The Musculoskeletal Services Framework - PDF document

The Musculoskeletal Services Framework responsibility:differently Musculoskeletal Services Framework DH Publications OrderlineE-mail: dh@prolog.uk.comTel: 08701 555 455Textphone: 08700 102 870 (8am to 6pm, Monday to Friday)www.dh.gov.uk/publications Policy Estates Performance IM&T Finance Partnership working HR/Workforce Planning Clinical Document purposeBest Practice Guidance ROCR refGateway ref 6857TitleThe Musculoskeletal Services FrameworkÐ A joint responsibilty: doing it differently AuthorDepartment of Health Publication date12 July 2006Target audiencePCT CEs, NHS Trust CEs, SHA CEs,Foundation Trust CEs, Medical Directors,Directors of PH, Directors of Nursing, ProfessionalsCirculation listMedical Directors, Allied HealthProfessionals, GPs, VoluntaryOrganisations, Royal Colleges and many individual professionalsDescriptionThe Musculoskeletal Services Frameworksummarises the current state ofthen provides a description of howservices could be improved and offerscase studies to assist NHS staff in extensively referenced throughout. Cross refN/A Superseded docsN/A 1.1IntroductionFramework.A joint responsibility: doing it differently of disease, injury or developmental disorder, to ensure thatIn England, as in the rest of the world, musculoskeletalconditions are common, and are a major cause of ill-health,pain and disability. It is estimated that nearly one-quarter ofadults and around 12,000 children are affected by long-standing musculoskeletal problems, such as arthritis, that limiteveryday activities. Musculoskeletal conditions are the mostcommon reason for repeat consultations with a GP, making upto 30% of primary care consultations. The prevalence ofthe number and proportion of older people in the population is projected to increase in future, so the number of people with musculoskeletal conditions will also rise. However, thefunctional impairment from musculoskeletal conditions variesdelivery of improved access. For those patients needinghospital treatment, by the end of 2008 patients will be waitingno longer than 18 weeks from GP referral to the start ofhospital treatment. This will cover the outpatient and inpatientwaits as now, and will also include, for the first time, the waitfor diagnostic services and tertiary referral, as part of thewhole patientÕs journey.range of individuals and organisations: patients; NHShealth and social care, and the importance of working with afull range of other agencies (including those responsible forWhere possible, the Framework is based on evidence-basedguidance or care pathways, and an integrated, multidisciplinaryapproach. Good practice points are set out for NHS and socialcare organisations, the implementation of which will helpimprove outcomes for adult and child patients, and theirfamilies and carers. Framework (MSF) and its role in improvinglooks at the extent of the problem, reporting theprevalence of musculoskeletal conditions and thelooking at the benefits of the approach;gives an example of a patient care pathway. dh ms main doc artwork 26/7/06 12:14 Page 5 access high-quality, effective and timely advice, assessment,diagnosis and treatment to enable them to fulfil their optimumhealth potential and remain independent. This will beaccomplished through systematically planned services, basedon the patient journey, and with integrated multidisciplinaryworking across the health economy.The following quotation from multidisciplinary, but the integration of the differentmusculoskeletal specialties varies between centres. Usually,rheumatologists, or orthopaedic surgeons, work closely withthe therapists, but there is little integration of the medicalspecialties themselves and there are few examples of clinicalorthopaedics, rheumatology, rehabilitation, physiotherapy andoccupational therapy, supported by specialist nurses, orthotics,prosthetics, podiatry, dietetics and all the other relevantdisciplines. Hopefully, this will change with time, as part of theClearly, within the NHS there are already health and social careteams and groups in this field who are working in this way.approaches, based on integrated, shared care.1.3 The approachThe approach is based on shared care, structured around thepatient journey, often defined in integrated care pathwaysand collaboration between, primary, secondary and social carecan reduce hospitalisation and yet, crucially, provide better careand a better service to patients and carers alike.Shared care is not new: its use has been described in theintegration and co-ordination of care across organisationalprovision of care, where possible, in the least Shared care processes depend for their success on theeducation of participating healthcare professionals, specificallydesigned information systems, and regular audit andevaluation of services delivered. Systematic processes of carecan be documented as clinical protocols, referral guidelines conditions, and many other disorders, has been wellICPs thus form the basis of redesignedmusculoskeletal services proposed in this Framework, based on the patientÕs entire journey. The emphasis is on preventionand self-care, with the patient an active agent, rather than a passive recipient, and on services that are co-ordinatedseamlessly: from public health information, to initial points of contact with primary care and referral on to more implementing care pathways for the management ofpatients with chronic disease are:enabling patients and carers to be involved indeveloping care pathways, to exercise choice andparticipate in their own care, and to have a moreof their care;tailoring services round the (often complex) needs offocusing efforts on self-management and prevention;improving patient outcomes through more effectiveand efficient assessment, diagnosis and treatment;For front-line staffrefocusing care around the patient;promoting use of evidence-based practice; promoting effective clinical governance andpromoting interdisciplinary team care and the SingleAssessment Process (SAP) to ensure that anindividualÕs support needs are considered in a improving communication between staff in allsettings (eg between primary care and hospital staff);providing a consistent decision support system for allprofessionals, including trainees;Organisational efficiencysupporting a unified care record and reducing timespent on record-keeping;identifying organisational barriers to the delivery ofpatient-centred care;improving the quality, consistency and efficiency ofcare, often reducing cost of care. dh ms main doc artwork 26/7/06 12:14 Page 6 in diagrammatic form on the inside front cover. It covers allelements of health and social care Ð prevention; self-careTreatment Services (CATS), positioned at the interface betweenprimary and secondary care; hospital specialist care;rehabilitation and supporting return to work Ð and aims to setsupport professionals in providing high-quality care forOne of the implications of the Framework is the provision of a wider range of services by a wider range of staff working in primary and community care services, so that patients can access care in convenient, community-based locations,process of care leading to better outcomes.social care professionals to provide more easily a high-qualitythat, and helps professionals to:treat patients at the appropriate point in the system (closerprovide patients with better information to manage theircondition, reducing avoidable admissions;plan/manage patient flows through primary and secondarycare, ensuring appropriate and timely referral to specialistcare services;develop capacity in primary care by offering a wider rangeof non-surgical alternatives, eg specialist practitioners,physiotherapy, podiatry, nursing, pain management advice,chiropractic, osteopathy etc;facilitate an individualÕs return to independent living,including returning to work and/or participation ineducation, where appropriate;use capacity in acute settings appropriately.Multidisciplinary Clinical Assessment and Treatment Services The development of multidisciplinary CATS is the keystone ofthe Framework. CATS brings together skilled professionalsfrom primary and secondary care Ð allied health professionalsinterests (GPwSIs), chiropractors, osteopaths and nurseand other specialists. Training for specialist registrars andothers can be provided. Functions include full biopsychosocialtreatment, radiological/haematological investigations, jointinjections, pain management and more.The service does not detract from the ÔnormalÕ functions ofprimary care professionals: it adds expertise which will benefitmany patients who would otherwise be referred to secondarycare. CATS can be located in communities, acute settings orboth. Successful CATS have involved health and social careprofessionals from all relevant specialties and professions, andpatients in the planning and implementation process. The implementation of CATS is discussed in Chapter 4. dh ms main doc artwork 26/7/06 12:14 Page 7 An example of a care pathway for adult patients with hip andpresented opposite, to illustrate the principles of the MSF inmore detail.health and inform an individualÕs decision to consult.There is strong evidencethat the provision of patientby the patient of the advice, can help to reduce pain andimprove coping skills in patients and also potentially reducecosts. Information can also promote exercise, avoidance ofobesity, good nutrition and prevention of injury.physiotherapists, chiropractors or osteopaths directly withoutthe need for GP referral, reinforcing the joint health messageand saving GP time. Integrated care such as advice on painmanagement, treatment or support can be accessed asrequired, from nurse practitioners, pharmacy, podiatry,occupational therapy and orthotic services. Each professionalcontributes to a single co-ordinated assessment of anindividualÕs health and social care needs, in line with the SingleAssessment Process for Older People and the CommonAssessment Framework for Children and Young People (and a proposed Common Assessment Framework for Adults).early referral guidance for rheumatoid arthritis in primary careare available (see Step 4: First-line specialist opinion in musculoskeletal CATS Multidisciplinary CATS support all primary care joint CATS provide specialist assessment, advice, investigation andappropriate onward referral where necessary. The service isstaffed by consultant AHPs, extended-scope physiotherapists,GPwSIs, nurse practitioners, chiropractors and osteopaths.Orthopaedic surgery and rheumatology teams need to beprovide essential specialist expertise.and willing to undergo surgery.To ensure that patients are listed (according to agreedprotocol) only when medically fit, multidisciplinary CATSshould include links to clinical pre-listing assessment (nursepractitioner-led). These services should include patienteducation on surgery and an early needs assessment toidentify and plan for an individualÕs anticipated support needson discharge.listed for surgery.In some cases, patients requiring primary hip or kneearthroplasty may be listed for surgery from the CATS, ie by aphysiotherapist or practitioner with special interests (PwSI)working in an extended role. .Priority scoring tools(eg Oxford Hip and Knee) can be useful in deciding urgency.patients are still medically fit for surgery, ensuring optimalsurgical team review, anaesthetic review, medical fitnessreview, pre-/ post-operative treatment/management ofdischarge planning (eg home equipment organisation, post-operative exercise explanation (occupational therapist, nurse,physiotherapist). The willingness of the patient to undergosurgery should be confirmed.Patients are discharged home and receive follow-up painmanagement and rehabilitation as necessary in an outpatientor community location. Both short-term and long-term surgicalfollow-up visits can be shared between the consultant teamconsultant time and limit follow-up Did Not Attends. SharedThe process is locally agreed, using protocols to extend roles asappropriate but ensure registrar training is fulfilled.are available.The remaining chapters of this document describe where we are now, and the impact of the Framework on thecommissioning, planning and organisation of services inprimary and secondary care. dh ms main doc artwork 26/7/06 12:14 Page 8 Chapter 1 �Ð Musculoskeletal Services Framework Page09 Shared between physiotherapist/nurse/consultantteam as locally agreedFeedback from specialistOutcome measure Self-referral care services, eg podiatry, provide training Agreement of patient surgery, interface with Fitness for surgery and discharge needs Agreed bookingsurgeryDischarge organisationexercise professionalPromote self-discharge dh ms main doc artwork 26/7/06 12:14 Page 9 Where we are dh ms main doc artwork 26/7/06 12:14 Page 10 Ð Car�e outside hospital Page3.1 Introductionpractitioner in the community, when they need additionalsupport and help. Clearly, people need access to differentservices depending on their circumstances, from access to firstcontacts for new patients through to intermittent or continuingmanagement and rehabilitation for patients with longer-termAt present, access is not always easy. However, somehealth economies have succeeded in breaking downboundaries and barriers to develop more flexible andresponsive services for people with musculoskeletal conditions. international evidence. The roles of primary care professionalsin the care of people with musculoskeletal disorders, includingself-care and prevention, are described. The processes thatneed to be in place for deploying and co-ordinating the fullnumber and quality of professionals with extended or specialistroles are emphasised. The crucially important role of primarycare trusts (PCTs) and local authorities in assessing the needscommissioning reshaped services based on need is also3.2 NHS and Social Care Long-TermThe Department of Health policy, promotes a new model to improve carerheumatoid arthritis. In looking at care delivery, the modeldescribes three main approaches that are key to the successfulcare of people with long-term conditions. These are:management approach to anticipate, co-ordinate and join up health and social care. Providing people who have a complex single need or multipleconditions with responsive specialist services, usingmultidisciplinary teams and disease-specific protocols andCollaboratively helping individuals and their carers to developthe knowledge, skills and confidence to care for themselvesand their condition effectively. This approach, including health promotion, underpins thecare elements of which are described in the following sections. covers research showing the benefits of self-care forindividuals and local health economies throughpreventing and managing conditions;looks at the effect lifestyle factors have ondeveloping and controlling musculoskeletal disordersand how risk factors can be reduced;access high-quality information about healthcare,providing details of places where such informationcan be found and the responsibilities of thoseproviding it;details the developing roles of professionals involvedin the provision of health and social care in a varietyrecommends action points on implementation of the dh ms main doc artwork 26/7/06 12:14 Page 19 Ð Car�e outside hospital Pageself-careImproving well-being is a cross-government agenda, whichhealth and social care services will play an important part indelivering. Commissioners in primary and community careshould consider scope to improve well-being in line with thePromotion conditions to promote healthy lifestyles. As described in Chapter 2, self-care is an equally importantstrand of the GovernmentÕs strategy and is one of the keypillars of the NHS Improvement PlanÕs vision for a patient-centred care system.consider to be the most reliable and appropriate information.Self-care is what most people do on a daily basis to look aftertheir health and prevent problems developing Ð takingworsen any health problems. Furthermore, researchÔsupporting self-care can improve health outcomes, increasecollaborative resource available to the NHS and social care Ðpatients and the publicÕ. However, people need access toreliable information about health in order to stay healthy andFor those who have a known condition, greater guidance maybe required Ð for example, the provision of support to helppatients access and interpret relevant information on theefficacy of treatment or develop the understanding and skillsVoluntary and communitysupport, through self-care networks, education and localpossible and reduce the risk of developing new problems.The Expert Patients Programme (EPP),an expanding NHS-based training programme that provideson a day-to-day basis, through courses delivered by peoplechronic musculoskeletal pain and disability may need achallenge to their often entrenched beliefs. The furtherexpansion of the scope and staffing of the EPP will helpaddress this. Provided with the necessary skills, people canbenefit of supported self-care is the potential reduction ofunplanned or episodic use of secondary care services.There is a need for information to help people navigate thesystem in order to understand entitlements and identifyopportunities. Provision of adequate low-level support servicesconditions and return to independent living following anepisode of hospital care.has been developed, often by patient organisations. In makingPhysical activity and diet, for example, can affectmusculoskeletal disorders. Physical inactivity and unhealthydiets have contributed to rapid increases in obesity in bothadults and children.England who are now either overweight or obese have anincreased risk of developing musculoskeletal disorders.individuals who already have musculoskeletal problems, theadditional weight, together with a decline in physical activity,general health and threaten their independence.contribute to the cause and/or progression of some conditions,for example, metabolic bone diseases such as osteoporosis.Smoking and excessive alcohol consumption may also increaseis a cross-government action plan seekingto achieve a more active and therefore healthier England.Although an active lifestyle is key to improving andmaintaining health, only 37% of men and 24% of women aresufficiently active to gain any health benefit. Three in ten boysand four in ten girls (aged 2 to 15 years) are not meeting theappropriate levels of physical activity.The Chief Medical OfficerÕs report PCTs. The report documents the up-to-date research evidenceof the benefits of physical activity in the prevention andtreatment of several conditions including musculoskeletaldisorders, focusing on osteoporosis, osteoarthritis and low backpain. The key points in relation to musculoskeletal conditionsare summarised below: ÔThe EPP has really helped me to take more control ofexperiencing the programme, my daily routine wouldbe exactly the same each day.Õ ÔMost people want to help themselvesÉ itÕs just thatthey donÕt know how.ÕBack care patient focus group dh ms main doc artwork 26/7/06 12:14 Page 20 Ð Car�e outside hospital PagePhysical activity can increase bone mineral density inFor best protection against osteoporosis there needs to beactivity that physically stresses the bone Ð such as running,especially girls, to increase their bone mineral density.Physical activity in later life can delay the progression ofosteoporosis, but it cannot reverse advanced bone loss.Physical activity programmes can help reduce the risk offalling, and therefore of fractures, among older people.No studies have directly confirmed that physical activity canprevent the onset of osteoarthritis. However, both absenceof and an excess of stress on the joints can increase the riskPhysical activity can have beneficial effects for people joint replacement, but excessive physical activity Obesity is likely to increase the pain felt by those withA variety of endurance activities that do not over-stress thelower back can alleviate low back pain. General leisure-timeactivities are recommended for people with low back painand excessive overall levels of physical activity.Posture-based exercise (eg pilates, yoga) and exercises to increasePCTs and public health networks will want to ensure that theyfocus on this report and implementing the actions with theirWhile there is high awareness of healthy eating, most peopleconsume less than the recommended amounts of fruit andvegetables but more than the recommended amounts of fat,salt and sugar. is aimed at all people and organisations with aninterest in improving food and nutrition in England Ð includinglocal communities, voluntary organisations, businesses, localauthorities and PCTs. It focuses on obesity education andprevention and improved nutritional standards in schools,hospitals and the workplace. PCTs and health professionalsshould use every opportunity to take forward therecommendations of the report, including the production health of individuals but also lead to large numbers ofattenders at accident and emergency (A&E) departments andfacilities. Individuals can take simple preventive measures suchas always wearing seat belts, ensuring that homes areaccident-proof, drinking alcohol in moderation and not drivingalcohol and trauma is compelling. In Great Britain in 2003,there were 19,010 casualties in road accidents involving illegalalcohol levels. Of these, 560 were fatal and 2,580 wereLocal health economies have a big part to play in reducing riskof accident and injury.promote educational initiatives (for example by working withparents of young children) and physical activity programmes(see above). Such programmes can help reduce the risks offalls, and therefore fractures, in older people. A&E staff arewell placed to play a key role in ensuring patients who presentwith a musculoskeletal condition are referred on to the mostappropriate service, such as a primary care professional or anto ensure that these referral processes are in place.Great Britain had a musculoskeletal condition caused Ð ormade worse Ð by their current or previous job. An estimated12.3 million working days are lost every year through work-related musculoskeletal problems. Certain occupations carry a high risk of osteoarthritis: farmers and agricultural labourersare much more likely to develop osteoarthritis of the hips whileprofessional footballers are especially prone to osteoarthritis ofthe knee. The workplace focus, through occupational health, is on primary prevention through accident prevention,As a major employer, the NHS must take these responsibilitiesseriously. NHS Plus (www.nhsplus.nhs.uk) is a network of occupational2000, provides an occupational health service to NHS staff andits website is a source of evidence-based guidelines ongood occupational health in the wider community. This shouldthe Health and Safety Executive (www.hse.gov.uk/msd). TheWorking Backs Scotland initiative has demonstrated theadvantages of such an approach to reducing sickness absenceand its resultant costs for the individual and society moregenerally. The programme offers information and advice toback pain (www.workingbacksscotland.com). dh ms main doc artwork 26/7/06 12:14 Page 21 Ð Car�e outside hospital PageIn addition, PCTs and GP practices are to make links with the DWP Pathways to Work pilots (Chapter2) being set up in their area for the benefit of their patients.Building on early success, from October 2005 there has beenan extension of the pilots in three phases to cover one-third most of the North East, North West and some parts of theWest Midlands, where there is a greater proportion of peoplecommunities also need to consider how they ensure thisready access to high-quality information and advice in order toof services and understand treatments. This informationto be medically accurate, relevant, consistent and easyto read. Thought should also be given to the informationpeople with sight impairments or learning difficulties andchildren and young people. Many voluntary sectororganisations provide excellent information and advice, andcommissioners are encouraged to make use of existingorganisations that deal with rarer conditions, patients can bedirected to the right organisation straight away. Reliablesources include patient organisations such as Arthritis ResearchCampaign, Arthritis Care and other members of the ArthritisDirect, DH, the National Library for Health and professionallyIn addition to websites, regularly published newsletters,information leaflets and telephone helplines are available tosupport self-management. Many NHS trusts also providehelpline services Ð often for patients with more complex healthPCTs can help support self-care by providing consistentinformation on musculoskeletal conditions across their health economy.www.dh.gov.ukAbout two-thirds of pharmacists work in over 10,000pharmacies throughout the UK. They have an important rolethey can help in primary prevention with general advice onolder people. They can advise on the safe and effective use ofmedicines, can provide educational materials and can assist inpatientsÕ self-management by recommending appropriatemedicines that are available over the counter without aprescription. They can support self-care, signpost appropriateservices and, where appropriate, carry out medicine usereviews. The new pharmacy contractual framework enablespharmacists to do even more to help people withmusculoskeletal problems.Patient-led organisations provide a wide range of supportincluding patient groups, websites, newsletters, self-management and volunteer training courses. There is a strongfocus on enhancing the individualÕs ability to self care whichreduces the need for reactive, unplanned and episodic use ofsecondary care services.care initiatives, and health professionals supporting suchgroups will want to be sure that advice is evidence-based.social care teamconditions account for a large and increasing proportion ofconsultations in primary care. As well as providing clinicalassessment, diagnosis and treatment, the primary care teamgives advice to adults and children on healthy lifestyles to helpto prevent musculoskeletal problems. Examples such as adviceon safe weight reduction, ÔHealthy WalksÕ and referral forexercise can be achieved through close partnership workingPeople can now access primary care professions through NHSwalk-in centres. These centres are designed to provide easierpatient access to primary care and have treated over 4.5walk-in centres have musculoskeletal problems and thus thereis an opportunity for these centres to provide valuable supportto the improvement of musculoskeletal services in the NHS.They might, for example, employ a range of professionalsincluding physiotherapists and refer patients presenting with amusculoskeletal condition to the most appropriate service, suchas a primary care professional or an ÔinterfaceÕ clinic (see ÔI came to see you just over a year ago with problemsrelating to recurrent lower backache and tendon painsto look for an arch support for my feet and to take upexercise. I purchased arch supports and joined a fitnessclub. Now a year on there is very little evidence of painand my gym membership has been a resounding ÔIt would be good to have physiotherapists based moreaccessibly, in primary care.Õ dh ms main doc artwork 26/7/06 12:14 Page 22 Ð Car�e at the interface Page4.1 IntroductionFor NHS patients with musculoskeletal problems, the presentsystem relies very heavily on referral to hospital for mostconditions. However, many patients with musculoskeletalproblems do not need to be treated in hospital and, indeed,can receive faster and more appropriate care in a communitysetting. This creates problems for both patients and clinicians.Rheumatologists and orthopaedic surgeons spend valuablepatients are referred to hospital whose needs could be bettermet elsewhere and often endure a wait for access to servicesduring which they receive very little active management. Thesepatients also increase the waiting times for those who dorequire specialist hospital care, particularly orthopaedic surgery,thus creating delays before crucial interventions can be offeredto this group of patients.reduces referrals to hospital while ensuring that patients aredirected towards the most appropriate services and clinicians.expansion of a multidisciplinary CATS working at the interfacebetween primary and secondary care. The well-designed CATSprovides efficient, rapid assessment, diagnosis and treatment ofpatients with a variety of musculoskeletal problemsThe Audit Commission considers the creation of CATS throughservice redesign as of Ôgreat strategic importanceÕ.provide evidence that such services can ensurethat patients are actively managed by skilled staff, rather thanbeing lost in the system or Ôbounced aroundÕ and thus helppatients to receive treatment at the appropriate time and to ¥focuses on the development of multidisciplinaryClinical Assessment and Treatment Services (CATS) Ðlooking at their structure, functions and benefits;¥provides practical advice on setting up a CATS,¥considers how certain clinical conditions can beeffectively addressed in this service; ¥recommends good practice points on setting upCATS. Clinical Assessment and TreatmentA number of health economies have already establishedservices of this type. The precise structure and functions ofexisting services vary from health economy to health economy.The generic functions are to:provide an expert multidisciplinary opinion for patientsreferred by their GPs, offering an alternative to direct referralscreen for important remedial conditions and refer patientsas appropriate;direct patients to appropriate services for investigation, or referral back to the GP;conduct clinical assessments; organise diagnosticinvestigations; provide advice and treatment, includingagree and test integrated care pathways (ICPs), which mustbe built on evidence-based guidelines with locally agreedprotocols and quality measures;facilitate referral, where necessary, to other primary orsecondary care services with agreed referral processes inplace which are understood by all;support the development of robust systems for monitoringIt should be noted that referral into a CATS may beinappropriate for some patient groups such as children andadolescents as their particular needs may require a higher levelAt the heart of the development of a successful CATS is theand secondary care and a robust clinical governance systemwith strong leadership and clear accountability. dh ms main doc artwork 26/7/06 12:14 Page 27 Patient groups will also need to be involved. Good, well-written literature for patients referred to the service will befrom the Department of Health, has been developing localnetworks to improve musculoskeletal service delivery. It issuggested that emerging CATS work with ARMA localnetworks. This will facilitate the process of engaging withIt takes time and careful planning to set up a CATS. Aneffective project management process with a dedicated projectPractical points from case studies are illustrated below: To set up a CATScare for a musculoskeletal opinion and length ofAscertain conversion rate for orthopaedic surgery (iethe percentage of patients attending outpatients whoare added to the waiting list), remembering thatpatients are added to lists not only at the firstconsultation, but by a variety of routes.Organise meetings of key stakeholders: consultants in orthopaedics, rheumatology, pain; key GPs;physiotherapists and other allied health professionals(AHPs); nurses; chiropractors; osteopaths; diagnosticservices; managers; patient representatives.Develop referral pathways; referral form based on care specialists.(NICE) guidance and ARMA Standards of Care).Agree clinical guidelines and protocols.Ensure appropriate arms of service available, eg painrestoration programmes.Put in place agreed training schedules andprogrammes of continual professional development.Agree outcome measures, referring to agreedprotocols and standards of care. These should includepatient satisfaction measures.Agree clinical audit framework and schedules. Ð Car�e at the interface PageClinical Assessment and TreatmentIt is recommended that each health economy explores theoption of establishing a CATS with an expectation that mostwill choose to implement this model of care in the next 12months. Setting up a service of this nature requires strongand a process that ensures the involvement ofpatients, health and social care staff from all sectors (primary,community and hospital care), information (IM&T) colleaguesand the voluntary sector. It is essential that clinicians andspecialists are fully engaged at the outset.location of a CATS is likely to vary from locality to locality,depending on the nature and distribution of services andcurrent clinical practice. They may be located in primary careboth locations can optimise the links between primary care and acute unit and communication; aid staff recruitment and retention; and promote staff education and clinical Staff providing care outside hospital need to understand clearlytheir own role and the roles of others, the referral routes intoclinicians and clinical governance processes.Staff providing hospital care also need to be fully engaged inthe process. The involvement of hospital consultants (inparticular orthopaedic surgeons, rheumatologists, painmanagement specialists and paediatricians/paediatric surgeons)is essential. The consultant (surgeon or physician) plays amajor role in diagnosis and assessment leading tosurgical/medical intervention and has the skill to be able tomatch an appropriate surgical/medical intervention with theneeds of the individual patient. It is only through closeresponsibility of medical or surgical intervention) that membersof the team will be empowered and trained to take on someof the responsibilities of diagnosis, assessment and directCurrently, clinical psychology services are mainly based insecondary care. Improved liaison between these services andCATS need to be established.Clinical assessments are an integral part of the widerany existing information (eg the Single Assessment Process A summary of the proposed intervention and agreed individualÕs integrated health and social care plan. dh ms main doc artwork 26/7/06 12:14 Page 28 Ð Car�e at the interface PageTask 1The current health status and needs of those withmusculoskeletal conditions, including children, should becurrent information sources on people with musculoskeletalin order to:understand the incidence/prevalence of musculoskeletaldisorders and health and healthcare inequalities;identify where patients are and their use of services;map services to identify areas of good practice and serviceevaluate current clinical and other outcomes. Health economies will already have noted the musculoskeletal problems should also be useful in supportingthe development of a CATS. Task 2Agreeing performance criteria and evaluation of the CATScollected in the CATS. While this needs to be agreed locally, subsequent referral and clinical/patient outcome. Specifically,it will be important to know the number of patients referreda breakdown of subspecialty referrals and geographicalinformation, so that referral patterns can be understood; evidence relating to the proportion of patients actuallyundergoing surgery;the workload of primary care services Ð as this is likely toincrease when the CATS is commissioned, leading to a needto increase capacity;continuing use of secondary care services. Evaluation of the CATS as part of a reshaped system will bebe collected from the outset.Task 3Plans for staffing a CATS should be based on an understandingof volumes of clinical activity; the potential of new professionalroles; and the impact of agreed care pathways. It is vital toappoint clinical, managerial and administrative staff inadequate numbers to ensure that the services can be deliveredthroughout the year without increasing waiting times,Health and social care staff from both primary and secondarycare need to meet regularly as a team, firstly to establish theservice and thereafter to share good practice and informationessential across different sectors Ð including independentproviders Ð recognising the increasing focus on plurality.It is important that those developing a CATS undertake earlydevelopment programmes. The CATS is a potential trainingresource for a range of health and social care professionals and others, in the effective management of people withmusculoskeletal problems.Task 418-week patient pathway from referral to start of treatmentconditions require investigations in order to make or confirmdiagnosis and offer appropriate interventions. The CATS teamscan, as part of the agreed care pathway, scheduleinvestigations and organise direct access for the patientwithout the need to refer to secondary care. Similarly, when a patient is referred to secondary care,diagnostic investigations can be organised by CATS staff beforethe appointment. Care pathways will need to be redesigned byworking with diagnostic staff, such as radiologists andradiographers, to reflect these changes. When planning localservices a review of capacity in relevant diagnostic servicesmay be useful, particularly as the development of CATS maylead to an increase in complex imaging.Task 5Social services currently support many people to maintain ahigh quality of life in their own homes, through the provisionof aids and adaptations or care packages. However, eligibilitycriteria and charging policies vary from one local authority toanother and the types of services that are available locally mayalso vary.Health economies need to work collaboratively with social careservices to ensure that people who would benefit from activeoccupational therapy intervention, as well as provision ofequipment and physical assistance to improve their lives, have dh ms main doc artwork 26/7/06 12:14 Page 29 some people. However, for others, controlling painfulsymptoms may be more complex and require a range ofcan be helpful and are particularly effective when offered onprompt and effective relief of acute pain where possible;can be provided by specialist nurses/AHPs. Usingappropriate self-management strategies, including symptomcontrol, patients will be able to manage their pain;rapid access for those who require prompt referral torapid access to specialist teams for complex cases requiringclinical review;long-term support for self-managed care;training for health professionals who manage acute andchronic pain;symptom control improved by practitioners/nursesÐ Car�e at the interface Page4.4 Clinical services provided Treatment ServiceMultidisciplinary CATS can be established to deal effectivelychronic), back pain, trauma from falls, osteoarthritis,inflammatory arthritis, osteoporosis, soft tissue injury, posturalproblems in children and minor musculoskeletal interventions The development of CATS will also allow many of theseprocedures to be carried out in primary care. Well-developedCATS are able to offer the following services to patients:The most common presenting symptom in people withmusculoskeletal problems is pain. Qualitative studieshave shown that what this group most want from NHSservices are pain control and help with improving function. Providing culturally appropriate services for prompt symptomcontrol through education, non-pharmacological andpharmacological treatment is pivotal to enabling an individual surgerypresenting toprimary carePrimary carerehabilitationexercise groupprogrammeCommunity back pain management serviceSecondary care service dh ms main doc artwork 26/7/06 12:14 Page 30 Ð Car�e at the interface PageHealth economies will want to ensure that there is a skilledteam to provide care for people with musculoskeletal pain.chiropractors.authorities will ensure that the best use is made of all availableservices, including facilities such as leisure centres. Painmanagement services in CATS are also a resource for providingtraining and support for healthcare professionals who treatpeople with musculoskeletal disordersDepartment of Health survey, 40% of adults reported backpain lasting more than a day in the previous 12 months, while15% said they were in pain throughout the year.Approximately 40% of those in pain consulted a GP for help.Up to 180 million working days were lost in 1997/98 due toEvidence shows that most of the care of people with back paincan be dealt with effectively in non-hospital settings such asCATS.At present, however, patients are often referred tooutpatient clinics without full assessment in primary care, withonly around 2% of these unselected referrals listed for surgery.are away from work and receive minimal management of their the CATS teams. Specialists work on site and triagereferrals together. Referrals to the teams are gradedaccording to complexity. The more complex painpatients undergo a multidisciplinary assessment andhave access to a range of treatment options Ðapproximately one-third enter specialist care thatinvolves medical and psychological treatmentapproaches. The less complex patients are managed bypractitioners (predominantly physiotherapists) andnurses specialising in pain management. Some 10% arereferred to a multiprofessional cognitive behaviouralprogramme that is also community-based. Thephysiotherapists can provide education on pain,acupuncture, graded exercise, pacing of activities andaccess to employment advisers according to need. Theysupervision, advice and education programmes.Specialist pain management nurses review patients whoare having difficulty implementing self-managementplans, help them identify priorities and then are able towork with patients to achieve change. They are alsoforms of pain relief. All take part in combined educationprogrammes and support other CATS professionals. Falls resulting in fractures are common, especially in olderpeople. They are often related to osteoporosis, an importantcause of fragility fractures, particularly in women. Osteoporosisaffects about 20% of women aged between 60 and 69 years,with increasing prevalence thereafter: the lifetime risk ofsustaining an osteoporotic fracture after the age of 60 is 45%.number of fractures is 60,000 at the hip, 50,000 at theforearm and 40,000 at the spine, resulting in an estimated50% of older people who suffer a fracture after a fall, find thatthey can no longer live independently,people a year die as a result of hip fractures, many related tofalls. The cost to the NHS of treating all fractures from falling Through the implementation of Standard Six of the care systems have now organised integrated falls services withprevention and treatment of osteoporosis as an essentiala history of recurrent falls and those at risk who can benefitfrom interventional schemes such as strength and balancetraining, home hazard and vision assessments, medicationreview, cardiac pacing and osteoporosis guidance. Integratedfalls and osteoporosis services (including fracture liaisonservices) require planning and implementation across manyprimary and secondary services is necessary.services fall naturally into the CATS model.The following three case studies describe three successful CATShave improved care for patients in their locale: dh ms main doc artwork 26/7/06 12:14 Page 31 Ð Car�e at the interface Page Ð Somerset Coast Primary Care Trustprimary and secondary care. Extended scopesupport staff and a development lead work together toimprove the quality of service for patients. A biopsychosocial model of care is used. It was awardedNHS Modernisation Award for Access in 2001. MRIs are performed within 2 weeks of request andpatients reviewed with the results within 4-6 weeksof request.63% of all GP musculoskeletal referrals are nowreferred to the MSIS.37% of all patients were given advice and discharged20% of the patients seen were referred for a surgicalopinion. 75-80% of these patients are listed forsurgery. The approximate cost saving of using this service isconversion rate to surgery than the local orthopaedichave shown that patients are very satisfied with the interface Ð University Hospital of North StaffordshireNHS Trust.Following reconfiguration of clinical services to create aLocomotor Directorate that includes Orthopaedics,clear that many patients were accessing services in anad-hoc manner. The service was therefore redesignedto deliver an effective, efficient and coherentcommunity and broke down barriers betweenprofessions, settings and organisations and differentmodels of care.The musculoskeletal service is clinician led with strongÐDynamic triage of pooled referrals Ð to reduce theattending surgical orthopaedic clinics.ÐSpecialist services and clinical teams across primaryand secondary care: musculoskeletal teamelective surgical; rheumatology; musculoskeletalchronic pain; back pain; and combined clinics. ÐCare Pathways, clinical algorithms, direct listingprotocols. Training and educationAudit and research appropriate clinical area to meet current NHS targetsImproved communication and learning processbetween professional groups and across healthservice organisations. Efficient use of facilities, time, skills and treatments(surgical, non-surgical, counselling) eg Orthopaedicsurgical clinic conversion rate increased from High levels of satisfaction with the service throughImproved governance and no increased clinical riskthrough close supervision, mentorship and appraisals. dh ms main doc artwork 26/7/06 12:14 Page 32 Ð Car�e at the interface Page Good practice action points to support CATSestablishment of a CATS service with minimal delay.The lead organisation, likely to be the lead primarycare trust, should be identified. Clinicians and managers who will be responsible fordeveloping and delivering the CATS need to beidentified and a project lead appointed. This projectteam needs to include a representative from socialThese staff need to agree the operational detail ofthe CATS (eg protocols for referrals to and from theservice; discharge from hospital and from CATS;direct listing of patients; ordering of diagnostic A process for communicating with and seeking advicefrom all stakeholders needs to be agreed, includingA communication strategy needs to be agreed andimplemented to ensure that all staff understand theStaff training needs to be organised in line with theoperational detail of the CATS. CATS staff and benchmarking data should be agreedwhere possible. The Facture Liasion Service, Western Infirmary, NorthThe Fracture Liaison Service (FLS) was set up in 1999 toensure that all women and men ?50yr presenting witha new fracture to A&E or to Orthopaedics & TraumaServices are routinely offered assessment forosteoporosis and, where necessary, receive treatmentfor fracture secondary prevention. The service covers apopulation of 960,000 in the greater Glasgow area:secondary care and bridges the current gaps inpatient care between Trauma Services, OsteoporosisServices and Primary Care. Central to the FLS is the Osteoporosis NurseSpecialist (ONS) whose roles are to: 1) identify allpatients with a new fracture at any skeletal site and2) arrange their subsequent assessment for fracturesecondary prevention at the Ôone-stopÕ FLS clinic.fracture for DXA (spine and hip) and subsequentosteoporosis are treated according to protocol, andreceive appropriate education.Current and past fracture histories, risk factors forosteoporosis and for fractures, DXA results andtreatment recommendations are recorded in the FLSthe GP and facilitates a regular programme of auditsIn addition to targeting treatment for fracturesecondary prevention, the FLS addresses, whereappropriate, non-skeletal contributions to fracture riskthrough referral to integrated falls-interventionThe FLS finds patients who have sustained fracturesrather than putting the onus on fracture patients toseek referral. This ensures equity of accessirrespective of socioeconomic deprivation and ethnicgroup.The service provides education about their conditionfor patients which is reinforced at exercise classes andagain through provision of a formal half-day meetingabout osteoporosis and fracture secondary prevention�Audit shows 80% of all fractur�e cases 50yr nowundergo assessment for fracture secondary preventionby the FLS; post-fracture mortality, morbidity andrefusal account for the remaining 20%. The FLS hastransformed the delivery of strategies for fracturesecondary prevention. dh ms main doc artwork 26/7/06 12:14 Page 33 Hospital care dh ms main doc artwork 26/7/06 12:14 Page 34 A series of interlinked policies supports NHS reform and waysof working, some of which are set out in Chapter 2. Theoverall aim of the reform agenda is to ensure that the NHSoffers high-quality care, led by the needs and wishes of todayÕspart of this reform programme.There are key changes that health economies will need tomake in order to improve the care of people withmusculoskeletal conditions and reduce waits and delays toCommissioners will lead much of the change. It is, however,imperative that the process involves all key stakeholders acrossthe whole health and social care system, including patients and their families: it is only possible to deliver change through¥population needs assessment (covering children, young¥identifying priorities and standards;¥planning services;¥commissioning services to meet assessed needs;¥managing performance and auditing, assessing andThese stages form a continuous cycle of improvement. Localimplementing recommendations contained in the MSF,covering all aspects of musculoskeletal care, from self carethrough to specialist care for adults and children, in eachhealth economy. Further detail on the actions needed at eachAs stated above, effective partnership working is central tosuccessful implementation of the MSF. A key action for healtheconomies in implementing the Framework is therefore tospecify and agree from ensure that the use of primary and secondary care isappropriate to patientsÕ needs. Alternative pathways willenable primary care trusts (PCTs) to diversify the range ofservices offered locally. Specifically, PCTs need to develop careprimary and secondary care and it is therefore recommendedthat all health economies explore the opportunities for creatingClinical Assessment and Treatment Service (CATS)secondary care is as seamless as possible. It is important that the pathways include detailed and agreedclinical audit measures, set within a wider governanceframework and, again, suggested measures and the deliveryguide details resources to help develop a robust governanceLastly, the publication of this Framework comes at a timewhen the NHS is undergoing a revolution in terms of, through the NHS Connecting for(www.connectingforhealth.nhs.uk) nationalprogramme. It is envisaged that eventually all patientsÕ recordsprofessionals and carers as well as patients themselves. The same technology is being harnessed to provide the and expertise to provide healthcare. This includes a specialist library for musculoskeletal disorders(www.library.nhs.uk/musculoskeletal) within the Nationalinformation and will need to develop comprehensiveAs commissioners will lead the change process, anaccompanying document has been prepared Ð published shortly.To raise awareness and assist in the engagement of. This will be published shortly.A booklet for patients has been prepared to explain thewill be published shortly.Further information is provided in . This will be published shortly. dh ms main doc artwork 26/7/06 12:15 Page 51 and social carestaff dh ms main doc artwork 26/7/06 12:15 Page 52 Ð Roles of health and social care staf�f PageThe following paragraphs describe the roles of a range of staffin the regulated health professions and social care, who maybe involved, directly or indirectly, in the care of people withWhile traditional roles remain the keystone of the service,professionals have now become freer to develop extendedand/or specialist roles, with the potential for imaginativereshaping of more responsive and flexible services, providingeasier access in a wider variety of settings. Many are able toaccept self-referrals and run their own caseloads. They referpatients to other professionals when necessary and willthemselves receive referrals from others.The contacts with professionals can be first contacts for newconditions, many of which will resolve in time, or they can bepart of the patientÕs continuing journey in dealing with morechronic or complex conditions. Traditional and newer roles are described.Numbers of professionals are given, as:workforce headcount numbers for qualified staff employedby the NHS in England, from the Department of Healthnumbers registered in the UK with the appropriateregulatory body (labelled ÔregisteredÕ with date);other specified sources.Roles of individual professions are outlined below inalphabetical order.The term Allied Health Professional (AHP) covers thirteendifferent professional groups. Several of these groups play acentral role in the delivery of musculoskeletal services:physiotherapists, podiatrists, orthotists and prosthetists,occupational therapists and diagnostic radiographers. The roleprofessionalsÕ.With the exception of diagnostic radiographers, all AHPsdescribed in this section are able to accept self-referralsdirectly, and refer onward as necessary. At present the serviceswhich accept self-referrals from patients are not widespreadand often at a pilot stage. Most patients are likely to stillaccess AHPs via the traditional route of GP or other clinicianreferral.The core services AHPs provide vary with profession but allInformation, education, treatment and supportTechnical skillsIntegrated care across primary and secondary servicesReferral to other professionalsPromotion of the expert patient programme.All the professions above are able to use Patient GroupDirection (PGDs). In addition chiropodists/podiatrists,physiotherapists and radiographers are able to act assupplementary prescribers.website www.dh.gov.uk/nonmedicalprescribing AHPs can develop their core skills in several ways:denote an AHP working in an expanded role within aprimary care or community setting. The term is equivalent toGPs and Nurses with Special Interests who undertake carewithin the community. AHPwSI does not relate to a specificgrade or speciality. It could range from junior staff to AHPAHPwSI is that the need to redesign services in order toimprove access for patients along with the service theyreceive drive the creation of these posts Ð seewww.dh.gov.uk/pricare/gp-specialinterests/ahpwsi.pdf dh ms main doc artwork 26/7/06 12:15 Page 53