identify both short-term and long-term needs and outcomes as well as monitor a patient’s progress and condition over time, and empower patients to take responsibility for their own care. Not all of this need be done directly by the GP, so long as there is a team around them, for example nurses and allied health professionals, working effectively together around the needs of the patient.
The Atlas of Variation clearly shows that there is deeply-embedded variation in the NHS. In particular, there is variation on MSK spending and on referral rates from primary into specialist care, the latter being more than five-fold in the typical clinical commissioning group area. Having clear referral criteria based on best practice evidence-based pathways can deal with this variation and identify further support and training needs in primary care. Most clinicians would agree that it is desirable for patients to be more engaged in decisions about their treatment options. The evidence from the Cochrane Collaboration is compelling, highlighting both the risk of over-treatment and how shared decision-making has a significant positive impact on patient care. The DH’s right care shared decision-making programme has commissioned three workstreams:
1. To develop more decision aids.
2. To evaluate the shared decision-making programme and to integrate decision aids in standard NHS technology.
3. To change the NHS culture to better embed shared decision-making in patient pathways.
Membership health improvement organisation the Advancing Quality Alliance (AQuA), based in the north west of England, is delivering the third workstream, and MSDs is one of its pilot clinical areas. The project, investigating the most effective way of implementing shared decision-making across integrated teams, will be complete in March 2013.
However, there is much that can be done now to bring shared decision-making to more patients, including:
- Signposting patients to the existing decision aids in the NHS Direct website
- Encourage patients to realise that their opinions and preferences are crucial in deciding on the best treatment option
- Understand that the clinician’s role is to support and advise the patient and not to tell them what to do
- Using short form decision aids or option grids to support the patient within the consultation to engage in shared decision-making. An option grid for early osteoarthritis knee has been developed.
The Institute of Health Improvement’s Triple Aim also provides a useful tool for GPs, geared around a) high quality patient experience, b) a population approach to planning and delivering care, based on unmet need, and c) delivering value while removing perverse incentives, duplication and waste.
The Arthritis and Musculoskeletal Alliance (ARMA), as the umbrella body representing the musculoskeletal community, brings together professional and patient organisations, and can help inform and direct GPs to a wide range of information, evidence and contacts. We are very interested in speaking with primary care professionals who wish to improve or are commissioning services for people with MSDs, including with a view to supporting local clinical network development: if that is you, please don’t hesitate to get in touch.
In the new NHS, primary care must lead the way in delivering better, more cost-effective care, and GPs must lead by example. Shared decision-making, effective referral mechanisms and support to self-manage are central to providing high-quality, patient-centred care. But first and foremost, it is all about listening, understanding, and supporting each patient through their patient journey. It will lead to better patient outcomes, better patient experience, and good use of limited NHS resources. And that is a win-win situation.
- Dr Alan Nye, associate medical director Pennine Care NHS Foundation Trust, clinical director AQuA (shared decision making) and director Pennine MSK Partnership Ltd (Alan.firstname.lastname@example.org), and Federico Moscogiuri (email@example.com; Twitter: @MoscogiuriF) is director of ARMA.