2019 president s lecture musculoskeletal practice current

2019 Presidents Lecture Musculoskeletal practice: Current state of play, opportunities and challenges Professor Lesley Haig, Principal, AECC University College Setting the scene Musculoskeletal conditions: scale, burden and impact Scale

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  1. 2019 President’s Lecture Musculoskeletal practice: Current state of play, opportunities and challenges Professor Lesley Haig, Principal, AECC University College

  2. Setting the scene

  3. Musculoskeletal conditions: scale, burden and impact

  4. Scale of the problem - UK Arthritis Research UK, 2017

  5. Burden of arthritis and other MSK conditions

  6. Economic impact of MSK • MSK conditions cost ~ £10bn healthcare spending each year • Hip fractures - £1.96bn • Ankylosing spondylitis - £3.8bn • 336m prescriptions MSK - £223.6m

  7. Impact on health and social services Primary care • 1 in 5 consult GP for LBP • 30% GP consultations MSK • 4.6m GP appointments per annum = 793 WTE GPs Secondary Care • Over 25% all surgical interventions in NHS Social Care • Personal Independence Payments £8.61bn

  8. Persistent low back pain impact • Leading cause of global disability (YLD) of 291 conditions Hoy et al, 2014 • 11% of disability burden in UK • £20bn each year economic cost • £5bn NHS cost • Over 45% EU workforce suffer backache over 12 months Eurofound, 2012 • 50% seek care – 35% private sector

  9. Individual impact MSK conditions • Pain • Distress • Functional limitation • Loss of sense of self • Need for validation • Social impact – roles, work, income, isolation • Need to navigate care system • Coping strategies Duffield et al, 2017; MacNeela et al, 2015; Snelgrove et al,2013;

  10. Impact on the UK workforce Changing landscape

  11. Risk factors and associated multimorbidities

  12. Risk Factors • Non-modifiable – age, gender (F) • Modifiable • Physical inactivity e.g. OA • Obesity e.g. regional pain syndromes • Smoking e.g. inflammatory arthritis • Poor nutrition • Direct causal relationships e.g. RA vs CVD and osteoporosis Duffield et al , 2017

  13. Associated Co-morbidities

  14. MSK and Mental Health • In England 4.6m have MH and physical health conditions • Those with long term physical health problems 2-3 x more likely to develop MH problem – mood disorders, anxiety, substance abuse, depression • Working aged disabled people: • 35.2% experience MSK conditions only • 20.2% experience mental health conditions only • 17.2% experience both Arthritis and Musculoskeletal Alliance, 2018

  15. Evidence-informed Guidance

  16. Return on Investment Interventions • Literature review • STarT Back √ • Physiodirect √ • Physio self-referral √ • ESCAPE-pain (knee) √ • CBT with exercise x • Vocational advice in primary care x • Yoga for healthy lower backs x PHE, 2017

  17. NICE Guidance LBP, 2016 • Self-management – information and advice √ • Group exercise √ • Manual therapy √ • Belts / corsets x • Traction x • Acupuncture x • Ultrasound x • PENs / TENs x • IFT x Imaging • Do not routinely offer imaging in a non-specialist setting • Explain to people that if they are being referred for specialist opinion, they may not need imaging. • Consider imaging in specialist settings only if the result is likely to change management.

  18. Physical Activity Interventions for MSK ARUK, 2017

  19. Changing Landscape

  20. NHS Long Term Plan (2019) • 5 year plan • Enhance primary medical services and community health • Improve maternity care • Personalised care for older people in community • Mainstream digital health

  21. Public Health Role

  22. Healthy Ageing and MSK Focus: - Inflammatory conditions - MSK pain – OA/LBP - Osteoporosis and fragility fractures PHE, 2017

  23. Focus on Patient-centred Care (PCC)

  24. Person-centred Approaches Framework • NHS constitution • 3 steps • Behavioral change approach - health coaching - making every contact count (MECC) - motivational interviewing (MI) HEE, 2017

  25. Characteristics of PCC: • Biopsychosocial perspective • Patient-as-person (not disease) • Sharing power and responsibility • Therapeutic alliance • Individual preferences, needs and values guide clinical decisions • Respectful and responsive care HEE, 2017

  26. Communication Skills • Enhance therapeutic alliance Ferreira et al, 2013 • Influence patient outcomes Darlow et al, 2012 • Influence patient satisfaction Hush et al, 2011 • Identify patient readiness to change • Identify and work with patients resistant to change (discordant) Miller and Rollnick, 2013 • Enhance treatment planning and goal setting Parry, 2004

  27. MSK Capabilities Framework for First Contact Practitioners (FCPs) Range of settings Not prescriptive • 14 capabilities in four domains: • A. Person-Centred Approaches • B. Assessment, Investigation and Diagnosis • C. Condition Management, Interventions and Prevention • D. Service and Professional Development 2018

  28. GP Partnership Review (2019) The current model of care in the NHS is too dependent on hospital-based care. This model is not sustainable, and we cannot move forward without change that includes general practice and partnerships at its heart. Recommendation 3: The capacity and range of healthcare professionals available to support patients in the community should be increased, through services embedded in partnership with general practice. …….enabling the creation of population-based multi-professional teams across primary and community care

  29. Innovation and Collaboration • Academic Health Sciences Networks • NHS Innovation Accelerator • NHS RightCare

  30. Digital Health Agenda Develop digital infrastructure • Better use of resources - Promote prevention / self - management Protect and manage data to - support patient journey Can be anxiety-provoking – - ‘Heart age’, self-diagnosis Telehealth and telecare • Remote consultations • Telephone triage •

  31. Public vs Private Sector • 11% population PMI • 18% individual subscribers • 53% NHS consultants in private practice • NHS Trusts can earn up to 49% income from private care • Currently £600m • Around 30% income in independent hospitals – NHS funded • NHS going global HSJ, 2017; King’s Fund, 2014

  32. Challenges

  33. Visibility and recognition • Numbers: • Chiropractic – 3.3k • Osteopathy – 5.3k • Physio – 58k (MSK network 14k, Physiofirst members 4.5k, Pain 11k, SEM 14k, MACP 1.1k) • We are all aware of excellent case studies • Awareness – multiprofessional education / working / exposure • Demystification / education of others about the profession • Autonomy as prescribers – nurses, some AHPs • NHS recognition as AHP? • NHS is huge, internally facing, medicine and nursing-focused

  34. Missing out? • GPs and nurses were deterred from referring patients to services such as pain management (incorporating CBT), acupuncture, chiropractic and osteopathy, by a perceived lack of NHS services, and/or a lack of familiarity with local providers of non-physio services. • For many, the only NHS-funded option after physiotherapy was to refer to a pain management clinic, which could be associated with high NHS costs, long waiting lists, and resource implications for patients .

  35. Opportunities

  36. NHS Saviours? • NHS austerity • Innovative ideas are welcome especially where they fill a gap / reduce burden on primary care • FCP • GP review – models / case studies / evidence • Triage • Advanced practitioners • Don’t wait to be asked!

  37. Opinion Leaders • Exemplary MSK skill set – especially in areas which nurses, physios, fitness professionals do not have • Teach them some of your techniques – they will see how great you are • Extend skill set? Rehab, public health • Employ other professionals and lead by example • Continue to demonstrate evidence-base – increase doctorally- qualified researcher base • Optimise chiropractic pre-qualifying curricula so graduates are abreast of wider health and social care agenda and have skills to work with a wide range of professionals

  38. Conclusions Make the vital visible!

  39. Thank you for your attention

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