FINAL MSK National Context

National Orthopaedic AllianceMusculoskeletal DiseaseNational ContextData in this presentation has been anonymised to allow it to be shared. For further information pleasecontact Ann Hoey, NOA Deputy Director via info.noa@nhs.netProfessor Peter Kay Hip and Knee Surgeon WWLNational Clinical Director MSK NHS EnglandPast President Hip Society and British Orthopaedic Association

MSK in the NHS England ( 7 -10bn)3-4th largest area of spend More years lived with MSK disability than any other disease 2nd cause of sever disability More time off work etc Not Kids, Cancer, Cardiac Is it a priority for payers? Under the Spot light Priority Economy ExpensiveVariationWaiting timesSocial care Work Benefits

Evidence-BasedInterventions: Response tothe public consultation andnext stepsPublished by NHS England in partnership with NHS ClinicalCommissioners, the Academy of Medical Royal Colleges, NHSImprovement and the National Institute for Health and CareExcellence

Carpal tunnel syndrome releaseThere was agreement to the inclusion of this proposal in the programme and general agreement to the clinicalcriteria, including from the British Society for Surgery of the Hand and the British Society for ClinicalNeurophysiology.We received requests for clarification which we responded to by: Adding information provided by the British Society for Surgery of the Hand andthe British Society for Clinical Neurophysiology.Amending the wording to reflect that while “service planning for themanagement of Carpal Tunnel Syndrome should include early access toneurophysiological testing the use of nerve conduction studies to diagnosecarpal tunnel syndrome” (clinician)., Nerve conduction should be carried outbefore surgery where possible as an aid to choosing appropriate treatment, forprognosis, and for reference in the event of a poor outcome.The British Society for Surgery of the Hand and the British Society of Clinical Neurophysiology approved thechanges to the recommendations and clinical criteria.

Where we are now Admitted Waiting ListEffective Use of Resource Procedures 23% of the Admitted waiting listNon EURBunionDupuytrensCarpal TunnelScopesTrigger FingerGanglionHyaluronic acid injections

Payment systemreform proposals for2019/20A joint publication byNHS England and NHS ImprovementOctober 20181.2 Our proposals . 51. 2.1 Duration of the tariff. 52. 2.2 A blended payment approach for emergency care. 53. 2.3 Outpatient attendances. 94. 2.4 Market forces factor .105. 2.5 Centralised procurement.116. 2.6 Maternity pathway.117. 2.7 Other payment reform proposals .13

What about MSK Not a central NHSE priorityStroke, Cardiovascular, Respiratory, Children Maternal, Cancer, Autism65% of CCGs and STPs say MSK is a priorityWhat have we got to help Internal knowledgeNice GuidanceRight CareGIRFTElective Care TransformationPublic HealthPersonalised CareAcademic health networksResearchHow do we decide what to put in place in a local healthcare economy?

PathwayPreventionPrevention Broadly egObesity, smokingPrevention: earlyReferral pathways todetection eg osteoprosis, appropriate secondaryfrailtycare (# or red flagsymptoms)InterventionReferral pathway toOperative Interventionconservative treatmente.g. physioOrthopaedics, Spinal,Rheumatology. Eg.Jointreplacement rates per100k populationGIRFTAdvice and guidance, MSKtriage services. First contactpractitionersHigh Impact Interventions, e.g.Osteoporosis, Back Pain, RheumatoidArthritis, Support FCP, Advice &Guidance, MSK Triage Services,Integrated Care Models, MedicinesOptimisation and Medicines ValueProgramme, Pain Managementprogrammes,Promote primary andsecondary prevention, workMSK Pathways, Falls Andin collaboration with PHE,Support FCP, MSK Triage,Fragility, Fraility,LA to address widerFCPPopulation appraochdeterminants of health andreduce inequalitiesCommissioning guidance:interventional Rx forbackpain, Hip arthroplasty,Knee arthroscoplasty andarthroscopy, shoulderdecompression.Choosing WiselyLifeCourse Approach, WiderNon-operative InterventionRevision, readmits, LOS,mortal, finance, litigation, hipimplant type, reducing smallno surgeons etcAdvice and guidance, MSK triage services. Firstcontact practitionersECTPRightCareProblem PresentsOutcomesSupport/ ResourcePROMsOtherOtherPROMsShared Decision Making,Reduce Inequalities in accessand outcomes, reduceunwarranted variationGIRFT Guidance, Trust DataPacks, Good Practice Manuals,Data Portal, Recommendations,Site Visit Report, Logic ModelsReduce referrals to secondarycare for MSK relatedconditions, ReduceMSK Handbooks, Evalutaion,Inequalities in access and Logic Modelsoutcomes, reduceunwarranted variationEmbed Shared DecisionMaking to ensure informedpatient choice andReport PROMs in focusappropriate referrals, ReducepacksInequalities in access andoutcomes, reduceunwarranted variationShared Decision MakingMSK Optimal Pathways, MSKFocus Packs, GP Practice packs,STP Packs, MSK Logic Models,Bespoke analytics, Storyboards,Case Books, Patient Stories,working with Spec Comm

reduce inequalitiesMSK Pathway Overview and Improvement Initiatives V4PreventionProblem PresentsPathwayChoosing WiselyPublic Health/GIRFTLocal AuthorityECTPSTP PrioritiesNHSI Op ProdRightCarePrevention Broadly egObesity, smokingLifeCourse Approach, WiderDeterminanants of health,reducing inequalities, riskfactors, Work & health,Health and WellbeingBoardsprogrammes,Commissioning guidance:Interventioninterventional Rx forPrevention: earlyReferral pathways to Referral pathway toOperativeInterventionbackpain, Hiparthroplasty, Non-operative Interventiondetection eg osteoprosis, appropriate secondary conservative treatmentKnee arthroscoplasty andfrailtycare (# or red flage.g. physioarthroscopy, shouldersymptoms)decompression.Orthopaedics, Spinal,Rheumatology. Eg.Jointreplacement rates per100k populationRevision, readmits, LOS,mortal, finance, litigation, hipimplant type, reducing smallno surgeons etcAdvice and guidance, MSKtriage services. First contactpractitionersAdvice and guidance, MSK triage services. Firstcontact practitionersPromote primary andsecondary prevention, workMSK Pathways, Falls Andin collaboration with PHE,Support FCP, MSK Triage,Fragility, Fraility,LA to address widerFCPPopulation appraochdeterminants of health andreduce inequalitiesTheatre productivityHigh Impact Interventions, e.g.Osteoporosis, Back Pain, RheumatoidArthritis, Support FCP, Advice &Guidance, MSK Triage Services,Integrated Care Models, MedicinesOptimisation and Medicines ValueProgramme, Pain Managementprogrammes,unwarranted variationOutcomesworking with Spec CommSupport/ ResourcePROMsOtherOtherPROMsShared Decision Making,Reduce Inequalities in accessPublicoutcomes,Health OutcomesandreduceFramework (PHOF)unwarrantedvariationGIRFT Guidance, Trust DataPacks,Good PracticeManuals,Joint StrategicNeeds Assessment,DataPortal,Recommendations,MSK ROITools,Knowledge andSiteVisit Report,IntelligenceHubs,Logic ModelsShared Decision MakingReduce referrals to secondarycare for MSK relatedconditions, ReduceMSK Handbooks, Evalutaion,Inequalities in access and Logic Modelsoutcomes, reduceunwarranted variationEmbedTBC Shared DecisionMaking to ensure informedpatient choice andReport PROMs in focusappropriate referrals, ReducepacksInequalities in access andoutcomes, reduceunwarranted variationTBCMSK Optimal Pathways, MSKFocus Packs, GP Practice packs,STP Packs, MSK Logic Models,Bespoke analytics, Storyboards,Case Books, Patient Stories,working with Spec Comm

“We must not use data like a drunkenman uses a lamp post: more forsupport than for illumination”.Understand data and collectively actupon it

Wave 1 - Elective Care Transformation Programme MSK handbooks: A SpotlightWave 1 Handbooks and Case Studies The handbook is a guide to ‘what, why and how’ ideascan be implemented locally to transform MSK servicesIt is informed by Wave 1 of rapid testing and includeearly outcomes and links to further evidenceThe case studies are more detailed accounts ofdifferent interventions and the learning from Wave mation/handbooks-and-case-studies/

Examples of Other Transformation Initiatives CCGs and STPs can use resources and learning developed by NHS England’s Elective Care TransformationProgramme to help address the steady rise in elective care referrals.High Impact Interventions - specifications2017 MSK triage Clinical Peer reviewHigh Impact Interventions - specifications2018/19 Ophthalmology First ContactPractitioner (MSK)Re-thinking referralsTransforming outpatients Advice and guidance services Patient-initiated, rapid access and virtual follow-up MSK triage and clinical review Telephone follow-up Standardised referraltemplatesSelf-management support Self-management education Self-management supportfor long term conditions Patient passportsAlerts to referring GPs using thee-RS when a local provider haslong waiting times for theservice their patient needs.The system suggestsalternative local providerswith shorter waiting times.

High Impact Intervention: MSK Triage What.§ MSK conditions affect 1 in 4 of the adult population, approximately 9.6 million adults in the UK.§ The NHS England RightCare programme has identified that 31% of total elective opportunitiesinvolve musculoskeletal pathways.§ Clinical triage services provide specialist clinical review of referrals after a GP has made areferral for a musculoskeletal condition.§ CCGs are delivering timely MSK triage with collaboration between clinicians in both primary andsecondary care and clear referral criteria.§ They are commonly delivered by NHS (hospital or community) or independent providers in acommunity setting.§ Referrals are often reviewed by physiotherapists, advanced physiotherapy practitioners, orGPwSIs who specialise in MSK conditions.

High impact intervention: MSK Triage (2) What § MSK triage is designed to drive establishment of specialist triage services so that patientsare seen by the right professional first time.§ It does not require an integrated triage and treatment service, although these can be bestpractice arrangements.§ The specification relates to all body parts and includes pain and rheumatological MSKrelated conditions.§ Exemptions will be defined locally e.g. urgent referrals for cancer.§ MSK triage services can reduce referrals to secondary care by up to 30%, with patientsoften seen in other community based services.§ This means that those patients who need to be seen by a hospital consultant are seen asquickly as possible.

High impact intervention: MSK Triage - Impact§ At the end of July 18, 90% of CCGs had rolled out MSK triage, withall others making significant progress.§ In order to articulate impact of the MSK triage the ECTP undertook animpact audit at the end of Q4 17/18. Provisional headlines:Ø Across all MSK triage schemes approximately 50% of all patientreferrals reviewed were diverted from secondary care.Ø Those CCGs that were compliant with the MSK triage specification bythe end of December 2017 had a significantly lower working dayadjusted referrals seen rate per 1,000 population at 9.7 compared tothose CCGs not compliant with the specification (11.3).Ø When comparing the same 2 month epoch from 16/17 to 17/18 thoseCCGs that were compliant with the MSK specification saw a 10%reduction in referrals compared to a 3% reduction in those that werenot compliant.